What is the main cause of a pressure ulcer? Correct Answer: Pressure
Prolonged pressure that exceeds normal capillary pressure can cause Correct
... [Show More] Answer: vessel collapse and thus tissue ischemia and possibly necrosis (Assess for hyperemia and blanchability)
Low pressure over a prolonged period can cause as much damage as Correct Answer: high pressure over a short period of time
What are the risks for pressure ulcer development? Correct Answer: 1. Impaired Sensory Perception (Can't feel pain/pressure)
2. Impaired Mobility (Unable to independently change position)
3. Alteration in Level of Consciousness (May/may not feel pressure or know how/be able to relieve it)
4. Shear (Force exerted parallel to skin resulting from gravity pushing down on body and resistance (friction) between client and surface)
5. Friction (Mechanical force exerted when skin dragged across coarse surface; force of two surfaces moving across one another)
6. Moisture (Reduces skin's resistance to other physical factors)
What does an assessment of a pressure ulcer include? Correct Answer: Depth of tissue involvement (staging), type and percentage of tissue in wound bed, wound dimension, exudate description, and condition of surrounding skin
What is an unstageable ulcer? Correct Answer: An unstageable ulcer is full-thickness tissue loss covered by slough and/or eschar
Stage I Pressure ulcer: Correct Answer: intact skin w/ nonblanchable area of redness, may be blue or purple in darker skin tones, may also include temperature change
Stage II Pressure ulcer: Correct Answer: partial-thickness skin loss; may include epidermis and/or dermis, superficial; presents as abrasion, blister, shallow crater
Stage III Pressure ulcer: Correct Answer: full-thickness skin loss; visible subcutaneous tissue, but bone, tendon, or muscle not exposed. may include undermining and/or tunneling
Stage IV Pressure ulcer: Correct Answer: full-thickness skin loss with exposed muscle, bone, or tendon; often includes undermining and tunneling
Granulation tissue Correct Answer: red and moist, signifies healing
Slough Correct Answer [Show Less]