Question

1. Describe the differences between the six classifications of pressure injuries. 2. How do you explain the fact that eschar must be removed before an injury can be accurately staged? 3. You are assigned to care for a 74-year-old male patient with a stage 3 pressure injury on his coccyx that is infected with methicillin-resistant Staphylococcus aureus (MRSA). You will need to irrigate the injury and apply a wet-to-damp dressing. You will also need to take the proper transmission-based precautions for MRSA in a wound. a. What makes a pressure injury classified as stage 3? b. How will you assess it for increasing or decreasing infection? c. How will you document the size and appearance of the wound? d. How will you apply the correct dressing for this wound?

Answer 1

1. Describe the differences between the six classifications of pressure injuries.

Answers :

• · Stage 1 pressure injury: non-blanchable erythema
• · Stage 2 pressure injury: partial-thickness skin loss
• · Stage 3 pressure injury: full-thickness skin loss
• · Stage 4 pressure injury: full-thickness tissue loss
• · Unstageable pressure injury: depth unknown
• · Suspected deep-tissue injury: depth unknown

2. How do you explain the fact that eschar must be removed before an injury can be accurately staged?

Ans :

• Eschar often signals a more advanced wound, typically a stage 3 or 4
• Current standard of care guidelines recommend that stable intact (dry, adherent, intact without erythema or fluctuance) eschar on the heels should not be removed. Blood flow in the tissue under the eschar is poor and the wound is susceptible to infection.
• While an eschar wound can't be staged in the same way most wounds can.

3. You are assigned to care for a 74-year-old male patient with a stage 3 pressure injury on his coccyx that  is infected with methicillin-resistant Staphylococcus aureus (MRSA). You will need to irrigate the injury and apply a wet-to-damp dressing. You will also need to take the proper transmission-based precautions for MRSA in a wound.

a. What makes a pressure injury classified as stage 3?

Ans :

During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.

b. How will you assess it for increasing or decreasing infection?

Ans : Infection assessed by the following factors

• Size of wound.
• Edge of wound.
• Site of wound.
• Wound bed

  Ø Healthy granulation tissue is pink in colour and is an indicator of healing. Unhealthy granulation is dark red in colour, often bleeds on contact, and may indicate the presence of wound infection.

• Necrotic tissue, slough, and eschar.
• Depth
• Surrounding skin.
• Infection.