Skin Integrity: Power Point: Ulcers

Question 1

Localized injury to the skin, usually over a bony prominence, as a result of pressure, or pressure in

Answer 1

pressure ulcer

Question 2

any force that causes slippage between a pair of contiguous articulated parts in a direction that parallels the plane in which they contact

Answer 2

shear

Question 3

The rubbing of one object or surface against another

Answer 3

friction

Question 4

the scope of ulcer problems annually

Answer 4

1,000,000 new ulcers
$6 billion
2.2 million medicare days

Question 5

extrinsic factors of pressure ulcers

Answer 5

excessive uniaxial pressure, friction or shear forces, impact injury, heat, moisture, posture, incontinence

Question 6

intrinsic factors of pressure ulcers

Answer 6

immobility, sensory loss, age, disease, body type, poor nutrition, infection, incontinence

Question 7

Incontinence is both

Answer 7

extrinsic and intrinsic factor

Question 8

wound assessment checklist

Answer 8

Location
Stage
Drainage (amount, color, odor)
Size
Pressure redistribution
Viable tissue in wound
Dressing used
Nutritional assessment (albumin)
Undermining/Tunneling

Question 9

Topical Treatment

Answer 9

Damp to dry (debridement)
Nutrient rich salves
Hyperoxygenation
Wound Vac

Question 10

Surgical Treatment

Answer 10

Debriedment

Skin grafts

Question 11

Prevention of Pressure Ulcers

Answer 11

Braden Scale Assessments

Question 12

Braden Scale Assessment includes measuring of….

Answer 12

Sensory perception
Moisture contact
Activity
Nutrition
Friction & Shear

Question 13

Do the Braden Scale Assessment….

Answer 13

Every patient, Every Shift

Question 14

Scoring of the Braden Scale

Answer 14

rated 1-4 (shear 1-3)
19-23 – no risk
15-18 – low risk
13-14 – moderate risk
10-12 – high risk
<9 – very high risk

Question 15

moderate risk (13-14)`

Answer 15

frequent turning
facilitating maximal remobilization
protecting the patient’s heels
providing a pressure-reducing support surface
providing foam wedges for 30-degree lateral positioning
managing moisture, nutrition, and friction and shear.

Question 16

high risk (10-12)

Answer 16

increases the frequency of turning
supplements turning with small shifts in position
facilitates maximal mobilization
protects the patient’s heels
provides a pressure-reducing support surface;
provides foam wedges for 30-degree lateral positioning
manages moisture, nutrition, and friction and shear

Question 17

very high risk (9 or below)

Answer 17

Add a pressure-relieving surface if the patient has intractable pain, severe pain exacerbated by turning, or additional risk factors such as immobility and malnutrition.
A lowair-loss bed is no substitute for a turning schedule.

Question 18

High Risk Sites

Answer 18

Bony Prominence
Occiput 
Ear~
Scapula
Elbow
spinous process
Sacrum
Heel
malleolus
pretibial crest
knee
trochanter
chin

Question 19

Preventative Measures

Answer 19

Adequate hydration/nutrition
Pressure reducing devices
Client/family/staff support
Improve activity
Specialty mattresses
Keep skin dry and clean