Pressure Ulcers

Front 1

Pressure ulcers may be described as having _______ or _______ thickness skin loss.

Back 1

partial or full thickness skin loss

Front 2

removal of infected and necrotic tissue

Back 2

debridement

Front 3

the use of scalpel, scissors, or other sharp instrument to remove devitalized tissue

Back 3

sharp debridement

Front 4

the use of wet-to-dry dressing, hydrotherapy, or wound irrigation to remove devitalized tissue

Back 4

mechanical debridement

Front 5

the application of topical debriding enzymes to devitalized tissue on a wound surface

Back 5

enzymatic debridement

Front 6

debridement using dressings that are applied to the wound to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids; contraindicated in infected wounds

Back 6

autolytic debridement

Front 7

Prolonged excessive moisture can result in what?

Back 7

maceration

Front 8

How does moisture contribute to pressure ulcers?

Back 8

causes maceration

Front 9

How does heat/fever contribute to pressure ulcers?

Back 9

increases metabolic needs; decreases nutrition to ulcer

Front 10

How does edema contribute to pressure ulcers?

Back 10

tissue fluid increases pressure on blood vessels

Front 11

How does obesity contribute to pressure ulcers?

Back 11

fatty tissue has decreased blood supply

Front 12

How does malnutrition contribute to pressure ulcers?

Back 12

causes dry scaly peeling skin; increases the risk for skin breakdown

Front 13

Which Stage of a pressure ulcer?:
Erythema that does not go away and does not blanch

Back 13

Stage I

Front 14

Which Stage of a pressure ulcer?:

Partial thickness skin loss involving epidermis, dermis, or both

Back 14

Stage II

Front 15

Which Stage of a pressure ulcer?:

Partial thickness skin loss involving epidermis, dermis, or both

Back 15

Stage 4

Front 16

What is the purpose of monitoring serum albumin?

Back 16

indicator of nutritional status

Front 17

removal of necrotic tissue so that healthy tissue can regenerate

Back 17

debridement

Front 18

What is the largest advantage of surgical/sharp debridement?

Back 18

it is the most rapid form of debridement

Front 19

Mechanical debridement may be done using what (3) methods?

Back 19

1. wet-to-dry dressings
2. hydrotherapy (ex. whirlpool)
3. wound therapy (ex. irrigation)

Front 20

Describe the syringe that should be used for mechanical debridement.

Back 20

35 mL syringe with a 19 gauge needle/catheter designed to deliver 8 psi

Front 21

What is the largest advantage of hydrotherapy and irrigation methods used in mechanical debridement?

Back 21

can be used to cleanse granulating wounds and soften eschar

Front 22

What is the largest disadvantage of wet-to-dry dressings a method of mechanical debridement?

Back 22

they are non-selective removing both nonviable and viable tissue

Front 23

the application of topical debriding enzymes to the devitalized tissue on the wound surface

Back 23

enzymatic debridement

Front 24

method of debridement where dressings are applied to the wound to allow necrotic tissue to self-digest by the action of enzymes present in wound fluids

Back 24

autolytic debridement

Front 25

formation of new, highly vascular tissue in a healing wound

Back 25

granulation

Front 26

What is the treatment method for eschar, aka "black" tissue?

Back 26

debridement

Front 27

PRESSURE ULCER

Back 27

localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction

Front 28

SUSPECTED DEEP TISSUE INJURY

Back 28

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 Tissue may be painful, firm, mushy, boggy, warmer, or cooler than adjacent tissue may be difficult to detect in dark skin tones

Front 29

STAGE I PRESSURE ULCER

Back 29

intact skin non-blanchable redness usually over bony prominence may be painful, firm, soft, warmer, or cooler than adjacent tissue may be difficult to detect in dark skin tones

Front 30

STAGE II PRESSURE ULCER

Back 30

partial thickness loss of dermis shallow open ulcer or intact or open/ruptured serum-filled blister red pink wound bed without slough presents as shiny dry shallow ulcer without slough or bruising this stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation

Front 31

STAGE III PRESSURE ULCER

Back 31

full thickness tissue loss subcutaneous fat may be visible slough may be present but does not obscure depth of tissue loss may include undermining and tunneling bone/tendon is not visible or directly palpable bridge of nose, occiput and malleolus may develop very shallow stage iii pressure ulcers

Front 32

STAGE IV PRESSURE ULCERS

Back 32

full thickness tissue loss exposed bone, tendon, or muscle slough or eschar may be present on some parts of wound bed often include underminng and tunneling can extend into muscle and supporting structures (ie. fascia, tendon, joint capsule) making osteomyelitis possible exposed bone/tendon visible and directly palpable

Front 33

UNSTAGEABLE PRESSURE ULCER

Back 33

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

Front 34

TRUE OR FALSE: THE STABLE ESCHAR ON THE HEEL SHOULD BE REMOVED

Back 34

false. it serves as "the body's natural (biological) cover and should not be removed

Front 35

BY WHOM WAS THE PRESSURE ULCER STAGING SYSTEM DEFINED IN 1975? WHAT ORGANIZATION REFINED THE DEFINITIONS, WHICH WERE MADE AVAILABLE IN 2007?

Back 35

shea
NPUAP - National Pressure Ulcer Advisory Panel