unit seven

Question 1

what is a pressure injury?

Answer 1

localized injury to skin and underlying tissue due to pressure or both pressure and shear; usually occurs over bony prominences

Question 2

how do you prevent pressure injuries?

Answer 2

1. pressure: turning schedule, redistribution
2. friction: lift rather than drag, pads between knees, heels and elbows
3. moisture: bowel and bladder program, moisturizures, protect skins from body fluids by absorption

Question 3

what does a stage 1 pressure injury look like?

Answer 3

• in epidermis
• skin is intact with non-blanchable erythema

Question 4

what does a stage 2 pressure injury look like?

Answer 4

• partial thickness loss with exposed dermis
• shallow open ulcer with red/pink wound without slough
• may be intact or open/ruptured serum filled/serousang blister
• adipose tissue is not visable

Question 5

what does a stage 3 pressure injury look like?

Answer 5

• full thickness tissue loss
• subQ tissue may be visible, but not tendons, fascia, cartilage, bones, or muscle
• may include undermining or tunneling

Question 6

what does a stage 4 pressure injury look like?

Answer 6

• full thickness tissue loss
• exposed bone, tendons, or muscle
• slough and eschar are present
• often includes tunneling or undermining

Question 7

what does a deep tissue pressure injury look like?

Answer 7

• intact or nonintact skin
• non blanchable deep red/maroon/purple discoloration
• epidermal separation revealing a dark wound bed or blood filled blister

Question 8

what does an unstageable pressure injury look like?

Answer 8

• injury cannot be staged because it is obscured by eschar or slough
• if slough/eschar is removed, a stage 3 or 4 pressure injury will be revealed

Question 9

what 6 categories does the braden scale assess?

Answer 9

1. sensory perception
2. moisture
3. activity
4. mobility
5. nutrition
6. friction and shear

the bigger the score, the lower the risk

Question 10

what are the two types of pain? what are the differences?

Answer 10

• acute pain is a response to an unpleasant stimuli/experience. it lasts from hours to a month
• chronic pain lasts longer than 3 months or past the time of normal tissue healing

Question 11

what are non-pharmacological pain management techniques?

Answer 11

• biologically based practices
• relaxation and guided imagery
• cutaneous stimulation
• physical movement
• spirituality and refelction