Pressure Ulcer

Question 1

Pressure ulcers are also known as _____ or ______

Answer 1

Bedsores or decubitus ulcers

Question 2

Pressure ulcers are caused by:

Answer 2

Tissue ischemia and/or necrosis which occurs as a result of soft tissue compression between hard objects such as bony prominences and external surfaces

Question 3

The iceberg effects means that pressure ulcers are formed ______

Answer 3

From the inside out. There can be extensive damage underneath with only a small sore showing.

Question 4

Pressure ulcers present:

1) Where?
2) What shape?
3) Painful or not painful?

Answer 4

1) Over bony prominences such as heels, sacrum, coccyx, greater trochanters, ischial tuberosities
2) Oval or round
3) Very painful

Question 5

What system do you use to document pressure ulcers?

Answer 5

NPUAP pressure ulcer staging system

Question 6

How do you stage pressure ulcers?

Answer 6

Based on the deepest level of damage; DO NOT decrease the stages as the wound heals

Question 7

If a pressure ulcer re-opens, how do you stage it?

Answer 7

Under the previous staging diagnosis

Question 8

What are some alternatives to the NPUAP staging system?

Answer 8

Pressure Ulcer Scale for Healing (PUSH)
Bates-Jensen Wound Assessment Tool
Sussman Wound Healing Tool

Question 9

What characterizes a Stage I pressure ulcer?

Answer 9

Intact Skin
Non-blanchable redness of a localized area over a bony prominence
May be painful, firm or soft, warmer or cooler than surrounding area
May indicate “at risk” persons

Question 10

What characterizes a Stage II pressure ulcer?

Answer 10

Partial thickness loss of dermis
Shallow open ulcer with a red/pink wound bed WITHOUT SLOUGH or bruising
May also present as an intact or open/ruptured serum-filled blister.

Make sure that the ulcer is indeed caused by the pressure

Question 11

What characterizes a Stage III pressure ulcer?

Answer 11

Full thickness tissue loss
Subcutaneous fat may be visibile, but bone, tendon, muscle are NOT exposed
Slough may be present
May include undermining or tunneling

Question 12

What characterizes a Stage IV pressure ulcer?

Answer 12

Full thickness tissue loss
Exposed bone, tendon, or muscle
Slough or eschar may be present on some parts of wound bed
Often includes undermining or tunneling

Question 13

What characterizes an unstagable pressure ulcer?

Answer 13

Unable to ascertain base of wound due to slough/eschar.

Once slough/eschar is debrided, stage properly

Question 14

What characterizes a deep tissue injury (DTI)?

Answer 14

Purple or maroon localized area of discolored intact skin or blood-filled blister

Question 15

How do you distinguish between a Stage II pressure ulcer and a DTI?

Answer 15

Stage II will have a serum-filled blister

DTI will have a blood-filled blister

Question 16

What are risk factors for developing pressure ulcers?

Answer 16

Nutritional deficits
Immobility
Incontinence (urine + feces = ammonia)
Sensory impairment
Chronic or critical illness
Impaired cognition

Question 17

What are standardized risk assessments used in wound care?

Answer 17

Braden - most popular
Norton
Gosnell

Question 18

Medical complications of pressure ulcers include:

Answer 18

Repeated wounding
Infection
Death

Question 19

The plan of care for wound care involves: (11)

Answer 19

Turning program!
Splints or other positioning devices
Support surfaces as indicated
Debridement of non-viable tissue
Treatment of any infection
Protecting the wound from contamination
Addressing moisture/continence issues
Correcting nutrition/hydration issues
Managing shear/friction
Patient/caregiver education
Dressings to promote moist wound healing

Question 20

Patient and caregiver education includes: (7)

Answer 20

Pressure relief/reduction
Frequent turning/repositioning
Dressing maintenance/application
Incontinence management
Nutritional issues
S/S of infection
Skin preservation

Question 21

What are some strategies for tissue load management? (7)

Answer 21

Pressure redistribution (from high risk to low risk areas)
Bed-based pressure reducing surfaces
Seating surfaces
Off-loading in gait
Reducing tissue loads over bony prominences
Controlling shear and friction
Immersion

Question 22

What are the differences between upper and lower vessels with regards to pressure and shear?

Answer 22

Lower vessels are more sensitive to pressure than upper

Upper vessels are more sensitive to shear than lower

Question 23

What is the exception for debriding eschar?

Answer 23

A dry, stable, intact eschar - optimize pressure and nutrition before removing

Question 24

What are some S/S of incontinence-associated skin breakdown?

Answer 24

Contact with urine or stool
Diffuse or irregular borders
Not over bony prominences

Question 25

What are some precautions to take to reduce shear and friction?

Answer 25

Keep HOB <30 when not contraindicated
What for skin irritation from friction
Remember that sitting activities are especially hazardous for shear
Watch for squirming or not clearing heels or buttocks

Question 26

What is a Kennedy Terminal Ulcer?

Answer 26

A sudden-onset, rapidly progressing, multi-colored, pear/butterfly shaped usually on the sacral area

Question 27

What is the best way to treat a pressure ulcer?

Answer 27

Trick question! Prevention is the best treatment.