Chapter 36

Question 1

bony prominence

Answer 1

are where bone sticks out / projects from flat surface of body; pressure point

Question 2

intact skin

Answer 2

normal intact skin without tissue damage / breakage

Question 3

pressure injury

Answer 3

local damage to skin and under-tissue

Question 4

shear

Answer 4

skin sticks to surface while moving in a direction leading to skin tearing from under layers / each other

Question 5

ulcer

Answer 5

shallow / deep crater sore of skin / mucous membrane

Question 6

common causes of pressure injuries ?

Answer 6

pressure / shearing of skin
- pressure from medical devices

Question 7

common pressure points ?

Answer 7

• back of head
• shoulder blades
• elbows
• hips
• spine
• sacrum
• knees
• ankles
• heels
• toes

Question 8

how do pressure ulcers form ?

Answer 8

loss of capillaries / veins —> less blood flow to local area

Question 9

pressure injury risks ?

Answer 9

• pressure
• shearing
• old age
• dry skin
• limited activity / bedridden
• incontinence
• poor circulation

Question 10

erythema

Answer 10

red / redness

Question 11

blanch

Answer 11

to become white

Question 12

nonblanchable

Answer 12

skin doesn’t become white when pressure is applied

Question 13

slough

Answer 13

dead tissue; usually yellow-ish / moist

Question 14

eschar

Answer 14

dead leathery tissue; usually black / brown

Question 15

stage 1 pressure injury

Answer 15

nonblanchable red area

Question 16

stage 2 pressure injury

Answer 16

• partial skin loss
• dermis partially showing
• intact / blistered

Question 17

stage 3 pressure injury

Answer 17

• full skin loss
• fat layer showing
• slough / eschar can be present

Question 18

stage 4 pressure injury

Answer 18

• full skin / fat layer loss
• muscle / tendon / ligament / cartilage / bone exposed
• slough / eschar may be present

Question 19

unstageable pressure injury

Answer 19

• skin / tissue loss
• extent of wound is unable to be seen because of slough / eschar

Question 20

deep tissue pressure injury

Answer 20

• intact nonblanchable skin
• area is deep purple / red

Question 21

turn clock

Answer 21

changing person w/ new position every 2 hours
1) supine
2) left side
3) right side
repeat until end of day

Question 22

how often should you reposition person in a chair yourself ?

Answer 22

at least every hour; sometimes sooner

Question 23

how often should person in chair be reminded to change positions themselves if possible ?

Answer 23

at least every 15 min

Question 24

bed cradle

Answer 24

• cradle over person in bed
• top linens brought over cradle

Question 25

heel elevator

Answer 25

raise heels / feet off the bed

Question 26

elbow / heel protectors

Answer 26

padded / gel cushioning fitting to the elbow / heel

Question 27

pads / cushions

Answer 27

padded / gel cushioning usually for chairs / wheelchairs

Question 28

special mattresses

Answer 28

• alternating pressure mattress: air tubes in mattress; inflate / deflate at certain times / locations
• rotating bed; same alignment but different pressure points each rotations

Question 29

trochanter rolls

Answer 29

towel rolled up preventing rolling of hips / legs outward

Question 30

foot-board

Answer 30

prevents foot drop

Question 31

common infection from pressure injuries ?

Answer 31

osteomyelitis; inflammation of bone / bone marrow