Question

1. Describe to me the different stages of pressure injuries. What are their identifying factors? 2. List 5 intervention for prevention of pressure injuries with a rationale for why you would perform these actions and how they help in prevention. 3. Identify 3 common sites for pressure injuries and tell me why. 4. What are some therapeutic measures that can be taken to help with the healing of pressure injuries? 5. Explain the difference between mechanical, enzymatic, autolytic, and surgical debridement of pressure injuries.

Answer 1

(1) Stage 1
The first stage is the mildest. It discolors the upper layer of the skin, commonly to a reddish color. In this stage, the wound has not yet opened, but the extent of the condition is deeper than just the top of the skin. The affected area may be sore to touch but has no surface breaks or tears. Patient may also experience mild burning or itching.
Stage 2
In the second stage, The patient will likely experience some pain from the ulcer. The sore area of the skin has broken through the top layer and some of the layer below. The break typically creates a shallow, open wound and you may or may not notice any drainage from the site.
Stage 3
Sores that have progressed to the third stage have broken completely through the top two layers of the skin and into the fatty tissue below. An ulcer in this stage may resemble a crater. It may also smell bad.In this stage, it’s important to look for signs of infection including:
foul odor
pus
redness
discolored drainage
Stage 4
Stage 4 ulcers are the most serious. These sores extend below the subcutaneous fat into the deep tissues like muscle, tendons, and ligaments. In more severe cases, they can extend as far down as the cartilage or bone. There is a high risk of infection at this stage.
These sores can be extremely painful. You can expect to see drainage, dead skin tissue, muscles, and sometimes bone. The patient skin may turn black, exhibit common signs of infection, and you may notice a dark, hard substance known as eschar (hardened dead wound tissue) in the sore.

(2) Interventions to prevent pressure injuries
Change the positon of the patient every 2 hourly .
Rationale: helps to improve blood supply to the area and expose that area to air
Massage the pressure sore prone areas with Vaseline or any lubricants to prevent the area from friction
This will help improving blood supply to the area Massage should be done during every 2 hourly position change
Provide wrinklefree bed for the patient .
Wrinkles on bed may cause injury to skin
Mobilize the patient by providing active and passive exercises ie., In bed itself, if possible bed to chair and then to walk according to his condition
Maintain a good level of hygiene.ie, personal hygiene and keep the patient away from moisture as the presence of moisture or sweat causes microorganisms to grow will lead to infection
Maintain a Brandon score chart daily to assess the patient's skin integrity

(3) Common pressure prone areas
Buttocks (due to the risk of contamination and moisture)
Hips (due to the friction)
Ankles and heels

(4) therapeutic measures

Pressure sores should be managed according to its severity.
Antibiotics like Neosporin can be applied locally for the wounds in starting stage
Administer Oxygen locally through a tube and the wound has to be exposed to it
For severe sores wound debridement should be done by the surgeon which will promote healing.
Clindamycin powder taken out from the capsule is applied locally .
Dressing of the wound should be done twice daily. Avoid wetting of the dressing and if wet it should be charged soon.
Insulin can be applied locally to promote healing.