Pressure Ulcers

How much do you know about managing pressure ulcers?

1. Pressure ulcers are categorized as

a. acute wounds.

b. chronic wounds.

c. partial-thickness wounds.

Correct Answer: ANSWER: b. All pressure ulcers are categorized as chronic wounds. They are staged (Stages I through IV) according to the depth and extent of tissue involvement.

2. A good way to assess your patient's pressure ulcer risk is to use

a. the Braden Scale for Predicting Pressure Sore Risk.

b. empirical knowledge derived from your experience with other patients with pressure ulcer.

c. a review-of-body-systems approach.

Correct Answer: ANSWER: a. The Braden Scale for Predicting Pressure Sore Risk measures such factors as sensory perception, skin moisture, patient activity, mobility, nutrition, and friction and shear. It is the most widely used pressure ulcer risk-assessment scale in the United States.

3. Which of the following interventions is most appropriate for preventing excessive heel pressure?

a. flexing the knees

b. placing a doughnut-shaped cushion under the feet

c. suspending the heels with a pillow

Correct Answer: ANSWER: c. Use a pillow or foam cushion to lift the heels off the mattress and eliminate the pressure. Take particular care, however, to avoid transferring pressure to the Achilles tendons. In addition, some support surfaces have a built-in pressure-reducing feature specifically designed to address heel pressure.

4. Which body position simultaneously relieves pressure from both the sacrum and the trochanter?

a. supine

b. 30-degree lateral position

c. 90-degree side-lying position

Correct Answer: ANSWER: b. A 30-degree lateral position is the best way to relieve pressure from the sacrum and trochanter. If needed, use pillows or a foam wedge to help the patient maintain the proper position. Cushion pressure points, such as the knees or shoulders, as well.

Source: Wound Care made Incredibly Easy!! Philadelphia, PA: Lippincott Williams & Wilkins; 2003.