Questions & Expertly Verified
Answers, .
Quiz____?
what are 6 risk factor components of Braden Scale for pressure ulcer? -
Answer✓✓
sensory perception, moisture, mobility, activity, nutrition, and
shear/friction
Quiz____?
What is the name of the organization that developed the pressure ulcer
staging? -
Answer✓✓
NPUAP (national pressure ulcer advisory panel)
Quiz____?
pathological effect of excessive pressure on soft tissue can be attributed
by 3 factors? what are they? -
Answer✓✓
tissue tolerance, duration of pressure, and intensity of pressure
Quiz____?
what are the extrinsic factors that impact pressure ulcers? -
Answer✓✓
increase in moisture, friction and shearing
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, Quiz____?
how does friction play a role in shearing which eventually leads to
pressure ulcer? -
Answer✓✓
friction alone causes only superfical abrasion, but with gravity it plays a
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.
Quiz____?
what are the intrisinc factors of pressur ulcers? -
Answer✓✓
nutritional debilitation, advanced age, low BP, stress, smoking, elevated
body temperature
Quiz____?
Aging skin undergoes what elements affecting risk for pressure ulcer? -
Answer✓✓
dermoepidermal junction flattens, less nutrient exchange occurs, less
resistance 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
Quiz____?
What does nonblanching erythema indicate in the skin r/t PU? -
Answer✓✓
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,when pressure is applied to the erythematic area skin becomes white
(blanched), but once relieved, erythema returns -indicating blood flow;
however in nonblanching erythema, skin does not blanche-indicating
impaired blood flow-suggesting tissue destructon
Quiz____?
why does sitting in a chair pose more of a risk in skin break down than
lying? -
Answer✓✓
deep tissue injury or PU is likely to occur sooner sitting down because
tissue offloading over boney prominences is higher
Quiz____?
Describe what you will see in deep tissue injury? -
Answer✓✓
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
Quiz____?
Describe stage I pressure ulcer? -
Answer✓✓
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
Quiz____?
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, Describe stage II pressure ulcer? -
Answer✓✓
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
Quiz____?
Describe stage III pressure ulcer? -
Answer✓✓
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
Quiz____?
Describe stage IV pressure ulcer? -
Answer✓✓
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
Quiz____?
Describe unstageble ulcers? -
Answer✓✓
full-thickness wound where base of the ulcer is covered by slough and/or
eschar, obscuring depth
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