ch 12 pressure ulcers Flashcards
3 classes of pts with greatest risk of developing a pressure ulcer
SCI
hospitalized
LTAC
a pressure wound is any wound caused by unrelieved pressure or a combination of pressure and shear forces
t or f
True
pressure ulcers can develop in less than 2 hours in the right conditions.
t or f
true
capillary closing pressure
13-32 mmHg
skin is more sensitive to the effects of ischemia and pressure than muscle.
t or f
False, muscle tissue has the highest metabolic rate and is most sensitive to compression and ischemia
most commonly used for pressure sore risk
braden scale
Braden pressure sore risk score interpretation
Scores < 13 =
Scores 13-14 =
Scores 15-18 =
Scores < 13 = high risk
Scores 13-14 = moderate risk
Scores 15-18 = mild risk
tests used for pressure sore RISK prediction/assessment
Braden, Norton, Gosnell
high or low score indicating greater risk for pressure ulcer
Braden:
Norton:
Gosnell:
braden: low
norton: low
gosnell: high
Category: Nonblanchable erythema of intact skin
category 1
category: Superficial ulcer that presents as a shallow crater without slough or bruising
May be ruptured or intact (fluid- or blood-filled) blister
Partial thickness, epidermis, dermis, or both
category II
category: Deep ulcer that presents as a deep crater; may have undermining or tunneling, full thickness, bone/tendon NOT visible
category III
category: Deep ulcer with extensive necrosis; often has undermining or sinus tracts, full thickness, bone, muscle, tendon or joint capsule are visible
category IV
category: obscured by eschar or slough
unstageable
category: Local area of purple or maroon discoloration of intact skin or blood-filled blister
Area may have been painful, firm, mushy, boggy, or warmer or cooler than surrounding tissue
suspected deep tissue injury
