Module 10- Pressure injuries and Skin Tears

Question 1

A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction

Answer 1

pressure injury

Question 2

Hospital acquired pressure injuries affect alot of patients and cost the US alot of money in health care T or F

Answer 2

true

Question 3

Explain the stages of pressure injuries

Answer 3

stage 1- redness no skin layers damaged
stage 2- sore extends into but not through any skin layers
stage 3- skin layers are completely lost, necrosis of the subcutaneous tissue may extend to but not through the fascia
stage 4- necrosis reaches beyond the fascia causing extensive damage to support structures such as bone and muscle.

Question 4

Once a pressure injury has been staged the stage can be reversed? T or F

Answer 4

false! staging cannot be reversed

Question 5

a pressure injury is a consequence of ____ and ___ to the tissue

Answer 5

ischemia and anoxia

Question 6

How do pressure injuries occur?

Answer 6

tissues are compressed, blood vessels are compressed and blood flow is diverted by continual pressure on the skin and underlying structures

Question 7

Pressure injuries in hospitalized patients are never events T or F

Answer 7

True, never events stage III-IV

Question 8

where will you most likely find a pressure injury?

Answer 8

over bony landmarks

Question 9

is the time for pressure injuries to occur the same for every patient

Answer 9

no

Question 10

Friction

Answer 10

a mechanical force exerted when two surfaces move

Question 11

shear

Answer 11

stress resulting from applied forces which cause two objects to deform in the transverse plane

Question 12

what happens when you raise the head of the bed

Answer 12

increased pressure on the sacrum

Question 13

who are skin tears common in?

Answer 13

really old and really young
critically or chronically ill

Question 14

explain the skin tear types

Answer 14

1. type 1 no skin loss
   -linear or flap tear that can be repositioned to cover the wound bed
2. type 2 partial flap loss
   -partial flap loss that cannot be repositioned to cover the wound bed
3. type 3 total flap loss
   -total flap loss exposing entire wound bed

Question 15

What is the braden scale?

Answer 15

an objective scale to determine a patient’s risk of developing pressure ulcers
common in acute and rehab settings
most commonly used for patients who are bed-or chair bound as well as those with an impaired ability to reposition

Question 16

what are the categories of the braden scale

Answer 16

sensory perception
moisture
activity
mobility
nutrition
friction and shear