1350: Pressure Ulcers EXAM 3

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  1. What is the first indication of a pressure ulcer?
    blanching of the skin (pale & white).
  2. What are some common causes of pressure ulcers?
    • External pressure occluding blood flow, lymph, oxygen & nutrients to tissue.
    • -->ischemia (lack of blood flow)
    • --->hypoxia (lack of oxygen)

    = necrosis of tissue and formation of ulcer.
  3. What are some risk factors (Pts at risk) for pressure ulcers and what nursing actions can be done to prevent them?
    immobility: turn q2h

    inadequate nutrition: encourage protein & vitamin C.

    moisture: maintain skin hygiene.

    • decreased: 
    • mental status, sensation, tissue perfusion
  4. Which chronic illnesses may cause decreased tissue perfusion making the Pt at risk for pressure ulcers?
    diabetes, edema, obesity
  5. Describe the difference between "friction" and "shear" and give an example.
    Friction: resembles abrasions, caused by wrinkled sheets. Common areas include the heels and elbows (bony prominence).

    Shear: skin separates from underlying tissue; pulling the pt versus lifting.
  6. Stages of pressure ulcers.

    Describe a stage 1 pressure ulcer.
    Intact skin with "non-blanchable" redness.

    pain, firm/soft, warmer/cooler than adjacent skin.
  7. Stages of pressure ulcers.

    Describe stage II of a pressure ulcer.
    *Partial thickness

    open ulcer, red or pink

    NO sloughing or bruising

    shiny and dry
  8. Stages of pressure ulcers.

    Describe a stage III pressure ulcer.
    *Full thickness tissue loss.

    Bone, tendon, or muscle, NOT exposed.



    Common areas include significant adipose tissue areas.
  9. Stages of pressure ulcers.

    Describe a stage IV pressure ulcer.
    *Full thickness tissue loss

    Bone, tendon, muscle EXPOSED.

    Slough/eschar present


    May result in OSTEOMYELITIS
  10. Stages of pressure ulcers.

    Describe a UNSTAGEABLE pressure ulcer.

    Why is it unstageable?
    *Full thickness tissue loss.

    Base of ulcer is covered by slough or eschar in the wound bed.

    It is unstageable because the slough and eschar cover the base of the wound; unless it is removed, we cannot determine the DEPTH of the ulcer.
  11. Stages of pressure ulcers.

    In an unstageable ulcer, why must you NOT remove a scab on the heel exhibiting eschar?
    A stable, dry, adherent, intact, without erythema, eschar on the heels is the body's "natural cover".
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1350: Pressure Ulcers EXAM 3
2014-11-29 20:37:57

Pressure ulcers
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