PRESSURE ULCER STAGING
This is the medical term for “pressure ulcer” according to current NPIAP terminology.
What is pressure injury?
This mnemonic represents the six components of a neurovascular assessment.
What are the “6 Ps” (Pain, Pallor, Pulselessness, Paresthesia, Paralysis, Poikilothermia/cold)?
ORIF stands for this surgical procedure.
What is Open Reduction Internal Fixation?
This common sensation causes amputees to feel pain or discomfort in the limb that has been removed.
What is phantom limb pain?
This assistive device provides the most stability for patients with impaired mobility but requires upper body strength and is not recommended for stairs.
What is a walker?
A Stage 1 pressure injury presents with this characteristic finding on intact skin.
What is non-blanchable redness/erythema?
(redness that doesn’t turn white when pressed)
When assessing capillary refill, you press on the nail bed and release. Normal capillary refill occurs within this time frame.
What is less than 3 seconds?
This type of fracture breaks through the skin, creating an open wound and high infection risk.
What is a compound (or open) fracture?
In the immediate post-operative period after amputation, the residual limb should be positioned in this manner to prevent contractures.
What is in extension (flat/straight) or prone position?
(NOT flexed; avoid prolonged hip/knee flexion to prevent contractures)
When a patient is prescribed “partial weight-bearing” status, they should bear this percentage of their body weight on the affected extremity.
What is 30-50%?
(or “toe-touch weight-bearing”; accept: limited weight, as tolerated up to 50%)
In this pressure injury, the wound extends through the epidermis and into this layer, appearing as a shallow open ulcer or intact/ruptured blister.
What is the dermis (partial-thickness skin loss)?
(Stage 2 Pressure Injury)
Your patient with a fractured tibia reports severe pain (9/10) in the affected leg that is unrelieved by pain medication. The leg feels tight.
These are early warning signs of this limb-threatening complication.
What is compartment syndrome?
After a fracture, patients are at risk for this life-threatening complication where fat globules enter the bloodstream, potentially causing respiratory distress and altered mental status.
What is fat embolism?
(or fat embolism syndrome)
Post-amputation, the residual limb is wrapped with elastic bandages in this specific pattern to control edema and shape the limb for prosthetic fitting.
What is a figure-eight pattern?
(spiral, firm, wrapping distal to proximal)
The Morse Fall Scale and Hendrich II are examples of these tools used to identify patients at risk for falls.
What are fall risk assessment tools (or fall risk screening tools)?
You discover a pressure injury on a patient’s sacrum with full-thickness tissue loss. You can see subcutaneous fat, but no muscle, tendon, or bone is visible.
Name the stage AND one priority nursing intervention.
What is Stage 3?
Priority interventions include: offloading pressure from the area, consulting wound care/provider, documenting accurately, ensuring adequate nutrition for healing.
During neurovascular assessment, you ask the patient to perform specific movements.
Describe TWO motor function tests you would perform for a patient with a lower extremity cast.
What are: - Dorsiflexion and plantarflexion of the foot/toes - Wiggling toes - Pushing foot against resistance
(Accept any two appropriate motor tests)
Your patient returns from surgery post-ORIF of the femur.
List THREE priority assessments you must perform in the immediate post-operative period.
What are (any three):
- Neurovascular status distal to the surgical site (6 Ps)
- Surgical site assessment (bleeding, drainage, dressing integrity)
- Pain level
- Vital signs
- Drain output (if applicable)
- Mobility/positioning
Your patient is 2 days post below-knee amputation (BKA). During wound assessment, you note purulent drainage and foul odor from the surgical site. The patient has a fever of 101.8°F.
Connect mobility and tissue integrity concepts: State the priority problem AND three immediate nursing actions.
Priority Problem: Infection of surgical site (or potential sepsis)
Nursing Actions: (any three)
- Notify surgeon immediately - Obtain wound culture per order
- Administer antibiotics as prescribed
- Document findings thoroughly - Monitor vital signs closely
- Assess for systemic infection signs
Your patient is 1 day post-ORIF of the hip and has orders to get out of bed to chair.
List the correct SEQUENCE of THREE critical steps to safely transfer this patient.
1. Perform pain assessment and medicate if needed (30 min before activity)
2. Assess patient’s weight-bearing status and review precautions (hip precautions: no flexion >90°, no adduction, no internal rotation)
3. Use mechanical lift or two-person assist with gait belt; move toward strong side; ensure non-slip footwear
(Accept variations that demonstrate safe transfer principles)
Your patient has a wound on the heel with a thick, dry, black eschar covering the wound bed. You cannot determine the depth.
What stage is this and what is your PRIMARY nursing concern before staging can occur?
What is Unstageable?
Primary concern: The eschar must be removed to determine true depth; assess for infection; do NOT remove stable, dry eschar on heels (this is controversial—staging cannot occur until eschar is removed; may also need to rule out deep tissue injury).
PRIORITY DECISION: You’re performing a neurovascular check on a patient 4 hours post-ORIF of the left radius. You note the fingers are pale, cool to touch, and the patient reports numbness and severe pain (8/10). Pulses are diminished.
Using clinical judgment, state your FIRST action, the rationale, and the potential consequence if not addressed immediately.
Action: Immediately notify the surgeon/provider (STAT)
Rationale: Signs indicate compromised arterial perfusion and possible compartment syndrome -
Consequence: Permanent nerve damage, tissue necrosis, limb loss if not treated within 4-8 hours (risk for irreversible tissue damage)
CASE ANALYSIS: A patient with a long bone fracture develops sudden confusion, petechiae on the chest, dyspnea, and hypoxia 24-48 hours post-injury.
Connect the concepts: Name the complication, explain the pathophysiology, and state TWO priority interventions.
Complication: Fat embolism syndrome
Pathophysiology: Fat globules from bone marrow enter circulation → lodge in pulmonary capillaries and cerebral circulation → cause respiratory distress and neurologic symptoms
Priority Interventions: (any two)
- Notify provider immediately
- Administer oxygen/maintain oxygenation
- Position patient for optimal ventilation
- Monitor respiratory status closely
- Prepare for possible mechanical ventilation
Discuss the relationship between the concepts of mobility, tissue integrity, and emotional well-being in amputation patients.
Provide TWO evidence-based nursing interventions that address ALL THREE concepts.
Relationship: Loss of mobility affects independence and self-image; tissue integrity concerns (healing, phantom pain) create anxiety; both impact quality of life and psychological adjustment.
Interventions: (any two)
- Early mobilization with physical therapy → improves mood, maintains tissue perfusion, prevents complications
- Peer support/support groups → addresses psychological needs while learning practical mobility adaptations
- Phantom limb pain management → improves comfort, enabling participation in mobility/rehabilitation
- Body image counseling → addresses psychological adjustment while promoting engagement in self-care and mobility activities
- Prosthetic education and fitting → provides hope for restored mobility, demonstrates progress in healing
CLINICAL JUDGMENT SCENARIO: Your immobile patient has been on bed rest for 5 days following spinal surgery. You notice decreased breath sounds in the bases, the patient reports calf pain, and has mild confusion.
What complications are you noticing? How do you interpret this? What is your responding priority? What will you reflect on?
Noticing: Decreased breath sounds (possible atelectasis/pneumonia), calf pain (possible DVT), confusion (possible hypoxia or fat embolism)
Interpreting: Multiple complications of immobility (respiratory compromise and venous thromboembolism)
Responding: FIRST: Assess oxygen saturation and respiratory status; Second: Do NOT massage calf (if DVT); Third: Notify provider immediately; Fourth: Anticipate orders for imaging (chest X-ray, Doppler ultrasound)
Reflecting: “I should have recognized earlier signs of immobility complications; need to be more proactive with turning, incentive spirometry, sequential compression devices, and early mobilization”