S1L1: Pressure Ulcers

Question 1

Wound caused by unrelieved pressure to the dermis and underlying structures

Answer 1

Pressure Ulcers

Question 2

Pressure ulcers are common in:

Answer 2

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

Question 3

Clinical presentation

First clinical sign of pressure ulceration

Answer 3

blanchable erythema

Question 4

Clinical presentation

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

Answer 4

Progression to superficial abrasion, blister, or shallow crater

Question 5

Clinical presentation

When full-thickness skin is lost,

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

Answer 5

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

Question 6

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

Answer 6

True

Question 7

Develop commonly to six primary bone areas which are:

Answer 7

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

Question 8

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

Answer 8

Supine

Question 9

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

Answer 9

2 hours

Question 10

Stages of Pressure Ulcer:

Non-blanchable erythema with intact skin

Answer 10

Stage 1

Question 11

Stages of Pressure Ulcer:

Partial thickness skin loss with exposed dermis

Answer 11

Stage 2

Question 12

Stages of Pressure Ulcer:

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

Answer 12

Stage 3

Question 13

Stages of Pressure Ulcer:

Full-thickness skin and tissue loss Until muscle/bone

Answer 13

Stage 4

Question 14

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.

Answer 14

Suspected Deep
Tissue Injury

Question 15

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.

Answer 15

Suspected Deep
Tissue Injury

Question 16

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 16

Suspected
Deep Tissue
Injury

Question 17

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 17

Suspected Deep
Tissue Injury

Question 18

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 18

Suspected Deep
Tissue Injury

Question 19

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 19

Suspected Deep
Tissue Injury

Question 20

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 20

Stage 1

Question 21

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Redness in the area but still has blanching

Answer 21

Suspected
Deep Tissue
Injury

Question 22

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

Extends up to the epidermis

Answer 22

Stage I

Question 23

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 23

Stage I

Question 24

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP

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

Answer 24

Stage I

Question 25

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

Answer 25

True

Question 26

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP May indicate 'at risk' persons (a heralding sign of risk)

Answer 26

Stage I

Question 27

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.

Answer 27

Stage II

Question 28

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP May also present as an intact or open/ruptured serum-filled blister

Answer 28

Stage II

Question 29

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)

Answer 29

Stage II

Question 30

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation

Answer 30

Stage II

Question 31

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

Answer 31

Stage III

Question 32

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP Slough may be present but does not obscure the depth of tissue loss.

Answer 32

Stage III

Question 33

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP May include undermining and tunneling.

Answer 33

Stage III

Question 34

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

Answer 34

True

Question 35

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

Answer 35

Shallow Deep

Question 36

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

Answer 36

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

Question 37

PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP Full-thickness tissue loss with exposed bone, tendon, or muscle.

Answer 37

Stage IV

Question 38

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.

Answer 38

Stage IV

Question 39

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

Answer 39

True

Question 40

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

Answer 40

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

Question 41

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

Answer 41

Osteomyelitis

Question 42

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

Answer 42

True

Question 43

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.

Answer 43

Unstageable

Question 44

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.

Answer 44

Unstageable

Question 45

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

Answer 45

Unstageable

Question 46

Sites of predilection for pressure ulcers: Supine (5)

Answer 46

Occiput Scapula Elbows Sacrum Heels

Question 47

Sites of predilection for pressure ulcers: Sidelying (8)

Answer 47

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)

Question 48

Sites of predilection for pressure ulcers: Prone (9)

Answer 48

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

Question 49

Sites of predilection for pressure ulcers: Long sitting (6)

Answer 49

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

Question 50

Sites of predilection for pressure ulcers: Short sitting (5)

Answer 50

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.