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POM > Wound Management and Skin Care > Flashcards

Wound Management and Skin Care Flashcards

1
Q

RFs for developing pressure ulcers determining scale

A

Braden scale. The lower the score, the higher the risk

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2
Q

What are the 6 RFs for pressure ulcers?

A

sensory perception, moisture, activity, mobility, nutrition and shear and friction

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3
Q

Sensory perception

A

Specialty mattress, floating heels, padding footboard, seat cushions

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4
Q

Moisture

A

Barrier cream

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5
Q

Activity and Mobility

A

Special mattress, seat cushion, PT/OT eval

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6
Q

Nutrition

A

Dietitian, megace, swallow eval, psych, dental

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7
Q

Friction/shear

A

tilt R or L off back while HOB up , gatch knee on bed

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8
Q

What are B cells and A cells?

A

B cells- Inflated
A cells- Deflated
Alternating every 10 minutes

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9
Q

What abnormal vital sign is most likely to cause a PU?

A

Fever!

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10
Q

Purple on skin?

A

Necrosis

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11
Q

Evaluating wound status assessment criteria

A

Etiology
Staging (only if PU)
Woundbed character/color
Periwound skin

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12
Q

Venous ulcer

A

Edema in limb, hemosiderin staining, erythemic to purple to brown, never goes away, not over bony prominence

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13
Q

PU

A

Irregular shape, not punched out

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14
Q

Arterial

A

Very round, defined borders, tissue is necrotic (poor perfusion), punched out

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15
Q

PU

A

Localised injury to skin over bony prominence

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16
Q

SDTI

A

Suspected Deep Tissue Injury

17
Q

Can Shear and friction be called a PU?

A

No !!

18
Q

Where does shear and friction occur?

A

In a soft tissue area?

19
Q

Where does a PU occur?

A

Over a bone

20
Q

Exception to needing bony prominence

A

Skin contact with a hard object

21
Q

Purple ulcer

A

indicated deep tissue injury

22
Q

MASD?

A

Moisture Associated Skin Damage

23
Q

Can MASDs be confused for pressure ulcers?

A

Shallow break in crack due to moisture not pressure.

24
Q

Shallow crater in a cluster?

A

Viral. Possibly HSV

POM (4 decks)

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