Pressure Ulcer

Question 1

What are the causes of pressure ulcers

Answer 1

Pressure against the skin in various areas interferes with circulation

Because the cell dies very quickly with that adequate blood supplies pressure ulcer can develop

Question 2

In which superficial layers of the tissue are pulled and stretch across the deep layer of tissue

Can cause damage to the skin if the patient is slid along the sheet for positioning rather than lifted

Answer 2

Sharing action

Question 3

What are some risk factors that make a patient more prone to developing pressure ulcer

Answer 3

Confinement, & immobility,

incontinence,

malnourished,

decreased level of consciousness, or confusion,

obesity, =diabetes,

dehydration&EDEMA, &excessive sweating,

extreme age,

Question 4

Confinement, & immobility,

incontinence,

malnourished,

decreased level of consciousness, or confusion,

obesity, =diabetes,

dehydration&EDEMA, &excessive sweating,

extreme age,

Answer 4

What are some risk factors that make a patient more prone to developing pressure ulcer

Question 5

What are some prevention measures used for pressure ulcers

Answer 5

Assess the skin of the patient every 8 to 24 hours

Reposition every two hours

Question 6

What positioning devices can be used to prevent pressure ulcers

Answer 6

Pillows, foam wedges, and padding for patients on bedrest to keep the bony
prominences from being in direct contact with another

Question 7

When the Side lying position in bed is use avoid positioning directly on

Answer 7

Trochanter

Question 8

If the patient is on best rates and has a pressure ulcer how should you maintain the head of the bed

Answer 8

At the lowest degree permitted by the medical condition limit the time at the head of the bed is elevated

Question 9

What lifting devices did you use to prevent pressure injuries

Answer 9

TRAPEZER or bed linens

Term of the patient rather than dragging those who cannot assist during transfer or positioning changes

Question 10

For patient with limited mobility what Devices should you use to prevent pressure injuries

Answer 10

Pressure reducing devices on the bed such as a

foam,

static air

alternating air, gel or a water mattress

Question 11

How can you minimize friction and sheer force

Answer 11

Using lubricants, protective film, protective dressing, protective padding

Question 12

They prevent pressure ulcers how did you keep the environmental humidity above

Answer 12

Above 40% and prevent exposure of cold tree dry skin with moisturizer

Question 13

When a patient is wheelchair-bound what should you not use

Answer 13

Do not use donut type devices

Question 14

Who is sitting on a chair or wheelchair how frequently should you change your position

Answer 14

Every 15 minutes or at least every hour

Question 15

What is the Braden scale system/Norton system and what are the areas that are assessed on this tools

Answer 15

Assessment used to predict pressure injury risk

Question 16

What is the braden scale check for

Answer 16

Sensory perception

moisture

activity

mobility

nutrition

friction and shear

Question 17

What are some of the common areas where pressure ulcers occur

Answer 17

Bony prominences area where the skin rub against each other

Prone: anterior superior iliac spine,patellae

Side lying: ears, greater tuberosity humerus, trochanter, head of the fibula, lateral MALLEOLUS

supine: scapula, vertebrae, sacrum, calcanei

Sitting; buttocks, scapula, vertebrae, sacrum

Question 18

Intact skin with purple or maroon discoloration

Tissue may be firm, BOGGY, painful, cool,

warm

Answer 18

Suspected deep tissue injury

Question 19

An area of intact skin that is reddened, deep pink, or mottled that does not blanch

Answer 19

Stage one

Question 20

Partial thickness skin loss involving the dermis and/or epidermis

The skin appears blistered or abraded or has a shallow crater

The area surrounding the damage skin is reddened And will probably feel hot or warmer than normal

Answer 20

Stage two

Question 21

The skin is ulcerated

There is crater like ulcers
In the underlying subcutaneous tissue is involved in the destructive process the ulcer may or may not be infected

Bacteria is almost always presented in this stage however in the count for a continued erosion of ulcers in production of drainage

Answer 21

stage three

Question 22

There is a deep ulceration and necrosis involving deeper underlining muscle and possible bony tissues

The ulcer can be dry, black and covered with a tough accumulation of necrotic tissue

It can be made up of wet and oozing dead cell and purulent exudate

Depth can be determined

Answer 22

Stage 4

Question 23

Full thickness wound with ESCHAR and/or tissue that obscure depth of determination

Answer 23

Unstageable

Question 24

Helps identify area of high pressure

The patient lives or sits on a centerfield mat

Red indicates?

Blue or green area suggest ?

Answer 24

Pressure mapping

Higher pressure

Lesser pressure

Question 25

Removal of any ESCHAR dead necrotic tissue must occur for the pressure ulcer to heal

Answer 25

Debridement

Question 26

The different types of debridement

Answer 26

Surgical
mechanical
chemical

Question 27

How do you a surgical procedure use for a pressure ulcers

Answer 27

Forceps and scissors

Question 28

What do a mechanical procedure use for pressure ulcers

Answer 28

Whirlpool bath

Wet - 2- dry Saline dressing

Question 29

What do a chemical procedure for pressure ulcers use

Answer 29

Dextranomer beads

Proteolytic enzymes

Or chemical products that breaks down the dead tissue and absorbed the exudate

Question 30

How would you clean a pressure ulcer

Answer 30

clean

Dry dressing for 8-24 hrs the. moisture

Question 31

What solution should you use while cleaning a pressure ulcer

Answer 31

Normal saline
Or shur clens
Light mechanical action with sponges or irrigation equipment

Question 32

How would you irritate the pressure ulcer

Answer 32

18g blunt needle or 30 ml syringe

30-50 ml needless syringe if red wound bed

Question 33

Increases the rate of healing

Answer 33

Electrical stimulation

Question 34

Suction applied to full surface of the wound via sponge and occlusive adhesive sheet

Stimulates formation of granulation tissue and pull away EXUDATE

Answer 34

Vacuum assistant wound closure

Question 35

Floods tissue with more oxygen than is normally available

Answer 35

Hyperbaric O2 therapy

Question 36

How should you document pressure ulcers

Answer 36

It should be measured and documented when they are discovered and at least once a week there after

Question 37

What are some characteristics that should be documented about the pressure ulcer

Answer 37

Exudate
Purulent- containing pus
Serosanguineous-containing serum and blood

Question 38

Amber colored or blood tinged

Answer 38

Serosanguineous exudate

Question 39

All aspects of this assessment, prevention measures , objective description and measurements of the pressure ulcer, in progress towards healing are documented regularly in the

And what is a good way to objectively document your findings

Answer 39

Push - pressure ulcer scales for healing

Or Coca

Question 40

Beige w a fishy odor

Answer 40

Proteus

Question 41

Brown with a fecal odor

Answer 41

Bacteroides

Question 42

Creamy yellow

Answer 42

Staphylococcus

Question 43

Green/blue with fruity odor

Answer 43

Pseudomonas