Pieper Pressure Ulcer Knowledge Test

Pieper Pressure Ulcer Knowledge Test

2E: Assessing Screening for Pressure Ulcer Risk

Background: The purpose of this tool is to determine if your facility has a process to screen patients for pressure ulcer risk. The tool is one of a series of Facility Assessment Checklists developed to identify areas that need improvement.

Reference: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools .

Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization.

Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative.

Assessment of Screening for Pressure Ulcer Risk

Does your facility have a process for screening that addresses all the areas listed below?

	Yes	No	Person Responsible	Comments
1. Do you screen all patients for pressure ulcer risk at the following times: Upon admission Upon readmission When condition changes
2. If the patient is not currently deemed at risk, is there a plan to rescreen at regular intervals?
3. Do you use either the Norton or Braden pressure ulcer risk assessment tool? If Yes, STOP. If No, please continue to #4.
4. If you are not currently using the Norton or Braden risk assessment, does your screening address the following areas: Impaired mobility: Bed Chair Incontinence: Urine Stool Nutritional deficits: Malnutrition Feeding difficulties Diagnosis of: Diabetes Mellitus Peripheral Vascular Disease Contractures Hx of pressure ulcers

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2F: Assessing Pressure Ulcer Care Planning

Background: This tool can be used to determine if your facility has a process for developing and implementing a pressure ulcer care plan for patients who have been found to be at risk or who have a pressure ulcer. The tool is one of a series of Facility Assessment Checklists developed to identify areas that need improvement.

Reference: Quality Partners of Rhode Island. Pressure Ulcers: Facility Assessment Checklists. Available at: https://www.qualitynet.org/dcs/ContentServer?cid=1098482996140&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools .

Instructions: Complete the checklist. For certain questions, you may want to consult with appropriate staff in your organization.

Use: Use the results of this assessment to identify issues that you need to deal with, and formulate goals for your pressure ulcer prevention initiative.

Assessment of Pressure Ulcer Care Plan

Does the care plan for pressure ulcers address all the areas below (as they apply)?

	Yes	No	Person Responsible	Comments
Impaired Mobility Assist with turning, rising, position Encourage ambulation Limit static sitting to 2 hours at any time
Pressure Relief Support surfaces: Bed Support surfaces: Chair Pressure-relieving devices Repositioning Bottoming out in bed and chair*
Nutritional Improvement Supplements Feeding assistance Adequate fluid intake Dietitian consult as needed
Urinary Incontinence Toileting plan Wet checks Treat causes Assist with hygiene Use of skin barriers and protectants
Fecal Incontinence Toileting plan Soiled checks
Skin Condition Check Intactness Color Sensation Temperature
Treatment Physician-prescribed regimen Appropriateness to wound staging Treatment reassessment timeframe
Pain Screen for pain related to ulcer Choose appropriate pain med Provide regular pain med administration Reassess effectiveness of med Assess/treat side effects Change or cease pain med as needed

* To determine if a patient has bottomed out, the caregiver should place his or her outstretched hand (palm up) under the mattress overlay below the existing pressure ulcer or that part of the body at risk for pressure formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out. 

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2G: Pieper Pressure Ulcer Knowledge Test

Background: This tool can be used to assess staff knowledge on pressure ulcer prevention. The 47-item test was developed by Pieper and Mott in 1995 to examine the knowledge of nurses on pressure ulcer prevention, staging, and wound description. Questions 1, 3, 15, 29, 33, and 40 have been modified from the original to make it more specific to hospital care.

Reference: Pieper B, Mott M. Nurses’ knowledge of pressure ulcer prevention, staging, and description. Adv Wound Care 1995;8:34-48.

Instructions:

1. Administer the test to nursing and other clinical staff members.
2. It is generally recommended that responses be anonymous, but some staff might appreciate the opportunity to receive individual feedback. Find out what people on your unit want to do.
3. Use the answer key to evaluate the responses. Note that some questions may need to be modified for your hospital.

Use: Mean scores on this test are usually analyzed. Analyze the test results. If you find gaps of knowledge, work with your education department to develop and tailor educational programs that address these items.

Pieper Pressure Ulcer Knowledge Test

For each question, mark the box for True, False, or Don’t Know.

Question	True	False	Don’t Know
1. Slough is yellow or cream-colored necrotic /devitalized tissue on a wound bed.
2. A pressure injury/ulcer is a sterile wound.
3. Foam dressings increase the pain in the wound.
4. Hot water and soap may dry the skin and increase the risk for pressure injury/ulcers.
5. Chair-bound persons should be fitted for a chair cushion.
6. A Stage 3 pressure injury/ulcer is a partial thickness skin loss involving the epidermis and/or dermis.
7. Hydrogel dressings should not be used on pressure injury/ulcers with granulation tissue.
8. A person confined to bed should be repositioned based on the individual’s risk factors and the support surface’s characteristics.
9. A pressure injury/ulcer scar will break down faster than unwounded skin.
10. Pressure injury/ulcers progress in a linear fashion from Stage 1 to 2 to 3 to 4.
11. Eschar is healthy tissue.
12. Skin that doesn’t blanch when pressed is a Stage 1 pressure injury/ulcer.
13. The goal of palliative care is wound healing.
14. A Stage 2 pressure injury/ulcer is a full thickness skin loss.
15. Dragging the patient up in bed increases friction.
16. Small position changes may need to be used for patients who cannot tolerate major shifts in body positioning.
17. Honey dressings can sting when initially placed in a wound.
18. An incontinent patient should have a toileting care plan.
19. A pressure redistribution surface manages tissue load and the climate against the skin.
20. A Stage 2 pressure injury/ulcer may have slough in its base.
21. If necrotic tissue is present and if bone can be seen or palpated, the ulcer is a Stage 4.
22. When possible, high-protein oral nutritional supplements should be used in addition to usual diet for patients at high risk for pressure injury/ulcers.
23. The home care setting has unique considerations for support surface selection.
24. When necrotic tissue is removed, an unstageable pressure injury/ulcer will be classified as a Stage 2 injury/ulcer.
25. Donut devices/ring cushions help to prevent pressure injury/ulcers.
26. A specialty bed should be used for all patients at high risk for pressure injury/ulcers.
27. Foam dressing may be used on areas at risk for shear injury.
28. Persons at risk for pressure injury/ulcers should be nutritionally assessed (i.e., weight, nutrition intake, blood work).
29. Biofilms may develop in any type of wound.
30. Critical care patients may need slow, gradual turning because of being hemodynamically unstable.
31. Blanching refers to whiteness when pressure is applied to a reddened area.
32. A blister on the heel is nothing to worry about.
33. Staff education alone may reduce the incidence of pressure injury/ulcers.
34. Early changes associated with pressure injury/ulcer development may be missed in persons with darker skin tones.
35. A footstool/footrest should not be used for an immobile patient whose feet do not reach the floor.
36. Deep tissue injury (DTI) may be difficult to detect in individuals with dark skin tones.
37. Bone, tendon, or muscle may be exposed in a Stage 3 pressure injury/ulcer.
38. Eschar is good for wound healing.
39. It may be difficult to distinguish between moisture associated skin damage and a pressure injury/ulcer.
40. Wounds that become chronic are frequently stalled in the inflammatory phase of healing.
41. Dry, adherent eschar on the heels should not be removed.
42. Deep tissue injury is a localized area of purple or maroon discolored intact skin or a blood-filled blister.
43. Massage of bony prominences is essential for quality skin care.
44. Poor posture in a wheel chair may be the cause of a pressure injury/ulcer.
45. For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals.
46. Patients who are spinal cord injured need knowledge about pressure injury/ulcer prevention and self-care.
47. In large and deep pressure injury/ulcers, the number of dressings used needs to be counted and documented so that all dressings are removed at the next dressing change.
48. A mucosal membrane pressure injury/ulcer is found on mucous membrane as the result of medical equipment used at that time on that location; this pressure injury is not staged.
49. Pressure injury/ulcers can occur around the ears in a person using oxygen by nasal cannula.
50. Persons, who are immobile and can be taught, should shift their weight every 30 minutes while sitting in a chair.
51. Stage 1 pressure injury/ulcers are intact skin with non-blanchable erythema over a bony prominence.
52. When the ulcer base is totally covered by slough, it cannot be staged.
53. Selection of a support surface should only consider the person’s level of pressure injury/ulcer risk.
54. Shear injury is not a concern for a patient using a lateral-rotation bed.
55. It is not necessary to have the patient with a spinal cord injury evaluated for seating.
56. To help prevent pressure injury/ulcers, the head of the bed should be elevated at a 45-degree angle or higher.
57. Urinary catheter tubing should be positioned under the leg.
58. Pressure injury/ulcers may be avoided in patients who are obese with use of properly sized equipment.
59. A dressing should keep the wound bed moist, but the surrounding skin dry.
60. Hydrocolloid and film dressings must be carefully removed from fragile skin.
61. Nurses should avoid turning a patient onto a reddened area.
62. Skin tears are classified as Stage 2 pressure injury/ulcers.
63. A Stage 3 pressure injury/ulcer may appear shallow if located on the ear, malleolus/ankle, or heel.
64. Hydrocolloid dressings should be used on an infected wound.
65. Pressure injury/ulcers are a lifelong concern for a person who is spinal cord injured.
66. Pressure injury/ulcers can be cleansed with water that is suitable for drinking.
67. Alginate dressings can be used for heavily draining pressure injury/ulcers or those with clinical evidence of infection.
68. Deep tissue injury will not progress to another injury/ulcer stage.
69. Film dressings absorb a lot of drainage.
70. Non-sting skin prep should be used around a wound to protect surrounding tissue from moisture.
71. A Stage 4 pressure injury/ulcer never has undermining.
72. Bacteria can develop permanent immunity to silver dressings.

Pieper Pressure Ulcer Knowledge Test: Answer Key

Question	Answer
1. Slough is yellow or cream-colored necrotic /devitalized tissue on a wound bed.	True
2. A pressure injury/ulcer is a sterile wound.		False
3. Foam dressings increase the pain in the wound.		False
4. Hot water and soap may dry the skin and increase the risk for pressure injury/ulcers.	True
5. Chair-bound persons should be fitted for a chair cushion.	True
6. A Stage 3 pressure injury/ulcer is a partial thickness skin loss involving the epidermis and/or dermis.		False
7. Hydrogel dressings should not be used on pressure injury/ulcers with granulation tissue.		False
8. A person confined to bed should be repositioned based on the individual’s risk factors and the support surface’s characteristics.	True
9. A pressure injury/ulcer scar will break down faster than unwounded skin.	True
10. Pressure injury/ulcers progress in a linear fashion from Stage 1 to 2 to 3 to 4.		False
11. Eschar is healthy tissue.		False
12. Skin that doesn’t blanch when pressed is a Stage 1 pressure injury/ulcer.	True
13. The goal of palliative care is wound healing.		False
14. A Stage 2 pressure injury/ulcer is a full thickness skin loss.		False
15. Dragging the patient up in bed increases friction.	True
16. Small position changes may need to be used for patients who cannot tolerate major shifts in body positioning.	True
17. Honey dressings can sting when initially placed in a wound.	True
18. An incontinent patient should have a toileting care plan.	True
19. A pressure redistribution surface manages tissue load and the climate against the skin.	True
20. A Stage 2 pressure injury/ulcer may have slough in its base.		False
21. If necrotic tissue is present and if bone can be seen or palpated, the ulcer is a Stage 4.	True
22. When possible, high-protein oral nutritional supplements should be used in addition to usual diet for patients at high risk for pressure injury/ulcers.	True
23. The home care setting has unique considerations for support surface selection.	True
24. When necrotic tissue is removed, an unstageable pressure injury/ulcer will be classified as a Stage 2 injury/ulcer.		False
25. Donut devices/ring cushions help to prevent pressure injury/ulcers.		False
26. A specialty bed should be used for all patients at high risk for pressure injury/ulcers.		False
27. Foam dressing may be used on areas at risk for shear injury.	True
28. Persons at risk for pressure injury/ulcers should be nutritionally assessed (i.e., weight, nutrition intake, blood work).	True
29. Biofilms may develop in any type of wound.	True
30. Critical care patients may need slow, gradual turning because of being hemodynamically unstable.	True
31. Blanching refers to whiteness when pressure is applied to a reddened area.	True
32. A blister on the heel is nothing to worry about.		False
33. Staff education alone may reduce the incidence of pressure injury/ulcers.		False
34. Early changes associated with pressure injury/ulcer development may be missed in persons with darker skin tones.	True
35. A footstool/footrest should not be used for an immobile patient whose feet do not reach the floor.		False
36. Deep tissue injury (DTI) may be difficult to detect in individuals with dark skin tones.	True
37. Bone, tendon, or muscle may be exposed in a Stage 3 pressure injury/ulcer.		False
38. Eschar is good for wound healing.		False
39. It may be difficult to distinguish between moisture associated skin damage and a pressure injury/ulcer.	True
40. Wounds that become chronic are frequently stalled in the inflammatory phase of healing.	True
41. Dry, adherent eschar on the heels should not be removed.	True
42. Deep tissue injury is a localized area of purple or maroon discolored intact skin or a blood-filled blister.	True
43. Massage of bony prominences is essential for quality skin care.		False
44. Poor posture in a wheel chair may be the cause of a pressure injury/ulcer.	True
45. For persons who have incontinence, skin cleaning should occur at the time of soiling and at routine intervals.	True
46. Patients who are spinal cord injured need knowledge about pressure injury/ulcer prevention and self-care.	True
47. In large and deep pressure injury/ulcers, the number of dressings used needs to be counted and documented so that all dressings are removed at the next dressing change.	True
48. A mucosal membrane pressure injury/ulcer is found on mucous membrane as the result of medical equipment used at that time on that location; this pressure injury is not staged.	True
49. Pressure injury/ulcers can occur around the ears in a person using oxygen by nasal cannula.	True
50. Persons, who are immobile and can be taught, should shift their weight every 30 minutes while sitting in a chair.		False
51. Stage 1 pressure injury/ulcers are intact skin with non-blanchable erythema over a bony prominence.	True
52. When the ulcer base is totally covered by slough, it cannot be staged.	True
53. Selection of a support surface should only consider the person’s level of pressure injury/ulcer risk.		False
54. Shear injury is not a concern for a patient using a lateral-rotation bed.		False
55. It is not necessary to have the patient with a spinal cord injury evaluated for seating.		False
56. To help prevent pressure injury/ulcers, the head of the bed should be elevated at a 45-degree angle or higher.		False
57. Urinary catheter tubing should be positioned under the leg.		False
58. Pressure injury/ulcers may be avoided in patients who are obese with use of properly sized equipment.	True
59. A dressing should keep the wound bed moist, but the surrounding skin dry.	True
60. Hydrocolloid and film dressings must be carefully removed from fragile skin.	True
61. Nurses should avoid turning a patient onto a reddened area.	True
62. Skin tears are classified as Stage 2 pressure injury/ulcers.		False
63. A Stage 3 pressure injury/ulcer may appear shallow if located on the ear, malleolus/ankle, or heel.	True
64. Hydrocolloid dressings should be used on an infected wound.		False
65. Pressure injury/ulcers are a lifelong concern for a person who is spinal cord injured.	True
66. Pressure injury/ulcers can be cleansed with water that is suitable for drinking.	True
67. Alginate dressings can be used for heavily draining pressure injury/ulcers or those with clinical evidence of infection.	True
68. Deep tissue injury will not progress to another injury/ulcer stage.		False
69. Film dressings absorb a lot of drainage.		False
70. Non-sting skin prep should be used around a wound to protect surrounding tissue from moisture.	True
71. A Stage 4 pressure injury/ulcer never has undermining.		False
72. Bacteria can develop permanent immunity to silver dressings.		False

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2H: Pressure Ulcer Baseline Assessment

Background: The purpose of this tool is to assess general staff knowledge on pressure ulcer prevention. It is shorter than the Pieper but has not been as widely used. The tool is available on the Web site of the Institute for Healthcare Improvement.

Reference: Adapted from: Iowa Health Des Moines. Pressure Ulcer Baseline Assessment. Available at: http://www.ihi.org/NR/rdonlyres/F2EF9AB3-BB0F-4D3D-A99A-83AC7E0FB0D3/6224/IowaHealthDesMoinesPUBaselineAssesment.pdf .

Instructions: Administer the questionnaire to registered nurses and nursing assistants. The survey may need to be modified if certain questions are not consistent with your policies and procedures.

Use: Use the findings to assess gaps in knowledge. Work with your education department to tailor specific education programs to the needs of your staff.

Pressure Ulcer Baseline Assessment for Registered Nurse

For which factors in the Braden Scale are you evaluating the patient’s ability to respond to verbal command?

A. Activity
B. Mobility
C. Sensory/Perception
D. Friction/Shear

Minimally, a patient in the acute care setting should be assessed for pressure ulcer risk at least every:

A. 48 hours
B. 24 hours
C. 8 hours
D. 4 hours

How often should you, the RN, assess and document skin condition?

A. Daily
B. Once a shift
C. Upon admission and discharge, every shift, and as patient condition warrants
D. Upon admission and discharge

What can you, the RN, do when one of your patients has discoloration of the skin (red, purple, blue) indicating pressure?

A. See what happens over the next 24 hours.
B. Let the next nurses know about it. Start a skin care plan.
C. Place the patient on a pressure-reducing surface and explain to the patient and family that the patient needs to limit pressure to the area.
D. B&C from above

Who is the primary person accountable for patient skin assessment, pressure ulcer prevention, and documentation?

A. WOC Nurse (ET nurse)
B. RN
C. Nursing assistant
D. All of the above

Pressure Ulcer Baseline Assessment for Nursing Assistant

What is the most common reason a patient gets a pressure ulcer?

A. Patient is a smoker.
B. Patient is very thin.
C. Patient is incontinent.
D. Patient does not move.

How often should you look at every patient’s skin to look for signs of redness or discoloration?

A. Daily, when patient bathes.
B. Every time the patients asks me to look.
C. Every 8 hours.
D. The RN should do that.

The correct procedure for checking an air mattress every shift is

A. Push down and if it feels soft it is OK.
B. Ask the patients if it feels like there is enough air underneath them.
C. Do a hand check by placing palm up and feeling for a cushion of air under the heaviest areas of the body.
D. The air mattress should be OK once it is blown up and does not need to be checked.

What should you report to your patient’s RN every shift?

A. Skin tears
B. Discoloration of skin, such as red, blue, or purple
C. Open sores
D. All of the above

Pressure Ulcer Baseline Assessment: Answer Key

Registered Nurse

For which factors in the Braden Scale are you evaluating the patient’s ability to respond to verbal command?

A. Activity
B. Mobility
C. Sensory/Perception
D. Friction/Shear

Minimally, a patient in the acute care setting should be assessed for pressure ulcer risk at least every:

A. 48 hours
B. 24 hours
C. 8 hours
D. 4 hours

How often should you, the RN, assess and document skin condition?

A. Daily
B. Once a shift
C. Upon admission and discharge, every shift, and as patient condition warrants
D. Upon admission and discharge

What can you, the RN, do when one of your patients has discoloration of the skin (red, purple, blue) indicating pressure?

A. See what happens over the next 24 hours.
B. Let the next nurses know about it. Start a skin care plan.
C. Place the patient on a pressure-reducing surface and explain to the patient and family that the patient needs to limit pressure to the area.
D. B&C

Who is the primary person accountable for patient skin assessment, pressure ulcer prevention, and documentation?

A. WOC Nurse (ET nurse)
B. RN
C. Nursing assistant
D. All of the above

Nursing Assistant

What is the most common reason a patient gets a pressure ulcer?

A. Patient is a smoker.
B. Patient is very thin.
C. Patient is incontinent.
D. Patient does not move.

How often should you look at every patient’s skin to look for signs of redness or discoloration?

A. Daily, when patient bathes.
B. Every time the patients asks me to look.
C. Every 8 hours.
D. The RN should do that.

The correct procedure for checking an air mattress every shift is

A. Push down and if it feels soft it is OK.
B. Ask the patients if it feels like they have enough air underneath them.
C. Do a hand check by placing palm up and feeling for a cushion of air under the heaviest areas of the body.
D. The air mattress should be OK once it is blown up and does not need to be checked.

What should you report to your patient’s RN every shift?

A. Skin tears
B. Discoloration of skin, such as red, blue, or purple
C. Open sores
D. All of the above 

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2I: Action Plan

Background: The purpose of this tool is to provide a framework for outlining steps that will be needed to design and implement the pressure ulcer prevention initiative.

Reference: Adapted from material produced by MassPro, a participant in the Centers for Medicare & Medicaid Services Quality Improvement Organization Program.

Instructions:

1. Note the date and the objective. A sample objective is provided.
2. The form lists six key tasks. For each, list in the second column the steps that will be taken to address the task, including tools to be used.
3. In developing the plan, it is not expected that you will provide results, only that you will lay out what needs to be done.
4. In the last two columns, determine who will have lead responsibility for completing each task, and estimate an appropriate timeframe for completing the activities.
5. Use the plan as a working document that can be revised. As you begin to carry out the plan, you may need to make adjustments and add details to the later tasks.

Use: Use the completed sheet to plan, manage, and carry out the identified tasks. The plan should guide the implementation process and can be continually amended and updated.

A sample completed form is shown below, followed by a blank form.

Pressure Ulcer Prevention Action Plan

Date: February 16, 2011

Improvement Objective: Implement standard pressure ulcer prevention practices within 6 months.

Key Interventions/Task	Steps To Complete Task and Tools To Use	Team Members Responsible for Task Completion	Target Date for Task Completion
	Examples	Examples	Examples
1. Analyze current state of pressure ulcer prevention practices in this organization.	Identify strengths and weaknesses using process mapping and gap analysis. Tool 2C and Tools 2E-2G.	Team leader, RNs, and WOCNs	Within 6 weeks from initiative start
Assess the current state of staff knowledge about pressure ulcer prevention. Tool 2H.	Education department	Within 6 weeks from initiative start
Set target goals for improvement.	QI department	Within 8 weeks from initiative start
2. Identify the bundle of prevention practices to be used in redesigned system.	Determine how comprehensive skin assessment should be performed	Wound care team	Within 12 weeks from initiative start
Decide which scale will be used for performing risk assessment.	Wound care team	Within 12 weeks from initiative start
Decide what items of pressure ulcer prevention should be in your bundle	Clinical staff members	Within 12 weeks from initiative start
3. Assign roles and responsibilities for implementing the redesigned pressure ulcer prevention practices.	Examples	Examples	Examples
Determine who will complete the daily skin and risk assessments. Tool 4A.	Implementation team	Within 16weeks from initiative start
Identify unit champions.	Team leader	Within 16 weeks from initiative start
Determine how prevention work will be organized at the unit level, such as paths of communication and lines of oversight.	QI team	Within 16 weeks from initiative start
4. Put the redesigned bundle into practice.	Engage staff and get them excited about the changes needed.	Team leader, unit staff	Within 12 weeks from initiative start
Pilot test the new practices.	QI department	Within 20 weeks from initiative start
5. Monitor pressure ulcer rates and practices.	Determine how incidence and prevalence data will be collected. Tool 5A.	QI department	Within 6 weeks from initiative start
Organize quarterly prevalence studies.	QI department	Within 6 weeks from initiative start, ongoing
6. Sustain the redesigned prevention practices.	Ensure continued leadership support.	Team leader	Within 4 weeks from initiative start and ongoing
Ensure ongoing support from other units such as facilities management and IT.	IT, facilities management, PT, dietitians	Within 40 weeks from initiative start
Designate responsibility and accountability for pressure ulcer prevention oversight and continuous quality improvement.	Team leader and implementation team	Within 40 weeks from initiative start

Pressure Ulcer Prevention Action Plan       Date: ________________________

Improvement Objective:

Key Interventions/Tasks	Steps To Complete Task and Tools To Use	Team Members Responsible for Task Completion	Target Date for Task Completion
1. Analyze current state of pressure ulcer prevention practices in this organization.
2. Identify the bundle of prevention practices to be used in redesigned system.
3. Assign roles and responsibilities for implementing the redesigned pressure ulcer prevention practices.
4. Put the redesigned bundle into practice.
5. Monitor pressure ulcer rates and practices.
6. Sustain the redesigned prevention practices.

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