Pressure Injury Basics
In 2016, the NPUAP changed the term "pressure ulcer" to this term.
What is "pressure injury"?
This stage is characterized by intact skin with non-blanchable redness
What is Stage 1?
This scale is commonly used to assess risk for pressure injuries.
What is the Braden Scale?
The main principle in treating any pressure injury is to do this to the affected area.
What is relieve pressure?
All pressure injuries must be documented with this key detail about the wound.
What is the stage of the pressure injury?
These two forces, in addition to pressure, contribute to pressure injury development.
What are friction and shear?
This stage may present as a serum-filled blister or partial-thickness skin loss with exposed dermis.
What is Stage 2?
Name two medical conditions that increase risk for skin breakdown.
What are diabetes and peripheral vascular disease? (Accept any two from: diabetes, hypotension, vascular disease, circulation disorders, etc.)
This type of equipment helps redistribute pressure for at-risk patients.
What is a pressure redistribution device (e.g., specialized mattress or cushion)?
This should be assessed and documented before, during, and after wound care.
What is pain?
This is the most important factor in determining how much pressure will cause tissue damage.
What is the client’s individual risk factors (such as tissue tolerance, comorbidities, etc.)?
This stage involves full-thickness skin loss, possibly exposing fat, but not muscle, tendon, or bone.
What is Stage 3?
This lifestyle factor, often related to vascular issues, increases risk for pressure injuries.
What is smoking?
This aspect of care should be coordinated with analgesic administration for wound pain.
What is wound care/procedures?
Educating clients and families should include information on this key prevention strategy.
What is repositioning/pressure relief?
This type of pressure injury is related to skin damage from a device used for diagnostic or therapeutic purposes.
What is a "Medical Device Related Pressure Injury"?
This stage involves full-thickness tissue loss with exposed bone, tendon, or muscle.
What is Stage 4?
This assessment must be done head-to-toe, focusing on bony prominences and under medical devices.
What is a skin assessment?
This is the recommended approach for managing incontinence to prevent pressure injuries.
What is a toileting plan and use of appropriate containment products?
This is the term for a pressure injury that develops despite appropriate preventive measures.
What is an "unavoidable pressure injury"?
This type of pressure injury occurs on mucous membranes and is not staged.
What is a "Mucosal Membrane Pressure Injury"?
This pressure injury cannot be staged due to full-thickness tissue loss covered by slough or eschar.
What is "Unstageable Pressure Injury"?
This is the term for skin damage caused by prolonged exposure to moisture, such as from incontinence.
What is Moisture Associated Skin Damage (MASD)?
These two types of pressure injuries require an interprofessional approach for comprehensive care.
What are all pressure injuries (but especially complex or non-healing ones)?
When a pressure injury heals, this should NOT be done to its stage in documentation.
What is reverse-staging?