Fund ch 19

Question 1

What are some pressure injury risk factors (8)

Answer 1

#1 immobility
#2 inactivity
#3 moisture
#4 Malnutrition
#5 Advanced age
#6 Altered sensory perception
#7 Lowered mental awareness
#8 Friction and shear

Question 2

What are some contributing factors in pressure injuries (3)

Answer 2

#1 Dehydration
#2 Obesity
#3 Edema

Question 3

What do you do if you note a reddened area when repositioning a patient?

Answer 3

reassess later to see whether reactive hyperemia is present. If the redness remains and the skin does not blanch to fingertip pressure, then the patient has a stage 1 pressure injury

Question 4

An area of intact skin that is red, deep pink, or mottled skin that does not blanch with fingertip pressure. In people with darker skin, there may be discoloration of the surrounding skin. Warmth, edema, and induration in comparison to surrounding tissue may be signs of a what stage pressure injury?

Answer 4

Stage 1 pressure injury

Question 5

Partial-thickness skin loss with exposed dermis. The wound bed is pink or red and moist and may appear as an intact or ruptured blister, what stage pressure injury?

Answer 5

Stage 2 pressure injury

Question 6

Full-thickness skin loss that looks like a deep crater and may extend to the fascia. Subcutaneous tissue is damaged or necrotic; fat is visible. Undermining and tunneling may be present. There may be damage to the surrounding tissue. What stage pressure injury?

Answer 6

Stage 3 pressure injury

Question 7

Full-thickness skin loss with extensive tissue necrosis or damage to muscle, bone, or supporting structures; sinus tracts may be present. Infection is usually widespread. The injury may appear dry and black, with a buildup of tough, necrotic tissue, or it can appear wet and oozing. What stage pressure injury?

Answer 7

Stage 4 pressure injury

Question 8

Loss of full thickness of tissue. The base of the injury is covered by eschar (tan, brown, or black) in the wound bed, or the base of the injury contains slough (yellow, tan, gray, green, or brown). What stage pressure injury

Answer 8

Unstageable pressure injury

Question 9

Localized discolored intact skin that is maroon or purple or a blood-filled blister resulting from damage to underlying soft tissue from pressure or shearing. What stage pressure injury?

Answer 9

Deep tissue pressure injury

Question 10

After a pressure injury hits stage ___, it is irreversible and it cannot go back it will be considered a stage __ scar and will be prone to injury

Answer 10

Stage 3

Question 11

If there has not been damage, then you expect the redness to subside in ___ to ___ minutes

Answer 11

30 to 45

Question 12

Pressure points where pressure injuries often occur

Answer 12

1 rim of ear