Ch22 Preventing Pressure Ulcers And Assisting With Wound Care

Question 1

How are pressure ulcers formed

Answer 1

Lack of movement and pressure against certain body pressure points

Question 2

Process of pressure ulcer formation

Answer 2

1-Pressure against tissue
2-Decreased blood flow to tissue
3-Tissues do not receive enough oxygen/nutrients
4-Tissues die
5-Dead tissue breaks creating ulcer

Question 3

Pressure points

Answer 3

Bony areas where pressure ulcers most likely form

Question 4

Factors that cause pressure ulcers (5)

Answer 4

• Old age causes skin to be thin with less blood flow
• poor nutrition and lack of fluids
• Moosture causes epidermis to soften
• Cardiovascular/respiratory problems prevent adequate oxygen and nutrients
• Friction and shearing injuries

Question 5

A person laying in bed should be repositioned every ___?

Answer 5

Two hours

Question 6

A person sitting should be repositioned every ___ ?

Answer 6

One hour

Question 7

When should I check for pressure ulcers?

Answer 7

Every opportunity I get such as when I reposition, bathe, dress, change soiled linens, give massages.

Question 8

How would I provide good skin care to prevent pressure ulcers?

Answer 8

By cleansing the skin gently, dry it well, use lotion, and clean and dry areas where skin touch skin (skin folds) by applying powder.

Question 9

What can I do to prevent pressure ulcers?

Answer 9

1-Take a walk with patients who can walk every hour or change position of paralyzed patients
2-keep bed linens clean dry wrinkle free
3-provide frequent back massage
4-minimizing skin friction
5-offer refreshing drinks and encourage to eat well
6-place pillow under persons calves when in supine position

Question 10

What special equipments can I use to prevent pressure ulcers? (5)

Answer 10

1-Elbow pads and heel booties
2-A bed cradle
3-Footboard
4-Pressure relieving mattress
5-Special beds

Question 11

What is a wound?

Answer 11

An injury that results in a break in the skin

Question 12

What do I do when repositioning a person with a drain?

Answer 12

Do not pull on the drain tubing, which may cause the drain to be pulled out of the wound

Question 13

When are Montgomery ties used?

Answer 13

When a wound is draining heavily. This type of securing the dressing can be left on the patient and the dressing can be the only thing changed.

Question 14

What supplies do I need when I assist a nurse with a dressing change? (6-8)

Answer 14

Gloves, gown, mask, paper towels/bed protecter, plastic bag, tape/Montgomery toes, dressing material, scissors

Question 15

What do I document after helping assisting the dressing change? (4)

Answer 15

1-date and time
2-appearance of wound
3-amount, color, and characteristic of wound drainage
4-type of dressing applied