Pressure Sores Flashcards
Pressure ulcers occur when skin and underlying tissues are placed under pressure that impairs blood supply, leading to tissue damage. Which of the following can cause pressure ulcers?
1 - friction
2 - continuous pressure
3 - shearing
4 - all of the above
4 - all of the above
Friction = rubbing of skin against a surface
Shearing = 2 skins surfaces rub against one another
Where do pressure sores most commonly occur?
1 - over boney prominences
2 - on sensitive skin (genitals)
3 - over commonly exposed skin
4 - over hairy surfaces
1 - over bone prominences
Typically location of thinnest subcutaneous tissue
Image shows most common sites
When skin is exposed to continuous pressure, shearing and friction, which of the following can occur?
1 - compression of blood vessels
2 - ischaemia
3 - hypoxia
4 - tissue damage and cell death
5 - all of the above
5 - all of the above
They typically occur in this order
Which of the following is NOT a common condition associated with increasing the risk of developing pressure sores?
1 - immobility
2 - chronic liver disease
3 - dementia
4 - poor blood flow (HF and lung disease) 5 - increasing age
2 - chronic liver disease
Which of the following is NOT a common condition associated with thin skin and thus increasing the risk of developing pressure sores?
1 - older age
2 - dry skin with dehydration
3 - chronic kidney disease
4 - poor nutrition and thin SC tissue
5 - external irritants (sweat, urine, feaces)
3 - chronic kidney disease
There are 5 stages of pressure sores. Which of the following is a stage 4 pressure sore?
1 - extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Difficult to heal and increased risk of fatal infection.
2 - unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
3 - reduced blood flow, warm and non-blanching erythema with intact skin.
4 - full-thickness skin loss (epidermis, dermis and SC tissue) damage or necrosis with drainage or slough, but not beyond the fascia.
5 - involvement of epidermis and/or dermis, superficial abrasion or blister.
1 - extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Difficult to heal and increased risk of fatal infection.
There are 5 stages of pressure sores. Which of the following is a stage 1 pressure sore?
1 - extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Difficult to heal and increased risk of fatal infection.
2 - unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
3 - reduced blood flow, warm and non-blanching erythema with intact skin.
4 - full-thickness skin loss (epidermis, dermis and SC tissue) damage or necrosis with drainage or slough, but not beyond the fascia.
5 - involvement of epidermis and/or dermis, superficial abrasion or blister.
3 - reduced blood flow, warm and non-blanching erythema with intact skin.
There are 5 stages of pressure sores. Which of the following is a stage 5 pressure sore?
1 - extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Difficult to heal and increased risk of fatal infection.
2 - unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
3 - reduced blood flow, warm and non-blanching erythema with intact skin.
4 - full-thickness skin loss (epidermis, dermis and SC tissue) damage or necrosis with drainage or slough, but not beyond the fascia.
5 - involvement of epidermis and/or dermis, superficial abrasion or blister.
2 - unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
There are 5 stages of pressure sores. Which of the following is a stage 3 pressure sore?
1 - extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Difficult to heal and increased risk of fatal infection.
2 - unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
3 - reduced blood flow, warm and non-blanching erythema with intact skin.
4 - full-thickness skin loss (epidermis, dermis and SC tissue) damage or necrosis with drainage or slough, but not beyond the fascia.
5 - involvement of epidermis and/or dermis, superficial abrasion or blister.
4 - full-thickness skin loss (epidermis, dermis and SC tissue) damage or necrosis with drainage or slough, but not beyond the fascia.
There are 5 stages of pressure sores. Which of the following is a stage 2 pressure sore?
1 - extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Difficult to heal and increased risk of fatal infection.
2 - unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
3 - reduced blood flow, warm and non-blanching erythema with intact skin.
4 - full-thickness skin loss (epidermis, dermis and SC tissue) damage or necrosis with drainage or slough, but not beyond the fascia.
5 - involvement of epidermis and/or dermis, superficial abrasion or blister.
5 - involvement of epidermis and/or dermis, superficial abrasion or blister.
Above what grade pressure sores should be referred through to specialist care?
1 - >4
2 - >3
3 - >2
4 - >1
2 - >3
Which of the following are key features of proper pressure sore management?
1 - adequate pressure redistribution
2 - good nutrition
3 - appropriate wound management
4 - prevent soiling and moisture
5 - all of the above
5 - all of the above
Reduce moisture and use lotions to help soften skin
Appropriate wound management is to reduce risk of infection and aid healing
Skin swabs are taken to guide antibiotic therapy
How often should patients be encouraged to mobilise or assisted to mobilise?
1 - every 15-30 minutes
2 - every 1-2 hours
3 - every 3-4 hours
4 - every 6-8 hours
2 - every 1-2 hours
