Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Integumentary > 11] Pressure Ulcers > Flashcards

11] Pressure Ulcers Flashcards

1
Q

Etiology of pressure ulcers

A

Capillaries are occluded and the tissue around is has no oxygen or nutrition —> this turns into tissue hypoxia which leads to cell death

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Shear is?

A

Internal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Major cause of undermining

A

Shearing

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Doing what causes increased shear forces

A

Elevating head of bed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How do we stage pressure ulcers?

A

NPUAP which describes the deepest level of tissue destroyed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Stage 1 pressure injury

A

Intact skin with non-blanchable redness

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Stage 2 pressure injury

A

Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

2 characteristics stage 2 pressure injuries can present as

A

Intact OR open/ruptured serum filled blister

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Stage 3 pressure injury

A

Full thickness- can see fat but BTM are not exposed;s slough may be present but does not obscure depth of tissue loss

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What stage does undermining and tunneling start in?

A

Stage 3 pressure injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Stage 4 pressure injury

A

Full thickness and you see MTB

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Stage 5 pressur einjury

A

Unstageable! Full thickness where base is covered by slough and/or Eschar

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Stage 6 pressure injury

A

Suspected deep tissue injury where its purple with intact skin or blood filled blister

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

The area may be precededby tissue that is painful,

firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

A

Stage 6- suspected deep tissue injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Pressure ulcer healing

A

Eschar —> slough —> granulation —> epithelialization

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is a Kennedy terminal ulcer

A

Specific pressure ulcer characterized by rapid onset and rapid tissue breakdown — SKIN FAILURE

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When do Kennedy terminal ulcers develop

A

Within 2-4 weeks before dying

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Where does Kennedy terminal ulcers happen and what shape

A

Sacrum/coccyx and are pear or butterfly shaped that can be purple, red blue or black with irregular borders

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Patho fo Kennedy ulcer

A

Blood shunts away from skin to vital organs

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

►Monitors healing or deterioration
►Uses minimal number of assessment parameters
►Reliable
►Easy to use

A

Documenting change : PUSH tool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Stage 1 healing time

A

14 days

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Stage 2 healing time

A

45 days

23
Q

Stage 3 healing time

A

90 days

24
Q

Stage 4 healing time

A

120 days

25
Q

With PI you want to manage

A

Incontinence

26
Q

Cleansing interventions

A

Remove devitalized tissue and decerase bacterial burden

27
Q

Intervention- debride

A

Sharp
Enzymatic
Autolytic

28
Q

Intervention- dressings

A

Create moist environment for wound healing

29
Q

►Most commonly used pressure ulcer risk assessment

A

Braden

30
Q

6 subscales of Braden

A 
Sensory perception 
Moisture
Activity
Mobility
Nutrition
Friction/shear
31
Q

Scoring for Braden

A

►Lower score = higher riskƒ

15-18 = at risk
ƒ13-14 = moderate risk
ƒ10-12 = high risk
ƒ<10 = very high risk
32
Q

Decreases interface pressure but not necessarily below capillary pressure

A

Pressure reduction

33
Q

Decreases of pressure below capillary pressures

A

Pressure relief

34
Q

do not move, reduce pressure by spreading load over large area

A

Static devices

35
Q

Use if a patient cannot assume a variety of
positions without bearing weight on pressure ulcers,
ƒ If pressure injury is not healing, or
ƒ If patient fully compresses static support
surface

A

Dynamic devices

36
Q

Use if a patient can assume variety of positions without bearing weight on existing pressure ulcer

A

Static devices

37
Q

Goes over foam or regular bed

A

Overlay

38
Q

Move; require motor to operate

A

Dynamic devices

39
Q

Series of connected air filled pillows with surface fabrics of low-friction material

A

Low air loss

40
Q

What PI would you use low air loss for?

A

Stage 3 or 4 on multiple turning surfaces

41
Q

Use when excessive moisture on intact skin; can dry skin and prevent pressure injury

A

Fluidized or high air loss (silicone coated glass beds that has air and fluid)

42
Q

Assessing performance of support surfaces

A

Bottoming out
Bunching in gel mattress
Deflating air mattress

43
Q

Standard repositioning measures in BED (6)

A 
Every 2 hours while in bed
30 degree turns but keep pt off trochanter 
Float heels 
Pillows b/w bony prominences
HOB less than 30 
Donuts are DO NOTS
44
Q

Standard repositioning in chair

A

Every 30 min

45
Q

all pressure ulcers cases in an institution whether admitted with or occurring during the stay

A

Prevalence

46
Q

The new pressure ulcer cases developed within the institution

A

Incidence

47
Q

Heel ulcer prevention protected what structures

A

Peroneal nerve and Achilles’ tendon contracture

48
Q

Use what to prevent sacral pressure ulcers in ICU because it does what

A

Silicone based dressing b/c it reduces shear, friction and excess moisture

49
Q

Stage 1 treatment

A

Relieve pressure and protect the area

50
Q

Stage 2 pressure ulcer

A

Partial thickness- there isnt too much drainage and a thin film, hydrocolloid foam or gel can be used

51
Q

Stage 3/4 PI

A

Full thickness- depending on amount of drainage you could use hydrocolloid, foam, gel, or calcium alginate

52
Q

Treatment for necrotic tissue slough or Eschar

A

Enzymatic debridement

53
Q

If ulcer becomes infect, what might you do for dressing

A

Dressing with silver

Integumentary (15 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions