Ger 13 Pressure Ulcers

Question 1

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

Answer 1

Braden scale

Question 2

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

Answer 2

less sensory loss is better

Question 3

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

Answer 3

less is better

Question 4

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

Answer 4

more is better

Question 5

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

Answer 5

ability to change position without help is better

Question 6

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

Answer 6

Ability to eat more na doften is better

Question 7

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

Answer 7

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

Question 8

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

Answer 8

higher

Question 9

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

Answer 9

> 19

Question 10

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

Answer 10

15-18

Question 11

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

Answer 11

13-14

Question 12

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

Answer 12

10-12

Question 13

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

Answer 13

< 9

Question 14

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

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

Answer 14

Sacrum
Heels
Ischial tuberosities
Greater trochanters
Lateral malleoli

Question 15

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

Answer 15

True

Question 16

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

Answer 16

False. It is shallow with only the dermis exposed

Question 17

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

Answer 17

True!

Question 18

What shows on a stage IV ulcer?

Answer 18

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

Question 19

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

Answer 19

Monitoring and protection as necessary.

Question 20

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

Answer 20

Moist dressings and wound cleansing with saline

Question 21

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

Answer 21

Debridement

Question 22

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

Answer 22

2-4 weeks