Pressure Ulcers

Question 1

Pressure Ulcer Etiology

Answer 1

tissue ischemia/necrosis as a result of soft tissue compression between hard objects

shear, friction, and moisture play roles

Question 2

Pressure Ulcer Presentation

Answer 2

over bony prominences
oval or round
watch for atypical locations
frequently painful
can be superficial to deep
necrosis possible
infection common

Question 3

NPUAP staging

Answer 3

pressure ulcers only

indicates deepest level of damage

reverse staging not an indication of healing

reopening of an ulcer goes back to original staging if higher

Question 4

NPUAP Stage 1

Answer 4

intact skin with non blanching redness

may be painful, firm, soft, warm or cool

Question 5

NPUAP Stage 2

Answer 5

partial thickness loss of dermis with a shallow, open ulcer

may have SERUM FILLED BLISTER

shiny or dry without slough or bruising

no necrosis

Question 6

NPUAP Stage 3

Answer 6

Full thickness tissue loss

no bone, muscle or tendon exposed

may have undermining or tunneling

can have necrotic tissue that doesnt cover base of wound

Question 7

NPUAP Stage 4

Answer 7

Full thickness with bone, tendon, or muscle exposed

often includes undermining or tunneling

slough or eschar possible

Question 8

Unstagable Pressure Ulcers

Answer 8

Full thickness loss, but base covered in slough or eschar

eschar can serve as a protective cover

Question 9

Deep tissue injury

Answer 9

Purple or maroon localized area of discolored, intact skin

BLOOD FILLED BLISTER

damage of underlying soft tissue from pressure or shear

injury from inside out, may resemble stage 4 once it gets through surface

Question 10

Pressure Ulcer Risk Factor

Answer 10

nutritional deficits
immobility
incontinence
sensory impairment
chronic/critical injury
impaired cognition

Question 11

Pressure Ulcer Risk Assessments

Answer 11

Braden: most popular-6 subscales, range of 6-23 with lower score=higher risk

Norton: 5 subscales, range of 5-20 with lower score=higher risk

Gosnell: 5 subscales, range of 5-20 with higher score=higher risk

Question 12

Incontinence-associated skin breakdown

Answer 12

aka: incontinence associated dermatitis (IAD)

not a pressure ulcer

diffuse or irregular borders

not over bony prominences

weakens skin-pressure ulcers may follow

Question 13

shear and friction precautions

Answer 13

keep HOB <30*

sitting activities dangerous for shear

Question 14

Pressure ulcer pt ed

Answer 14

turning schedule
no massage
no donut cushions
HEP

Question 15

Skin failure

Answer 15

new concept

skin is an organ-goes with mutliorgan failure

rapidly progresses-death usually w/in 2 wks

kennedy terminal ulcer