Pressure Injuries and Their Stages
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Pressure Injuries and Their Stages

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Questions and Answers

What is a key method in tissue load management for preventing pressure ulcers?

  • Implementing turning and positioning schedules (correct)
  • Increasing bed rest duration
  • Encouraging prolonged sitting
  • Using water mattresses

    • Which type of support surface is considered effective for pressure redistribution?

  • Water beds
  • Standard mattresses
  • Memory foam pillows
  • Pressure-reducing cushions (correct)

    • What is the recommended frequency for repositioning a bed-bound patient to prevent pressure ulcers?

  • Three times a day
  • Every hour
  • Every two hours (correct)
  • Every three hours

    • Which device can be used to reduce friction when repositioning a patient?

    <p>Friction-reducing sheets</p> Signup and view all the answers

    What is essential to manage in order to prevent pressure ulcers effectively?

    <p>Pressure, friction, and shear</p> Signup and view all the answers

    What is the primary purpose of medical asepsis?

    <p>To reduce the number and spread of microorganisms</p> Signup and view all the answers

    Which of the following is an example of a practice associated with medical asepsis?

    <p>Washing hands before and after patient contact</p> Signup and view all the answers

    Which risk is specifically associated with heat therapy?

    <p>Potential for burns</p> Signup and view all the answers

    Which practice would most likely fall under medical asepsis?

    <p>Cleaning equipment with disinfectants</p> Signup and view all the answers

    What type of therapy is likely to cause tissue damage if applied for too long?

    <p>Heat therapy</p> Signup and view all the answers

    Which of the following actions is NOT a practice of medical asepsis?

    <p>Using sterile instruments during operations</p> Signup and view all the answers

    Cold therapy is most likely to be associated with which of the following risks?

    <p>Risk of frostbite</p> Signup and view all the answers

    What is a key reason for the proper disposal of contaminated materials in medical asepsis?

    <p>To minimize the risk of spreading infections</p> Signup and view all the answers

    What is dehiscence in relation to wound complications?

    <p>Partial or total separation of wound layers</p> Signup and view all the answers

    Which intervention is NOT recommended for evisceration?

    <p>Leave patient unattended until help arrives</p> Signup and view all the answers

    Internal hemorrhage can lead to which of the following conditions?

    <p>Formation of a hematoma</p> Signup and view all the answers

    What is a common symptom of infection in a wound?

    <p>Increased body temperature and WBC count</p> Signup and view all the answers

    What is evisceration specifically characterized by?

    <p>Protrusion of viscera through the incision</p> Signup and view all the answers

    What initial nursing intervention should be performed for a patient with hemorrhage?

    <p>Apply pressure or packing to the wound</p> Signup and view all the answers

    Which of the following could be a consequence of uncontrolled wound infection?

    <p>Delayed healing and tissue discoloration</p> Signup and view all the answers

    What could cause hemorrhage in a wound?

    <p>Dislodged clot or erosion of a blood vessel</p> Signup and view all the answers

    Which action is vital when managing a patient with a suspected infected wound?

    <p>Clean the wound and apply a dressing</p> Signup and view all the answers

    What signifies an evisceration in a wound?

    <p>Visible organs through a wound opening</p> Signup and view all the answers

    What should be done with a sterile solution container once it is opened?

    <p>It must be thrown away after one use.</p> Signup and view all the answers

    Which of the following is a disadvantage of dry heat therapy?

    <p>Burns</p> Signup and view all the answers

    What type of moist heat therapy is recommended for maintaining constant temperature?

    <p>Sitz baths</p> Signup and view all the answers

    Which of the following is NOT a common disadvantage of moist cold therapy?

    <p>Loss of body heat</p> Signup and view all the answers

    What is a recommended safety consideration when applying dry cold therapy?

    <p>Set timer for a prescribed length of application.</p> Signup and view all the answers

    What type of dry heat device should be monitored for potential electric shock?

    <p>Electric heating pads</p> Signup and view all the answers

    Which type of cold therapy involves using cold compresses?

    <p>Moist cold</p> Signup and view all the answers

    What is a potential issue when using hypothermia blankets for cold therapy?

    <p>Continuous monitoring required</p> Signup and view all the answers

    What should be used to cover dry heat applications for safety?

    <p>Protective cloth</p> Signup and view all the answers

    Which type of dry heat application is most likely to cause electric shock?

    <p>Electric heating pads</p> Signup and view all the answers

    What is a key early warning sign of potential pressure injury development?

    <p>Localized area of nonblanchable erythema</p> Signup and view all the answers

    How does ischemia affect the appearance of the skin?

    <p>Makes the skin appear pale and cool</p> Signup and view all the answers

    What happens to the skin after pressure is relieved from an ischemic area?

    <p>Hyperemia occurs rapidly in the area</p> Signup and view all the answers

    Which of the following describes a Stage 1 pressure injury?

    <p>Intact skin with localized nonblanchable erythema</p> Signup and view all the answers

    What characterizes a Stage 2 pressure injury?

    <p>Partial thickness skin loss with exposed dermis</p> Signup and view all the answers

    What does a Stage 4 pressure injury involve?

    <p>Full thickness skin loss with exposed fascia or bone</p> Signup and view all the answers

    Which statement best describes an unstageable pressure injury?

    <p>Full thickness loss obscured by slough or eschar</p> Signup and view all the answers

    What is a common presentation of Deep Tissue Pressure Injury?

    <p>Intact skin with nonblanchable redness</p> Signup and view all the answers

    In which type of pressure injury is granulation tissue likely to be absent?

    <p>Stage 2 pressure injury</p> Signup and view all the answers

    What do undermining, tunneling, and epibole indicate in a pressure injury?

    <p>Advanced or worsening injury stages</p> Signup and view all the answers

    What is the proper description of partial thickness injuries?

    <p>Only a portion of the dermis remains intact</p> Signup and view all the answers

    What significant factor contributes to the development of pressure injuries?

    <p>Prolonged pressure and ischemia</p> Signup and view all the answers

    What does the presence of slough or eschar in a wound indicate?

    <p>Depth and true stage cannot be determined</p> Signup and view all the answers

    Which of the following is NOT a characteristic of full-thickness skin loss?

    <p>Presence of intact dermis</p> Signup and view all the answers

    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.

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