Exemplar 21.3: Pressure Ulcers

Pressure ulcers can result when pressure on the tissue between a bony prominence and the external surface of the body distorts the capillaries and interferes with normal blood flow.

Pressure ulcers can also result from shearing forces that tear and injure blood vessels.

Which of the following patients are at risk for getting a pressure ulcer?

A nurse is caring for an elderly patient who was hospitalized for a myocardial infarction. She judges that he is at risk for pressure ulcers because he is intolerant to activity, elderly, and suffering from a cardiovascular disease. Which of the following interventions are appropriate for the nurse to initiate in order to decrease the patient's risk of developing a pressure ulcer?

A nurse is caring for a quadriplegic patient. He is confined to bed due to his immobility. Which of the following interventions are appropriate for preventing pressure ulcers in this patient?

You are speaking with a group home employee about your immobile patient's risk for pressure ulcers. The employee is not CNA or BSN trained, but has been working with the profoundly handicapped for the past 10 years. Which of the following statements made by the group home employee indicates that she understands what you have just taught her about preventing pressure ulcers?

What stage of pressure ulcer does this describe? Nonblanchable erythema of intact skin. Usually occurs in a localized area over a bony prominence. The affected area may be painful, and of a different temperature and consistency than the surrounding skin.

What stage of pressure ulcer does this describe? Partial thickness skin loss, with dermal involvement. It presents as shallow and open, without sloughing. It may also present as an intact or open blister with pus or blood in it, or as dry and shiny.

What stage of pressure ulcer does this describe? Full thickness skin loss, with damage or necrosis of subcutaneous tissue. It's like a deep crater. It can be with or without undermining and tunneling of adjacent tissue. Sloughing may be present, but bone, tendon, and muscle cannot be seen yet. The depth varies depending on anatomical location.

What stage of pressure ulcer does this describe? Full thickness skin loss with extensive tissue damage and necrosis. Undermining and tunneling are usually present, along with visability of the muscle, tendon, and bone. Slough or eschar may be present. The ulcer can extend into muscle and supporting structures.

What stage of pressure ulcer does this describe? Full thickness tissue loss, with depth completely obscured by slough or eschar in the wound bed.

A suspected deep tissue injury looks like intact skin with purple discoloration or a blood filled blister. It indicates damage of underlying soft tissue from pressure or shear.

Which of the following patients would have a stage II pressure ulcer?

When may surgical debridement of a pressure ulcer be necessary?

Which wound dressings are used to treat stage I pressure ulcers?

What type of wound dressing would be used for a stage II pressure ulcer?

What type of dressing would be used for stage III pressure ulcers?

What type of dressing would be used for stage IV pressure ulcers?

Match the drop down option with the type of dressing. -[blank_start]Wet-to-dry gauze dressing[blank_end]: Allows necrotic material to soften and adhere to the gauze, causing debridement of the wound. By doing that, it enhances healing. -[blank_start]Skin prep Granulex[blank_end]: Toughens intact skin, preserves skin integrity, prevents skin breakdown, increased blood supply, adds moisture, aids in removal of necrotic tissue. -[blank_start]Vacuum-assisted closure[blank_end]: Creates a negative pressure to help reduce edema, increase blood supply and oxygenation, and decrease bacterial colonization. It also helps promote moist wound healing and granulation tissue formation. -[blank_start]Hydrocolloid dressing[blank_end]: Prevents skin breakdown and promotes healing without crust formation over the ulcer. It is permeable to air and water vapor, and it prevents the growth of anaerobic organisms. By doing this, it enhances healing. -[blank_start]Proteolytic enzymes[blank_end]: Serves as debriding agents in inflamed and infected lesions. -[blank_start]Transparent dressings[blank_end]: Prevents skin breakdown, the entrance of moisture, and the entrance of bacteria. It does, however, allow oxygen and moisture vapor in. By doing this, it enhances healing.

Transparent and hydrocolloid dressings are still okay if the pressure ulcer is infected.

Transparent and hydrocolloid dressings or skin barriers are contraindicated in stage IV pressure ulcers

Which of the following does the nurse NOT report when he/she finds a pressure ulcer?

A person who scores a 16 on the Braden Scale is not at risk for a pressure ulcer.

A nurse is teaching a client about how to take care of her newly immobilized husband's pressure ulcer. Which of the following statements spoken by the patient's wife indicates that she understands the discharge teaching you have given her about caring for, and preventing another, pressure ulcer?