Ch 48 Skin Integrity and Wound Care

Question 1

What is a pressure ulcer?

Answer 1

Impaired skin integrity related to unrelieved, prolonged pressure; localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure with shear and/or friction.

Question 2

List contributing factors associated with pressure ulcers.

Answer 2

Decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition

Question 3

List factors that contribute to the formation of a pressure ulcer.

Answer 3

Any factor that interferes with blood flow, in turn interferes with cellular metabolism and the function or life of the cells; prolonged, intense pressure affects cellular metabolism by decreasing or obliterating blood flow, resulting in tissue ischemia and tissue death

Question 4

Name 3 pressure-related factors that contribute to pressure ulcer development.

Answer 4

Pressure intensity, pressure duration, tissue intolerance

Question 5

What is pressure intensity?

Answer 5

When the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur

Question 6

What is blanching?

Answer 6

It occurs with the normal red tones of the light-skinned patient are absent. Does not occur in darkly pigmented skin

Question 7

What is pressure duration?

Answer 7

Can be low pressure over a prolonged period of time or high pressure over a short period of time both causing tissue damage; extended pressure occludes blood flow and nutrients and contributes cell death

Question 8

What is tissue tolerance?

Answer 8

The ability of tissue to endure pressure; depends on the integrity of the tissue and the supporting structures

Question 9

What are risk factors for developing pressure ulcers?

Answer 9

Impaired sensory perception, impaired mobility, alteration in level of consciousness, shear (necrosis deep in tissue), friction (effect top layer of skin) and moisture

Question 10

What is included in assessment of pressure ulcers?

Answer 10

Depth of tissue involvement (stage), type and approx. percentage of tissue in wound bed, wound dimension, exudate description, and condition of surrounding skin

Question 11

T/F You can stage an ulcer covered with necrotic tissue.

Answer 11

FALSE!! Necrotic tissue covers the depth of the ulcer so staging is not possible

Question 12

Stage I Pressure Ulcer

Answer 12

Nonblanchable redness of intact skin; usually over bony prominence; discoloration of skin, warmth, edema, hardness or pain (may be difficult to detect in dark skin tones)

Question 13

Stage II Pressure Ulcer

Answer 13

Partial-thickness skin loss involving epidermis, dermis or both or a blister; red-pink wound bed without slough or bruising; intact or open/ruptured serum-filled or serosangineous filled blister

Question 14

Stage III Pressure Ulcer

Answer 14

Full-thickness skin/tissue loss with visible fat but bone, tendon or muscle is NOT exposed; slough MAY be present and it MAY include undermining and tunneling

Question 15

Stage IV Pressure Ulcer

Answer 15

Full-thickness tissue loss with exposed bone, tendon or muscle; slough or eschar MAY be present and often includes undermining and tunneling