ANATOMY , PRESSURE INJURY STAGING , BRADEN SCALE &
DRESSING SELECTIONS COMPLETE ACCURATE EXAM REAL
QUESTIONS AND ACCURATE DETAILED ANSWERS WITH
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REVISED EXAM \Emory University | Dermatology|
Describe what you will see in deep tissue injury?
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
Describe stage I pressure ulcer?
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
,Describe stage II pressure ulcer?
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
Describe stage III pressure ulcer?
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
Describe stage IV pressure ulcer?
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
Describe unstageble ulcers?
full-thickness wound where base of the ulcer is covered by slough and/or
eschar, obscuring depth
,When should eschars not be removed?
when it's stable with dry, adherent, and intact w/out erythema on the
heel; this serves as the body's natural cover and should not be removed.
Therapeutic function of pressure distribution is accomplised by what 2
factors?
immersion and envelopement
what are some general guidelines for caring for patients on a support
surface?
support surfaces alone doe snot prevent or heal PUs, fuctions best with
minimal linens and pads under patients, must be able to assume variety
of positions to prevent bottoming out, patients should be turned
regardless of support surfaces, patients who sit with a risk for PU should
have a sitting plan- duration, position, and posture
, Define immersion?
depth of penetration or skining into surgace allowing pressure to be
spread out over surrounding area rather than directly over boney
prominence
Define envelopement?
is the ability of support surface to conform to irregularities without
causing substantial increase in pressure
what is bottoming out?
this occurs when depth of penetration or sinking is excessive, allowing
increased pressure to concentrate over boney prominences
what factors contribute to bottoming out?
weight, disproportion of weight and size such as amputation, tendency
to keep HOB >30 degrees, inappropriate support surface settings