Final - Pressure sores and prevention

Question 1

risk of pressure sore increases …

Answer 1

over time after injury

if you’ve had one previously

Question 2

top reasons for re-hospitalizations

Answer 2

1. urinary tract infection
2. pressure sores
3. respiratory complications

Question 3

first visible sign of a pressure sore is change in

Answer 3

skin surface
temperature
turgor (dehydration)
*damage can be initiated in the muscle tissue before signs show on skin

Question 4

grade 1

Answer 4

• no blanching

- redness, warmth

Question 5

grade 2

Answer 5

• loss of dermis, epidermis

- blister

Question 6

grade 3

Answer 6

• subcutaneous tissue

- full thickness

Question 7

grade 4

Answer 7

• muscle. bone

- necrosis

Question 8

3 causes of pressure sores

Answer 8

1. interface pressure: perpendicular interaction between object and surface
2. friction: rubbing of one surface on another
3. shear: two forces move in parallel directions

Question 9

risk of pressure sores

Answer 9

moisture
incontinence
immobility, age, sensory loss, disease, poor nutrition

Question 10

Braden Scale

Answer 10

determines a patient’s risk of pressure ulcer in hopes to minimize the risk

Question 11

6 components of the braden scale

Answer 11

1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. shear

Question 12

Braden scale score

Answer 12

1 - high degree of risk
4 - low degree of risk

higher the score, the less the risk

Question 13

low risk

Answer 13

sensation intact

client can move freely for pressure relief

Question 14

moderate risk

Answer 14

sensation intact and pressure relief unlikely to perform as needed

sensation impaired and ability to do pressure relief

Question 15

high risk

Answer 15

sensation intact, unable to do pressure relief, current sore history

sensation impaired, unable to do, current sore history

Question 16

most vulnerable skin

Answer 16

scar tissue after initial pressure sore

Question 17

prevent pressure sores in wheelchairs

Answer 17

1. perform regular pressure reliefs
2. custom wheelchair
3. appropriate seat cushion

Question 18

pressure reliefs in the wheelchair

Answer 18

1 min every 30 min

side to side tilt
tricep push up
lean forward

Question 19

types of seat cushions (paper for advantage/disadvantage) and goals

Answer 19

foam
gel
air
hybrid
contour
*do not use a donut

goals:

• comfort
• distribute pressure and promote skin protection
• postural support
• encourage optimal function

Question 20

prevent pressure sores in bed

Answer 20

move every 2 hours - place body in at least 30 deg incline laterally

prone if tolerated

Question 21

types of beds

Answer 21

foam
gel
low air loss
air fluidized