Term
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Definition
| A pressure ulcer is a localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction. |
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Term
| How does one classify pressure ulcers? |
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Definition
| Based on a 4-stage system. |
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Term
| Describe stage 1 of the 4-stage pressure ulcer classification system. |
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Definition
| Intact skin with nonblanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching. It's colour may differ from surrounding area. |
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Term
| Describe stage 2 of the 4-stage pressure ulcer classification system. |
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Definition
| Partial-thickness skin loss involving epidermis, dermis or both. The ulcer is superficial and presents itself clinically as an abrasion, blister or shallow crater. |
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Term
| Describe stage 3 of the 4-stage pressure ulcer classification system. |
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Definition
| Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. |
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Term
| Describe stage 4 of the 4-stage pressure ulcer classification system. |
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Definition
| Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound. Often includes undermining and tunneling. |
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Term
| What is non-blanching erythema? |
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Definition
| It is when the area is much darker than the surrounding skin and does not blanch with fingertip pressure. |
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Term
4 stages of pressure ulcer |
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Definition
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Term
| What are the risk factors for pressure ulcer development? |
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Definition
Impaired SENSORY perception
Impaired MOBILITY
CONSCIOUSNESS level
SHEAR
FRICTION
MOISTURE |
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Term
| What are the 2 fall risk assessment tools? |
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Definition
| Norton Scale and Braden Scale |
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Term
| Which fall risk assessment tool is most commonly used in Singapore? |
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Definition
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Term
| What are the indicators of pressure ulcer risk used in the Braden Scale? |
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Definition
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction & Shear |
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Term
| What equipment can be used to relieve pressure ulcers? |
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Definition
Alternating Pressure Mattresses
Alternating Pressure Mattress Overlay
Heel Protector (sheepskin or otherwise)
Multi-cell Air Cushion |
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Term
| Which is more cost-effective? Alternating pressure mattresses or alternating pressure mattress overlays? |
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Definition
| Alternating Pressure Mattresses |
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Term
| Why is nutrition an indicator of pressure ulcer risk under the Braden scale? |
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Definition
| Nutrition affects healthy skin and wound healing. |
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Term
| What can be done to reduce the risk of pressure ulcer due to Shearing & Friction and limited Activity and Mobility? |
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Definition
POSITIONING INTERVENTIONS:-
When in lateral position, the body should be <30 degrees to the bed surface.
Head of the bed should be elevated to <30 degrees.
Re-position at least every 2 hrs.
2-Hourly Turning
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Term
| How do you address the risk of pressure ulcer due to Moisture? |
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Definition
Barrier Cream
Air-dry Method
(Diapers should be avoided.) |
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Term
| What is being done currently to reduce risk of pressure ulcer due to poor Nutrition? |
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Definition
| Consumption of specialized amino acid mixture |
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Term
| How do we reduce tisk of pressure ulcer due to Lack of Sensory Perception? |
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Definition
| Vigilance on the part of the nurse. Be aware of areas prone to pressure ulcer. (ie Nose: NG tube/O2 apparatus. Ear: Lying on side of the head/O2 apparatus. etc) |
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Term
| Patient & Caregiver Education on Pressure Ulcers |
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Definition
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Term
| What do you need to take note of when examining the skin prior to personal care & hygiene? |
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Definition
Texture (Smooth)
Thickness (Abrasions?)
Turgour
Temperature (Warm)
Colour
Hydration (Supple)
Blemishes (lesions, acne etc) |
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Term
| What should you take note of in foot care? |
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Definition
Shape of foot
Shape and size of toes
Condition of skin
Gait
Circulation (Palpation of dorsalis pedis and posterior tibial pulses)
Sensation (Assess sensation to light touch, pinprick and temperature.)
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Term
| What should you take note of in nail care? |
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Definition
| Inspect fingernails and toenails for inflammation, dryness, cracking |
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Term
| Name the characteristics of the oral cavity you should take note of in oral care. |
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Definition
Colour
Hydration
Texture
Lesions |
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Term
| Why is oral care especailly important for nursing home residents? |
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Definition
| It reduces the bacterial count in oral secretions which, when aspirated, causes bacterial infection which can lead to pneumonia. |
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Term
| Aside from patients prone to aspiration, what other kind of patient needs oral care in particular and why? |
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Definition
| Patients with decreased oral secretions (eg chemotherapy and radiation patients). Their oral cavity becomes dry and oral mucosal tissues are prone to imflammation. |
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