Exam 2: Week 7, Pressure Injuries 1

Question 1

What is the Braden scale?

Answer 1

A scale used to predict a patient’s risk of developing a pressure ulcer

(categories: mobility, activity, sensory perception, skin moisture, nutritional status, friction/shear)

Question 2

What is the expected healing time frame for pressure ulcers? (list each timeframe by stage)

Answer 2

Stage 1: Within 1-3 weeks
Stage 2: Within 2-6 weeks
Stage 3/4: 8-13 weeks

Question 3

List 4 ways a clinician can reposition a patient

Answer 3

• Turning sheet
• Trapeze bar
• Support surfaces
• Hoyer lift

(Note: avoid “dragging” a patient to reposition them)

Question 4

What are the 4 factors that contribute to the development of a pressure injury/ulcer

Answer 4

Pressure

Friction:
- occurs when two surfaces move across one another

Shear:
- Displaces deep tissue, not superficial
- Skin stays in tact
- Leads to ischemia and necrosis

Moisture

Question 5

T or F? You can only stage a stage 4 pressure injury if a bone is present

Answer 5

False… an ulcer with exposed bone, tendon, or ligaments would be classified as a stage 4 ulcer

Question 6

90% of pressure ulcers can be prevented with interventions such as…

Answer 6

• Education
• Positioning
• Mobility
• Nutrition
• Incontinence management

Question 7

List the Braden scale score ranges and what they indicate

Answer 7

<13: High risk

13-14: Moderate risk (65-90% chance of developing stage II ulcer or deeper)

15-16: Mild risk (50-60% chance of developing a stage I ulcer)

<18: At risk

(note: if a patient has major risk factors such as fever, diastolic <60, hemodynamic instability, or advanced age then it is recommended they get moved one risk category higher)

Question 8

List and describe some moisture associated skin damage conditions?

Answer 8

Intertrigo: Inflammation in skin folds related to perspiration, friction, and bacterial/fungal bioburden

Periwound maceration: Skin breakdown from wound exudate

Incontinence Associated Dermatitis (IAD): Urine, stool, secondary cutaneous infection

Question 9

T or F? Pressure can impact the vascular network by increasing interstitial fluid pressure, increasing capillary pressure, decreasing lymphatic flow, restricting blood flow and can also cause ischemia/necrosis

Answer 9

True

Question 10

Pressure related damage depends on…

Answer 10

• Intensity of pressure
• Duration of pressure
• Tissue tolerance

Question 11

Differentiate between hyperemia and ischemia skin breakdown

Answer 11

Hyperemia (too much blood flow to an area)
- Skin breaks down within 30 mins

Ischemia (too little blood flow to an area)
- Skin breakdown after 2-6hrs

Question 12

Differentiate between necrosis and ulceration skin breakdown

Answer 12

Necrosis
- Skin breaks down after 6 hours of continuous pressure (will have gray/blue coloration)

Ulceration
- Skin breaks down within 2 weeks after necrosis, possible infection

Question 13

T or F? Pressure and time have an inverse relationship when referring to pressure injury formation

Answer 13

True

Question 13

List some intrinsic and extrinsic risk factors for developing ulcers?

Answer 13

Intrinsic
- Diabetes
- Smoking
- Malnutrition
- Immunosuppression
- Vascular disease
- Spinal cord injury
- Contractures
- Prolonged immobility

Extrinsic
- Lying on hard surfaces
- Poor skin hygiene

Question 14

Describe deep tissue injuries (DTI)

Answer 14

• Purple or maroon area
• Intact skin or blood blister
• Area may be preceded by pain, temp change, texture change

Question 15

Differentiate between the 4 stages of ulcers

Answer 15

Stage I:
- Intact skin with non-blanchable erythema (constant redness)
- Redness does not dissolve within 30 mins of pressure removal

Stage II:
- Partial thickness (into the dermis)
- Open wound, but shallow
- “3 P’s”… Pink, Partial, Painful
- Also includes blisters

Stage III:
- Full thickness (through epidermis, dermis, into subcutaneous tissue)
- Slough/necrotic tissue may be present

Stage IV:
- Full thickness (through epidermis, dermis, subcutaneous tissue
- Impacts bone, ligaments, tendons, etc.
- Slough/Eschar typically present

UNSTAGEABLE if wound bed is covered by eschar/slough

Question 16

Which bed position is worst for shear forces? How can this be prevented?

Answer 16

Semi-Fowler’s position… put the head of the bed less than 30 degrees

Question 17

How often should a patient change positions?

Answer 17

2 hours for a full change

15-30 minutes (offload for 1-3 minutes)

Question 18

Describe group 1 mattresses/overlays

Answer 18

These devices are “pressure reducing” and “preventative”

Examples: Gel foam overlay, waffle overlay, pressure pad/pump

Patient Population: Those “at-risk” on the braden scale (or have stage 1 or 2 ulcer)

(Benefits: Pressure and shear reduction)

Question 19

Describe group 2 specialty mattresses

Answer 19

These devices are “pressure relieving” and “Reactive/Active”

Can be controlled with a remote or machine (which regulates bed temp, shear, and can raise/lower the head or feet). They are also perforated (holes in it)

Examples: Low air mattress, alternating pressure mattresses

Patient Population: Multiple Stage 2 ulcers on trunk/pelvis

Question 20

Describe group 3 air fluidized beds

Answer 20

These devices are “pressure active”

Examples: Clinitron bed, skytron air fluidized therapy bed

Patient Population: (Individuals must have all of the following)
- Multiple Stage 3 or 4 ulcers
- Entirely bed ridden
- “Group 2” mattresses did not work

Question 21

Which product can you use to protect against urine incontinence?

Answer 21

Petroleum