Wound Care: Pressure Injuries

Question 1

pressure injury

Answer 1

areas of localized tissue destruction/damage caused by compression of soft tissue over a bony prominence and an external surface for prolonged period of time

Question 2

3 examples/ names of pressure injuries

Answer 2

bedsore
decubitus ulcer
pressure sore

Question 3

any surgery over _____ hours increases the risk of developing pressure injuries

Answer 3

3

Question 4

why are pediatrics at higher risk of pressure injuries

Answer 4

they outgrow devices

Question 5

T or F: patients with diabetes have a higher risk of pressure injuries

Answer 5

T

Question 6

physiology of pressure injuries

Answer 6

compression > vascular insufficiency > tissue anoxia > cell death

Question 7

how quickly can deformation of skin happen

Answer 7

10s of minutes

Question 8

how quickly can ischemia of the skin happen

Answer 8

several hours

Question 9

T or F: moisture and impaired circulation increases risk of pressur einjury

Answer 9

T

Question 10

the use of _____ drugs increases the risk of pressure injuries

Answer 10

inotropic

Question 11

4 forces related to pressure injuries

Answer 11

1 - pressure
2 - shear
3 - friction
4 - moisture

Question 12

the ____ the bend, the more pressure you get in the sacral region

Answer 12

higher

Question 13

common locations for pressure injuries

Answer 13

• sacrum/coccyx
• ischial tuberosity
• heels
• trochanters
• posterior head

Question 14

posterior head pressure injuries are more common in what population

Answer 14

pediatrics

Question 15

what does the braden scale predict

Answer 15

pressure ulcer risk

Question 16

class 1 pressure relief device

Answer 16

simple pressure pad devices (gel overlays, foam mattresses)

Question 17

what are class 1 pressure relief devices used

Answer 17

• a patient who cannot turn/move themselves to relieve pressure
• pts who have a pressure injury on pelvis or trunk

Question 18

class 2 pressure relief device

Answer 18

• relieves pressure over bony prominences for sustained periods of time
• renaissance mattress, flotation mattress

Question 19

when are class 2 pressure relief devices used

Answer 19

• pts with multiple pressure injuries that are not improving
• pts with large stage 3/4 pressure injuries

Question 20

class 3 pressure relief device

Answer 20

• advanced pressure relief device… air fluidized bed
• clinitron bed

Question 21

when are class 3 pressure devices used

Answer 21

• when a conservative treatment plan has failed after 30 days

Question 22

T or F: you do not have to turn pts if they are using a pressure relief device

Answer 22

false

Question 23

how should you encourage a pt to sleep unless it is contraindicated

Answer 23

with head of bed less than 30 degrees

Question 24

time when up in chair should be limited to ____ hours per episode

Answer 24

1-2

Question 25

how to help manage moisture to prevent pressur einjuries

Answer 25

- only use an underpad if needed - only use adult diapers when out of bed - make sure to cleanse pt well if they have incontinence and apply a moisture barrier

Question 26

T or F: the heels should be floated at ALL times

Answer 26

T

Question 27

patients should be repositioned every ____ hours

Answer 27

2

Question 28

when positioning in sidelying, you should do a _____ degree lateral turn

Answer 28

30 *stay off bony prominences *you should be able to visibly see that a pt is turned

Question 29

self-pressure relief options

Answer 29

- boosting - leaning forward - weight-shift - recline - standing/walking

Question 30

why is boosting not ideal for most pts

Answer 30

you have to boost for at least 2 minutes to make a difference and that's hard!

Question 31

why is it important to lift the heels when transferring a pt?

Answer 31

transfer sheets usually do not go all the way to the heels so that can cause friction when transferring

Question 32

deep tissue pressure injury

Answer 32

persistent non-blanchable deep red, maroon, or purple discoloration

Question 33

stage 1 pressure injury

Answer 33

- skin is intact with a localized area of non-blanchable erythema - color changes do not include purple or maroon discoloration

Question 34

stage 2 pressure injury

Answer 34

- partial thickness loss of skin with exposed dermis - wound bed is viable and may also present as a blister - no fat or deeper tissues visible, no slough or eschar

Question 35

if a pressure injury has any depth it is past a stage _____

Answer 35

2

Question 36

stage 3 pressure injury

Answer 36

- full thickness loss of skin in which adipose is visible in the ulcer and granulation tissue and epibole are often present - may have slough or eschar - no muscle/tendon/lig are exposed

Question 37

if slough or eschar obscures the extent of tissue loss the wound it _____-

Answer 37

unstageable

Question 38

stage 4 pressure injury

Answer 38

- full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, lig, cartilage, or bone in the ulcer - epibole, undermining, or tunneling often present - slough or eschar may be visible

Question 39

can mucosal membrane pressure injuries be staged

Answer 39

no, due to the anatomy

Question 40

T or F: you can back stage a pressure injury

Answer 40

F: for example, a stage 4 is always a stage 4. It can be a healing stage 4 or a healed stage 4

Question 41

you can assign _____ stage to a pressure injury

Answer 41

one

Question 42

how to treat pressure injuries

Answer 42

1 - reduce/eliminate pressure 2 - reduce friction/shear 3 - ther-ex 4 - ADLs 5 - manage incontinence 6 - nutrition 7 - bedrest is NOT the answer