Pressure Ulcers

Question 0

Skin

Answer 0

Largest organ
Covers 2 square meters in adult
Acidic protective coating PH 4.2-5.6
Ranges from 1/8-1/25in in thickness
Receives 1/3 of body's circulating blood volume

Question 1

Tissue Integrity

Answer 1

State of structurally intact and physiologically functioning epithelial tissues such as the integument (including skin and subcutaneous tissues) and mucous membranes

Question 2

Skin Functions

Answer 2

Sensation 
Vitamin D synthesis
Thermo-regulation via circulation and sweating
Protects 
Skin immune system

Question 3

Skin layers

Answer 3

Dermal
Epidermis
Dermis

Question 4

Epidermis layers

Answer 4

Stratum corneum
Stratum lucidem
Stratum granulosem
Stratum spinosum
Melanocyte
Stratum basale

Question 5

Dermis layers

Answer 5

Papillae
Papillary region
Reticular region

Question 6

Physiologic Processes

Answer 6

Protection
Absorption
Secretion
Excretion

Epithelial cells cover all internal and external body surfaces

Question 7

Factors that alter skin

Answer 7

Age
Sun
Hydration
Soaps
Nutrition 
Medications

Question 8

Diseases that impact skin

Answer 8

Diabetes
Auto immune disorders
Cancer
Vascular disorders
Psychiatric

Question 9

Pressure Ulcer

Answer 9

Pressure sore
Decubitus ulcer
Bed sore

Question 10

Pathogenesis

Answer 10

Pressure intensity

• tissue ischemia
• blanching

Pressure duration
Tissue tolerance

Question 11

Pressure Ulcer Risk Factors

Answer 11

Impaired sensory perception
Alterations in level of consciousness 
Impaired mobility
Shear 
Friction
Moisture

Question 12

Pressure ulcer prevention

Answer 12

Pressure relief devices
Skin care
Incontinence care
Activity
Nutrition
Prevention

Question 13

Eschar

Answer 13

Black tissue, tissue necrosis

Question 14

Stage 1 PU

Answer 14

Intact skin with non-blanchable redness

Changes in color, warmth, sensation, tissue consistency (no open areas)

Question 15

Stage 2 PU

Answer 15

Partial thickness skin loss involving epidermis, dermis, or both

Superficial, loss of epidermis or dermis (abrasion, blister, shallow crater)

Question 16

Stage 3 PU

Answer 16

Full thickness tissue loss with visible fat

Damage or necrosis of subQ fat layer that extends to fascia
Deep crater, may undermine

Question 17

Stage 4 PU

Answer 17

Full thickness tissue loss with exposed bone, muscle, or tendon

Extensive destruction, damaged bone, cartilage, muscle, tendon or joint capsules, tissue necrosis may be present

Question 18

Braden scale

Answer 18

Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction/Shear

Question 19

Suspected deep tissue injury

Answer 19

Dark purple, non blanchable

Question 20

Unstageable

Answer 20

Eschar, unable to determine depth

Question 21

Specialty mattress indicators

Answer 21

• Patient is paraplegic or quadriplegic
• Skin breakdown on 2+ turning surfaces
• Stage 3 or 4 PU on bony prominence
• Altered level of consciousness/mentation/or inability to recognize painful stimuli or need to reposition self frequently
• NPO>72hrs
• poor nutrition
• albumin 10min in chair BID and NWB

Question 22

NP:ASSESSMENT

Answer 22

A-location and extent of tissue damage-measure
Pain, edema, redness, drainage, wound edges approximated
-inspect for bleeding, foreign bodies, associated injuries
-determine status of tetanus immunization

Question 23

NP:DIAGNOSIS

Answer 23

• risk for impaired skin integrity
• impaired skin integrity
• impaired tissue integrity
• risk of infection
• pain

Question 24

NP:PLAN

Answer 24

• Maintain skin integrity
• Demonstrate progressive wound healing
• Patient education

Question 25

NP: IMPLEMENTATION

Answer 25

• moist wound healing
• nutrition and fluid
• preventing infection
• positioning

Question 26

NP: EVALUATION

Answer 26

• Skin and tissue integrity maintained
• Wound decreases in size
• Demonstrates understanding of preventative care