Wounds and pressure ulcers

Question 1

abrasions

Answer 1

trauma to the skin resulting in a breakage (often caused by a fall, sliding impact)

Question 2

punctures

Answer 2

small holes in the skin, allowing air passage into the wound

Question 3

bites

Answer 3

insect, animal, human

Question 4

surgical wounds

Answer 4

incisions, resections, grafts, ampulations

Question 5

pressure injuries

Answer 5

prolonger exposure to pressures

Question 6

traumatic wounds

Answer 6

burns, thermal, gunshot, devolving, compression, crash

Question 7

venous stasis ulcers

Answer 7

poor lower extremity circulation, varicose veins

Question 8

arterial ulcers

Answer 8

from damage to arteries due to lack of blood flow to tissue

Question 9

diabetic ulcer

Answer 9

high prevalence
from diabetes
commonly on bottom of foot

Question 10

factors that predispose formation of decubitus ulcers

Answer 10

bed sores!

• immobility, weight loss or gain, edema, incontinence, dec sensation, dec circulation, dehydration, age related skin changes

Question 11

etiology and risks

Answer 11

pressure, dec circulation leading to necrosis
on bony prominences
intensity and duration determine severity

Question 12

stage 1 pressure ulcer

Answer 12

• skin intact, non blanch able redness
• may be a different temp or itchy

Question 13

stage 2 pressure ulcer

Answer 13

• involves the dermis with partial thickness loss
• a shallow open ulcer than can be shiny to dry
• wound bed is pink/red without slough or bruising
• can also be a blister that ruptures

Question 14

stage 3 pressure ulcer

Answer 14

• full thickness tissue loss
• depth is not insured if slough (necrosis) is present
• bone/tendon/muscle are not exposed

Question 15

stage 4 pressure ulcer

Answer 15

• full thickness tissue loss with bone, tendon, or muscle visible or directly palpable
• osteomyelitis is possible

Question 16

unstageable pressure ulcers

Answer 16

full thickness tissue loss, slough, scar which covers the base of the ulcer

Question 17

wound management

Answer 17

occlusive dressings, debridement, surgery, grafting

Question 18

evaluation

Answer 18

• skin integrity
• risk factors
• non medical settings: may do more (inspect and measure, document, infection, pain scale, change dressings, healing progress)

Question 19

re-eval

Answer 19

low risk: whenever there is a change in their status
high risk: every 12 hours

Question 20

intervention

Answer 20

• wound management and cleaning, clothes/footwear, sleep, activity, bed mobility and positioning, PREVENTION and education
• equipment: w/c cushions
• train individual and caregivers on weight shifting

Question 21

weight shifting

Answer 21

• full push ups, lateral leans, forward leans, w/c tilts
• occur every 30 min for 30 sec or every 60 min for 60 sec
• incorporate in daily activities

Question 22

skin checks

Answer 22

• keep skin free of excessive moisture, dryness, heat
• check 2x/day
• look at bony prominences
• fluids and nutrition to promote healing
• mirror