types of injuries

Question 1

where are pressure ulcers most commonly found and what causes them?

Answer 1

sacrum and heels
results from prolonged pressure or pressure in combination with shearing force
will generally heal by secondary intention

Question 2

what pathophysiological processes occur when a pressure ulcer is forming?

Answer 2

stop capillary flow to the tissues
deprives tissues of oxygen and nutrients
cell death aka tissue necrosis

Question 3

the influencing factors of pressure ulcers are what?

Answer 3

pressure intensity
pressure duration
tissue tolerance factors
shearing forces
moisture

Question 4

what things contribute to the ability of the tissues to tolerate pressure?

Answer 4

nutrition
perfusion
co-morbidities
condition of soft tissue

Question 5

list the factors that put people at risk for getting pressure ulcers

Answer 5

advanced age
anemia
diabetes
elevated body temperature
friction
immobility
incontinence
impaired circulation
low diastolic BP
mental deterioration
neurological disorders
obesity
pain
prolonged surgery
vascular disease

Question 6

ability to stage a pressure ulcer depends on what?

Answer 6

extent of tissues involved
visible or palpable tissue in the ulcer bed
national pressure ulcer advisory panel guidelines
presence of slough or eschar may prevent staging until it is removed

Question 7

what are characteristics of a deep tissue injury?

Answer 7

purple or maroon localized area of discolored intact skin or blood-filled blister
can be preceded by tissue that is painful, firm, mushy, and boggy
this indicates damage of underlying soft tissue from pressure or sheer

Question 8

what are the four things that you assess for in darker skin patients?

Answer 8

darker areas of skin surrounding the area being assessed
skin temperature of the affected area and the area surrounding
skin/tissue consistency
patient sensation; may report itchy or painful

Question 9

what categorizes a stage 1 pressure ulcer?

Answer 9

intact skin that is nonblanchable in a localized area
may be painful, soft, firm, warmer, or cooler compared to adjacent tissue

Question 10

what categorizes a stage 2 pressure ulcer?

Answer 10

partial-thickness loss of dermis
shallow open ulcer with red/pink wound bed
intact or rupture serum-filled blister
shiny or dry shallow ulcer without sloughing or bruising
fat tissue, granulation tissue, slough, and eschar arent present

Question 11

what categorizes a stage 3 pressure ulcer?

Answer 11

full-thickness skin loss
subcu tissue may be visible but bone, tendon, or muscle are not
presents as deep crater with possible undermining or adjacent tissue

Question 12

what categorizes a stage 4 pressure ulcer?

Answer 12

full-thickness loss extends to muscle, bone, or supporting structures
bone,tendon, or muscle may be visible or palpable
undermining and tunneling may occur
slough or eschar may be present on some parts of the wound bed

Question 13

unstageable ulcers can be categorized by what factors?

Answer 13

full-thickness tissue loss in which actual depth or ulcer is completely obscured by slough or eschar in wound bed
slough or eschar must be removed to expose the base of the wound in order to stage
stable, dry eschar on heels should not be removed

Question 14

An unstageable ulcer can have slough present, what does slough look like?

Answer 14

yellow
tan
green
gray
brown

Question 15

an unstageable ulcer can have eschar present, what does eschar look like?

Answer 15

tan
brown
black

Question 16

what can some complications be of pressure ulcers?

Answer 16

infection
repeat ulcers
repeat pressure injury/tissue breakdown
cellulitis

Question 17

infections can cause complications in pressure ulcers but what type of infections can occur?

Answer 17

leukocytosis
fever
increased ulcer size, odor, or drainage
necrotic tissue
indurated, warm, and painful

Question 18

what can cause cellulitis and what can cellulitis cause?

Answer 18

untreated ulcers
spread of inflammation/infection to subcutaneous tissue, connective tissue, and bone
thus leading to sepsis and death

Question 19

prevention measures for pressure ulcers involve what?

Answer 19

redistribution of pressure
keep skin dry (apply barrier ointment if incontinence)
reposition the drawsheet/transfer board, position patient at 30 degrees lateral position, HOB at 30 degrees or less
turning schedule
nutrition and fluid intake

Question 20

what are some surgical treatments if the pressure ulcer gets bad enough?

Answer 20

skin graft
skin flap
musculocutaneous flaps

Question 21

how does the skin appear if an arterial ulcer is present?

Answer 21

thin
shiny
dry
loss of hair on ankles and feet
even wound margins
pale deep wound bed

Question 22

where can aterial ulcers be found?

Answer 22

between toes or on tips of toes
on phalangeal head
lateral malleous
or any area with rubbing footwear

Question 23

what causes arterial uclers?

Answer 23

ischemia and nutrition deprivation as a result of decreased circulation

Question 24

what patients are at a higher risk of getting arterial ulcers?

Answer 24

atherosclerosis
PVD
diabetes
smoking
hypertension
advanced age
obese
cardiovascular disease

Question 25

how do you treat arterial ulcers?

Answer 25

stents to treat ischemia
topical treatments to help heal the ulcer

Question 26

what causes a venous ulcer to form on a patient?

Answer 26

occurs when blood can not flow upward from veins in the legs
chronic venous insufficiency occurs whenever valves are damaged, allowing blood to lean backwards

Question 27

what patients are at a high risk for getting venous ulcers?

Answer 27

pregnant
deep vein thrombosis
pregnancy
imcompetent valves
cognitive heart failure
muscle weakness
advanced age
family history
obesity

Question 28

how do venous ulcers present on a patient?

Answer 28

found in lower legs
irregular wound margins with superficial ruddy granular tissue
surround skin will be red, scaly, weepy, and thin

Question 29

what therapy(s) could be used to help from getting venous ulcers?

Answer 29

compression therapy
it promotes blood return thus preventing blood from pooling

Question 30

what are some common causes of diabetic ulcers?

Answer 30

peripheral neuropathy
fissures in skin
decreased ability to fight infection
diabetic foot deformities

Question 31

where on the body would you find diabetic ulcers?

Answer 31

plantar aspect of the foot
over metatarsal heads
under heels and on toes

Question 32

how do diabetic ulcers present themselves?

Answer 32

even wound margins
painless
rounded or oblong shape with surrounding callous

Question 33

what are some treatments for diabetic ulcers?

Answer 33

removing stress/pressure from the injured site
debriding wound
antibiotics if infection occurs

Question 34

clinical manifestations of cellulitis would include..

Answer 34

hot, tender, erythematous area with diffuse borders
chills, malaise, and fever

Question 35

what are treatments for cellulitis?

Answer 35

MOIST heat, elevation, immobilization
systemic antibiotic therapy
hospitalization if sever enough infection
progression to gangrene if left untreated

Question 36

what are the two most common microorganims that cause the infection in cellulitis?

Answer 36

staph and strep

Question 37

what can be used for skin and soft tissue infections?

Answer 37

cephalosporins
some penicillins
carbapenems
vancomycin
clindamycin
linezolid
daptomycin
levofloxacin

Question 38

what are treatments for psoriasis?

Answer 38

topical treatments
systemic treatments
phototherapy - coal tar

Question 39

what are the two processes of psorasis?

Answer 39

accelerated maturation of epidermal cells
excessive activity of inflammatory cells