Chapter 36 Pressure injuries

Question 1

Bony prominence

Answer 1

an area where the bone sticks out or projects from the flat surface of the body
pressure point

Question 2

Intact skin

Answer 2

Normal skin and skin layers without damage or breaks

Question 3

Pressure injury

Answer 3

localized damage to the skin and underlying soft tissue, the injury is usually over a bony prominence or related to a medical or other device and results from pressure or pressure combination with shear

Question 4

Shear

Answer 4

when layers of the skin rub against each other, when the skin remains in place and underlying tissues move and stretch

Question 5

Ulcer

Answer 5

A shallow or deep crater-like sore of the skin or mucous membrane

Question 6

Supine position pressure points

Answer 6

-back of head
- shoulder blades
- elbows
- sacrum
- heels

Question 7

Lateral position pressure points

Answer 7

• side of head
• ear
• shoulder
• hip
  -greater trochanter
  -thigh
• knees
• leg
• ankle
• heel

Question 8

Prone position pressure points

Answer 8

• cheek and ear
• shoulder
• breast
• elbows
• ribs
• hip bones
• genitalia
• thighs
• knees
• toes

Question 9

Fowlers position

Answer 9

• back of head
• shoulders
• sacrum
• lower hip bones
• heels
• toes

Question 10

sitting position pressure points

Answer 10

• shoulders
• sacrum
• hips
• lower hip bones
• feet

Question 11

Blanchable

Answer 11

when pressure is applied to the skin, blood is pressed away. Skin turned white and then returns to normal color

Question 12

Non-blanchable

Answer 12

the skin doesn’t become white or pale when pressure is applied

Question 13

Slough

Answer 13

dead tissue that is shed from the skin it is usually light colored, soft, and most

Question 14

Eschar

Answer 14

is thick, leatherly dead tissue that may be loose or adhered to the skin. Black or brown in color

Question 15

Stage 1 pressure injury

Answer 15

Non-blanchable erythema of intact skin

Skin is intact and has reddened

Question 16

Step 2 pressure injury

Answer 16

Partial-thickness skin loss with exposed dermis

Wound is pink or red and moist. May involve a broken or intact blister. Fat and deeper tissues are not visible

Question 17

Stage 3 pressure injury

Answer 17

Full-thickness skin loss

Skin is gone. Fat can be seen in the ulcer. Slough, eschar or both may occur

Question 18

Stage 4 pressure injury

Answer 18

Full-thickness skin and tissue loss

Skin is gone. Muscle, tendon, ligament, cartilage or bone is exposed. Slough, eschar or both may be present

Question 19

Unstageable pressure injury

Answer 19

Obscured full-thickness skin and tissue loss

Skin and tissue loss. The extent of tissue damage cannot be seen because of slough or eschar. When slough is removed, injury can be seen

Question 20

Deep tissue pressure injury

Answer 20

Persistent non-blanchable deep red, marron, or purple discoloration

Intact or non-intact skin is deep red, maroon, or purple and remains non-blanchable. The wound is dark or is a blood-filled blister

Question 21

Reposition bedfast persons at least

Answer 21

1 - 2 hours

Question 22

Reposition chairfast persons every

Answer 22

15 minutes

Question 23

Bed cradle

Answer 23

a metal frame placed on the bed and over the person.
Top linens are brought over the cradle to prevent pressure on legs, feet, toes

Question 24

Heel elevators

Answer 24

raise the heels and feet off the bed

Question 25

Elbow and heel protectors

Answer 25

are made of foam padding, pressure-relieving gel, sheepskin or other cushioning materials.
They fit the shape of elbows and heels

Question 26

Gel or fluid filled pads and cushions

Answer 26

have pressure-relieving gel or fluid. Used for chairs and wheelchairs

Question 27

Special beds

Answer 27

Some have air flowing through the mattress