Chapter 41

Question 1

Avoidable Pressure Injury

Answer 1

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

Question 2

Bedfast

Answer 2

Confined to bed

Question 3

Bony Prominence

Answer 3

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

Question 4

Chairfast

Answer 4

Confined to a chair

Question 5

Colonized

Answer 5

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

Question 6

Epidermal Stripping

Answer 6

Removing the epidermis (outer skin layer) as tape is removed from the skin

Question 7

Eschar

Answer 7

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

Question 8

Intact Skin

Answer 8

Normal skin and skin layers without damage or breaks

Question 9

Pressure Injury

Answer 9

Localized damage to the skin and underlying soft tissue; the injury is usually over a bony prominence or related to a medical or other device and results from pressure or pressure in combination with shear

Question 10

Shear

Answer 10

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

Question 11

Skin Breakdown

Answer 11

Changes or damage to intact skin - normal skin and skin layers

Question 12

Slough

Answer 12

Dead tissue that is shed from the skin; it is usually light colored, soft, and moist; may be stringy at times

Question 13

Unavoidable Pressure Injury

Answer 13

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