What type of patient do you think would be MOST at risk for developing a PI?

A 55-year-old with a knee injury who can reposition themselves in bed

A 68-year-old with a hip fracture who is confused and incontinent of urine

A 75-year-old with a minor skin abrasion and broken ankle who uses a walker

A 45-year-old with a mild fever and nausea who is eating little

A 68-year-old with a hip fracture who is confused and incontinent of urine

Slough:

Thick, stringy yellow or white tissue, indicating the presence of dead tissue

Eschar:

Black or brown necrotic tissue that is hard or leathery

Epithelial tissue:

New skin growing over a wound bed

Deeper structures:

In severe cases, the wound bed may expose deeper structures like bones, ligaments, or tendons.

Tunneling:

Narrow channels extending from the wound into deeper tissue layers.

Undermining:

Areas where the tissue under the wound edges erodes, creating a pocket.

Abscess:

Localized collections of pus indicating infection.

Bone Palpation:

Exposed bone indicates a more advanced stage.

Fistulas:

Abnormal connections between the wound and other body parts or organs.

Non-blanchable erythema:

Redness that does not turn white when pressed, indicating a Stage 1 PI.

Redness that does not turn white when pressed, indicating a Stage __ PI.

1 PI

Periwound Area

Deepening of natural color:

Particularly noticeable in patients w/darker skin tones, this can indicate underlying damage.

Periwound Area

Signs of pressure and shear damage:

Look for evidence of undermining or tunneling.

Documentation

Describing the wound

Detailed notes on the wound's - size, depth, appearance, and changes over time

Documentation

Photographic records

Using photographs to visualy document the wound's condition and progression.

Documentation

Regular Reassessment

Regular reassessment to adjust care plans based on the wound's healing trajectory and any new developments.

What stage is this PI

The appearance of a full thickness wound with some yellow tissue, granulation, epibole and maceration indicates it is a Stage 3 PI.

It’s too deep to be a Stage 2 PI, there are no deeper structures exposed to make it a Stage 4 PI, and since we can see the wound base, it is stageable.

What stage is this pressure injury?

The appearance of a partial thickness wound with pink tissue indicates a Stage 2 PI. If there were full tissue loss it would be a Stage 3 PI. There is a break in the skin, so it is not a Stage 1, and no deeper structures are exposed to make it a Stage 4 PI.

You are caring for a patient with a PI who previously had full-thickness tissue damage involving subcutaneous tissue. The PI is showing signs of healing. What stage PI would this be considered?

Even though the PI shows signs of healing, it remains classified as a Stage 3 PI. The original severity of the injury is maintained in documentation to reflect the initial extent of tissue damage.

Stage 1 PIs involve intact skin with non-blanchable erythema. Stage 2 PIs involve partial-thickness skin loss.

Stage 4 PIs involve full-thickness skin loss extending through the subcutaneous tissue with exposed underlying structures, such as muscle or bone.

What stage is the PI?

Unstageable pressure injuries involve full-thickness tissue loss with the wound base obscured by slough or eschar, making it impossible to determine the true depth until these are removed (NPIAP, 2023).

SORE^®

The SORE^® mnemonic may be used to identify devices contributing to device-related PIs (Baranoski & Ayello, 2020). It stands for:

Stock Items

Objects

Required medical devices

Electronic Equipment

What does KTU stand for?

Kennedy Terminal Ulcer

* Unique ulcers that occur at the end of live.

* Typically form within a single day.

KTU Characteristeics include:

• Location: Typically develops on the sacrum
• Shape: Often presents as a pear-shaped or butterfly-shaped bruise
• Color: Like a bruise, color ranges with shades of red, yellow, purple, or blue in the initial stages and turning black as the tissue dies
• Borders: Borders are often irregular, without uniform size or shape

KTU are a result of

• Reduced blood flow
• Malnutrition
• Too many toxins in the body

____ are considered an unavioidable Pi. There is no way to determine the risk of developing a _______

KTU / KTU

Once an ____ pressure injury is debrided and the wound bed is visible, the correct stage should be assigned based on the depth and severity of the tissue damage. This process accurately reflects the current condition of the wound and is not considered reverse staging.

A Stage 1 DTPI is not appropriate nomenclature, leaving it classified as unstageable does not apply once the base of the wound is visible, and staging is never reversed or downgraded.

unstageable

What stage is this injury?

Unstageable

* The base of the wound is obscured by eschar, making it unstageable. There would be a visible wound base if it were a 2, 3, or 4 PI.

Identify this lesion

Mucosal Membrane Device-Related PI

Device-Related PI

Stage 3 PI

Unstageable PI

Device-Related PI

* The shape of the injury mirrors the shape of the g-tube’s fixation ring, making this a Device-Related PI. It is not on a mucosal membrane, and the other options are incorrect due to depth and visible wound bed.

____ involve full-thickness tissue loss obscured by slough or eschar, preventing accurate staging until debridement reveals the wound depth, at which point appropriate staging can be assigned.

Unstageable PIs

__ __ __ are caused by sustained pressure from medical devices and often mirror the shape of the device. Regular skin checks and preventive measures, such as proper fitting and adjustment of devices, are essential to prevent these injuries.

Device-related pressure injuries

___ are rapidly developing ulcers that occur at the end of life, distinct from typical pressure injuries. They should be managed with a focus on patient comfort rather than aggressive treatment.

KTUs

Braden Moisture Subscale Scores: 4 or 3

Rarely or occasionally moist

Braden Moisture Subscale Scores: 2

Very Moist

Braden Moisture Subscale Scores: 1

Constantly Moist

Braden Mobility Subscale Scores: 4 or 3

No limitation or slightly limited

• Reactive/CLP^b (air, foam, gel, fiber, or viscous fluid, or combinations)
• AMG sheepskin overlay (Prevention only) ^c

Braden Mobility Subscale Scores: 2 or 1

Very limited or completely immobile

*Reactive /CLP

*Active w/AP feature

Braden Mobility Subscale Scores: 2

• Reactive/CLP
• Reactive/CLP with LAL feature

• Reactive/CLP with LAL feature

Braden Mobility Subscale Scores: 1

• Reactive/CLP
• Reactive/CLP with LAL feature

• Reactive/CLP with LAL feature
• Reactive/CLP with AF feature (Treatment only)

Suggested support surface overlay or mattress selections for pressure injury prev. & treatment on Braden Mobility & Moisture Subscores

Note: Persons with multiple Stage 2, or large (of sufficient size to compromise a turning surface) or multiple Stage 3 or Stage 4 pressure injuries on the trunk or pelvis involving more than one available turning surface should be placed on a support surface with a low air loss or an air fluidized feature.

Suggested Support Surface overlay or Mattress selections for PI prevention & treatment based on Braden Mobility & Moisture Subscores TABLE A

In this table, the ________ refers to all types of Support Surfaces in this category with the exception of AMG sheep skin overlays, which are noted separately.

Reactive/CLP