VN125 Clinical FON Chp 18 Pressure ulcers

Question 1

Care of Skin

Answer 1

Observe color, texture, thickness, turgor, temperature and hydration.

7 P’s (Pulse, Pallor,

Normal skin has the following characteristics:

• In tact without abrasions
• Warm and moist
• Localized changes in texture across surface
• Good turgor (elastic and firm) smooth and soft
• Skin color variations from ody part to body part

Question 2

Suspected deep tissue injury

Answer 2

Wound appears locatlized purple or maroon area of discolored, intact skin or a blood-filled blister. Caused by underlying soft tissue damage from puressure and or shear forces.
Painful, firm, mushy, boggy, or warm to cool compared to adjacent tissue.

Question 3

Stage 1 pressure ulcer

Answer 3

Intact nonblanchable erythema (redness).

Color differs from surrounding area.

Question 4

Stage 2 pressure ulcer

Answer 4

Partial thickness loss of dermis, shallow open ulcer, usually shiny or dry with red-pink wound bed without slough or bruising.
Intact or open serum filled blisters.

Question 5

Stage 3 pressure ulcer

Answer 5

Full thickness tissue loss in which dubcut fat is cometimes visible.
Undermining and tunneling possible.

Question 6

Stage 4 pressure ulcer

Answer 6

Full tissue thickness loss with exposed bone, tendon or muscle. Sometimes slough or eschar present on some parts of the wound bed.

Question 7

Unstageable pressure ulcer

Answer 7

Full thickness tissue loss, wound base covered by slough (yellow, tan, gray, green or brown) and/or eschar in the wound bed that will usually be tan, brown or black.

Question 8

Pressure ulcer points

Answer 8

Occiput (Back of head)
Scapulae (Shoulder blades)
Thoracic vertabrae (T1-T12)
Elbows
Sacrum (lower back)
Coccyx (tail bone)
Iliac crest (upper hip bones)
Ischial tuberosities (groin)
Greater trochanters (lower hip)
Medial knees
Lateral knees
Medial Malleoli (inner ankel)
Lateral malleoli (outer ankel)
Calcaneus (heel)

Question 9

10 interventions to prevent pressure ulcers

Answer 9

1- Turn q2hrs
2- Pressure relieving devices (mattress)
3- Body alingment
4- Limit char sitting to no longer than 1 hour
5- Encourage ambulation
6- Massage around affected area
7- Clean dry, moisturized skin especially around boney prominences
8- Encourage adequate nutrition and hydration
9- Use lift sheets to move pt. in bed
10- Leave blisters intact by warpping in guaze or applying hydrocolloid dressing

Question 10

Risk factors for pressure ulcers

Answer 10

1- Extremes of age
2- Immobility 
3- Poor nutrition
4- Mechanical forces
5- Pronounced boney prominences
6- Incontinences (enzymes in stool, acid in urine)
7- Poor circulation (lack of oxygen and nutrients to skin)
8- Edema 
9- Altered sensation 
10- Environmental moisture

Question 11

Braden Risk assessment scale

Answer 11

Sensory perception (ability to respond to meaningfuly to pressure, related to discomfort
Moisture (degree to which skin is exposed to moisture)
Activity (degree of physical activity)
Mobility (ability to change and control body position)
Nutrition (usual food intake pattern)
Friction and shear

Score 15-16= low risk; 13-14= moderate risk; 12 or less= high risk.