pressure injury

Question 1

cell adaptation to sublethal injury

Answer 1

• hypertrophy (cell growth)
• hyperplasia (increased cell production)
• atrophy (cell degeneration)
• metaplasia (one type of tissue is replaced by another type)
• dysplasia (abnormal development of cells)
• anaplasia (loss of specialized feature of a cell)

Question 2

causes of lethal cell injury

Answer 2

• hypoxia/ischemia
• heat
• cold
• radiation
• electrothermal injury
• mechanical trauma
• chemical injury
• microbial injury
• neoplastic growth

Question 3

apoptosis

Answer 3

programmed cell death

Question 4

necrosis

Answer 4

• tissue death
• not normal in developed tissues
• serious when many cells involved

Question 5

defence against cell injury

Answer 5

• skin and mucous membranes
• mononuclear phagocyte system
• inflammatory response
• immune system

Question 6

inflammatory response

Answer 6

• biological response to cell injury cause by pathogens, irritants, chronic conditions
• divided into vascular response, cellular response, exudate formation, healing

Question 7

inflammatory response: exudate formation

Answer 7

• fluid and leukocytes move from circulation to site of injury
• CM: redness, swelling, heat, malaise, tachycardia, temperature increase, chills

Question 8

inflammatory response: healing process

Answer 8

• regeneration
• repair: primary intention (initial phase, granulation phase, maturation and scar contraction), secondary and tertiary intention

Question 9

ability of cells to regenerate

Answer 9

• labile cells (skin, lymphoid, bone marrow, mucous membranes) divide constantly
• stable cells (liver, pancreas, kidney) retain the ability to regenerate if organ is injured
• permanent cells (CNS, cardiac) do not regenerate

Question 10

wound classification

Answer 10

• cause (surgical/non-surgical)
• underlying pathology (vascular, pressure, diabetes)
• duration (acute, chronic)
• level of contamination
• depth of tissue
• colour

Question 11

healing complications

Answer 11

• Adhesions
• Contractures
• Dehiscence and evisceration
• Excess granulation tissue
• Fistula formation
• Infection
• Hemorrhage
• hypertrophic scars and keloids

Question 12

nursing health promotion for inflammation and healing

Answer 12

• prevent infection
• minimize inflammation
• adequate nutrition

Question 13

nursing acute intervention for inflammation and healing

Answer 13

• observation and vitals
• fever
• RICE (rest, ice, compress, elevate)
• heat
• wound management: cleaning, debriding, moisture
• negative pressure therapy
• electrical stimulation

Question 14

pressure injuries

Answer 14

localized injury to skin or underlying soft tissue as a result of excessive or prolonged pressure, shear, and tissue deformation

Question 15

causes of pressure injuries

Answer 15

• pressure
• shearing force
• friction
• excessive moisture

Question 16

pressure injuries risk factors

Answer 16

• diabetes
• immobility
• poor nutrition
• poor circulation
• poor hydration
• incontinence

Question 17

pressure injuries CM

Answer 17

depends of extent of tissue involved and is stages according to deepest level of tissue damage

Question 18

stage 1 pressure injuries

Answer 18

• lightly pigmented
• only epidermis effected
• skin intact
• non-blanchable erythema

Question 19

stage 2 pressure injuries

Answer 19

• partial thickness skin loss involving the epidermis and dermis

Question 20

stage 3 pressure injuries

Answer 20

• full thickness loss of skin that extends to the subcutaneous tissue

Question 21

stage 4 pressure injuries

Answer 21

• large wound present
• muscle, tendon, or bone may be exposed

Question 22

unstageable pressure injuries

Answer 22

• dark eschar
• slough

Question 23

nursing and interprofessional management of pressure injuries

Answer 23

• reposition frequently
• foam mattresses
• alternating pressure mattresses
• lift sheets
• wheelchair cushions
• padded commode seats
• heel boots