How do pressure ulcers develop? - Answers Tissue is compressed between a bony prominence
and an external surface for a prolonged period causing tissue death.
What pressure factors contribute to pressure ulcer development? - Answers Intensity
Duration
Tolerance
What are risk factors for pressure ulcers? - Answers Impaired blood flow
Moisture
Smoking
Chronic illness
Immobility
Friction and shear
Incontinence
Poor nutrition and hydration
Altered LOC
Altered sensory perception
History of pressure ulcer
What interventions can be done to prevent pressure ulcers? - Answers Reposition
Off load heels
HOB no more than 30 degrees
Keep skin dry; moisture barrier cream
Redistribution equipment
Sitting limited for max of 2 hours
Patient should shift q15min in chair
Foam ear cushion for nasal cannula
When should the Braden scale be used? - Answers Within first 24 hours of admission and every
, shift
What are the topics looked at with the Braden scale? - Answers Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction & shear
High risk patients and patients with existing pressure ulcers should NOT be on _ ________ ___. -
Answers a regular bed
Describe eschar. - Answers Black or brown necrotic tissue.
May not be removed on the HEEL unless there is infection because it is protective.
Anywhere else it must be removed.
What is slough? - Answers Yellow necrotic tissue that should be debrided.
May be present in stage III and IV pressure ulcers.
What is granulation tissue? - Answers Healing skin; very red.
What should be assessed about a wound? - Answers Location and etiology
Duration
Size and shape
Color
Type/amount of tissue
Wound edges
Peri-wound
Pain
Exudate
Odor
Drains