Pressure Injury (pressure ulcer)

Med Surg: Integumentary - Skin

Pathophysiology MOST tested

Damage to the skin and/or the underlying tissue over a bony prominence,
common with bed-ridden clients who are not turned adequately or from a
medical device (oxygen therapy)
Most common areas:
• lower back & buttocks (sacrum & coccyx)
• heels & ankles
• hip bones
• shoulder area & elbows

6 Stages of Pressure Injuries

Stage 1 = 1 layer of damage (epidermis)

Red skin that is NON blanchable & NOT broken
Stage 2

Epidermis
Stage 2 = 2 layers of damage
Dermis
Open wound: affecting both the epidermis & dermis.
Wound bed is red / pink & shiny or dry.
Stage 3
Epidermis Stage 3 = 3 layers of damage (epidermis, dermis, & subcutaneous)
Dermis
Full thickness skin loss into the subcutaneous fat; wound may
Subcutaneous
tissue
tunnel under the edges of the wound bed
Stage 4

Stage 4 = 4 layers of damage

Epidermis

Dermis

Subcutaneous tissue Extends all the way down into muscle, bone, or tendon.
Muscle & bone

Unstageable NCLEX TIP

Eschar (black / brown)
Slough (yellow stringy)
Eschar (black / brown) dead necrotic tissue
MEMORY TRICK: EsCHARCOAL
Slough (yellow stringy)
MEMORY TRICK: Slough = skin of a chicken
*These wounds need to be debrided before a stage is made

Deep tissue

The fatty tissue is injured below the skin (dark purple, &
sometimes open wound)

Causes & Risks Treatments

Assess skin & document Kaplan Question

Bed ridden (first 24 hours) The nurse is teaching a client
Turn every 1 - 2 hours
Incontinence 3.5 - 5.0
with a stage 1 pressure injury
on the greater trochanter of
Nutrition: Protein & Fluids
Poor nutrition (2 - 3 L / day) the left hip. What should be
included in teaching?
Urine output 30 mL/hr or Less
Diabetic neuropathy Change positions
= Kidney Distress every hour
Liver cirrhosis = Low Albumin
ALBUMIN

Albumin (norm: 3.5 - 5.0)

Monitor:
Stage, Size, Color Kaplan Question
Braden Scale Which finding contributes to
delayed wound healing in a
MEMORY TRICK:
client with a stage 3 pressure
BS - Braden Scale injury:
monitors for risk factors Urine output 25 mL/hr
BS - Broken Skin