Pressure Ulcerations

Question 1

What causes a pressure ulcer

Answer 1

• results from unrelieved pressure (above 32 mmHg), friction, shear, or stress

Question 2

Extrinsic factors of pressure ulcers

Answer 2

• pressure with shear or moisture

Question 3

Intrinsic factors of pressure ulcers

Answer 3

• maceration
• decrease skin resilience
• malnutrition
• decreased circulation
• decreased sensation
• impaired mobility/activity
• incontinence
• altered level of consciousness

Question 4

Clinical presentation of pressure ulcers

Answer 4

• circular pattern over bony prominence
• greatest ischemia near bone
• may take shape of object
• generally not painful

Question 5

What is the first step in medical management of a pressure ulcer

Answer 5

• take the pressure away

Question 6

Braden Scale levels of risk

Answer 6

High risk: 10-12
Moderate risk: 13-14
Mild risk: 15-18
No risk: 19-23

Question 7

Stage I pressure ulcer

Answer 7

• intact skin
• non-blanch able erythema
• skin temp. can be warm or cool
• tissue consistency can be firm or boggy
• can be painful or itchy

Question 8

Stage II pressure ulcer

Answer 8

• partial thickness wound
• shallow open ulcer or open/ruptured serum filled blister
• red or pink wound bed
• adipose not visible
• slough & eschar are not present
• no bruising

Question 9

Stage III pressure ulcer

Answer 9

• full thickness tissue loss
• can see adipose tissue
• slough may be present
• undermining or tunneling may be present
• fascia, muscle, tendon, ligament, cartilage and/or bone are NOT exposed

Question 10

Stage IV pressure ulcer

Answer 10

• full thickness
• slough or eschar may be present
• undermining, tunneling, or sinus tracts
• exposed or easily palpable bone, tendon, or muscle

Question 11

Unstageable pressure ulcer

Answer 11

• full thickness skin & tissue loss
• extent of tissue damage cannot be determined due to slough or eschar
• must be removed to expose wound bed & true depth
• stable eschar on heels or ischemic areas should not be softened or removed

Question 12

Suspected Deep Tissue Injury (SDTI)

Answer 12

• bruising & palpable loss of tissue tension
• blood filled blister due to damage of underlying skin
• painful, firm, mushy, boggy, warm/cooler surrounding skin