Ger 13 Pressure Ulcers Flashcards

1
Q

This is a scale used for assessing risk for pressure ulcers.

A

Braden scale

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2
Q

On the Braden scale, what is a good result for 1. sensory perception?

A

less sensory loss is better

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3
Q

On the Braden scale, what is a good result for moisture?

A

less is better

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4
Q

On the Braden scale, what is a good result for activity?

A

more is better

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5
Q

On the Braden scale, what is a good result for mobility?

A

ability to change position without help is better

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6
Q

On the Braden scale, what is a good result for nutrition?

A

Ability to eat more na doften is better

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7
Q

On the Braden scale, what is a good result for friction and shear?

A

ability to keep good posture in bed/chain without help is better

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8
Q

Is a higher or lower # (from 1-4) is better on the Braden scale?

A

higher

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9
Q

At what point or higher is there no risk on the Braden scale?

A

> 19

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10
Q

At what range should is it at risk, and you should manage moisture?

A

15-18

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11
Q

At what range is there a modeerate risk, and you should manage nutrition?

A

13-14

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12
Q

At what range is there a high risk and u should manage friction and shear?

A

10-12

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13
Q

What range is there a very high risk and u should manage general care and gentle handling?

A

< 9

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14
Q

What are the 5 points of usual locations for pressure ulcers?

(think things that contact a bed when u lay down)

A
Sacrum
Heels
Ischial tuberosities
Greater trochanters
Lateral malleoli
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15
Q

True or False: a stage I ulcer shows redenned skin that doesnt blanch when pressed.

A

True

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16
Q

True or False: a stage II ulcer is deep to the fatty tissue.

A

False. It is shallow with only the dermis exposed

17
Q

True or False: a stage III ulcer is deep to the fatty tissue.

A

True!

18
Q

What shows on a stage IV ulcer?

A

it’s such a deep ulcer that muscle and bone are exposed

19
Q

What are the 2 methods of managmenet for a stage I ulcer?

A

Monitoring and protection as necessary.

20
Q

If you find a patient with an ulcer down to the dermis, what are the 2 management steps?

A

Moist dressings and wound cleansing with saline

21
Q

In addition to cleansing and antibiotics for a stage III/IV ulcer, what do you do if necrotic tissue is present?

A

Debridement

22
Q

After what time do you sample culture and give system antibiotics?

A

2-4 weeks