Exam (elaborations)
wound certification exam/159 Complete Answered Questions
wound certification exam/159 Complete Answered Questions
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wound certification exam/159Complete Answered Questions
what are 6 risk factor components of Braden Scale for pressure ulcer? - -
sensory perception, moisture, mobility, activity, nutrition, and shear/friction
-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
-Define immersion? - -depth of penetration or skining into surgace allowing
pressure to be spread out over surrounding area rather than directly over
boney prominence
-Define envelopement? - -is the ability of support surface to conform to
irregularities without causing substantial increase in pressure
-what is bottoming out? - -this occurs when depth of penetration or sinking
is excessive, allowing increased pressure to concentrate over boney
prominences
, -what factors contribute to bottoming out? - -weight, disproportion of weight
and size such as amputation, tendency to keep HOB >30 degrees,
inappropriate support surface settings
-When should you consider reactive support surface with features and
components such as low air loss, alternating pressure, viscous or air fluids? -
-for patients who cannot effectively position off their wound, have PUs in
multiple turning surfaces, or have PUs that fail to improve despite optimal
comprehensive management
-When should active support surface be considered? - -when effective
positioning is determined by an MD to be medically contraindicated
-What is the difference between an active and reactive support surfaces/ - -
active support surface is a powered mattress or overlay that changes it's
load- distribution with or without applied load; pressure is redistributed
across the body by inflating and deflating the cells of alternating zones.
conversely a reactive support surface moves or changes load-distribution
properties only in response to applied load, such as the patient's body.
-When are active support surfaces appropriate? - -when manual frequent
repositioning is not possible
-when are reactive support surfaces appropriate? - -for pressure ulcer
prevention
-what is a benefit in low air loss feature and when is it contraindicated? - -
low air loss assists in managing mositure. It is contraindicated in patients
with unstable spine and it puts patients at risk for entrapment
-when is an air fluidized feature integrated in bed systems appropriate? - -
for patients with multiple stage III or Iv pressure ulcers, burns, myocutaneous
skin flap
-for what kind of patients are traditional air-fluidized bed not recommended?
- -pulmonary diseases or unstable spine patients
-what are some general guidelines for caring for patients on a support
surface? - -support surfaces alone doe snot prevent or heal PUs, fuctions
best with minimal linens and pads under patients, must be able to assume
variety of positions to prevent bottoming out, patients should be turned
regardless of support surfaces, patients who sit with a risk for PU should
have a sitting plan- duration, position, and posture
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