NUR1460C MODULE 5 UPDATED ACTUAL Questions and
CORRECT Answers
Where do pressure ulcers commonly occur? Over bony areas
-Sacrum
-Ischium
-Trochanters
-Heels
Friction Pressure Injury occurs when the skin is rubbed repeatedly against a surface
Friction Pressure Injury Example A bedbound elderly patient is frequently repositioned without being properly
lifted. As the nurse drags the patient up in bed without using a draw sheet or lift
device, the patient’s heels and sacral area rub repeatedly against the sheets.
Over time, this causes redness and superficial skin breakdown on the lower back
and heels.
Shear Pressure Injury skin stays in place, but the body underneath slides in a different direction
Shear Pressure Injury Example Imagine a patient sitting up in bed. Over time, they slowly slide down the bed, but
their skin sticks to the sheets. The bones and muscles move down, while the skin
stays in place. This stretches and squishes the tissue underneath, especially
around the tailbone (sacrum) or heels, and causes damage inside.
Risk Factors of Pressure Injury -Immobility
-Poor Nutrition/Fluid Status
-Impaired Cognition
-Impaired Senses
-Incontinence/Moisture
-Friction/Shearing
-Low O2/Perfusion
-Medical Conditions
What does the Braden Scale Measure? (Lower Score = Higher RIsk)
-Sensory
-Moisture
-Activity
-Mobility
-Nutrition
-Friction & Shear
Braden Score 19-23 Low or No Risk
Braden Score 15-18 Mild Risk
Braden Score 13-14 Moderate Risk
Braden Score 10-12 High Risk
, Braden Score 9 or Below Very High Risk
What does the Norton Pressure Ulcer Scale Measure? -Physical Condition
-Mental State
-Activity
-Mobility
-Incontinence
Norton 16-30 Low Risk for pressure ulcer
Norton 11-15 Moderate Risk for pressure ulcer
Norton 10 or Below High Risk for pressure ulcer
Assessment for Pressure Ulcer -Inspect Whole Body
-Assess Location
-Assess Size (LxWxD)
-Assess Color (blanching, maceration)
-Assess if tunneling or undermining
What is Blanching? when you press on the skin and it turns white (or lighter) for a few seconds, then
returns to normal color.
What does non-blanchable redness mean? Warning sign – possible pressure injury (Stage 1 ulcer). The skin stays red even
when you press it.
What is Maceration? when skin becomes soft, pale, wrinkled, and fragile due to too much moisture
(like being wet for a long time).
-⚠ Increases the risk for infection and slows wound healing
What is the epidermis? thin, outer layer of the skin that you can see
fx of epidermis? Protects against dirt, germs, and water loss
what kind of nerves do the epidermis have? Has no blood vessels, but has some nerve endings for touch and pain
What is the dermis? Thicker layer under the epidermis
fx of dermis? Contains nerves, blood vessels, sweat glands, and hair follicles
what kind of nerves do the dermis have? Rich in sensory nerves for touch, pressure, pain, heat, and cold
What is the subcutaneous? A deep layer of fat and connective tissue under the dermis
fx of subcutaneous? Cushions and insulates the body; connects skin to muscles
What kind of nerves do the subcutaneous have? Fewer nerves, but still some deep pressure and pain receptors
Serous clear (water from blood)
CORRECT Answers
Where do pressure ulcers commonly occur? Over bony areas
-Sacrum
-Ischium
-Trochanters
-Heels
Friction Pressure Injury occurs when the skin is rubbed repeatedly against a surface
Friction Pressure Injury Example A bedbound elderly patient is frequently repositioned without being properly
lifted. As the nurse drags the patient up in bed without using a draw sheet or lift
device, the patient’s heels and sacral area rub repeatedly against the sheets.
Over time, this causes redness and superficial skin breakdown on the lower back
and heels.
Shear Pressure Injury skin stays in place, but the body underneath slides in a different direction
Shear Pressure Injury Example Imagine a patient sitting up in bed. Over time, they slowly slide down the bed, but
their skin sticks to the sheets. The bones and muscles move down, while the skin
stays in place. This stretches and squishes the tissue underneath, especially
around the tailbone (sacrum) or heels, and causes damage inside.
Risk Factors of Pressure Injury -Immobility
-Poor Nutrition/Fluid Status
-Impaired Cognition
-Impaired Senses
-Incontinence/Moisture
-Friction/Shearing
-Low O2/Perfusion
-Medical Conditions
What does the Braden Scale Measure? (Lower Score = Higher RIsk)
-Sensory
-Moisture
-Activity
-Mobility
-Nutrition
-Friction & Shear
Braden Score 19-23 Low or No Risk
Braden Score 15-18 Mild Risk
Braden Score 13-14 Moderate Risk
Braden Score 10-12 High Risk
, Braden Score 9 or Below Very High Risk
What does the Norton Pressure Ulcer Scale Measure? -Physical Condition
-Mental State
-Activity
-Mobility
-Incontinence
Norton 16-30 Low Risk for pressure ulcer
Norton 11-15 Moderate Risk for pressure ulcer
Norton 10 or Below High Risk for pressure ulcer
Assessment for Pressure Ulcer -Inspect Whole Body
-Assess Location
-Assess Size (LxWxD)
-Assess Color (blanching, maceration)
-Assess if tunneling or undermining
What is Blanching? when you press on the skin and it turns white (or lighter) for a few seconds, then
returns to normal color.
What does non-blanchable redness mean? Warning sign – possible pressure injury (Stage 1 ulcer). The skin stays red even
when you press it.
What is Maceration? when skin becomes soft, pale, wrinkled, and fragile due to too much moisture
(like being wet for a long time).
-⚠ Increases the risk for infection and slows wound healing
What is the epidermis? thin, outer layer of the skin that you can see
fx of epidermis? Protects against dirt, germs, and water loss
what kind of nerves do the epidermis have? Has no blood vessels, but has some nerve endings for touch and pain
What is the dermis? Thicker layer under the epidermis
fx of dermis? Contains nerves, blood vessels, sweat glands, and hair follicles
what kind of nerves do the dermis have? Rich in sensory nerves for touch, pressure, pain, heat, and cold
What is the subcutaneous? A deep layer of fat and connective tissue under the dermis
fx of subcutaneous? Cushions and insulates the body; connects skin to muscles
What kind of nerves do the subcutaneous have? Fewer nerves, but still some deep pressure and pain receptors
Serous clear (water from blood)
