Chapter 32 Pressure Injuries Flashcards

1
Q

Avoidable pressure injury

A

A pressure injury that develops from the improper use of the nursing process

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

Bony prominence

A

An area where the bone sticks out or projects from the flat surface of the body

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

Chairfast

A

Confined to a chair

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

Colonized

A

The presence of bacteria on the wound surface or in wound tissue; the person does not have signs and symptoms of an infection

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

Erythema

A

Redness of the skin

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

Eschar

A

Thick, leathery dead tissue that may be loose or adhered to the skin; it is often black or brown

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

Friction

A

The rubbing of one surface against another

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

Intact skin

A

Normal skin without opening or damage

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

Pressure injury

A

Localized damage to the skin and or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. Injury occurs as a result of intense and or prolonged pressure or pressure in combination with shear

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

Shear

A

When layers of the skin rub against each other; when the skin remains in place and underlying tissue move and stretch and tear underlying capillaries and blood vessels causing tissue damage

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

Slough

A

Dead tissue that is soft and often moist and appears white, yellow, green or tan; tissue may be firmly attached or loose and stringy

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

Unavoidable pressure injury

A

A pressure injury that occurs despite efforts to prevent one through proper use of the nursing process

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

Bedfast

A

Confined to a bed

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

Pressure injury stages

A

Stage 1 the skin is intact
Stage 2 partial -thickness skin loss (blister or shallow ulcer)
Stage 3 Full -Thickness skin loss (slough is dead tissue that is soft and often moist)
Stage 4 Full-Thickness skin and tissue loss with muscle, tendon, and bone exposures. (Eschar)
Unstageable Full-thickness tissue loss with the injury covered by slough and eschar
Deep Tissue Injury - purple or maroon localized area of discolored intact skin or blood filled blister.

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

A pressure injury is

A

Localized damage to the skin and underlying soft tissue

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

Pressure injuries are the result of

A

Unrelieved pressure

17
Q

Which of the following contributes to the development of pressure injuries?

A

Shear and friction

18
Q

A pressure injury can develop within

A

2 to 6 hours

19
Q

The following are risk factors for pressure injuries except

A

Balanced diet

20
Q

Which is the most common site for a pressure injury?

21
Q

In a light-skinned person , the first sign of a pressure injury is

A

A reddened area

22
Q

A person care plan includes the following. Which should you question?

A

Scrub and rub the skin during bathing

23
Q

When positioning a person, you should position them

A

Using assist devices

24
Q

What is the preferred position for preventing pressure injuries?

A

30 degrees lateral position

25
Besides heel and foot elevators , which are used to keep the heels and ankles off the bed?
Pillows
26
Person sitting in a chair should shift their position every
15 minutes
27
A person is sitting in a chair. The feet do not touch the floor. What should you do?
Position the feet on a foot rest
28
Which are not used to treat pressure injuries
Plastic draw sheets and waterproof pads
29
The following are sources of moisture except
Barrier ointment
30
You see a reddened area on the person skin. What should you do?
Tell the nurse
31
The nurse tells you that the person pressure injury is colonized. This means that
Bacteria are present
32
Inflammation of the bone and bone marrow is
Osteomyelitis
33
Which of the following is not a prevention measure for pressure injuries?
Massage bony areas
34
Which is correct for preventing or treating pressure injuries?
Make sure shoes fit properly