pressure ulcers

Question 1

What is a localized injury to the skin and or underlying tissue, over a bony prominence as a result of pressure ?

Answer 1

Pressure ulcer

Question 2

Can you reverse stage an ulcer

Answer 2

Never

Question 3

What does a stage 2 pressure ulcer look like

Answer 3

pink, partial thickness and painful to touch

Question 4

how many hours of sustained pressure can the skin tolerate before tissue ischemia sets in.

Answer 4

2-6 hours

Question 5

What can cause a pressure ulcer

Answer 5

Pressure

Question 6

What does a suspected deep tissue injury look like ?

Answer 6

Intact skin that is purple or maroon in a localized area, can have a blood filled blister.

Question 7

What does a stage 4 pressure ulcer look like?

Answer 7

Full thickness tissue loss with bone, tendon and muscle exposed. Slough or escar in some areas of the wound bed. Have undermining and tunneling.

Question 8

Moisture of the skin can lead to

Answer 8

tissue softening and maturation

Question 9

What does a stage 3 pressure ulcer look like

Answer 9

full thickness tissue loss, subcuq fat can be visible No bone, tendon, or muscle are exposed. Slough present but does not obscure the depth of the tissue loss.

Question 10

For a stage 3/4 pressure ulcer what type of dressing?

Answer 10

1. For highly exudative wounds, use highly absorptive dressing or packing, calcium alginate 2. Wounds with necrotic debris must be debrided Debridement can be autolytic, mechanical (wet to moist), or surgical 3. Shallow, clean wounds can be dressed with hydrocolloid wafers, semipermeable foam, or polyurethane film 4. Deep wounds can be packed with gauze; if the wound is deep and highly exudative, an absorptive packing should be used

Question 11

Do you debried an escar wound?

Answer 11

No leave it alone.

Question 12

What would a stage 1 pressure ulcer look like?

Answer 12

Intact skin with nonblanchable redness of the localized area. over a bony prominence.

Question 13

What does a suspected deep tissue injury feel like on the skin?

Answer 13

painful to touch, firm , mushy skin, can be boggy, tissue can be warm or cooler can precede color change.

Question 14

name the body prominence that a pressure ulcer can occur.

Answer 14

elbow, inner knee, back of head, ears, lower back and buttocks, heels

Question 15

For a stage 2 pressure ulcer what type of dressing?

Answer 15

Hydrocolloid wafers Semipermeable foam dressing Polyurethane film

Question 16

What will a stage 1 pressure ulcer feel like on the skin?

Answer 16

Firm and painful to touch, warm or cooler then surrounding tissue .

Question 17

What are Extrinsic factors that can lead to a pressure ulcer

Answer 17

Shearing, frictional, moisture

Question 18

You can only stage a pressure ulcer wound if you can

Answer 18

visualize the wound base

Question 19

Stage 4 pressure ulcer increases the risk of

Answer 19

osteomyelitis

Question 20

For a stage 1 pressure ulcer or suspected deep tissue injury what type of dressing?

Answer 20

Polyurethane film Hydrocolloid wafer Semipermeable foam dressing

Question 21

increased hydro static pressure reduces?

Answer 21

arterial inflow leads to tissue ishemia

Question 22

Unstagable ulcer how would you treat it?

Answer 22

debride before deciding on further therapy

Question 23

Intrinsic factors that can lead to a pressure ulcer

Answer 23

nutritional debilitation, age, low B/P, stress, smoking, elevated body temp, miscellaneous factors

Question 24

Shearing forces lead to what type of pressure ulcer

Answer 24

full thickness ulcer

Question 25

How many stages for a pressure ulcer

Answer 25

5

Question 26

name the #1 and 2 areas for pressure ulcers

Answer 26

sacrum and heels

Question 27

How can nutritional debilitation lead to pressure ulcer formation

Answer 27

Low protein intake and albumin in the blood leads to poor wound healing.

Question 28

What would a stage 2 pressure ulcer look like ?

Answer 28

Partial thickness loss of the dermis presenting as a shallow open ulcer with a red pink wound bed without slough or bruising. Can be serum filled blister

Question 29

what is an unstageable ulcer

Answer 29

Wound bed is obscure ( can not see) covered with eschar.

Question 30

Frictional forces lead to what type of pressure ulcer

Answer 30

partial thickness

Question 31

For a heel ulcer with escar how would you treat ?

Answer 31

Do not remove eschar on heel ulcers because it can help promote healing (eschar in other locations should be debrided)

Question 32

do pressure ulcers have stages

Answer 32

yes