Units 1-5

Question 1

What is the Braden scale used for?

Answer 1

Pressure Ulcer Risk

Question 2

Ranges of Braden scale?

Answer 2

10-12 high, 13-14 moderate, 15-18 mild… lower the number higher the risk

Question 3

How many Gordon’s Functional Patterns are there?

Answer 3

11

Question 4

What Stage of a pressure ulcer is this?

-non-blanchable erythema with intact epidermis
- reddened unbroken skin
- may look different for darkly pigmented skin

Answer 4

Stage One

Question 5

What Stage of a pressure ulcer is this?

• partial thickness skin loss
• involves the epidermis, dermis or both
• superficial, shallow ulcer or blister

Answer 5

Stage 2

Question 6

What Stage of a pressure ulcer is this?

• full thickness skin loss extending through the underlying fascia, bone, tendon, or muscle
• deep crater with or without undermining

Answer 6

Stage 3

Question 7

What Stage of a pressure ulcer is this?

• full thickness skin loss extending through the underlying fascia involving underlying muscles, tendon or bone

Answer 7

Stage 4

Question 8

What Stage of a pressure ulcer is this?

when you cannot see the wound bed and needs debriding first

Answer 8

Unstageable

Question 9

What is a PUSH tool for?

Answer 9

Pressure Ulcer Scale for Healing. Used to assess length, width and depth, tissue type, amount of exudate, undermining, tunneling

Question 10

What is Debridement

Answer 10

Removal of necrotic tissue/nonviable tissue that interferes with wound healing

Question 11

What are the 4 methods of Debridement

technically 5

Answer 11

• surgical(scalpel)
• mechanical (whirlpool, irrigation, wet to dry)
• biological (maggot therapy)
• chemical (topical application of enzymes)
• autolytic – synthetic dressings used over eschar to be self-digested by action of enzymes

Question 12

What does NERDS stand for?

Answer 12

N: NON-HEALING WOUND
E: EXUDATE
R: RED AND BLEEDING
D: DEBRIS
S: SMELL