Week 6 - Pressure Ulcers

Question 1

What is the etiology (cause) of pressure ulcers? (4)

Answer 1

1. Pressure - skin and soft tissue compressed
2. Shearing force - skin stationary, tissue below moves
3. Friction - surfaces rub the skin
4. Excessive moisture

Question 2

What are the risk factors of pressure ulcers? (4)

Answer 2

• loss of mobility
• confusion
• poor nutritional status
• dehydration

Question 3

ISTAP Skin Test Classification DIagrams + types of skin tears

Answer 3

• Shearing: loss of collagen (frail tissue or skin)
• brunt force

Question 4

DIagram for pressure points for pressure ulcers/sores, bedsores, and decubitus ulcers. Where are you most likely to see ulcers?

Answer 4

• over bony prominence
• ie underweight people more likely to get it

Question 5

What is a stage 1 pressure ulcer?

Answer 5

• intact skin with non-blanchable redness of a localized area, usually over a bony prominence

Question 6

What is a stage 2 pressure ulcer? (2)

Answer 6

• partial thickness loss of dermis presenting as a shallow open ulcer with a red pink moist wound bed, without slough
• may also present as an intact or open/ruptured serum-filled blister

Question 7

What is a stage 3 pressure ulcer? (2)

Answer 7

• full thickness tissue loss
• subcutaneous fat may be visible, but bone, tendon or muscle are not exposed

Question 8

What is a stage 4 pressure ulcer?

Answer 8

Full thickness tissue loss with exposed bone, tendon, or muscle (can see underlying tissue)

Question 9

What is an unstageable pressure ulcer?

Answer 9

• full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is so obscured by slough or eschar

Question 10

What is suspected deep tissue injury pressure ulcers?

Answer 10

• a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Question 11

What is exudate?

Answer 11

fluid that leaks out of blood vessels into nearby tissues

Question 12

What are the 4 types of wound drainage or exudate?

Answer 12

• serous
• serosanguineous
• sanguineous
• purulent

Question 13

What is serous fluid? (2)

Answer 13

• clear, watery plasma
• WNL: expected with wound healing

Question 14

What is serosanguineous fluid? (3)

Answer 14

• pale, red, watery
• mixture of clear and red fluid (blood)
  WNL - expected with wound healing

Question 15

What is sanguineous fluid? (2)

Answer 15

• bright red
• active bleeding

Question 16

What is purulent fluid?

Answer 16

• thick, yellow, green, tan or brown
• possible infection