and Correct Detailed Answers Already Graded
A+
What is the most common type of wound? - CORRECT ANSWER-pressure
injury
what is a pressure injury? - CORRECT ANSWER-localized damage to the skin
and/or underlying soft tissue
- usually under a bony prominence or related to a medial or other device
prone pressure points - CORRECT ANSWER-- metatarsals
- patella
- pubic symphysis
- breasts (female)
- acromion
- zygoma
tissue hyperemia - CORRECT ANSWER-definition: redness (increased blood
flow)
time frame: 30 mins
,time to recovery: 1 hour if pressure is relieved
tissue ischemia - CORRECT ANSWER-definition: deeper redness with damage
of the underlying tissue
time frame: 2-6 hours of unrelieved pressure
time to recover: 36 hours if pressure is relieved
necrosis - CORRECT ANSWER-definition: destruction of tissue
time frame: > 6 hours of unrelieved pressure
time to recover: reversal may or may not occur
what is the braden scale? - CORRECT ANSWER-used to estimate risk for
pressure injury
sensory perception: braden's scale - CORRECT ANSWER-ability to respond
meaningfully to pressure-related discomfort (verbalizing discomfort)
moisture: braden's scale - CORRECT ANSWER-degree to which skin is exposed
to moisture
,reasons pressure injuries occur - CORRECT ANSWER-- intense and/or
prolonged pressure
- pressure in combination with shear
primary cause of pressure injury - CORRECT ANSWER-immobility
- causes pressure at specific sites and decreased blood flow
friction - CORRECT ANSWER-caused by two surfaces rubbing against each
other (superficial)
- ex: sliding a patient on the bed or chair
shear - CORRECT ANSWER-distorts both superficial and deep tissue capillaries
which leads to tissue anoxia and tissue necrosis
- within layers of the tissue
when sitting a patient up in bed from supine to site, how does pressure change? -
CORRECT ANSWER-decreases: head, scapula, elbow
increases: butt and heels
, ** the thicker the mattress, the greater the shear is at the hip hinge when raising
the bed at the hinge of the hips
supine pressure points - CORRECT ANSWER-- occipital protuberance
- scapula
- olecranon
- sacrum
- calcaneus
side-lying pressure points - CORRECT ANSWER-- ear
- acromion process
- greater trochanter of femur
- medial and lateral condyles of femur
- lateral malleolus of fibula
activity: braden's scale - CORRECT ANSWER-degree of physical activity
mobility: braden's scale - CORRECT ANSWER-ability to change and control
body position
- shifting in bed