Pressure Ulcers

Question 1

Any lesion caused by unrelieved pressure resulting in damage to underlying tissue

Answer 1

pressure ucler

Question 2

What is the path that leads to a pressure ulcer?

Answer 2

Compression of soft tissue –> decreased tissue blood supply vascular insufficiency –> tissue anoxia –> cell death

Question 3

What are risk factors for pressure ulcers?

Answer 3

1. Pressure(perpendicular force)/ Shear (parallel force)/ Friction
2. Excessive moisture
3. Impaired mobility
4. Malnutrition - low serum albumin levels for building and repairing tissue
5. Impaired sensation
6. Advanced age
7. History of pressure ulcer

Question 4

Where are pressure ulcers most commonly located?

Answer 4

Majority on lower half of body over boney prominence

1. Sacrum
2. Greater trochanter
3. ischial tuberosity
4. posterior calcaneus
5. lateral malleolus

Question 5

What is the standard for changing positioning in lying down and sitting?

Answer 5

every 2 hours lying down

every 15 minutes when sitting

Question 6

What stage? intact skin with non-blanchable redness of localized area usually over a bony prominence; darkly pigmented skin may not have visible blanching; its color may differ from the surroundings

Answer 6

Stage 1

Question 7

What state? loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough; may also present as intact or open/ ruptured serum-filled blisters

Answer 7

Stage 2

- partial thickness

Question 8

What stage? subcutaneous fat may be visible but bone, tendon or m’s are not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunnelling

Answer 8

Stage 3

- full thickness tissue loss

Question 9

What stage? Tissue loss with exposed tendon or muscle; slough or eschar may be present on some parts of the wound bed; often includes undermining tunneling

Answer 9

Stage 4

- full thickness tissue loss with exposed tendon or m

Question 10

What stage? Full thickness tissue loss in which the base of the ulcer is covered by slough, and/or eschar in the wound bed

Answer 10

Unstagable

Question 11

What would warrant a suspected deep tissue injury

Answer 11

• purple or maroon localized area of discolored intact skin
• blood filled blister due to damage of underlying soft tissue from pressure and/or shear
• area may be preceded tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue