Week 4: Pressure Ulcers Flashcards Preview

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Flashcards in Week 4: Pressure Ulcers Deck (40):
1

What is a localized area of tissue necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence?

Pressure ulcer

2

What is the greatest risk for pressure ulcers?

IMMOBILITY

3

Which populations are at most risk for pressure ulcers?

individuals with spinal cord injuries, hospitalized patients, individuals in long-term care facilities

4

What is the capillary closing pressure?

13-32 mmHG

5

Pressure ulcers are a result of:

inverse pressure-time relationship, individual hemodynamic factors, and body location

6

____ is more sensitive to pressure than _____

Muscle, skin

7

What is a localized area of blanchable erythema?

reactive hyperemia

8

What predisposes skin to PU by causing maceration, increasing shear, and increasing friction forces?

moisture

9

What is a force parallel to soft tissue?

shear

10

What is two surfaces moving across one another

friction

11

What shape is produced by shear forces?

teardrop

12

What is the second most common risk factor?

malnutrition

13

more than _____ of patients with PUs are over 70 years old.

half

14

Scar tissue only attains up to ____% of the strength of the original tissue

80%

15

What are the most widely used screening tools for screening of pressure ulcers?

Braden Scale for Predicting Pressure Sore Risk
Norton Risk Assessment Scale
Gosnell Pressure Sore Risk Assessment

16

What are different ways of classifying pressure ulcers?

Integumentary Preferred Practice Patterns
Shea Staging System
International NPUAP/EPUAP Pressure Ulcer Classification System

17

What are the benefits of the International NPUAP/EPUAP PU Classification System?

- Promotes uniform understanding of the depth of tissues involved
- Excellent reliability
- Clinicians must stage pressure ulcers for Medicare reimbursement
- Determines type of support surface to be used
- Can be used for research studies

18

What tissues are involved in a stage 1 PU?

may be superficial or may the the first sign of deeper tissue involvement

19

What tissues are involved in a stage 2 PU?

partial thickness (epidermis and/or dermis)

20

What tissues are involved in a stage 3 PU?

full thickness (epidermis, dermis, and subcutaneous)... bone or tendon not visible

21

What tissues are involved in a stage 4 PU?

full thickness with underlying deep tissue exposed

22

Practice pattern for Stage II PU?

C

23

Practice pattern for Stage III PU?

D

24

What tissues are involved in unstageable ulcers?

full thickness (III or IV)

25

What are certain PUs unstageable?

base obscured by eschar or slough

26

What are some limitations of the NPUAP/EPUAP PU Classification System?

Stage I is not an ulcer by definition, clinicians may erroneously reverse stage a pressure ulcer, significant revision of prior system (takes time to adapt)

27

What is the 5PT method of characterizing pressure ulcers?

Pain, Position, Presentation, Periwound, Pulses, Temperature

28

What are the areas at most risk when a patient is lying supine?

Posterior heel, sacrum/coccyx, spinous process, medial humeral epicondyle, scapula, occiput

29

What are the areas at most risk when a patient is lying sidelying?

Malleolus, medial and lateral femoral condyles, greater trochanter, lateral humeral epicondyle, ear

30

What are the areas at most risk when a patient is lying prone?

Anterior tibia, anterior knee, ASIS

31

What are the areas at most risk when a patient is seated?

Sacrum/coccyx, ischial tuberosity, greater trochanter

32

95% of pressure ulcers are located over:

sacrum, greater troch, ischial tub, posterior calcaneous, lateral malleolus

33

Temperature is increased in areas of _______ and decreased in areas of ______.

reactive hyperemia, ischemia

34

What are the major observational scales of pressure ulcers?

Sessing, Bates-Kensen Wound Assesment Tool (WBAT), Pressure Ulcer Scale of Healing (PUSH)

35

How long does a Stage I PU take to heal?

1-3 weeks

36

How long does a Stage II PU take to heal?

days to weeks

37

How long does a Stage III or IV PU take to heal?

average of 8-13 weeks

38

Ulcers that do not decrease in size within ____ weeks should be reassessed for alternative/adjunctive interventions.

2 weeks

39

What should be done with sounds that fail to progress in a timely manner and that show signs/symptoms of infection?

culture

40

What should be done with wounds that have exposed bone or with deep wounds with purulent or malodorous drainage?

assess for osteomyelitis