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Chapter 37: Pressure Ulcers
Terms in this set (39)
Normal skin and skin layers without damage or breaks is
_________________ is the presence of bacteria on the wound surface or in wound tissue; the person does not have signs and symptoms of an infection.
Dead tissue that is shed from the skin is
A pressure ulcer that develops from the improper use of the nursing process is an
Avoidable pressure ulcer
A __________ is an area where the bone sticks out or projects from the flat surface of the body.
Thick, leathery dead tissue that may be loose or adhered to the skin is
Another name for bony prominence is
____________ occurs when layers of the skin rub against each other; when the skin remains in place and underlying tissues move and stretch and tear underlying capillaries and blood vessels causing tissue damage.
____________ means confined to bed.
The rubbing of one surface against another is
An ______________ is a pressure ulcer that occurs despite efforts to prevent one through proper use of the nursing process.
Unavoidable pressure ulcer
A localized injury to the skin and/of underlying tissue, usually over a bony prominence, resulting from pressure or pressure in combination with shear is a
___________ means confined to a chair.
Removing the epidermis as tape is removed from the skin is
Changes or damage to intact skin is
A pressure ulcer occurs because
Skin and underlying tissue is damaged by pressure or pressure in combination with shear and/or friction.
Older and disabled persons are at great risk for pressure ulcers because of
Thin and fragile skin
Risk factors for pressure ulcers are all of the following except
Helping the person to drink plenty of liquids
The first sign of a pressure ulcer in an area may be
Reddened skin over a bony prominence
Mrs. greene keeps sliding down in bed. The nurse tells you to raise the head of the bed no more than 30 degrees. This position will prevent tissue damage caused by
In children and infants, pressure ulcers commonly occur
On the back of the head
A Kennedy terminal ulcer occurs
Over a bony prominence 2 to 3 days before death
A stage 3 pressure ulcer would have
A blister or shallow ulcer
The most common site for a pressure ulcer is the
When following a re-positioning schedule, the person should be re-positioned
According to the person's re-positioning schedule
One way to prevent friction in the bed is to
Powder sheets lightly
Bed cradles are used to
Prevent pressure on the legs, feet, and toes.
When the person is using some special beds, it allows
Re-positioning without moving the person.
Centers for Medicare & Medicaid Services
National Pressure Ulcer Advisory Panel
The Joint Commission
Name the stage of pressure ulcer described in each of these.
A. The skin is gone and subcutaneous fat may be exposed.
B. In a person with dark skin, skin color may differ from surrounding areas.
C. Muscle, tendon, and bone are exposed and damaged. Eschar may be present.
D. The wound may involve an abrasion, blister, or shallow crater.
A. Stage 3
B. Stage 1
C. Stage 4
D. Stage 2
You can help prevent shearing by raising the head of the bed only _____________. The care plan tells you
- 30 degree
- When to raise the head of the bed
- How far to raise the head of the bed
- How long (in minutes) to raise the head of the bed
Explain how the following conditions place a person at risk for pressure ulcers.
A. Urinary or fecal incontinence
B. Poor nutrition
C. Limited mental awareness
D. Circulatory problems
E. Have weight loss or are very thin
A. Urine and feces irritate the skin and lead to skin breakdown.
B. A balanced diet is needed to nourish the skin properly.
C. Person does not know to move or change position to prevent pressure ulcers.
D. Cells and tissues die when starved of oxygen and nutrients.
E. Loss of muscle and fat reduces padding between bones and surfaces.
Explain how these protective devices help prevent pressure ulcers.
A. Bed cradle prevents pressure on ____
B. Heel and elbow protectors promote _____ and reduce _____ and _____
C. Heel and foot elevators raise______
D. Gel or fluid-filled pads have
E. Special beds distribute ___________. There is little pressure on _______
A. The legs, feet, and toes
B. Comfort; shear; friction
C. The heels and feet off of the bed
D. Pressure-relieving gel or fluid
E. Body weight; body parts
Describe dressings used to treat pressure ulcers.
A. Wet dressings must be ________. If too moist, the dressing can _____________.
B. Dressing may absorb ___________. When the dressing is removed, the _____________ is removed.
A. Moist enough to promote healing; interfere with healing
B. Drainage (slough); slough
According to the CMS, infection is present in stages ____________ of pressure ulcers.
2, 3, and 4
When you observe and report skin problems to the nurse, it can prevent
Further skin breakdown
When you speak up for your patients and residents, this is called being an
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