Flashcards in Ger 13 Pressure Ulcers Deck (22)
This is a scale used for assessing risk for pressure ulcers.
On the Braden scale, what is a good result for 1. sensory perception?
less sensory loss is better
On the Braden scale, what is a good result for moisture?
less is better
On the Braden scale, what is a good result for activity?
more is better
On the Braden scale, what is a good result for mobility?
ability to change position without help is better
On the Braden scale, what is a good result for nutrition?
Ability to eat more na doften is better
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
Is a higher or lower # (from 1-4) is better on the Braden scale?
At what point or higher is there no risk on the Braden scale?
At what range should is it at risk, and you should manage moisture?
At what range is there a modeerate risk, and you should manage nutrition?
At what range is there a high risk and u should manage friction and shear?
What range is there a very high risk and u should manage general care and gentle handling?
What are the 5 points of usual locations for pressure ulcers?
(think things that contact a bed when u lay down)
True or False: a stage I ulcer shows redenned skin that doesnt blanch when pressed.
True or False: a stage II ulcer is deep to the fatty tissue.
False. It is shallow with only the dermis exposed
True or False: a stage III ulcer is deep to the fatty tissue.
What shows on a stage IV ulcer?
it's such a deep ulcer that muscle and bone are exposed
What are the 2 methods of managmenet for a stage I ulcer?
Monitoring and protection as necessary.
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
In addition to cleansing and antibiotics for a stage III/IV ulcer, what do you do if necrotic tissue is present?