MODULE 1 NDNQI PRESSURE INJURIES
WITH COMPLETE SOLUTIONS
Pressure tInjury t- tcorrect tanswers t-localized tdamage tto tthe tskin tand tunderlying tsoft
ttissue tusually tover ta tbony tprominence tor trelated tto ta tmedical tor tother tdevice. t
The tinjury tcan tpresent tas tintact tskin tor tan topen tulcer tand tmay tbe tpainful. tThe
tinjury toccurs tas ta tresult tof tintense tand/or tprolonged tpressure tor tpressure tin
tcombination twith tshear. tThe ttolerance tof tsoft ttissue tfor tpressure tand tshear tmay
talso tbe taffected tby tmicroclimate, tnutrition, tperfusion, tco-morbidities tand tcondition tof
tthe tsoft ttissue.
Pressure t- tcorrect tanswers t-Pressure tis tthe tforce t(per tunit tarea) texerted
tperpendicular tto tthe tskin tsurface. tPressure tdamages tthe tskin tand tunderlying
ttissues tby t
(1) tdirectly tdeforming tand tdamaging ttissue; t
(2) tcompressing tsmall tblood tvessels thindering tblood tflow tand tnutrient tsupply tand t
(3) tthrough tischemia-reperfusion tinjury. tWhen tpressure tis tredistributed tover ta
tgreater tsurface tarea, tthe tpressure tis tless tintense tin tany tone tarea.
, Shear tstress t- tcorrect tanswers t-Shear tstress tis tthe tforce t(per tunit tarea) texerted
tparallel tto tthe ttissue.
Shear tstrain t- tcorrect tanswers t-Shear tstrain tis tthe tactual tdistortion tor tdeformation tof
ttissue tas ta tresult tof tshear tstress. tSome tshear tstrain toccurs tat trest. tShear tstrain tis
tintensified tin tcertain tclinical tsituations t(e.g., traising tthe thead tof tthe tbed t> t30
tdegrees; tdragging trather tthan tlifting twhile trepositioning). tOne tlayer tof ttissue tslides
tover tanother tdeforming tadipose tand tmuscle ttissue tand tdisrupting tblood tflow.
Stage t1 tPressure tInjury t- tcorrect tanswers t-Intact tskin twith ta tlocalized tarea tof tnon-
blanchable terythema, twhich tmay tappear tdifferently tin tdarkly tpigmented tskin.
tPresence tof tblanchable terythema tor tchanges tin tsensation, ttemperature, tor tfirmness
tmay tprecede tvisual tchanges. tColor tchanges tdo tnot tinclude tpurple tor tmaroon
tdiscoloration; tthese tmay tindicate tdeep ttissue tpressure tinjury.
Slough t- tcorrect tanswers t-Whitish tdead ttissue
Eschar t- tcorrect tanswers t-Dead ttissue tlike ta tscab tthat tsheds tor tfalls toff tfrom
thealthy tskin. tIt's tcaused tby tburns tand tpressure twounds
Eschar tis ttypically ttan, tbrown, tor tblack, tand tmay tbe tcrusty
Blanch tTest t- tcorrect tanswers t-Blanch tTest: tApply tlight tpressure. tSkin tshould
tblanch tor tlighten. tRelease. tSkin tshould treturn tto tnormal tcolor tdue tto tnormal
treactive thyperemia.
Blanchable: tSkin tblanches twith tpressure. tColor treturns timmediately twith trelease.
Non-blanchable: tNo tblanch, tpersistent tredness tin tlightly tpigmented tskin.
Stage t2 tPressure tInjury t- tcorrect tanswers t-Partial tthickness tskin tloss twith texposed
tdermis. t
The twound tbed tis tviable, tpink tor tred, tmoist, tand tmay talso tpresent tas tan tintact tor
truptured tserum-filled tblister.
Adipose t(fat) tis tnot tvisible tand tdeeper ttissues tare tnot tvisible.
Granulation ttissue, tslough tand teschar tare tnot tpresent.
These tinjuries tcommonly tresult tfrom tadverse tmicroclimate tand tshear tin tthe tskin
tover tthe tpelvis tand tshear tin tthe theel.
Stage t3 tPressure tInjury t- tcorrect tanswers t-Full tthickness tloss tof tskin, t
adipose t(fat) tis tvisible tin tthe tulcer tand tgranulation ttissue tand tepibole t(rolled twound
tedges) tare toften tpresent. t
Slough tand/or teschar tmay tbe tvisible. tThe tdepth tof ttissue tdamage tvaries tby
tanatomical tlocation; tareas tof tsignificant tadiposity tcan tdevelop tdeep twounds.
Undermining tand ttunneling tmay toccur. t
WITH COMPLETE SOLUTIONS
Pressure tInjury t- tcorrect tanswers t-localized tdamage tto tthe tskin tand tunderlying tsoft
ttissue tusually tover ta tbony tprominence tor trelated tto ta tmedical tor tother tdevice. t
The tinjury tcan tpresent tas tintact tskin tor tan topen tulcer tand tmay tbe tpainful. tThe
tinjury toccurs tas ta tresult tof tintense tand/or tprolonged tpressure tor tpressure tin
tcombination twith tshear. tThe ttolerance tof tsoft ttissue tfor tpressure tand tshear tmay
talso tbe taffected tby tmicroclimate, tnutrition, tperfusion, tco-morbidities tand tcondition tof
tthe tsoft ttissue.
Pressure t- tcorrect tanswers t-Pressure tis tthe tforce t(per tunit tarea) texerted
tperpendicular tto tthe tskin tsurface. tPressure tdamages tthe tskin tand tunderlying
ttissues tby t
(1) tdirectly tdeforming tand tdamaging ttissue; t
(2) tcompressing tsmall tblood tvessels thindering tblood tflow tand tnutrient tsupply tand t
(3) tthrough tischemia-reperfusion tinjury. tWhen tpressure tis tredistributed tover ta
tgreater tsurface tarea, tthe tpressure tis tless tintense tin tany tone tarea.
, Shear tstress t- tcorrect tanswers t-Shear tstress tis tthe tforce t(per tunit tarea) texerted
tparallel tto tthe ttissue.
Shear tstrain t- tcorrect tanswers t-Shear tstrain tis tthe tactual tdistortion tor tdeformation tof
ttissue tas ta tresult tof tshear tstress. tSome tshear tstrain toccurs tat trest. tShear tstrain tis
tintensified tin tcertain tclinical tsituations t(e.g., traising tthe thead tof tthe tbed t> t30
tdegrees; tdragging trather tthan tlifting twhile trepositioning). tOne tlayer tof ttissue tslides
tover tanother tdeforming tadipose tand tmuscle ttissue tand tdisrupting tblood tflow.
Stage t1 tPressure tInjury t- tcorrect tanswers t-Intact tskin twith ta tlocalized tarea tof tnon-
blanchable terythema, twhich tmay tappear tdifferently tin tdarkly tpigmented tskin.
tPresence tof tblanchable terythema tor tchanges tin tsensation, ttemperature, tor tfirmness
tmay tprecede tvisual tchanges. tColor tchanges tdo tnot tinclude tpurple tor tmaroon
tdiscoloration; tthese tmay tindicate tdeep ttissue tpressure tinjury.
Slough t- tcorrect tanswers t-Whitish tdead ttissue
Eschar t- tcorrect tanswers t-Dead ttissue tlike ta tscab tthat tsheds tor tfalls toff tfrom
thealthy tskin. tIt's tcaused tby tburns tand tpressure twounds
Eschar tis ttypically ttan, tbrown, tor tblack, tand tmay tbe tcrusty
Blanch tTest t- tcorrect tanswers t-Blanch tTest: tApply tlight tpressure. tSkin tshould
tblanch tor tlighten. tRelease. tSkin tshould treturn tto tnormal tcolor tdue tto tnormal
treactive thyperemia.
Blanchable: tSkin tblanches twith tpressure. tColor treturns timmediately twith trelease.
Non-blanchable: tNo tblanch, tpersistent tredness tin tlightly tpigmented tskin.
Stage t2 tPressure tInjury t- tcorrect tanswers t-Partial tthickness tskin tloss twith texposed
tdermis. t
The twound tbed tis tviable, tpink tor tred, tmoist, tand tmay talso tpresent tas tan tintact tor
truptured tserum-filled tblister.
Adipose t(fat) tis tnot tvisible tand tdeeper ttissues tare tnot tvisible.
Granulation ttissue, tslough tand teschar tare tnot tpresent.
These tinjuries tcommonly tresult tfrom tadverse tmicroclimate tand tshear tin tthe tskin
tover tthe tpelvis tand tshear tin tthe theel.
Stage t3 tPressure tInjury t- tcorrect tanswers t-Full tthickness tloss tof tskin, t
adipose t(fat) tis tvisible tin tthe tulcer tand tgranulation ttissue tand tepibole t(rolled twound
tedges) tare toften tpresent. t
Slough tand/or teschar tmay tbe tvisible. tThe tdepth tof ttissue tdamage tvaries tby
tanatomical tlocation; tareas tof tsignificant tadiposity tcan tdevelop tdeep twounds.
Undermining tand ttunneling tmay toccur. t
