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• What is the name of the organization that developed the pressure ulcer
staging? -✓✓NPUAP (national pressure ulcer advisory panel)
• pathological effect of excessive pressure on soft tissue can be
attributed by 3 factors? what are they? -✓✓tissue tolerance, duration of
pressure, and intensity of pressure
• what are the extrinsic factors that impact pressure ulcers? -✓✓increase
in moisture, friction and shearing
• how does friction play a role in shearing which eventually leads to
pressure ulcer? -✓✓friction alone causes only superfical abrasion, but
with gravity it plays a synergistic effect leading to shearing. When
gravity pushes down on the body and resistance (friction) between the
patient and surface is exerted, shearing occurs. because skin does not
freely move, primary effect of shearing occurs at the deeper fascial level.
• what are the intrisinc factors of pressur ulcers? -✓✓nutritional
debilitation, advanced age, low BP, stress, smoking, elevated body
temperature
• Aging skin undergoes what elements affecting risk for pressure ulcer?
-✓✓dermoepidermal junction flattens, less nutrient exchange occurs,
,less resistance to shearing, changes in sensory perception, loss of dermal
thickness, increased vascular fragility; ability of soft tisuse to distribute
mechanical load w/out comprosing blood flow is impaired
• What does nonblanching erythema indicate in the skin r/t PU? -
✓✓when pressure is applied to the erythematic area skin becomes white
(blanched), but once relieved, erythema returns -indicating blood flow;
however in nonblanching erythema, skin does not blanche-indicating
impaired blood flow-suggesting tissue destructon
• why does sitting in a chair pose more of a risk in skin break down than
lying? -✓✓deep tissue injury or PU is likely to occur sooner sitting
down because tissue offloading over boney prominences is higher
• 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