Test 4--Chapter 36 Pressure Ulcers Flashcards
Where do pressure ulcers usually occur?
over bony prominences
What are common causes of pressure ulcers?
friction
shearing
pressure
What force scrapes the skin, causing an open area?
Friction
What is shear force?
The skin sticks to a surface while deeper tissues move downward.
- This occurs when the person slides down in the bed or chair.
CMS has standards about pressure ulcers.
- Nursing centers must evaluate each person’s condition and pressure ulcer risk factors.
- Identify and implement a comprehensive ____ ____ and measures that meet the resident’s _____ and goals.
- The care plan must include measure to _______ or _______ a person’s risk factors.
- Centers must _______ and evaluate the effect of these measures and _______ measures as needed.
- Residents with a pressure ulcer must receive the necessary treatment and services to promote healing, prevent ________, and prevent new _____ from developing.
CMS has standards about pressure ulcers.
- Nursing centers must evaluate each person’s condition and pressure ulcer risk factors.
- Identify and implement a comprehensive care plan and measures that meet the resident’s needs and goals.
- The care plan must include measure to reduce or remove a person’s risk factors.
- Centers must monitor and evaluate the effect of these measures and revise measures as needed.
- Residents with a pressure ulcer must receive the necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing.
Risk factors for pressure ulcers include:
- Breaks in the ____
- Poor _____ to an area
- Moisture
- Dry skin
- Irritation by _____ and feces
Risk factors include:
- Breaks in the skin
- Poor circulation to an area
- Moisture
- Dry skin
- Irritation by urine and feces
When should you report any signs of skin breakage or pressure ulcers?
immediately
Persons at risk for pressure ulcers are:
- Are ______ or chairfast
- Need some or total help in ______
- Are agitated or have involuntary muscle movements
- Have loss of ______ or bladder control
- Are exposed to _____
- Have poor nutrition or poor fluid ______
- Have lowered _____ awareness
- Have problems sensing ____ or pressure
- Have circulatory problems
- Are older
- Are _____ or very thin
- Refuse care. A resident’s right to refuse treatment
- Have a healed Stage 3 or 4 pressure ulcer
Persons at risk for pressure ulcers are:
- Are bedfast or chairfast
- Need some or total help in moving
- Are agitated or have involuntary muscle movements
- Have loss of bowel or bladder control
- Are exposed to moisture
- Have poor nutrition or poor fluid balance
- Have lowered mental awareness
- Have problems sensing pain or pressure
- Have circulatory problems
- Are older
- Are obese or very thin
- Refuse care. A resident’s right to refuse treatment
- Have a healed Stage 3 or 4 pressure ulcer
What stage pressure ulcer is this?
The skin is red in persons with light skin. The skin is red, blue, or purple in persons with dark skin
Stage 1
What stage pressure ulcer is this?
Partial-thickness skin loss; it may involve a blister or shallow ulcer
Stage 2
What stage pressure ulcer is this?
Full-thickness skin loss; subcutaneous fat may be exposed. Slough may be present
Stage 3
What stage pressur ulcer is this?
Full-thickness tissue loss with muscle, tendon and bone exposed and damaged. Slough and eschar may be present.
Stage 4
What stage pressure ulcer is this?
Full-thickness tissue loss with the ulcer covered by slough and/or eschar.
unstageable
•dead tissue that is shed from the skin.
Usually light colored (yellow, tan, gray, green, or brown), soft, and moist, it may be stringy at times.
Slough
thick, leathery dead tissue that may be loose or adhered to the skin; it is tan, brown, or black.
eschar
