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Flashcards in Ger 13 Pressure Ulcers Deck (22)
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1

This is a scale used for assessing risk for pressure ulcers.

Braden scale

2

On the Braden scale, what is a good result for 1. sensory perception?

less sensory loss is better

3

On the Braden scale, what is a good result for moisture?

less is better

4

On the Braden scale, what is a good result for activity?

more is better

5

On the Braden scale, what is a good result for mobility?

ability to change position without help is better

6

On the Braden scale, what is a good result for nutrition?

Ability to eat more na doften is better

7

On the Braden scale, what is a good result for friction and shear?

ability to keep good posture in bed/chain without help is better

8

Is a higher or lower # (from 1-4) is better on the Braden scale?

higher

9

At what point or higher is there no risk on the Braden scale?

> 19

10

At what range should is it at risk, and you should manage moisture?

15-18

11

At what range is there a modeerate risk, and you should manage nutrition?

13-14

12

At what range is there a high risk and u should manage friction and shear?

10-12

13

What range is there a very high risk and u should manage general care and gentle handling?

< 9

14

What are the 5 points of usual locations for pressure ulcers?

(think things that contact a bed when u lay down)

Sacrum
Heels
Ischial tuberosities
Greater trochanters
Lateral malleoli

15

True or False: a stage I ulcer shows redenned skin that doesnt blanch when pressed.

True

16

True or False: a stage II ulcer is deep to the fatty tissue.

False. It is shallow with only the dermis exposed

17

True or False: a stage III ulcer is deep to the fatty tissue.

True!

18

What shows on a stage IV ulcer?

it's such a deep ulcer that muscle and bone are exposed

19

What are the 2 methods of managmenet for a stage I ulcer?

Monitoring and protection as necessary.

20

If you find a patient with an ulcer down to the dermis, what are the 2 management steps?

Moist dressings and wound cleansing with saline

21

In addition to cleansing and antibiotics for a stage III/IV ulcer, what do you do if necrotic tissue is present?

Debridement

22

After what time do you sample culture and give system antibiotics?

2-4 weeks