Exam 2: Week 8, Pressure Injuries 2

Question 1

Why is it important to use a skin cleanser with a balanced pH?

Answer 1

Because a skin cleanser with a high pH will dry out the skin

Question 2

List 3 skin barriers that prevent breakdown

Answer 2

Petroleum
- Excellent protection against urine

Dimethicone
- Less greasy, less occlusive

Zinc oxide
- Effective against urine and fecal incontinence
- Difficult to remove at times

Question 3

How often should a patient change positions?

Answer 3

Every 2 hours if lying down, but every 15-30 mins if patient is in a wheelchair

Question 4

Explain tissue interface pressure

Answer 4

• Measures capillary closing pressure
• Sensors placed between the support surface and skin
• take 3 measurements and average the results
• Ideally want the pressure from the surface less than the pressure that closes the capillaries

Question 5

List support surfaces by group and provide examples

Answer 5

Group 1: Mattress overlays (Anything that lays on top of a mattress)
- Monitor carefully because the gel may harden in cold weather
- Must be at least 4 inches thick

Group 2: Specialty mattresses

Group 3: Air fluidized support surfaces/beds
- Makes transfers more difficult

Question 6

What are the 3 main steps of caring for patient’s with pressure injuries

Answer 6

1. Protect surrounding skin
2. Address wound bed
3. Minimize pressure and shear forces (+ educate the patient)

Question 7

Which modalities (biophysical agents) can be used with pressure injuries?

Answer 7

• Estim (for stage 3 and 4 ulcers, as well as non-healing stage 2 ulcers)
• Ultrasound/MIST
• Laser
• Pulse lavage with suction or closed pulse lavage (for pressure injuries with high wound bioburden or infection)
• NPWT

Question 8

What is a deep tissue injury (DTI)?

Answer 8

An injury in which the skin remains intact, but the tissue beneath is damaged (will often have a purple or maroon coloration… basically a blood blister)

Question 9

In order to decrease shear, the head of bed (HOB) should be positioned less than ______ degrees

Answer 9

30

Question 10

List the scoring of the Wagner scale

Answer 10

0 – no open lesion, may have cellulites

1 – superficial ulcer/partial thickness

2 - deep ulcer to tendon or bone

3 – deep ulcer with abscess or osteomyelitis

4 – localized gangrene

5 – gangrene of the entire foot