Pressure Ulcers

Question 1

Stage I pressure Ulcer

Answer 1

Non blanchable erythema that persists > 30 min after removal of pressure, intact skin.
Discoloration of skin, warmth, edema (may be first signs in those with darker skin)

Question 2

Stage II pressure Ulcer

Answer 2

Partial thickness skin loss involving epidermis, dermis, or both
Superficial ulcer: abrasion, blister or shallow crater

Question 3

Stage III pressure Ulcer

Answer 3

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia

Question 4

Stage IV pressure Ulcer

Answer 4

Full thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, or supporting structures (tendon, joint, capsule)

Question 5

Risk assessment scales

Answer 5

Braden, Norton, RAPS scale

Question 6

Norton Scale Factors

Answer 6

Physical condition, mental condition, activity, mobility, incontinence

Question 7

Factors in all

Answer 7

general physical condition, mental state, activity, mobility, incontinence, food intake, fluid intake, nutritional status, moisture, sensory perception, friction and shear, skin type, bodily constitution, body temperature, serum albumin.

Question 8

Pressure Ulcer Prevention

Answer 8

Skin care, pressure relief, reducing shear forces with transitional movements.
Nutritional status, cognitive status, tone status.