Pressure Ulcer

Question 1

Stage 1 pressure ulcer

Answer 1

Red, warm, intact skin that doesn’t blanche

Question 2

Example of stage 1 pressure ulcer

Answer 2

Looks like sunburn

Question 3

How would you describe a stage 2 pressure ulcer

Answer 3

Superficial damage to the skin (epidermis or dermis) There will be a break in the skin

Question 4

Examples of stage 2 pressure ulcer

Answer 4

Abrasion, blisters, shallow craters

Question 5

Clinical sign of a stage 3 pressure ulcer

Answer 5

skin that is deeply damaged, but does not extend through fascia

Question 6

Example of stage 3 pressure 3

Answer 6

deep crater

Question 7

stage 4 pressure ulcer

Answer 7

Skin is deeply damaged, wound shows muscle tissues and ligaments

Question 8

Nursing interventions to prevent pressure ulcers from developing

Answer 8

Turn client every 2 hours
Keep skin clean and dry
Proper diet and hydration
Inspect skin and document daily

Question 9

Inspection of skin should include what

Answer 9

Common pressure points
Sacrum
Butt
heels
back of head
elbows
shoulders
hips

Question 10

What measures/assess risk of skin breakdown

Answer 10

Braden Scale
Sensory perception
Moisture
Activity
Mobility
Friction
Shear