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(3) PT in Special Conditions > S1L1: Pressure Ulcers > Flashcards

S1L1: Pressure Ulcers Flashcards

1
Q

Wound caused by unrelieved pressure to the dermis and underlying structures

A

Pressure Ulcers

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2
Q

Pressure ulcers are common in:

A

Common in individuals who are immobilized for a long period of time

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3
Q

Clinical presentation

First clinical sign of pressure ulceration

A

blanchable erythema

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4
Q

Clinical presentation

Progression to () abrasion, (), or shallow ()

A

Progression to superficial abrasion, blister, or shallow crater

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5
Q

Clinical presentation

When full-thickness skin is lost,

(1) Ulcer appear as __
(2) Bleeding is ___
(3) Tissues are ____ and ___

A

Ulcers appear as deep carter, bleeding is minimal, and tissues are indurated and warm

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6
Q

T/F: Tunneling or undermining is often present. Thus, affectation continues to deepen extending to the dermis, hypodermis, muscle, then exposing the bone

A

True

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7
Q

Develop commonly to six primary bone areas which are:

A

o (1) Sacrum
o (2) Coccyx
o (3) Greater trochanter
o (4) Ischial tuberosity
o (5) Calcaneus (heel)
o (6) Lateral Malleolus

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8
Q

Pressure is present especially when pt. is in what position?

A

Supine

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9
Q

It is important to reposition/turn the patient every ___ hrs

A

2 hours

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10
Q

Stages of Pressure Ulcer:

Non-blanchable erythema with intact skin

A

Stage 1

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11
Q

Stages of Pressure Ulcer:

Partial thickness skin loss with exposed dermis

A

Stage 2

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12
Q

Stages of Pressure Ulcer:

Full-thickness skin loss no slough or necrosis Until fat layer or hypodermis

A

Stage 3

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13
Q

Stages of Pressure Ulcer:

Full-thickness skin and tissue loss Until muscle/bone

A

Stage 4

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14
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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.

A

Suspected Deep
Tissue Injury

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15
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

The area may be preceded by tissue that
is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

A

Suspected Deep
Tissue Injury

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16
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Deep tissue injury may be difficult to detect in individuals with dark skin tones.

A

Suspected
Deep Tissue
Injury

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17
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Evolution may include a thin blister over a dark wound bed.

A

Suspected Deep
Tissue Injury

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18
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

The wound may further evolve and become covered by thin eschar.

A

Suspected Deep
Tissue Injury

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19
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Evolution may be rapid, exposing additional layers of tissue even with optimal treatment

A

Suspected Deep
Tissue Injury

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20
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Intact skin with nonblanchable redness of a localized area usually over a bony prominence.

A

Stage 1

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21
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Redness in the area but still has blanching

A

Suspected
Deep Tissue
Injury

22
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Extends up to the epidermis

A

Stage I

23
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

A

Stage I

24
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.

A

Stage I

25
Q

T/F: Stage I may be difficult to
detect in individuals with dark skin tones

A

True

26
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

May indicate ‘at risk’ persons (a heralding
sign of risk)

A

Stage I

27
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Partial-thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

A

Stage II

28
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

May also present as an intact or
open/ruptured serum-filled blister

A

Stage II

29
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Presents as a shiny or dry shallow ulcer
without slough or bruising (bruising
indicates suspected deep tissue injury)

A

Stage II

30
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

This stage should not be used to describe
skin tears, tape burns, perineal dermatitis,
maceration, or excoriation

A

Stage II

31
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Full-thickness tissue loss. Subcutaneous fat
(hypodermis) may be visible, but bone,
tendon, and muscle are not exposed

A

Stage III

32
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Slough may be present but does not obscure the depth of tissue loss.

A

Stage III

33
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

May include undermining and tunneling.

A

Stage III

34
Q

T/F: The depth of a Stage Ill pressure ulcer varies by anatomical location.

A

True

35
Q

The bridge of the nose, ear, occiput, and malleoli do not have subcutaneous tissue and Stage Ill ulcers can be _____. In contrast, areas of significant adiposity can develop extremely _______ Stage Ill pressure ulcers

A

Shallow

Deep

36
Q

T/F: In Stage 3, Bone/tendon is visible or directly palpable.

A

False: Bone/tendon is not visible or directly palpable.

37
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Full-thickness tissue loss with exposed bone, tendon, or muscle.

A

Stage IV

38
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Slough or eschar may be present on some parts of the wound bed.

Often include undermining and tunneling.

A

Stage IV

39
Q

T/F: The depth of a Stage IV pressure ulcer varies by anatomical location.

A

True

40
Q

T/F: In stage 4, the bridge of the nose, ear, occiput, and malleoli do not have subcutaneous tissue and these ulcers are deep.

A

False: The bridge of the nose, ear, occiput, and malleoli do not have subcutaneous tissue and these ulcers can be shallow.

41
Q

Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon, or joint capsule) making ______ possible.

A

Osteomyelitis

42
Q

T/F: In stage 4, Exposed bone/tendon is visible or directly palpable.

A

True

43
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound.

A

Unstageable

44
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

A

Unstageable

45
Q

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover and should not be removed

A

Unstageable

46
Q

Sites of predilection for pressure ulcers:

Supine (5)

A

Occiput
Scapula
Elbows
Sacrum
Heels

47
Q

Sites of predilection for pressure ulcers:

Sidelying (8)

A

side of the head (ear),
shoulder (acromion process),
Hip (iliac crest),
greater trochanter
spine
knees (if on top of each other can develop pressure ulcer at medial condyle)
leg (head ng fibula)
ankle (lateral malleolus and side of calcaneus)

48
Q

Sites of predilection for pressure ulcers:

Prone (9)

A

cheek and ear
breast (for women)
elbows
ribs
hip bones (ASIS, or if masyadong naka protrude yung iliacus natin)
genitalia (male)
thighs
knees
toes

49
Q

Sites of predilection for pressure ulcers:

Long sitting (6)

A

Back of head
shoulders
sacrum
lower hip bones (ischial tuberosities)
heels
toes

50
Q

Sites of predilection for pressure ulcers:

Short sitting (5)

A

Shoulders
Sacrum
Hips
Lower hip bones (ischial tuberosities)
Feet

Note: kaya chairs are at the midthoracic area para di nakasandal and magkaroon ng problems sa scapula area.

(3) PT in Special Conditions (40 decks)

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