Mr James London

Question 1

Mr London has very limited mobility, how often should you assist him to change position to prevent the development of a pressure injury?

Answer 1

Two hourly

Question 2

Pressure injuries form primarily as a result of what?

Answer 2

Tissue necrosis

Question 3

You conduct a Braden scale assessment for Mr London to assess his risk of developing a pressure injury. What risk factors are assessed using the Braden Scale?

Answer 3

Sensory perception, moisture, activity, mobility, nutrition, friction, shear

Question 4

Based on the Braden scale what score places him at the highest level of risk?

Answer 4

12

Question 5

When Mr London is in a supine position, what are the potential sites of pressure injury?

Answer 5

Unprotected pressure points at sacrum, heels, scapulae, elbows and back of head

Question 6

You notice Mr London has partial- thickness skin loss involving the epidermis and possibly dermis in the sacral region, what stage of injury will you document in the patient records?

Answer 6

Stage II

Question 7

During assessment of Mr London you note a reddened area over his coccyx. What should your next actions for him include?

Answer 7

Reposition the patient off the coccyx and reassess in one hour