ATI CASE STUDIES ON PRESSURE ULCERS, TRAUMA, AND DIABETES MANAGEMENT 2025

ATI CASE STUDIES ON PRESSURE ULCERS, TRAUMA,
AND DIABETES MANAGEMENT 2025



PRESSURE ULCER ASSESSMENT AND STAGING
Key Terms/Concepts
 Pressure Ulcer: A localized injury to the skin and/or underlying tissue, usually
over a bony prominence, as a result of pressure, or pressure in combination with
shear and/or friction.
 Braden Scale: A tool used to assess a patient's risk of developing pressure
ulcers based on sensory perception, moisture, activity, mobility, nutrition, and
friction/shear.
 Diabetic Ketoacidosis (DKA): A serious complication of diabetes characterized
by high blood sugar, ketones in the urine, and acidosis, often requiring
emergency treatment.
Key Assessments/Findings
 Pressure Ulcer Staging:
Stage Description
I Non-blanchable erythema of intact skin.
Partial thickness loss of dermis presenting as a shallow open ulcer with a
II
red pink wound bed.
III Full thickness tissue loss; subcutaneous fat may be visible.
IV Full thickness tissue loss with exposed bone, tendon, or muscle.
Full thickness tissue loss where the base of the ulcer is covered by slough or
Unstageable
eschar.
Interventions
 Wound Care: Clean pressure ulcers with saline and use appropriate dressings to
promote healing.
 Nutritional Support: Ensure adequate nutrition to support wound healing,
including protein and caloric intake.
 Patient Education: Teach patients and caregivers about pressure ulcer
prevention, including repositioning and skin care.
Key Complications
 Infection: Pressure ulcers can become infected, leading to systemic
complications.
 Sepsis: A severe infection that spreads throughout the body, potentially life-
threatening.
 Amputation: In severe cases of peripheral artery disease or diabetic ulcers,
amputation may be necessary.
Key Medications

,  Insulin: Used to manage blood glucose levels in diabetic patients, especially in
cases of DKA.
 Potassium Replacement: Essential in managing electrolyte imbalances during
treatment of DKA or HHS.
Facts to Memorize
 Staging of pressure ulcers:
 Stage I: Intact skin with non-blanchable redness.
 Stage II: Partial thickness loss of dermis, shallow open ulcer.
 Stage III: Full thickness tissue loss, subcutaneous fat may be visible.
 Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle.
 Unstageable: Full thickness tissue loss where the base of the ulcer is
covered by slough or eschar.
 Braden Scale scoring:
 Sensory perception: 1-4
 Moisture: 1-4
 Activity: 1-4
 Mobility: 1-4
 Nutrition: 1-4
 Friction and shear: 1-3
 Normal saline for wound cleansing: 4-15 psi pressure.
Reference Information
 Risk factors for pressure ulcers:
 Older age, immobility, incontinence, contractures, neurologic disorders,
pain.
 Equipment for wound cleansing:
 30-mL syringe with a 19-gauge needle for adequate irrigation pressure.
Concept Comparisons
Concept Description
Stage I Pressure
Intact skin with non-blanchable redness.
Ulcer
Stage II Pressure
Partial thickness loss of dermis, shallow open ulcer.
Ulcer
Stage III Pressure
Full thickness tissue loss, subcutaneous fat may be visible.
Ulcer
Stage IV Pressure
Full thickness tissue loss with exposed bone, tendon, or muscle.
Ulcer
Unstageable Full thickness tissue loss where the base of the ulcer is covered by slough
Pressure Ulcer or eschar.
A tool to assess risk for pressure ulcers based on sensory perception,
Braden Scale
moisture, activity, mobility, nutrition, and friction/shear.




Understanding Pressure Ulcer Staging

,  Pressure ulcers are classified into stages based on the depth
of tissue damage. The stages range from I to IV, with Stage
I being the least severe and Stage IV being the most severe.
 Stage II ulcers present as shallow open ulcers with a red-
pink wound bed, indicating partial thickness loss of dermis
without slough.
 Stage III ulcers involve full thickness loss of skin,
potentially exposing subcutaneous fat, while Stage IV
ulcers expose bone, tendon, or muscle.
 Unstageable ulcers occur when eschar or slough obscures
the wound bed, making it impossible to assess the depth
accurately.
Assessment Findings and Risk Factors
 M.J.'s right trochanter ulcer is classified as Stage II due to
its characteristics, while the left trochanter ulcer is
unstageable due to the presence of eschar.
 The assessment of the scapulae indicates a Stage I pressure
ulcer, particularly in patients with darker skin tones where
color changes may be subtle.
 Risk factors for pressure ulcers include older age,
immobility, incontinence, and neurologic disorders, while
factors like anemia and diabetes were noted as not
applicable for M.J.

,  The Braden Scale is utilized to assess risk, with a total
score of 10 indicating high risk for pressure ulcer
development.
Cleaning and Managing Pressure Ulcers
 Proper cleansing of pressure ulcers is crucial to prevent
further damage; a 30-mL syringe with a 19-gauge needle is
recommended for effective irrigation without trauma.
 The presence of necrotic tissue and eschar necessitates
removal to promote healing, which can be achieved
through various debridement methods.
 Antiseptic solutions should be avoided as they can be
cytotoxic to healing tissues, and dry dressings are
inappropriate for granulating wounds.
Roles in Pressure Ulcer Management
Interdisciplinary Team Roles
 The dietitian evaluates nutritional status and recommends
supplements to support healing.
 Home health aides assist with personal care and light
housekeeping, ensuring the patient’s hygiene and comfort.
 Social workers help manage financial resources and
provide referrals to support services.
 Physicians monitor the medical condition and develop
treatment strategies for pressure ulcers.