Question | Answer |
The etiology of a skin tear is ______________ and is caused by _________ and _________. | MARSI, friction and shear |
Friction is a factor in what kind of injuries? | Top down |
Shear is a factor in what kind of injuries? | Bottom up |
T or F: Bottom up injuries are usually preventable | True |
T or F: Epidermis and dermis are more resilient to pressure than muscle. | True |
Most common pressure ulcer site? | Sacrum |
Second most common pressure ulcer site? | heel |
Who's at higher risk for PUs? | Geriatrics
Pediatrics with devices
SCI (Spinal cord injurieis)
Critical care |
African Americans are at higher risk for PUs than caucasion? | True |
Major risk factors for PU? (5) | advanced age
fractured hip
spinal cord injury
significant mobility impairment
exposure to excessive moisture |
___________ up damage is caused by intense or sustained compression of the tissue and begins at the _______________. | Bottom up, muscle-bone interface |
Braden scores: 15-18 | Mild risk |
Braden:
mild risk | 15-18 |
Braden Scores:
13-14 | Moderate risk |
Braden:
Moderate Risk: | 13-14 |
Braden Scores:
10-12 | High risk |
Braden:
High risk | 10-12 |
Braden Scores:
9 or below | Very high risk |
Braden:
Very high risk | <9 |
Friction is what kind of injury? | Top Down |
Shear is what kind of injury? | Bottom Up |
What is the biggest risk factor for PU development? | Immobility! |
Patients with fecal incontinence are how many times more likely to develop a PU? | 22x |
Patients with fecal incontinence: their skin has an increase in _________ and increases ___________. | pH, and trans epidermal water loss (TEWL) |
5 AREAS OF SKIN ASSESSMENT: | temperature of skin
color of skin
skin texture and turgor
integrity of skin
moisture status |
Skin assessment is NOT a wound assessment. | TRUE |
PU staging:
Stage I: | Nonblanchable erythema |
PU staging:
Stage II: | Partial Thickness skin loss |
PU staging:
Stage III: | Full Thickness Skin loss |
PU staging:
Stage IV: | Full thickness tissue loss |
T or F:
Staging pressure ulcers:
You can back stage and healing occurs | FALSE |
PU:
3 factors that impede healing: | Comorbid conditions
tissue perfusion/meds
limited or unavailable resources for care |
Partial thickness wounds show evidence of healing in how many weeks? | 1-2 |
Full thickness wounds show evidence of healing in how many weeks? | 2-4 |
3 classes of support surfaces: | Preventative VS Therapeutic
Type (wheelchair, bed)
Medium or components |
PU: visual inspection is fraught with error? | TRUE |
What type of support surface is a powered mattress or overlay that changes is load distribution properties with or without an applied load? | ACTIVE |
What type of support surface moves or changes its load distribution properties only response to an applied load? | REACTIVE |
Nutritional recommendations:
How many kcal per kg body weight per day? | 30-35 |
Nutritional recommendations:
How much protein per day? | 1.25-1.5 g/kg/day |
Nutritional recommendations:
How much fluid per kg? | 30mL per kg EXCEPT IN THOSE WITH RENAL OR CARDIAC DISTRESS |
T or F?
Skin damage from moisture is not a PU? | TRUE |
Skin damage from moisture increases PU risk? | TRUE |
What type of support surface for:
LARGE FULL THICKNESS WOUNDS | ex: stage III and IV or ulcers that involve multiple turning surfaces: low air loss or air fluidized surfaced may be indicated |
PU are unavoidable when: | hemodynamic instability
poor nutrition and hydration
advance directives prohibiting nutritional support |
T or F?
Pressure redistribution surfaces replace repositioning? | FALSE, pressure redistribution surfaces DO NOT replace repositioning! |