11] Pressure Ulcers

Question 1

Etiology of pressure ulcers

Answer 1

Capillaries are occluded and the tissue around is has no oxygen or nutrition —> this turns into tissue hypoxia which leads to cell death

Question 2

Shear is?

Answer 2

Internal

Question 3

Major cause of undermining

Answer 3

Shearing

Question 4

Doing what causes increased shear forces

Answer 4

Elevating head of bed

Question 5

How do we stage pressure ulcers?

Answer 5

NPUAP which describes the deepest level of tissue destroyed

Question 6

Stage 1 pressure injury

Answer 6

Intact skin with non-blanchable redness

Question 7

Stage 2 pressure injury

Answer 7

Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed

Question 8

2 characteristics stage 2 pressure injuries can present as

Answer 8

Intact OR open/ruptured serum filled blister

Question 9

Stage 3 pressure injury

Answer 9

Full thickness- can see fat but BTM are not exposed;s slough may be present but does not obscure depth of tissue loss

Question 10

What stage does undermining and tunneling start in?

Answer 10

Stage 3 pressure injury

Question 11

Stage 4 pressure injury

Answer 11

Full thickness and you see MTB

Question 12

Stage 5 pressur einjury

Answer 12

Unstageable! Full thickness where base is covered by slough and/or Eschar

Question 13

Stage 6 pressure injury

Answer 13

Suspected deep tissue injury where its purple with intact skin or blood filled blister

Question 14

The area may be precededby tissue that is painful,

firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Answer 14

Stage 6- suspected deep tissue injury

Question 15

Pressure ulcer healing

Answer 15

Eschar —> slough —> granulation —> epithelialization

Question 16

What is a Kennedy terminal ulcer

Answer 16

Specific pressure ulcer characterized by rapid onset and rapid tissue breakdown — SKIN FAILURE

Question 17

When do Kennedy terminal ulcers develop

Answer 17

Within 2-4 weeks before dying

Question 18

Where does Kennedy terminal ulcers happen and what shape

Answer 18

Sacrum/coccyx and are pear or butterfly shaped that can be purple, red blue or black with irregular borders

Question 19

Patho fo Kennedy ulcer

Answer 19

Blood shunts away from skin to vital organs

Question 20

►Monitors healing or deterioration
►Uses minimal number of assessment parameters
►Reliable
►Easy to use

Answer 20

Documenting change : PUSH tool

Question 21

Stage 1 healing time

Answer 21

14 days

Question 22

Stage 2 healing time

Answer 22

45 days

Question 23

Stage 3 healing time

Answer 23

90 days

Question 24

Stage 4 healing time

Answer 24

120 days

Question 25

With PI you want to manage

Answer 25

Incontinence

Question 26

Cleansing interventions

Answer 26

Remove devitalized tissue and decerase bacterial burden

Question 27

Intervention- debride

Answer 27

Sharp Enzymatic Autolytic

Question 28

Intervention- dressings

Answer 28

Create moist environment for wound healing

Question 29

►Most commonly used pressure ulcer risk assessment

Answer 29

Braden

Question 30

6 subscales of Braden

Answer 30

``` Sensory perception Moisture Activity Mobility Nutrition Friction/shear ```

Question 31

Scoring for Braden

Answer 31

►Lower score = higher riskƒ ``` 15-18 = at risk ƒ13-14 = moderate risk ƒ10-12 = high risk ƒ<10 = very high risk ```

Question 32

Decreases interface pressure but not necessarily below capillary pressure

Answer 32

Pressure reduction

Question 33

Decreases of pressure below capillary pressures

Answer 33

Pressure relief

Question 34

do not move, reduce pressure by spreading load over large area

Answer 34

Static devices

Question 35

Use if a patient cannot assume a variety of positions without bearing weight on pressure ulcers, ƒ If pressure injury is not healing, or ƒ If patient fully compresses static support surface

Answer 35

Dynamic devices

Question 36

Use if a patient can assume variety of positions without bearing weight on existing pressure ulcer

Answer 36

Static devices

Question 37

Goes over foam or regular bed

Answer 37

Overlay

Question 38

Move; require motor to operate

Answer 38

Dynamic devices

Question 39

Series of connected air filled pillows with surface fabrics of low-friction material

Answer 39

Low air loss

Question 40

What PI would you use low air loss for?

Answer 40

Stage 3 or 4 on multiple turning surfaces

Question 41

Use when excessive moisture on intact skin; can dry skin and prevent pressure injury

Answer 41

Fluidized or high air loss (silicone coated glass beds that has air and fluid)

Question 42

Assessing performance of support surfaces

Answer 42

Bottoming out Bunching in gel mattress Deflating air mattress

Question 43

Standard repositioning measures in BED (6)

Answer 43

``` Every 2 hours while in bed 30 degree turns but keep pt off trochanter Float heels Pillows b/w bony prominences HOB less than 30 Donuts are DO NOTS ```

Question 44

Standard repositioning in chair

Answer 44

Every 30 min

Question 45

all pressure ulcers cases in an institution whether admitted with or occurring during the stay

Answer 45

Prevalence

Question 46

The new pressure ulcer cases developed within the institution

Answer 46

Incidence

Question 47

Heel ulcer prevention protected what structures

Answer 47

Peroneal nerve and Achilles’ tendon contracture

Question 48

Use what to prevent sacral pressure ulcers in ICU because it does what

Answer 48

Silicone based dressing b/c it reduces shear, friction and excess moisture

Question 49

Stage 1 treatment

Answer 49

Relieve pressure and protect the area

Question 50

Stage 2 pressure ulcer

Answer 50

Partial thickness- there isnt too much drainage and a thin film, hydrocolloid foam or gel can be used

Question 51

Stage 3/4 PI

Answer 51

Full thickness- depending on amount of drainage you could use hydrocolloid, foam, gel, or calcium alginate

Question 52

Treatment for necrotic tissue slough or Eschar

Answer 52

Enzymatic debridement

Question 53

If ulcer becomes infect, what might you do for dressing

Answer 53

Dressing with silver