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, what are 6 risk factor components of Braden Scale for sensory perception, moisture, mobility, activity, nutrition, and shear/friction
pressure ulcer?
What is the name of the organization that developed the NPUAP (national pressure ulcer advisory panel)
pressure ulcer staging?
pathological effect of excessive pressure on soft tissue tissue tolerance, duration of pressure, and intensity of pressure
can be attributed by 3 factors? what are they?
what are the extrinsic factors that impact pressure increase in moisture, friction and shearing
ulcers?
how does friction play a role in shearing which eventually friction alone causes only superfical abrasion, but with gravity it plays a
leads to pressure ulcer? synergistic effect leading to shearing. When gravity pushes down on the body
and resistance (friction) between the patient and surface is exerted, shearing
occurs. because skin does not freely move, primary effect of shearing occurs at
the deeper fascial level.
what are the intrisinc factors of pressur ulcers? nutritional debilitation, advanced age, low BP, stress, smoking, elevated body
temperature
Aging skin undergoes what elements affecting risk for dermoepidermal junction flattens, less nutrient exchange occurs, less resistance
pressure ulcer? to shearing, changes in sensory perception, loss of dermal thickness, increased
vascular fragility; ability of soft tisuse to distribute mechanical load w/out
comprosing blood flow is impaired
What does nonblanching erythema indicate in the skin r/t when pressure is applied to the erythematic area skin becomes white (blanched),
PU? but once relieved, erythema returns -indicating blood flow; however in
nonblanching erythema, skin does not blanche-indicating impaired blood flow-
suggesting tissue destructon
why does sitting in a chair pose more of a risk in skin deep tissue injury or PU is likely to occur sooner sitting down because tissue
break down than lying? offloading over boney prominences is higher
Describe what you will see in deep tissue injury? purple or maroon localized area of discolored intact skin skinor blood filled
blister; may be preceded by painful, firm, mushy, or boggy; skin may be warmer
to cooler in adjacent tissue. In dark skin, thin blister or eschar over a dark wound
bed may bee seen
Describe stage I pressure ulcer? Intact skin with nonblanchable redness of localized area. Will not see blanching
in dark skin, but changes in skin tissue consistency (firm vs boggy when
palpated), sensation (pain), and warmer or cooler temperature may differ from
surrounding area
Describe stage II pressure ulcer? partial-thickness wound where epidermis and tip of dermis is lost with red-pink
wound bed w/out slough. may also present as intact or open/ruptured serum -
filled blister
Describe stage III pressure ulcer? full-thickness wound where both epidermis and dermis is lost and subcutaneous
tissue may be visible, but deeper structures such as muscle, bone, and tendon
are not exposed; slough my be present but it doesn't obscure depth and
tunneling and undermining may be present
Describe stage IV pressure ulcer? full-thickness wound with exposed bone,tendon, and muscle; slough or eschar
may be seen in some parts of the wound bed. you will often see tunneling and
undermining. Osteomyelitis may be dxed at this stage, since bone is palpable
Describe unstageble ulcers? full-thickness wound where base of the ulcer is covered by slough and/or eschar,
obscuring depth