Pressure Ulcers Quiz Flashcards
What are the 6 risk factors of the Braden Scale?
Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear
What is the score range of the Braden Scale?
Lowest is 6 (severe), Highest is 23 (mild)
What are local factors affecting wound healing?
Pressure, Desiccation, Maceration, Trauma, Edema, Infection, Necrosis
What are the systemic factors affecting wound healing?
Age, Circulation, oxygenation, nutrition and fluid, medications, immunosuppression
What is necessary for pressure ulcer Tx?
Moist wound healing, reducing the pain for dressing changes, reducing the pressure in the area, re-positioning the patient.
How can you relieve pressure on the food and bony areas?
Float heels off the bed w/ pillows, use pillows b/w knees and ankles; use waffle boot; DON’T use rolled towel at Achilles.
How can you protect skin from moisture?
Clean and dry skin after each incontinence; don’t use diapers, change sheets when needed due to perspiration, establish bowel and bladder program for incontinent pt
How can you protect skin from friction and shear?
Use lift sheet to turn or transfer pt; maintain head of bed at or below 30 degrees; use a pressure reducing cushion for sitting (not a donut ring b/c it creates venous congestion)
What should a chair bound pt do to reduce pressure?
Teach them to shift weight every 15 minutes; if they can’t reposition pt every hour; provide a pressure reducing device and tell them to rock side to side or move their legs)
What is the definition of a pressure ulcer?
a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.
Causes of Pressure uclers?
Pressure, Shear, Friction, Moisture
What is stage 1 pressure ulcer?
intact skin w/ nonblanchable redness
What is stage 2 pressure ulcer?
partial thickness loss of dermis, shallow open ulcer w/ red pink wound bed WITHOUT SLOUGH (can also be an intact or open/ruptured serum-filled blister)
What is stage 3 pressure ulcer?
full thickness tissue loss, fat may be visible, slough may be present but doesn’t obscure the depth of tissue loss
What is stage 4 pressure ulcer?
full thickness tissue loss, EXPOSED bone, tendon or muscle
What is an unstageable ulcer?
Means the base has slough or eschar so depth and stage can’t be determined.
What is eschar?
cornified or dried out dead tissue; tan, brown, black
What is slough?
liquefied or wet dead tissue; white, yellow, light tan (its leathery)
What is undermining?
bigger area of tissue destruction than can be seen (extends under the edge which is a little raised)
What is tunneling?
Tracts extending out from the wound.
What is maceration?
cells are overly hydrated, moist skin (usually with urinary and fecal incontinence)
What is desiccation?
cells dehydrate and die in dry environment
How can an infections affect wound healing?
the bacteria in the wound stresses the body and energy spent to fight the microorganisms instead of repairing/healing
What does it mean if the area doesn’t blanch?
Then the oxygen has already been removed.
Suspected deep tissue injury looks like what?
purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
What is unique about moisture wounds?
They are usually linear (like down the gluteal cleft from incontinence)
How do you measure wounds?
LxWxD (in centimeters)
Length is 12 o’clock to 6 o’clock
Width is 3 o’clock to 9 o’clock
Depth- bottom of wound bed to wound edge
What does a wound assessment tell you?
it determines the status of the wound, barriers to healing, and signs of complication
How do you assess a wound?
Inspect (sight and smell); palpate (appearance, drainage, odor and pain)
What are the 4 types of drainage?
Drainage is an inflammatory response due to fluid and cells escaping the blood vessels.
SEROUS- clear
SANGUINEOUS- contains RBCs
SEROSANGUINEOUS- clear and RBCs (pinkish)
PURULENT- contains WBCs (thick yellow/white)
How do you clean a linear wound like incision?
Wipe top to bottom in one motion–start directly over wound and move outward 4-2-1-3-5
How do you clean an open wound like ulcer?
wipe in concentric circles, starting directly over the wound and moving outward
Which kind of wounds are sterile, and which are clearn?
Surgical wounds are sterile cleaning. Pressure ulcers are clean wound cleaning.
What are 4 types of wound complications?
Infection, hemorrhage, dehiscence (wound opens), evisceration (organ protrudes through the wound)
Heat effects
dilates peripheral blood vessels, increases local blood flow, reduces muscle tension, reduces pain
Cold effects
constricts peripheral blood vessels, reduces muscle spasms, produces numbness, promotes comfort (decreasing the local release of pain-producing substances like histamine, serotonin, bradykinin)
Anything that has heat or cold should….
not have that applied to it.
What should orders include?
type of application, area to be treated, frequency and duration
