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pressure ulcers
WOCN program
| Question | Answer |
|---|---|
| what are the pathologic effects of excessive pressure on soft tissue attributed to? | tissue ischemia caused by blockage of blood and lymph flow, reperfusion injury -intensity of pressure, duration of pressure and tissue tolerance |
| what is the standard for capillary closing pressure? | 12-32 mmHg |
| identify three extrinsic factors that affect tissue tolerance | moisture, shear, friction |
| shearing affects deeper tissue layers where as friction affects superficial layers- true or false | True |
| define the term reactive hyperemia | an area of erythema that was exposed to pressure, when the pressure was remover vessels dilate in respones to the temporary anoxia. Is transient. |
| what two categories were added to pressure ulcer staging? | suspected deep tissue injury and unstageable |
| a pressure ulcer from a nasogastric tube can be documented as _________ | mucosal pressure ulcer |
| a stage 4 pressure ulcer that is resurfacing and has granulation is documented as __________ | healing stage 4 pressure ulcer |
| what is the Braden Q scale? | the Braden for pediatrics |
| an inexpensive off loading product to "float" the heel is _________ | pillow-and is the current recommendation |
| a patient with an ischial tuberosity pressure ulcer should be limited to sitting to _________ hours _______ times a day | 1, 3x |
| what are some risk factors for developing pressure ulcer for the intraoperative patients? | length of procedure, warming device used, comorbidity, 3 or more anesthetic agents |
| explain the importance of documentation in preventing pressure ulcers | itisthe only way to determine if a PU was avoidable or unavoidable, protect against litigation, data collection |
| define the term immersion | depth of penetration or sinking in to the surface allowing the pressure to be spread over the surrounding area |
| when there is less than one inch of material between the support surface and the skin, using the palm of a hand is called _______ | Bottoming out |
| explain the difference between Reactive and Active support surfaces and give an example of each | Reactive responds to pressure, active changes pressure automatically at set intervals |
| a patient does not have to be turned every 2 hours if on a continuous lateral rotation therapy bed- true or false | False |
| continuous lateral rotation therapy beds are indicated for patients with cardiopulmonary condition, not stage 3 and 4 pressure ulcers- true or false | True |
| a patient with stage 3 trochanter pressure ulcers and stage 4 sacral pressure ulcer in the acute care setting would best be managed with what type of bed or overlay? | Air fluidized bed |
| a disadvantage to a low air loss bed is that it can cause wound desiccation- true or false? | True |
| a foam overlay should have a base height of at least ____ inches? | 3" |
| describe factors the wound care nurse needs to consider when selecting a support surface for each patient who has pressure ulcers? | Location, stage, condition of pt., mobility, fall risk, |
| describe the etiology of pressure ulcers | intensity and duration of pressure, tolerance/condition of tissue tissue ischemia |
| describe the pathology of pressure ulcers | ischemia caused by capillary occlusion |
| list four extrinsic factors that contribute to the development of pressure ulcers | moisture, intensity and duration of pressure |
| define capillary pressure and capillary closing pressure | capillary closing pressure is the amount of pressure required to collapse the capillary. 12-32 mmHg is the range. capillary pressure is higher on arterial side, lower on venous side. |
| describe prevention interventions to decrease the incidence of pressure ulcer development | pressure redistribution, offloading, minimize friction and shear, keep skin clean and dry, improve nutrition, pt and pcg education |
| identify two risk assessment tools | Braden scale, Norton scale |
| list three categories of support surfaces and selection criteria | foam, gel, fluids (viscous fluid, air, water) |
| describe the medical and surgical management of pressure ulcers | Medical- auto lyric or enzymatic debridement, offloading, management of bio burden, Surgical- debridement, graft, flap, |
| explain incidence of pressure ulcers | the number of patients who were initially ulcer free who develop a pressure ulcer within a particular time period in a defined population (for ex LTC incidence 31%) -for example 31 of 100 pts who were PU free at SOC developed PU in "x"months |
| explain prevalence of pressure ulcers | point prevalence : the # of pts with a pressure ulcer at a given POINT in time in a given population -on one day period prevalence: the # of pt's with a PU over a specific PERIOD of time in a given population "December |
| list intrinsic factors that affect tissue tolerance | age, nutrition, hypotension, stress, smoking, |
| what stage PU is a serum filled blister | stage II |
| explain envelopement | support surface conforms to pt's body and irregularities (dsgs, etc) |
| viscoelastic foam | memory foam |
| elastic foam | non memory foam |
| shear stress | force on the tissue |
| shear strain | deformation of tissue as a result of shear stress |
| Braden scale no risk | 19-30 |
| Braden scale at risk | 15-18 |
| Braden scale moderate risk | 13-14 |
| Braden scale high risk | 10-12 |
| Braden scale very high risk | 0-9 |
| Which is more critical in the development of PU's intensity or duration of pressure | Duration |
| low air loss | flow of air to assist in managing the heat and humidity of the skin, connected pillows and pump, slow continuous air flow, can reduce IAD, can pull heat and moisture away from skin or airflow to skin, low friction cover, set to pt's wgt for press. redistr |
| air fluidized bed | high air loss, floats pt, 1/3 of body above surface, 2/3 below, warm air flows through silicone beads, body fluids flow freely through beads, used for burns, myocut. flaps, multiple st 3 or 4 PU's |
| high specification foam | elastic and viscoelastic foams, are open celled |
| closed cell foam | like camping pad-nonpermeable |
| What stage PU is a blood filled blister | Unstageable OR suspected deep tissue injury |
| Describe presentation of suspected deep tissue injury (SDTI) | Intact skin, purple or maroon, boggy, mushy or firm, painful, warmer or cooler than adjacent tissue, includes blood filled blister |
| Describe unstageable PU characteristics | If the wound bed is not visible it is unstageable - it is full thickness tissue loss, can be covered with eschar, slough, or both |
| Describe granulation tissue | Red, moist, cobblestone, not friable |
Created by:
Beth Perry
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