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Questions and Answers
What is a key method in tissue load management for preventing pressure ulcers?
What is a key method in tissue load management for preventing pressure ulcers?
Which type of support surface is considered effective for pressure redistribution?
Which type of support surface is considered effective for pressure redistribution?
What is the recommended frequency for repositioning a bed-bound patient to prevent pressure ulcers?
What is the recommended frequency for repositioning a bed-bound patient to prevent pressure ulcers?
Which device can be used to reduce friction when repositioning a patient?
Which device can be used to reduce friction when repositioning a patient?
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What is essential to manage in order to prevent pressure ulcers effectively?
What is essential to manage in order to prevent pressure ulcers effectively?
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What is the primary purpose of medical asepsis?
What is the primary purpose of medical asepsis?
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Which of the following is an example of a practice associated with medical asepsis?
Which of the following is an example of a practice associated with medical asepsis?
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Which risk is specifically associated with heat therapy?
Which risk is specifically associated with heat therapy?
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Which practice would most likely fall under medical asepsis?
Which practice would most likely fall under medical asepsis?
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What type of therapy is likely to cause tissue damage if applied for too long?
What type of therapy is likely to cause tissue damage if applied for too long?
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Which of the following actions is NOT a practice of medical asepsis?
Which of the following actions is NOT a practice of medical asepsis?
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Cold therapy is most likely to be associated with which of the following risks?
Cold therapy is most likely to be associated with which of the following risks?
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What is a key reason for the proper disposal of contaminated materials in medical asepsis?
What is a key reason for the proper disposal of contaminated materials in medical asepsis?
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What is dehiscence in relation to wound complications?
What is dehiscence in relation to wound complications?
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Which intervention is NOT recommended for evisceration?
Which intervention is NOT recommended for evisceration?
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Internal hemorrhage can lead to which of the following conditions?
Internal hemorrhage can lead to which of the following conditions?
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What is a common symptom of infection in a wound?
What is a common symptom of infection in a wound?
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What is evisceration specifically characterized by?
What is evisceration specifically characterized by?
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What initial nursing intervention should be performed for a patient with hemorrhage?
What initial nursing intervention should be performed for a patient with hemorrhage?
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Which of the following could be a consequence of uncontrolled wound infection?
Which of the following could be a consequence of uncontrolled wound infection?
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What could cause hemorrhage in a wound?
What could cause hemorrhage in a wound?
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Which action is vital when managing a patient with a suspected infected wound?
Which action is vital when managing a patient with a suspected infected wound?
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What signifies an evisceration in a wound?
What signifies an evisceration in a wound?
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What should be done with a sterile solution container once it is opened?
What should be done with a sterile solution container once it is opened?
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Which of the following is a disadvantage of dry heat therapy?
Which of the following is a disadvantage of dry heat therapy?
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What type of moist heat therapy is recommended for maintaining constant temperature?
What type of moist heat therapy is recommended for maintaining constant temperature?
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Which of the following is NOT a common disadvantage of moist cold therapy?
Which of the following is NOT a common disadvantage of moist cold therapy?
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What is a recommended safety consideration when applying dry cold therapy?
What is a recommended safety consideration when applying dry cold therapy?
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What type of dry heat device should be monitored for potential electric shock?
What type of dry heat device should be monitored for potential electric shock?
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Which type of cold therapy involves using cold compresses?
Which type of cold therapy involves using cold compresses?
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What is a potential issue when using hypothermia blankets for cold therapy?
What is a potential issue when using hypothermia blankets for cold therapy?
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What should be used to cover dry heat applications for safety?
What should be used to cover dry heat applications for safety?
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Which type of dry heat application is most likely to cause electric shock?
Which type of dry heat application is most likely to cause electric shock?
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What is a key early warning sign of potential pressure injury development?
What is a key early warning sign of potential pressure injury development?
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How does ischemia affect the appearance of the skin?
How does ischemia affect the appearance of the skin?
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What happens to the skin after pressure is relieved from an ischemic area?
What happens to the skin after pressure is relieved from an ischemic area?
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Which of the following describes a Stage 1 pressure injury?
Which of the following describes a Stage 1 pressure injury?
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What characterizes a Stage 2 pressure injury?
What characterizes a Stage 2 pressure injury?
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What does a Stage 4 pressure injury involve?
What does a Stage 4 pressure injury involve?
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Which statement best describes an unstageable pressure injury?
Which statement best describes an unstageable pressure injury?
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What is a common presentation of Deep Tissue Pressure Injury?
What is a common presentation of Deep Tissue Pressure Injury?
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In which type of pressure injury is granulation tissue likely to be absent?
In which type of pressure injury is granulation tissue likely to be absent?
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What do undermining, tunneling, and epibole indicate in a pressure injury?
What do undermining, tunneling, and epibole indicate in a pressure injury?
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What is the proper description of partial thickness injuries?
What is the proper description of partial thickness injuries?
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What significant factor contributes to the development of pressure injuries?
What significant factor contributes to the development of pressure injuries?
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What does the presence of slough or eschar in a wound indicate?
What does the presence of slough or eschar in a wound indicate?
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Which of the following is NOT a characteristic of full-thickness skin loss?
Which of the following is NOT a characteristic of full-thickness skin loss?
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Study Notes
Pressure Injuries
- Early warning sign of pressure injury: blanching (pale and white) of skin area under pressure
- Appearance of skin with ischemia: paler than areas with adequate circulation
- Appearance of skin after ischemia: pressure relieved, rapid followed by hyperemia
- Development of pressure injury: pressure continues after ischemia
- Pressure injury development: interventions depend on early recognition of stage
- Classification: partial thickness - portion of dermis intact; full thickness - entire dermis severed, can expose bone, tendon, or muscle
- Classification: unstageable - full-thickness loss where true depth cannot be determined
- Stage 1 pressure injury: intact skin with nonblanchable erythema
- Stage 1 pressure injury: may appear differently in darkly pigmented skin
- Stage 1 pressure injury: painful, firm/soft, warm/cool
- Stage 2 pressure injury: partial-thickness skin loss with exposed dermis, presents as shallow, open ulcer or ruptured/intact blister
- Stage 2 pressure injury: granulation tissue, slough, or eschar not present
- Stage 3 pressure injury: full-thickness skin loss, shallow or deep open ulcer
- Stage 3 pressure injury: adipose and granulation tissue often present and visible
- Stage 3 pressure injury: slough/eschar (non-obscuring), undermining, tunneling, epibole
- Stage 4 pressure injury: full-thickness skin and tissue loss
- Stage 4 pressure injury: presents as shallow or deep, open ulcer with exposed/palpable fascia, muscle, tendon, ligament, cartilage, or bone
- Stage 4 pressure injury: slough/eschar (non-obscuring), undermining, tunneling, epibole
- Unstageable Pressure Injury: obscured full-thickness skin and tissue loss, true depth cannot be determined
- Unstageable Pressure Injury: extent of tissue damage cannot be confirmed because it is obscured by slough and/or eschar
- Deep Tissue Pressure Injury: results from intense and/or prolonged pressure and shearing where bone and muscle interface
- Deep Tissue Pressure Injury: presents as persistent, nonblanchable deep red, maroon, or purple discoloration of intact or nonintact skin
- Deep Tissue Pressure Injury: epidermal separation revealing dark wound bed, or blood-filled blister, painful, firm, mushy, boggy, warm/cool
Preventing Pressure Ulcers
- Tissue load management: therapeutic means to manage pressure, friction, and shear
- Turning and positioning schedules: every 2 hours for bed-bound patients, every hour for chair-bound patients
- Positioning devices: pillows, foam wedges, pressure-reducing boots
- Support surfaces: pressure redistribution devices (cushions, mattresses, beds)
- Friction-reducing sheets and lifting devices
Drainage Systems
- Dehiscence: partial or total separation of wound layers
- Evisceration: complete separation of wound with protrusion of viscera through incision
- Evisceration interventions: place patient in low - Fowler's position, cover with sterile nonadherent dressing moistened with sterile 0.9% sodium chloride solution, notify healthcare provider, do not leave patient unattended
- Hemorrhage: excessive bleeding (trauma, slipped suture, dislodged clot, infection, erosion of blood vessel by foreign body)
- Internal hemorrhage: formation of hematoma, pressure on surrounding blood vessels (tissue ischemia)
- Hemorrhage interventions: apply pressure or packing, clean wound and apply/check dressing, administer fluid replacement and medication, prepare for surgical intervention.
- Wound infection: immune system fails to control growth of microorganisms
- Wound infection symptoms: drainage and foul odor, pain, redness, and swelling, increased body temperature, WBC count, delayed healing, discoloration of granulation tissue
- Wound infection nursing interventions: clean wound and apply dressing, administer antimicrobials and other medications, manage symptoms
Heat and Cold Therapy Risk Factors
Heat Therapy Risks
- Burns
- Changes in sensation
- Electric shock
- Leaking
- Pain
- Redness
Cold Therapy Risks
- Hypothermia
- Leaking
- Numbness
- Pain
- Skin irritation
Medical Asepsis (Clean Technique)
- Purpose: reduce the number and spread of microorganisms
- Application: used in everyday patient care, such as administering oral medications, cleaning wounds, and performing non-invasive procedures
- Practices: hand hygiene (washing hands before and after patient contact), wearing gloves when handling body fluids, cleaning equipment and surfaces with disinfectants, proper disposal of contaminated materials (e.g., using biohazard bags)
Dry Heat Therapy
- Types: hot water bags, hot packs, electric heating pads, aquathermia pads
- Considerations: avoid lying or leaning on equipment, cover with protective cloth, set timer for prescribed length of application
- Disadvantages: burns, changes in sensation, electric shock, leaking, pain, redness
Moist Heat Therapy
- Types: warm compresses, sitz baths, warm soaks
- Considerations: maintain constant temperature, set timer for prescribed length of application
- Disadvantages: dripping, evaporation, rapid cooling
Dry Cold Therapy
- Types: ice bags, cold packs, hypothermia (cooling) blankets
- Considerations: cover with protective cloth, set timer for prescribed length of application
- Disadvantages: continuous monitoring (hypothermia blankets), leaking, numbness, pain, skin irritation
Moist Cold Therapy
- Type: cold compresses
- Considerations: maintain constant temperature, set timer for prescribed length of application
- Disadvantages: dripping, evaporation, rapid warming
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Description
This quiz covers essential information about pressure injuries, including early warning signs, skin appearance during ischemia, and the classification of pressure injuries. Understanding these concepts is crucial for effective management and intervention. Test your knowledge on the different stages of pressure injuries.
