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- 1. Multiple Choice
Stage I Pressure Injury
Non blanching when pressed. (Redness with pressure persists after 30 mins In dark pigmented skin the color may be red or blue)
Epidermis, irregular or regular area of erythema, firm and boggy
- 2. Multiple Choice
Stage II Pressure Injury
Partial thickness skin loss, through dermis.Early fibrosis & pigment changes occur
May look like a blister, abrasion or shallow ulcer with more distinct edgesI
- 3. Multiple Choice
Stage III Pressure Injury
Full thickness skin loss, extending through subcutaneous fat.Base of wound infected, often with some areas of slough foul smelling tissue.
Presents like a crater and may have undermining and tunneling of adjacent tissue.
- 4. Multiple Choice
Stage IV Pressure Injury
Undermining is even more common and there may be sinus tracts.
Extension of injury through deep fascia, bone is visible at base of wound. Osteomyelitis & septic arthritis can be present.
- 5. Multiple Choice
Unstageable Pressure Injury
Actual depth unknown as need to remove the eschar and /or slough.
Present as a dry or wet eschar or/and slough.Palpate to estimate the depth.
- 6. Multiple Choice
Deep Tissue Pressure Injury
Bottom Up”. Deep purple or maroon “bruised” area, or as a blood blister under intact skin
Recognize through visual or palpation
- 7. Multiple Choice
Pressure Injury associated Medical devices
- 8. Multiple Choice
Choose Stage I Pressure Injury
- 9. Multiple Choice
What is the definition of pressure injury?
is one of the major causes of skin breakdown in lying, sitting and occurs during transfers, reaching, weight shifts or repositioning.
Localized damage to the skin and underlying soft tissue, usually over a bony prominence or related to a medical or other device’ – National Pressure Ulcer Advisory Panel (NPUAP) (2016)
Reduce the duration and magnitude of pressure over vulnerable areas of the body
the force of rubbing two surfaces against one another.
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