1 . The most common areas where pressure injuries occur are the
| A) | | hands and neck. |
| B) | | coccyx and neck. |
| C) | | sacrum and coccyx. |
| D) | | back of the head and hands. |
The development of pressure-induced skin injury and
subsequent ulceration usually arises in the setting of failing health and loss of independent
mobility. In a community-based study of 12,650 patients older than 60 years of age enrolled in
a primary care panel, 366 (2.9%) subsequently developed a pressure injury during the 40-month
surveillance period [11]. The two most
prominent risk factors were prior history of pressure injury and placement in a long-term care
facility, followed by comorbid conditions such as diabetes, falls, cataracts, renal
insufficiency, and cardiovascular disease. In a national study of 1,524 adults residing in 95
long-term care facilities, 443 (29%) developed a new pressure injury during the 12-week
observational period; factors associated with increased risk included higher initial severity
of illness, history of previous pressure injury, weight loss, feeding difficulty, use of
catheters, and use of positioning devices [12].
2 . An increased risk for pressure injury development is noted in patients
| A) | | with increased nutritional intake. |
| B) | | who weigh less than 119 pounds. |
| C) | | who consume more protein than average. |
| D) | | with body mass index between 20 and 25. |
Poor nutrition, intravascular volume depletion, and
peripheral vascular disease can each lead to unhealthy skin and impaired wound healing,
which in turn increases the risk of developing pressure injuries. Low body weight is also
a concern. Weight less than 119 pounds or a body mass index (BMI) less than 20 indicates
increased risk for pressure injury development [19].
Recent weight loss, decreased nutritional intake,
inadequate dietary protein, and impaired ability to feed oneself have been identified as
risk factors for pressure injury development. An estimated 50% of elderly patients
admitted to hospitals have suboptimal protein nutrition [19]. When there is a sustained deficit of protein as an energy source,
skin and soft tissues become more vulnerable to injury. In managing patients with pressure
injury, or those at risk, the amount of protein in the diet appears to influence prognosis
for recovery and prevention. In one study, patients who received a 24% increase in protein
intake had significant improvements in pressure injury healing and prevention of new skin
injury compared to those who received a 14% increase [20]. The potential role of nutritional supplementation on pressure injury
management and prevention is an area of ongoing research [21,22].
3 . The greatest risk for developing a pressure injury is assigned a Braden Scale score of
| A) | | 9 or less. |
| B) | | 10–12 |
| C) | | 13–14 |
| D) | | 15–18 |
THE BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK
| Domain | Scorea |
|---|
| 1 | 2 | 3 | 4 |
|---|
| Sensory perception: The ability to respond meaningfully to pressure-related
discomfort | Completely limited: Unresponsive (does not moan, flinch, or grasp) to painful
stimuli due to diminished level of consciousness or sedation OR limited ability to
feel pain over most of body surface. | Very limited: Responds only to painful stimuli and cannot communicate
discomfort except by moaning or restlessness OR has a sensory impairment that
limits the ability to feel pain or discomfort over half of body. | Slightly limited: Responds to verbal commands, but cannot always communicate
discomfort or need to be turned OR has some sensory impairment that limits ability
to feel pain or discomfort in one or two extremities. | No impairment: Responds to verbal commands and has no sensory deficit that
would limit ability to feel or voice pain or discomfort. |
| Moisture: Degree to which skin is exposed to moisture | Constantly moist: Skin is kept moist almost constantly by perspiration,
urine, etc. Dampness is detected every time patient is moved or turned. | Very moist: Skin is often, but not always, moist. Linen must be changed at
least once a shift. | Occasionally moist: Skin is occasionally moist, requiring an extra linen
change approximately once a day. | Rarely moist: Skin is usually dry. Linen only requires changing at routine
intervals. |
| Activity: Degree of physical activity | Bedfast: Confined to bed | Chairfast: Ability to walk severely limited or non-existent. Cannot bear own
weight and/or must be assisted into chair or wheelchair. | Walks occasionally: Walks occasionally during day, but for very short
distances, with or without assistance. Spends majority of each shift in bed or
chair. | Walks frequently: Walks outside the room at least twice a day and inside the
room every two hours during waking hours. |
| Mobility: Ability to change and control body position | Completely immobile: Does not make even slight changes in body or extremity
position without assistance. | Very limited: Makes occasional slight changes in body or extremity position
but unable to make frequent or significant changes independently. | Slightly limited: Makes frequent though slight changes in body or extremity
position independently. | No limitations: Makes major and frequent changes in position without
assistance. |
| Nutrition: Usual food intake pattern | Very poor: Never eats a complete meal. Rarely eats more than one-third of any
food offered. Eats two servings or less of protein per day. Takes fluids poorly.
Does not take a liquid dietary supplement. OR is nothing by mouth and/or
maintained on clear liquids or intravenous for more than five days. | Probably inadequate: Rarely eats a complete meal and generally eats only
about half of any food offered. Protein intake includes only three servings of
meat or dairy products per day. Occasionally will take a dietary supplement. OR
receives less than optimum amount of liquid diet or tube feeding. | Adequate: Eats more than half of most meals. Eats a total of four servings of
protein each day. Occasionally will refuse a meal but will usually take a
supplement if offered. OR is on a tube feeding or total parental nutrition regimen
that probably meets most of nutritional needs. | Excellent: Eats most of every meal. Never refuses a meal. Usually eats a
total of four or more servings of protein. Occasionally eats between meals. Does
not require supplementation. |
| Friction and shear | Problem: Requires moderate-to-maximum assistance in moving. | Potential problem: Moves feebly or requires minimum assistance. During a
move, skin probably slides to some extent against sheets, chair restraints, or
other devices. Maintains relatively good position in chair or bed most of the
time, but occasionally slides down. | No apparent problem: Moves in bed and in chair independently and has
sufficient muscle strength to lift up completely during move. Maintains good
position in bed or chair at all times. | — |
| aA lower Braden Scale
Score indicates a lower level of functioning and, therefore, a higher level of
risk for pressure ulcer development. Risk levels assigned to each score range: ≤9
is very high risk, 10–12 is high risk, 13–14 is moderate risk, and 15–18 is mild
risk. Scores of 19 or greater are considered very low or no risk. |
4 . In which of the following pressure injury stages is the skin still intact?
| A) | | Stage 1 |
| B) | | Stage 2 |
| C) | | Stage 4 |
| D) | | Unstageable |
STAGING OF PRESSURE INJURIES
Deep tissue injury is described as a purple or maroon
localized area of discolored, intact or non-intact skin or a blood-filled blister caused by
damage of underlying soft tissue from pressure and/or shear (Image
1). The area may be preceded by tissue that is painful, firm,
mushy, boggy, warmer, or cooler as compared to adjacent tissue.
5 . In patients with normal immune response, the inflammatory phase of pressure injury healing occurs
| A) | | in the first 0 to 3 days. |
| B) | | 3 to 12 days after the ulcer develops. |
| C) | | 14 to 30 days after the ulcer develops. |
| D) | | for up to 1 year after the ulcer develops. |
PHASES OF WOUND HEALING: AN OVERVIEW
The standard signs and symptoms of inflammation are
erythema, swelling, increased temperature, and pain. In normal healing, these signs are only
minimally noticeable, and during the inflammatory phase of wound healing, they are
considered a normal response [35]. In
general, this phase occurs in the first 0 to 3 days after injury development but may last
longer if healing is impaired.
6 . Which of the following is the most sensitive marker to assess patient's nutritional status?
| A) | | Albumin |
| B) | | Transferrin |
| C) | | Prealbumin |
| D) | | Total protein |
Blood tests may be ordered to assess nutritional status and
overall health status. No laboratory study of nutritional status can absolutely predict
pressure injuries; however, monitoring a patient's protein status is of value. There are many
serologic markers used to assess a patient's nutritional status; prealbumin level is one of
the most sensitive. Prealbumin is a protein with a much shorter half-life than the other
serologic markers; therefore, its level gives a more accurate picture of current
conditions.
7 . Radiographic studies are indicated in a patient with pressure injury
| A) | | to rule out osteomyelitis. |
| B) | | when bone infection is suspected. |
| C) | | to rule out vasculitis and skin cancers. |
| D) | | Both A and B |
If infection is suspected, culture of the pressure injury is
important to determine the pathogen. In some cases, a wound biopsy is performed to rule out
vasculitis and skin cancers. An x-ray is done if bone infection is suspected and to rule out
osteomyelitis. A bone scan is carried out when x-ray findings are equivocal.
8 . Which of the following is NOT a primary objective for the management of pressure injuries?
| A) | | Pressure reduction |
| B) | | Managing a moist wound environment |
| C) | | Increasing the frequency of dressing changes |
| D) | | Minimizing or eliminating friction and shear forces |
The primary objectives for prevention and arrest of
progression are:
Preventive skin care
Pressure reduction, minimizing or eliminating friction and shear forces
Adequate nutrition
Exudate management
Prevention of wound infection
Managing moist wound environments
Decreasing the frequency of dressing changes
9 . In poorly nourished patients, optimal healing of pressure injuries requires a protein intake of
| A) | | 0.25–0.5 g/kg/day. |
| B) | | 1.25–1.5 g/kg/day. |
| C) | | 12.5–15 g/kg/day. |
| D) | | 25–50 g/kg/day. |
The provision of an optimal diet (e.g., 30–35 kcalories/kg
body weight for adults who are at risk for malnutrition), including the addition of
supplemental protein, amino acids, zinc, and vitamins, has been shown to reduce risk of
pressure-induced skin injury and to speed wound healing. The recommended daily protein
intake for healthy adults (0.8 g/kg of body weight) may not be adequate in the frail elderly
or under conditions of chronic inflammation and loss of lean body mass. For dietetic
management of adults at high risk of pressure injury or delayed wound healing, the
recommended intake is 1.25–1.5 g protein/kg body weight daily [29,42].
10 . Debridement is contraindicated if
| A) | | no eschar develops on the heels. |
| B) | | undermining or tunneling is present. |
| C) | | necrotic tissue is present in the wound. |
| D) | | there is inadequate blood supply to support wound healing. |
The method of debridement used depends on the amount of
necrotic tissue present, the location of the wound, and the patient's overall condition
[35]. Patients with stage 3 or 4 pressure
injuries who have undermining and/or tunneling or extensive necrotic tissue should have a
surgical evaluation for possible surgical debridement of the wound, if this is consistent
with their condition and goals of care [29].
Infected wounds may require systemic antibiotic treatment and immediate surgical debridement
[15]. Maintenance debridement should be
continued until there is a covering of granulation tissue in the wound bed and the wound is
free of necrotic tissue [29]. Debridement is
contraindicated if there is inadequate blood supply to support wound healing.
11 . For patients in long-term care or home care, the Agency for Healthcare Research and Quality recommends what method(s) of debridement?
| A) | | Surgical |
| B) | | Maggot therapy |
| C) | | Autolytic and enzymatic |
| D) | | Debridement is not recommended. |
Autolytic debridement uses the body's own enzymes and
moisture to heal the injury. To be successful, there must be sufficient white blood cells
available to the wound and a moist environment [13]. A layer of wound exudate should be kept in contact with the surface
of the wound, usually using a moisture-retaining dressing [10,15,35]. This allows fluid
to accumulate in the wound, rehydrating necrotic tissue and making it possible for enzymes
in the wound to digest the dead tissue [35]. For a wound covered with dry eschar, it is appropriate to crosshatch the eschar, as
this allows a faster build-up of moisture in the wound [35]. In their clinical practice guidelines for pressure injury treatment,
the Agency for Healthcare Research and Quality recommends autolytic and enzymatic
debridement as the preferred approach for patients in long-term care or home care and for
patients who cannot tolerate other methods of debridement [35,46]. In general, this type of debridement is ideal for patients with stage
3 or 4 injuries with light-to-moderate exudates.
12 . Which type of debridement uses collagenase, papain, becaplermin, or trypsin to help loosen necrotic tissue?
| A) | | Surgical |
| B) | | Autolytic |
| C) | | Enzymatic |
| D) | | Mechanical |
Enzymatic debridement is a selective method of
debridement in which concentrated enzymes (e.g., collagenase, papain, becaplermin,
trypsin) attack collagen and liquefy necrotic wound debris without damaging viable tissue.
Enzymatic debridement is used either alone or in combination with other techniques to
remove necrotic tissue and promote wound healing [53,54]. For instance,
collagenase and moisture retentive dressings can work in synergy, thereby enhancing
debridement [47].
13 . Which dressing type is appropriate for wounds with heavy exudate?
| A) | | Alginate |
| B) | | Hydrogel |
| C) | | Hydrocolloid |
| D) | | Transparent film |
OVERVIEW OF DIFFERENT DRESSINGS FOR PRESSURE ULCERS
| Dressing Type | Description | Indication | Advantages | Disadvantages |
|---|
| Transparent film | Adhesive, semipermeable, polyurethane membrane that allows water to vaporize
and cross the barrier | Management of stage 1 and 2 pressure ulcers with light or no exudates; may be
used with hydrogel or hydrocolloid dressings for full-thickness wounds |
| Retains moisture | | Impermeable to bacteria and other contaminants | | Facilitates autolytic debridement | | Allows for wound observation | | Does not require secondary dressing (e.g., tape, wrap) |
|
| Not recommended for infected wounds or wounds with drainage | | Requires border of intact skin for adhesion | | May dislodge in high-friction areas | | Not recommended on fragile skin |
|
| Hydrogel | Water- or glycerin-based amorphous gels, impregnated gauze, or sheet dressings;
amorphous and impregnated gauze fill the dead tissue space and can be used for deep
wounds | Management of stage 2, 3, and 4 ulcers; deep wounds; and wounds with necrosis
or slough |
| Soothing, reduces pain | | Rehydrates wound bed | | Facilitates autolytic debridement | | Fills dead tissue space | | Easy to apply and remove | | Can be used in infected wounds or to pack deep wounds |
|
| Not recommended for wounds with heavy exudate | | Dehydrates easily if not covered | | Difficult to secure (amorphous and impregnated gauze need secondary
dressing) | | May cause maceration |
|
| Alginate | Derived from brown seaweed; composed of soft, nonwoven fibers shaped into ropes
or pads | May be used as primary dressing for stages 3 and 4 ulcers, wounds with
moderate-to-heavy exudate or tunneling, and infected or noninfected wounds |
| Absorbs up to 20 times its weight | | Forms a gel within the wound | | Conforms to the shape of the wound | | Facilitates autolytic debridement | | Fills in dead tissue space | | Easy to apply and remove |
|
| Not recommended with light exudate or dry scarring or for superficial
wounds | | May dehydrate the wound bed | | Requires secondary dressing |
|
| Foam | Provides a moist environment and thermal insulation; available as pads, sheets,
and pillow dressings | May be used as primary dressing (to provide absorption and insulation) or as
secondary dressing (for wounds with packing) for stage 2 to 4 ulcers with variable
drainage |
| Nonadherent, although some have adherent borders | | Repels contaminants | | Easy to apply and remove | | Absorbs light-to-heavy exudate | | May be used under compression | | Recommended for fragile skin |
|
| Not effective for wounds with dry eschar | | May require a secondary dressing |
|
| Hydrocolloid | Occlusive or semiocclusive dressings composed of materials such as gelatin and
pectin; available in various forms (e.g., wafers, pastes, powders) | May be used as primary or secondary dressing for stage 2 to 4 ulcers, wounds
with slough and necrosis, or wounds with light to moderate exudates; some may be
used for stage 1 ulcers |
| Impermeable to bacteria and other contaminants | | Facilitates autolytic debridement | | Self-adherent, molds well | | Allows observation, if transparent | | May be used under compression products (compression stockings, wraps, Unna
boot) | | May be applied over alginate dressing to control drainage |
|
| Not recommended for wounds with heavy exudate, sinus tracts, or
infection | | May curl at edges | | May injure fragile skin upon removal | | Contraindicated for wounds with packing |
|
| Moistened gauze | 2×2- or 4×4-inch square of gauze soaked in saline for packing | May be used for stage 3 and 4 ulcers and for deep wounds, especially those with
tunneling or undermining | Accessible |
| Must be remoistened often | | Time-consuming to apply |
|
14 . Which medications should be avoided as much as possible for routine pain management in patients with pressure injuries?
| A) | | Opioids |
| B) | | NSAIDs |
| C) | | Acetaminophen |
| D) | | Both B and C |
For mild-to-moderate pain, nonsteroidal anti-inflammatory
drugs (NSAIDs) or acetaminophen may be used. Opioids should be avoided as much as possible,
as the sedative effects boost immobility; however, they may be necessary during dressing
changes and/or debridement.
15 . Which of the following is a thermal effect of therapeutic ultrasound that may be beneficial for patients with pressure injuries?
| A) | | Increased collagen elasticity |
| B) | | Speeds up inflammatory process |
| C) | | Increased release of growth factors |
| D) | | Increased muscle and joint stiffness |
THERMAL AND NON-THERMAL EFFECTS OF THERAPEUTIC ULTRASOUND
| Thermal | Non-Thermal |
|---|
| Increased collagen elasticity | | Decreased muscle and joint stiffness | | Decreased pain | | Decreased muscle spasm | | Increased oxygen transport | | Hyperemia |
|
| Speeds up inflammatory process | | Increases release of growth factors | | Fibroblast and endothelial cell proliferation | | Increased collagen production | | Accelerated angiogenesis | | Better organization of collagen matrix |
|
16 . The Pressure Ulcer Scale for Healing (PUSH) tool assesses what three domains of the pressure ulcer to determine wound progression?
| A) | | Size, odor, and color |
| B) | | Comorbidities, pain, and tissue in wound bed |
| C) | | Size, exudate amount, and tissue in wound bed |
| D) | | Wound location, signs of infection, and exudates |
Reverse staging of pressure injuries is not an acceptable
approach to gauging the level of wound healing. Healed pressure injuries do not replace lost
muscle, subcutaneous fat, or dermis [29].
Tools that appropriately measure degrees of healing include the Bates-Jensen Wound
Assessment Tool and the Pressure Ulcer Scale for Healing (PUSH) tool [15,86]. The Bates-Jensen Wound Assessment Tool has thirteen variables that
provide a composite picture of the status of the wound [15]. The PUSH tool uses scores in three domains (i.e., size, exudate amount,
and tissue type) to indicate improvement or deterioration of the injury (Table
6) [87].
When using this tool, surface area is calculated by multiplying the greatest length (head to
toe) by the greatest width (side to side) in centimeters. After removal of the dressing and
before applying any topical agent to the injury, the amount of exudate is estimated as none,
light, moderate, or heavy. Finally, the type(s) of tissue present in the wound bed is
evaluated (i.e., necrotic, slough, granulation, epithelial, or closed). A score of 0 on the
PUSH tool indicates the wound has healed, whereas the highest score of 17 indicates wound
degeneration [15]. Results of the assessment
should be recorded; a decrease in score over time indicates improvement.
17 . Circumferential erythema and/or induration up to 2 cm from the wound are indicative of
| A) | | cellulitis. |
| B) | | septic shock. |
| C) | | Marjolin ulcer. |
| D) | | necrotizing fasciitis. |
The condition of the surrounding skin surface up to 4 cm
from the edge of the wound circumferentially must also be assessed and documented. Its
characteristics should be noted, particularly color and integrity [10]. Maceration from excessive drainage may
indicate that the dressing used is not appropriate and a different product is needed.
Circumferential erythema and/or induration up to 2 cm from the wound are indicative of
cellulitis.
18 . The first sign of Marjolin ulcer is
| A) | | flu-like illness. |
| B) | | abrupt resolution of the wound. |
| C) | | change in the character of the wound. |
| D) | | a decrease in drainage and an increase in odor. |
The first sign of Marjolin ulcer is a change in the
character of the wound. Drainage increases, and the odor of the drainage becomes putrid. In
some cases, there is frank bleeding. Diagnosis is made after histologic examination of a
specimen removed from the injury, usually at the time of a flap closure. Confirmation of the
diagnosis requires a preoperative tissue biopsy; wedge biopsy is the method of
choice.
19 . To be considered unavoidable, a pressure injury must develop
| A) | | after a delay in detection or diagnosis. |
| B) | | while a patient is being cared for at home. |
| C) | | in spite of timely, appropriate interventions. |
| D) | | in a patient being cared for in an acute care facility. |
MEDICO-LEGAL ASPECTS OF INJURY CARE
As noted, despite best patient care and treatment, not all
pressure injuries are avoidable [139]. In
long-term care, the NPIAP defines an unavoidable injury as one that occurs even though "the
facility had evaluated the individual's clinical condition and pressure injury risk factors;
defined and implemented interventions that are consistent with individual needs, goals, and
recognized standards of practice; monitored and evaluated the impact of the interventions;
and revised the approaches as appropriate" [140]. In addition to establishing the definition for long-term care
facilities, in 2014 the NPIAP sought to establish consensus (80% agreement among conference
delegates) on whether pressure injury development may be unavoidable in some individuals and
whether there is a difference between pressure injuries and end-of-life skin changes.
Unanimous consensus was reached for the following statements [141]:
Most (but not all) pressure injuries are avoidable.
Comorbid conditions can contribute to unavoidable pressure injuries.
Some situations render pressure injury development unavoidable, including:
Hemodynamic instability worsened by physical movement
Poor nutrition/hydration status and/or advanced directive that prohibits
artificial nutrition/hydration
Pressure redistribution surfaces cannot replace turning/repositioning
Skin cannot always survive even when pressure from external body skin is
alleviated
20 . Which of the following factors may lead to a determination of neglect?
| A) | | Poor documentation |
| B) | | Inadequate nutrition |
| C) | | Inadequate prevention |
| D) | | All of the above |
MEDICO-LEGAL ASPECTS OF INJURY CARE
FACTORS LEADING TO A DETERMINATION OF NEGLECT
| Inadequate prevention | | Poor documentation | | Inadequate nutrition | | Inadequate medical care | | No family notification | | Poor care planning | | Wound severity and outcome |
|
