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A localized area of necrotic soft tissue that occurs when pressure applied to the skin over time is greater than normal capillary pressure.
Pressure Ulcer
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What is the initial sign of pressure?
Erythea (Redness of skin)
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What are the risk factors for pressure ulcers? Select all that apply.
1. Immobility
2. Exercise
3. Advanced age.
4. Malnutrition
1, 3, 4
Page 184
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How is a pressure ulcer described? Give an example.
By the location of the bone structure involved. Sacral Decubitus Ulcer.
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Patients with senory loss, or paralysis may not be aware of the discomfort associated with prolonnged pressure on the skin and therefore may not change their position themselves to relieve the pressure. True or False
True
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What areas of the body are most susceptible to the effects of shear?
Sacrum and Heels
It occurs when the pt. slides down in bed, or when the pt is positioned or moved imporoperly.
Page 185
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What is the term to describe the skin staying intact while the bone shifts?
Shear.
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What factors contribute to the development of pressure ulcers?
Immobility, Impairred Sensory Perception, Decreases Nutrition Status, Decreased Tissue Perfusion, Friction and Shear, and Increased Moisture.
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How often should the nurse turn their patient to reduce forming a pressure ulcer?
Every 2 hours
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A protein made by the liver
Albumin
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Measures the amount of protein in the clear liquid portion of the blood
A serum albumin test measures the amt of protein in the clear liquid portion of the blood.
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What do low albumin levels indicate?
Slow Healing
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What stage ulcer is occuring when the skin breaks, and edema persists. It may also be described as partial-thickness wound?
Stage II Page 187
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What stage is the ulcer when it is described as a full-thickness wound? Infection develops, necrosis and draining continue, and the ulcer extends into subcutaneious tissue.
Stage III
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What stage is the ulcer when erthema progresses to dusky blue-gray?
Stage I
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What purpose does Protein serve in healing pressure ulcers?
Tissue Repair
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How does the consumption of Vit. C contribute to healing pressure ulcers?
Support integrity of capillary wall.
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Should a nurse massage reddened areas as an intervention to promote healing of pressure ulcers? Why or why not?
No it may increase the damage to already traumatized skin and tissue.
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