Assessment and Management of Pressure Injuries

According to the Agency for Healthcare Research and Quality (AHRQ, 2014), annually in the United States, 2.5 million patients in acute care settings are affected by pressure-related injuries to the skin. One single pressure injury may take months to heal and can substantially impact a patient's quality of life along with their ability to financially manage costs associated with care. Treatment of the injury places an additional strain on expenditures incurred by the hospital or facility to address this unplanned patient event. A vital component of the Certified Wound Care Nurse (CWCN) or Certified Wound Care Nurse-Advanced Practice (CWCN-AP) role is to have a thorough understanding of as well as provide increased knowledge to health care professionals in addressing mechanisms to decrease pressure injury formation early in a patient's plan of care. These wound care specialists are instrumental in serving as experts, role models, and mentors pertinent to increasing other clinicians' understanding and competency levels in skin assessment, concomitant interventions, and pressure injury prevention. More specifically, improving pressure injury competency by providing enhanced and continued education on pressure injury prevention in all continuums of a nurse's professional development is a key responsibility in the job description of both CWCN and CWCN-AP nursing professionals. The Wound Ostomy Continence Nursing Certification Board (WOCNCB) provides certification examinations to recognize and validate the unique knowledge and skills of wound care nursing specialists. When planning for these examinations, it is important to understand that it is expected that the test taker is well-prepared in the principles of pressure injury prevention and can apply them to various patient care scenarios. The accompanying review questions have a focus on pressure injury-related wounds. Without looking at the answer or the rationale, attempt to answer the questions. The rationale will facilitate your review of content as well as help you refine your test-taking skills. To learn more about how to prepare for certification as a CWCN or CWCN-AP, please visit the exam preparatory resources available on the WOCNCB website, www.wocncb.org. CWCN-FOCUSED REVIEW QUESTIONS 1. The CWCN provides education to an adult patient with a stage 3 pressure injury, who also adheres to a vegan diet. Which foods are recommended to be high in protein, supporting wound healing for this patient? Chickpeas, lentils, tofu Cantaloupe, fortified cereals, fish Quinoa, poultry, kiwi Cheese, oranges, broccoli Content outline: 010308 Cognitive level: Analysis CORRECT ANSWER: A. Chickpeas, lentils, tofu Rationale: There are an increasing number of people in the United States and worldwide who are consuming a vegan diet for a variety of reasons, including health, environmentalism, and animal advocacy. The CWCN should be aware of this trend and incorporate higher protein options into patient education when appropriate. Chickpeas, lentils, and tofu are protein-rich food sources that are acceptable in a vegan diet. A person following a vegan diet consumes only plant foods (vegetables, fruits, grains, beans, and nuts) and does not eat any animal products, such as meat, fish, dairy, eggs, and honey. A diet with adequate protein is required to influence a positive nitrogen balance, which is recommended for wound healing. In the first group of foods, a cooked serving of 1-cup chickpeas provides 14.5 g of protein, 1-cup lentils provides 17.9 g, and ½-cup tofu provides 19.9 g. The second group of foods is not 100% suitable for a vegan. Cantaloupe is a whole food plant-based option, which is vegan compliant; 100-g serving provides 1.3-g protein; however, it is better suited as a source of vitamin C, at 58.7 mg, which meets 98% of daily value requirements. Fortified cereals are typically highly processed and careful label reading is important to avoid ingredients which are animal-based, such as powdered milk, butter, milk fat, and honey. A fish is an animal and would not be congruent with a vegan diet. The third group of foods is not 100% suitable for a vegan diet. Whole grains such as quinoa would be an excellent food recommendation for a vegan diet, containing 16 g of protein per 1 cup of cooked. Poultry is an animal and would not be congruent with a vegan diet. Kiwi is vegan compliant, with only 1 g of protein per one large kiwi fruit; however, it packs an 84.4-mg punch of vitamin C. The fourth group of foods is not 100% suitable for a vegan diet. Cheese is an animal by-product and is not congruent with a vegan diet. Citrus such as a navel orange provides 0.9-g protein and 100% vitamin C for recommended daily allowance. Broccoli is a vegan-compliant food, which provides 4.6-g protein and also contains zinc, vitamins A and C. 2. The WTA-C is conducting a routine follow-up patient visit to observe and measure wound dimensions of a stage 2 pressure injury located on the patient's sacrum. Which observation would indicate a possible deterioration in the wound and necessitate a discussion with the supervising CWCN to modify plan of care? Circumferential epithelialization No change in wound dimensions Dark purple/maroon wound base Moist wound base Content outline: task 2(d,q); task 3(b,a,c) Cognitive level: Application CORRECT ANSWER: C. Dark purple/maroon wound base Rationale: It is necessary for the WTA-C to have a good understanding of wound assessment parameters and how to observe wounds for signs of deterioration or failure in healing progress. Collecting objective wound data is necessary in guiding the plan of care. The presence of a dark purple/maroon wound base in a pressure injury indicates a change in wound condition. This change constitutes a deterioration in the previously staged 2 pressure injury. The WTA-C would provide this observation data to their supervising CWOCN, who will need to reassess the patient's wound and overall condition, making modifications and/or recommendations in pressure injury prevention and treatment interventions. The first option is incorrect as circumferential epithelialization would be evidence of progress toward wound healing and not indicative of a deterioration in the wound. No change in wound dimensions is not automatically determined as a negative finding, making the second option not an appropriate answer. It would be beneficial to review the time frame observed between assessments. Knowing this information would guide the WTA-C in understanding if any changes in wound dimension had been expected. The fourth option is incorrect; a moist wound base is an appropriate finding for a stage 2 pressure injury, and indicates effective wound management is being applied. CWCN-AP-FOCUSED REVIEW QUESTIONS 3. As a CWCN-AP, you are consulted to see a patient in the outpatient clinic with an unstageable pressure injury to their right heel. Th e wound on the right heel is completely covered by soft, brown eschar. You notice that the periwound area is indurated, warm-to-touch, and tender to the patient. In addition, there is a moderate amount of malodorous purulent drainage on the previous dressing and the base of the eschar is pliable on palpation. Review of the medical records shows the patient has just had an arterial Doppler vascular study and adequate perfusion to the extremity is confirmed. Given these assessment findings, what should be your first intervention? Order a hydrocolloid dressing to protect the wound from further friction and shear. Order a heel-relief device to off -load the extremity when patient is in bed. Perform conservative sharp debridement to remove the nonviable eschar from the base of the wound. Order a C-reactive protein (CRP) lab test. Content outline: 4C1j Cognitive type: Application CORRECT ANSWER: C. Perform conservative sharp debridement to remove the nonviable eschar from the base of the wound. Rationale: A careful review of the question stem reveals that the patient has an unstageable pressure injury to the right heel, which demonstrates unstable eschar. Stable eschar is brown or black in color and usually has dry, hard, leathery characteristics, which serve as the body's natural (biological) cover and there are no signs of infection present. Unstable eschar is brown or black in color, and commonly accompanied by inflammation with boggy (spongy) and slimy characteristics. Bacteria are present on viable tissue underneath the unstable eschar. The first selection of the intervention using the hydrocolloid dressing is not the correct answer. Hydrocolloid dressings are inappropriate for infected wounds and this pressure injury is currently demonstrating signs/symptoms of active infection. Next, obtaining a heel-relief device to off-load the extremity when the patient is in bed is necessary and mandated but is not the priority, given the selection of “next steps” in the answering queue of this question. However, a heel suspension device will need to be ordered to relieve further pressure, shear, and damage to the area of the heel in order to promote effective wound healing. In the meantime, instructing the patient/caregiver to simply place pillows under the patient's leg in order to “float” the heel off the bed surface is an effective educational emphasis and strategy. In order to distribute the weight of the leg appropriately, teach the patient/caregiver to offload the foot without placing undue pressure on the Achilles tendon and popliteal vein. Performing conservative sharp debridement to remove the nonviable, boggy eschar from the base of the wound is the correct answer since it is one of the priorities of treatment. If there is a high indication of infection, unstable heel eschars should be appropriately debrided since nonviable and necrotic tissue can be a breeding ground for pathogenic agents. Additionally, debriding the wound to reveal a viable base will enable a clear, comprehensive assessment to guide appropriate treatment of the heel pressure injury. Although obtaining lab tests such as the CRP, along with others such as erythrocyte sedimentation rate (ESR), may serve to provide additional information about the extent of inflammation (eg, infections such as osteomyelitis) and subsequent treatment effectiveness, it is likely to not be the first intervention to undertake immediately in the selection of given answers. 4. Th e CWCN-AP is asked to give a formal presentation that describes the various wound dressing categories for pressure injuries. At the end of the lecture, the discussion was opened to receive questions from the audience of nursing professionals. One of the participants asks the CWCN-AP to recommend an appropriate dressing category for a noninfected and clean stage 2 pressure injury. Of the dressing selections, what is the most appropriate answer? Silver-impregnated Collagen Alginate Hydrogel Content outline: 4C2d Cognitive type: Analysis CORRECT ANSWER: D. Hydrogel Rationale: As stated in the stem, the stage 2 pressure injury that the nurse is asking the presenter to target for dressing selection guidance is noninfected. Therefore, a silver-impregnated dressing is not the correct answer. Dressings that contain silver are most often utilized to address antimicrobial indications. The second collagen selection would not be an appropriate answer; these dressings are considered advanced wound care products and most commonly applied to “stalled” wounds. They are often utilized for difficult-to-heal wounds since they are frequently costlier to purchase, although price can vary. Since stage 2 pressure injuries are shallow, partial-thickness wounds with minimal drainage, the use of collagen is not the best choice in the selection options. Alginate dressings are utilized for heavily draining wounds, which would be an unlikely assessment finding in a stage 2 pressure injury, making this an inappropriate answer. Therefore, the best answer is the hydrogel dressing, which is an appropriate option for clean, noninfected stage 2 pressure injuries and can be used in a wide variety of wounds. Made with over 90% water, hydrogel dressings provide adequate moisture to promote wound healing, are relatively inexpensive, and can add soothing comfort along with pain relief for the patient with this type of wound.

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