Pressure Ulcers Quiz

Question 1

What are the 6 risk factors of the Braden Scale?

Answer 1

Sensory perception, Moisture, Activity, Mobility, Nutrition, Friction and Shear

Question 2

What is the score range of the Braden Scale?

Answer 2

Lowest is 6 (severe), Highest is 23 (mild)

Question 3

What are local factors affecting wound healing?

Answer 3

Pressure, Desiccation, Maceration, Trauma, Edema, Infection, Necrosis

Question 4

What are the systemic factors affecting wound healing?

Answer 4

Age, Circulation, oxygenation, nutrition and fluid, medications, immunosuppression

Question 5

What is necessary for pressure ulcer Tx?

Answer 5

Moist wound healing, reducing the pain for dressing changes, reducing the pressure in the area, re-positioning the patient.

Question 6

How can you relieve pressure on the food and bony areas?

Answer 6

Float heels off the bed w/ pillows, use pillows b/w knees and ankles; use waffle boot; DON’T use rolled towel at Achilles.

Question 7

How can you protect skin from moisture?

Answer 7

Clean and dry skin after each incontinence; don’t use diapers, change sheets when needed due to perspiration, establish bowel and bladder program for incontinent pt

Question 8

How can you protect skin from friction and shear?

Answer 8

Use lift sheet to turn or transfer pt; maintain head of bed at or below 30 degrees; use a pressure reducing cushion for sitting (not a donut ring b/c it creates venous congestion)

Question 9

What should a chair bound pt do to reduce pressure?

Answer 9

Teach them to shift weight every 15 minutes; if they can’t reposition pt every hour; provide a pressure reducing device and tell them to rock side to side or move their legs)

Question 10

What is the definition of a pressure ulcer?

Answer 10

a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction.

Question 11

Causes of Pressure uclers?

Answer 11

Pressure, Shear, Friction, Moisture

Question 12

What is stage 1 pressure ulcer?

Answer 12

intact skin w/ nonblanchable redness

Question 13

What is stage 2 pressure ulcer?

Answer 13

partial thickness loss of dermis, shallow open ulcer w/ red pink wound bed WITHOUT SLOUGH (can also be an intact or open/ruptured serum-filled blister)

Question 14

What is stage 3 pressure ulcer?

Answer 14

full thickness tissue loss, fat may be visible, slough may be present but doesn’t obscure the depth of tissue loss

Question 15

What is stage 4 pressure ulcer?

Answer 15

full thickness tissue loss, EXPOSED bone, tendon or muscle

Question 16

What is an unstageable ulcer?

Answer 16

Means the base has slough or eschar so depth and stage can’t be determined.

Question 17

What is eschar?

Answer 17

cornified or dried out dead tissue; tan, brown, black

Question 18

What is slough?

Answer 18

liquefied or wet dead tissue; white, yellow, light tan (its leathery)

Question 19

What is undermining?

Answer 19

bigger area of tissue destruction than can be seen (extends under the edge which is a little raised)

Question 20

What is tunneling?

Answer 20

Tracts extending out from the wound.

Question 21

What is maceration?

Answer 21

cells are overly hydrated, moist skin (usually with urinary and fecal incontinence)

Question 22

What is desiccation?

Answer 22

cells dehydrate and die in dry environment

Question 23

How can an infections affect wound healing?

Answer 23

the bacteria in the wound stresses the body and energy spent to fight the microorganisms instead of repairing/healing

Question 24

What does it mean if the area doesn’t blanch?

Answer 24

Then the oxygen has already been removed.

Question 25

Suspected deep tissue injury looks like what?

Answer 25

purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear

Question 26

What is unique about moisture wounds?

Answer 26

They are usually linear (like down the gluteal cleft from incontinence)

Question 27

How do you measure wounds?

Answer 27

LxWxD (in centimeters) Length is 12 o'clock to 6 o'clock Width is 3 o'clock to 9 o'clock Depth- bottom of wound bed to wound edge

Question 28

What does a wound assessment tell you?

Answer 28

it determines the status of the wound, barriers to healing, and signs of complication

Question 29

How do you assess a wound?

Answer 29

Inspect (sight and smell); palpate (appearance, drainage, odor and pain)

Question 30

What are the 4 types of drainage?

Answer 30

Drainage is an inflammatory response due to fluid and cells escaping the blood vessels. SEROUS- clear SANGUINEOUS- contains RBCs SEROSANGUINEOUS- clear and RBCs (pinkish) PURULENT- contains WBCs (thick yellow/white)

Question 31

How do you clean a linear wound like incision?

Answer 31

Wipe top to bottom in one motion--start directly over wound and move outward 4-2-1-3-5

Question 32

How do you clean an open wound like ulcer?

Answer 32

wipe in concentric circles, starting directly over the wound and moving outward

Question 33

Which kind of wounds are sterile, and which are clearn?

Answer 33

Surgical wounds are sterile cleaning. Pressure ulcers are clean wound cleaning.

Question 34

What are 4 types of wound complications?

Answer 34

Infection, hemorrhage, dehiscence (wound opens), evisceration (organ protrudes through the wound)

Question 35

Heat effects

Answer 35

dilates peripheral blood vessels, increases local blood flow, reduces muscle tension, reduces pain

Question 36

Cold effects

Answer 36

constricts peripheral blood vessels, reduces muscle spasms, produces numbness, promotes comfort (decreasing the local release of pain-producing substances like histamine, serotonin, bradykinin)

Question 37

Anything that has heat or cold should....

Answer 37

not have that applied to it.

Question 38

What should orders include?

Answer 38

type of application, area to be treated, frequency and duration