Pressure Ulcers: Prevention and Management

Course #48852 - $40 • 10 Hours/Credits


Study Points

  1. Discuss the epidemiology, etiology, and pathogenesis of pressure ulcers.
  2. Identify patients at risk based on extrinsic and intrinsic factors important to pathogenesis.
  3. Recognize and define the severity and progression of pressure ulcers by stage.
  4. Analyze techniques available for the diagnosis of pressure ulcers.
  5. Develop an effective strategy for skin care and prevention of pressure ulcers.
  6. Choose appropriate options for wound cleansing, debridement, and dressing based on wound types.
  7. Manage other aspects of the care of patients with pressure ulcers, including pain management and infectious complications.
  8. Create individual treatment plans based on patient characteristics and pressure ulcer stage.
  9. Identify the qualities of a pressure ulcer that should be monitored.
  10. Outline possible complications and comorbidities of pressure ulcers and their treatment.
  11. Describe the medico-legal aspects of pressure ulcers and the significance of correct documentation and patient education.

    1 . The most common areas where pressure ulcers occur are the
    A) hands and neck.
    B) coccyx and neck.
    C) sacrum and coccyx.
    D) back of the head and hands.

    PATHOGENESIS

    The age and health of overlying skin determine the ease with which ulceration of the superficial layers occurs. In the elderly, skin and subcutaneous tissue gradually lose regenerative, protective, and sensory functions. Chronic conditions or intercurrent illness such as diabetes, arthritis, incontinence, neurologic impairment, cigarette use, and hypotension are all associated with increased susceptibility and prevalence of pressure ulcers [63]. As noted, pressure ulcers develop most commonly over the sacrum and coccyx, hips and buttocks, and heels [6].

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    2 . The most important factor in the development of pressure ulcers is
    A) age.
    B) friction.
    C) poor nutrition.
    D) unrelieved pressure.

    RISK FACTORS

    For a given patient, immobility that leads to unrelieved pressure to the skin over a boney prominence is the most important factor in the development of pressure ulcers [5,85]. Individual risk factors for pressure ulcers may be categorized as extrinsic or intrinsic. Extrinsic factors are external conditions in the immediate environment that place a vulnerable individual at risk (e.g., moisture, compression from an applied device). Intrinsic factors are conditions and comorbidities peculiar to the individual that confer risk (e.g., advanced age, poor nutrition, smoking history).

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    3 . An increased risk for pressure ulcer development is noted in patients
    A) with increased nutritional intake.
    B) who weigh less than 119 pounds.
    C) who consume more protein than average.
    D) with body mass index between 20 and 25.

    RISK FACTORS

    Poor nutrition, intravascular volume depletion, and peripheral vascular disease can each lead to unhealthy skin and impaired wound healing, which in turn increases the risk of developing pressure ulcers. Low body weight is also a concern. Weight less than 119 pounds or a body mass index (BMI) less than 20 indicates increased risk for pressure ulcer development [80].

    Recent weight loss, decreased nutritional intake, inadequate dietary protein, and impaired ability to feed oneself have been identified as risk factors for pressure ulcer development. An estimated 50% of elderly patients admitted to hospitals have suboptimal protein nutrition [80]. When there is a sustained deficit of protein as an energy source, skin and soft tissues become more vulnerable to injury. In managing patients with pressure ulcer, or those at risk, the amount of protein in the diet appears to influence prognosis for recovery and prevention. In one study, patients who received a 24% increase in protein intake had significant improvements in ulcer healing and prevention of new skin injury compared to those who received a 14% increase [24].

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    4 . The greatest risk for developing a pressure ulcer is assigned a Braden Scale score of
    A) 9 or less.
    B) 10–12
    C) 13–14
    D) 15–18

    RISK FACTORS

    THE BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK

    DomainScorea
    1234
    Sensory perception: The ability to respond meaningfully to pressure-related discomfortCompletely limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body surface.Very limited: Responds only to painful stimuli and cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment that limits the ability to feel pain or discomfort over half of body.Slightly limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned OR has some sensory impairment that limits ability to feel pain or discomfort in one or two extremities.No impairment: Responds to verbal commands and has no sensory deficit that would limit ability to feel or voice pain or discomfort.
    Moisture: Degree to which skin is exposed to moistureConstantly moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.Very moist: Skin is often, but not always, moist. Linen must be changed at least once a shift.Occasionally moist: Skin is occasionally moist, requiring an extra linen change approximately once a day.Rarely moist: Skin is usually dry. Linen only requires changing at routine intervals.
    Activity: Degree of physical activityBedfast: Confined to bedChairfast: Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair.Walks occasionally: Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair.Walks frequently: Walks outside the room at least twice a day and inside the room every two hours during waking hours.
    Mobility: Ability to change and control body positionCompletely immobile: Does not make even slight changes in body or extremity position without assistance.Very limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.Slightly limited: Makes frequent though slight changes in body or extremity position independently.No limitations: Makes major and frequent changes in position without assistance.
    Nutrition: Usual food intake patternVery poor: Never eats a complete meal. Rarely eats more than one-third of any food offered. Eats two servings or less of protein per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is nothing by mouth and/or maintained on clear liquids or intravenous for more than five days.Probably inadequate: Rarely eats a complete meal and generally eats only about half of any food offered. Protein intake includes only three servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR receives less than optimum amount of liquid diet or tube feeding.Adequate: Eats more than half of most meals. Eats a total of four servings of protein each day. Occasionally will refuse a meal, but will usually take a supplement if offered. OR is on a tube feeding or total parental nutrition regimen that probably meets most of nutritional needs.Excellent: Eats most of every meal. Never refuses a meal. Usually eats a total of four or more servings of protein. Occasionally eats between meals. Does not require supplementation.
    Friction and shearProblem: Requires moderate-to-maximum assistance in moving.Potential problem: Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair restraints, or other devices. Maintains relatively good position in chair or bed most of the time, but occasionally slides down.No apparent problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.
    aA lower Braden Scale Score indicates a lower level of functioning and, therefore, a higher level of risk for pressure ulcer development. Risk levels assigned to each score range: ≤9 is very high risk, 10–12 is high risk, 13–14 is moderate risk, and 15–18 is mild risk. Scores of 19 or greater are considered very low or no risk.
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    5 . Pressure injuries are classified into how many stages?
    A) 3
    B) 4
    C) 5
    D) 6

    STAGING OF PRESSURE INJURIES

    The National Pressure Ulcer Advisory Panel (NPUAP), in conjunction with a consensus conference format involving 400 health professionals, redefined the definition of pressure injuries in 2016 and provided an illustrated staging scheme that classifies pressure injuries by the depth and extent of tissue injury into six stages [89,98]. The NPUAP defines pressure injury as [89]:

    "... localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, comorbidities, and condition of the soft tissue."

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    6 . In which of the following pressure injury stages is the skin still intact?
    A) Stage 1
    B) Stage 2
    C) Stage 4
    D) Unstageable

    STAGING OF PRESSURE INJURIES

    Suspected deep tissue injury is described as a purple or maroon localized area of discolored, intact skin or a blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear (Image 1). The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.

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    7 . In which of the following pressure injury stages is there full-thickness skin and tissue loss and the base of the ulcer is covered by slough, obscuring the wound bed?
    A) Stage 1
    B) Stage 3
    C) Stage 4
    D) Unstageable

    STAGING OF PRESSURE INJURIES

    Unstageable pressure injuries are defined as full-thickness skin and tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black), obscuring the wound bed (Image 6). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.

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    8 . In patients with normal immune response, the inflammatory phase of pressure ulcer healing occurs
    A) in the first 0 to 3 days.
    B) 3 to 12 days after the ulcer develops.
    C) 14 to 30 days after the ulcer develops.
    D) for up to 1 year after the ulcer develops.

    PHASES OF WOUND HEALING: AN OVERVIEW

    The standard signs and symptoms of inflammation are erythema, swelling, increased temperature, and pain. In normal healing, these signs are only minimally noticeable, and during the inflammatory phase of wound healing, they are considered a normal response [88]. In general, this phase occurs in the first 0 to 3 days after ulcer development, but may last longer if healing is impaired.

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    9 . Which of the following is the most sensitive marker to assess patient's nutritional status?
    A) Albumin
    B) Transferrin
    C) Prealbumin
    D) Total protein

    DIAGNOSIS

    Blood tests may be ordered to assess nutritional status and overall health status. No laboratory study of nutritional status can absolutely predict pressure ulcers; however, monitoring a patient's protein status is of value. There are many serologic markers used to assess a patient's nutritional status; prealbumin level is one of the most sensitive. Prealbumin is a protein with a much shorter half-life than the other serologic markers; therefore, its level gives a more accurate picture of current conditions.

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    10 . Radiographic studies are indicated in a patient with pressure ulcer
    A) to rule out osteomyelitis.
    B) when bone infection is suspected.
    C) to rule out vasculitis and skin cancers.
    D) Both A and B

    DIAGNOSIS

    If infection is suspected, culture of the pressure ulcer is important to determine the pathogen. In some cases, a wound biopsy is performed to rule out vasculitis and skin cancers. An x-ray is done if bone infection is suspected and to rule out osteomyelitis. A bone scan is carried out when x-ray findings are equivocal.

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    11 . Which of the following is NOT a primary objective for the management of pressure ulcers?
    A) Pressure reduction
    B) Managing a moist wound environment
    C) Increasing the frequency of dressing changes
    D) Minimizing or eliminating friction and shear forces

    PREVENTION AND TREATMENT

    The primary objectives for prevention and arrest of progression are:

    • Preventive skin care

    • Pressure reduction, minimizing or eliminating friction and shear forces

    • Adequate nutrition

    • Exudate management

    • Prevention of wound infection

    • Managing moist wound environments

    • Decreasing the frequency of dressing changes

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    12 . A patient who requires moderate assistance with bed mobility and is at high risk for pressure ulcer development should have what type of therapeutic support surface?
    A) Rotational surface
    B) Reactive support surface, powered
    C) Reactive support surface, non-powered
    D) Active support surface with multi-zoned surface

    PREVENTION AND TREATMENT

    THERAPEUTIC SUPPORT SURFACE SELECTION TOOL

     Validated Risk Assessment Category or Pressure Ulcer Description
    At risk
    OR
    Redness present that fades quickly when pressure is removed
    Moderate risk
    OR
    One pressure ulcer (excluding the heels) where the patient can be positioned off the ulcer
    High risk
    OR
    One pressure ulcer (excluding the heels) and redness over another area
    Very high risk
    OR
    Multiple pressure ulcers (excluding the heels) or the patient cannot be positioned off of an ulcerated area
    Ability to change position in bed (e.g., bed mobility)Total assist to change position in bed.Reactive support surface (non-powered) (e.g., air/gel/foam overlay)Reactive support surface (non-powered) (e.g., air/gel/foam overlay)
    Active support surface:
    Multi-zoned surface (e.g., alternating pressure mattress, rotational surface), or powered reactive support surface (e.g., low air loss)
    Active support surface:
    Multi-zoned surface (e.g., alternating pressure mattress, rotational surface) or powered reactive support surface (e.g., low air loss)
    Moderate assistance with bed mobility required.Reactive support surface (non-powered) (e.g., air/gel/foam overlay or high-density foam mattress)Reactive support surface (non-powered) (e.g., foam overlay with air section inset in the area of the wound)Reactive support surface (non-powered) (e.g., foam overlay with air section inset in the area of the wound)
    Active support surface:
    Multi-zoned surface (e.g., alternating pressure mattress, rotational surface) or powered reactive support surface (e.g., low air loss)
    Patient independent with or without a device with bed positioning. (Light assist may be required.)Reactive support surface (non-powered) (e.g., high-density foam mattress)Reactive support surface (non-powered) (e.g., foam overlay with air section insert)Reactive support surface (non-powered) (e.g., air/gel/foam overlay)Reactive support surface (powered if the control is within the patient's reach)
    Instructions for use of this clinical tool: Determine the patient's level of risk and level of mobility in bed and follow the column-and-row intersection to determine the appropriate reactive or active support system.
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    13 . In poorly nourished patients, optimal healing of pressure ulcers requires a protein intake of
    A) 0.25–0.5 g/kg/day.
    B) 1.25–1.5 g/kg/day.
    C) 12.5–15 g/kg/day.
    D) 25–50 g/kg/day.

    PREVENTION AND TREATMENT

    The provision of an optimal diet (e.g., 30–35 kcalories/kg body weight for adults who are at risk for malnutrition), including the addition of supplemental protein, amino acids, zinc, and vitamins, has been shown to reduce risk of pressure-induced skin injury and to speed wound healing. The recommended daily protein intake for healthy adults (0.8 g/kg of body weight) may not be adequate in the frail elderly or under conditions of chronic inflammation and loss of lean body mass. For dietetic management of adults at high risk of pressure injury or delayed wound healing, the recommended intake is 1.25–1.5 g protein/kg body weight daily [8,89].

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    14 . Which cleansing agent is highly effective in fungating lesions, especially againstPseudomonas aeruginosa?
    A) Acetic acid
    B) Normal saline
    C) Dakin's solution
    D) Hydrogen peroxide

    PREVENTION AND TREATMENT

    Generally, normal saline is used for cleansing pressure ulcers. In ulcers with necrotic tissue, debris, or confirmed or suspected infection, antimicrobials or surfactants should be considered. For infected wounds, diluted povidone-iodine may be used as the irrigation fluid. However, it should not be used during the granulation phase of healing. Acetic acid (0.5%) is highly effective in fungating lesions, especially against Pseudomonas aeruginosa. There are various cleansing agents available in the market, but normal saline is usually the best option. [18].

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    15 . Debridement is contraindicated if
    A) no eschar develops on the heels.
    B) undermining or tunneling is present.
    C) necrotic tissue is present in the wound.
    D) there is inadequate blood supply to support wound healing.

    PREVENTION AND TREATMENT

    The method of debridement used depends on the amount of necrotic tissue present, the location of the wound, and the patient's overall condition [88]. Patients with stage 3 or 4 pressure ulcers who have undermining and/or tunneling or extensive necrotic tissue should have a surgical evaluation for possible surgical debridement of the wound, if this is consistent with their condition and goals of care [89]. Infected wounds may require systemic antibiotic treatment and immediate surgical debridement [82]. Maintenance debridement should be continued until there is a covering of granulation tissue in the wound bed and the wound is free of necrotic tissue [89]. Debridement is contraindicated if there is inadequate blood supply to support wound healing.

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    16 . For patients in long-term care or home care, the Agency for Healthcare Research and Quality recommends what method(s) of debridement?
    A) Surgical
    B) Maggot therapy
    C) Autolytic and enzymatic
    D) Debridement is not recommended.

    PREVENTION AND TREATMENT

    Autolytic debridement uses the body's own enzymes and moisture to heal the ulcer. To be successful, there must be sufficient white blood cells available to the wound and a moist environment [83]. A layer of wound exudate should be kept in contact with the surface of the wound, usually using a moisture-retaining dressing [82,85,88]. This allows fluid to accumulate in the wound, rehydrating necrotic tissue and making it possible for enzymes in the wound to digest the dead tissue [88]. For a wound covered with dry eschar, it is appropriate to crosshatch the eschar, as this allows a faster build-up of moisture in the wound [88]. In their clinical practice guidelines for pressure ulcer treatment, the Agency for Healthcare Research and Quality recommends autolytic and enzymatic debridement as the preferred approach for patients in long-term care or home care and for patients who cannot tolerate other methods of debridement [88,90]. In general, this type of debridement is ideal for patients with stage 3 or 4 ulcers with light-to-moderate exudates.

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    17 . Which type of debridement uses collagenase, papain, becaplermin, or trypsin to help loosen necrotic tissue?
    A) Surgical
    B) Autolytic
    C) Enzymatic
    D) Mechanical

    PREVENTION AND TREATMENT

    Enzymatic debridement is used either alone or in combination with other techniques to remove necrotic tissue and promote wound healing [19,20]. It is also indicated when surgical debridement is not possible. Concentrated enzymes, such as collagenase, papain, becaplermin, or trypsin, are applied to help loosen the necrotic tissue, which is then manually removed. Usually, stage 3 or 4 ulcers are considered candidates for enzymatic debridement. Application of the enzyme should be discontinued when the wound is free of necrotic tissue. If eschar is present, it should be crosshatched prior to introduction of the enzyme to improve efficacy, as enzymes are not active on a dry surface.

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    18 . Which dressing type is appropriate for wounds with heavy exudate?
    A) Alginate
    B) Hydrogel
    C) Hydrocolloid
    D) Transparent film

    PREVENTION AND TREATMENT

    OVERVIEW OF DIFFERENT DRESSINGS FOR PRESSURE ULCERS

    Dressing TypeDescriptionIndicationAdvantagesDisadvantages
    Transparent filmAdhesive, semipermeable, polyurethane membrane that allows water to vaporize and cross the barrierManagement of stage 1 and 2 pressure ulcers with light or no exudates; may be used with hydrogel or hydrocolloid dressings for full-thickness wounds
    Retains moisture
    Impermeable to bacteria and other contaminants
    Facilitates autolytic debridement
    Allows for wound observation
    Does not require secondary dressing (e.g., tape, wrap)
    Not recommended for infected wounds or wounds with drainage
    Requires border of intact skin for adhesion
    May dislodge in high-friction areas
    Not recommended on fragile skin
    HydrogelWater- or glycerin-based amorphous gels, impregnated gauze, or sheet dressings; amorphous and impregnated gauze fill the dead tissue space and can be used for deep woundsManagement of stage 2, 3, and 4 ulcers; deep wounds; and wounds with necrosis or slough
    Soothing, reduces pain
    Rehydrates wound bed
    Facilitates autolytic debridement
    Fills dead tissue space
    Easy to apply and remove
    Can be used in infected wounds or to pack deep wounds
    Not recommended for wounds with heavy exudate
    Dehydrates easily if not covered
    Difficult to secure (amorphous and impregnated gauze need secondary dressing)
    May cause maceration
    AlginateDerived from brown seaweed; composed of soft, nonwoven fibers shaped into ropes or padsMay be used as primary dressing for stages 3 and 4 ulcers, wounds with moderate-to-heavy exudate or tunneling, and infected or noninfected wounds
    Absorbs up to 20 times its weight
    Forms a gel within the wound
    Conforms to the shape of the wound
    Facilitates autolytic debridement
    Fills in dead tissue space
    Easy to apply and remove
    Not recommended with light exudate or dry scarring or for superficial wounds
    May dehydrate the wound bed
    Requires secondary dressing
    FoamProvides a moist environment and thermal insulation; available as pads, sheets, and pillow dressingsMay be used as primary dressing (to provide absorption and insulation) or as secondary dressing (for wounds with packing) for stage 2 to 4 ulcers with variable drainage
    Nonadherent, although some have adherent borders
    Repels contaminants
    Easy to apply and remove
    Absorbs light-to-heavy exudate
    May be used under compression
    Recommended for fragile skin
    Not effective for wounds with dry eschar
    May require a secondary dressing
    HydrocolloidOcclusive or semiocclusive dressings composed of materials such as gelatin and pectin; available in various forms (e.g., wafers, pastes, powders)May be used as primary or secondary dressing for stage 2 to 4 ulcers, wounds with slough and necrosis, or wounds with light to moderate exudates; some may be used for stage 1 ulcers
    Impermeable to bacteria and other contaminants
    Facilitates autolytic debridement
    Self-adherent, molds well
    Allows observation, if transparent
    May be used under compression products (compression stockings, wraps, Unna boot)
    May be applied over alginate dressing to control drainage
    Not recommended for wounds with heavy exudate, sinus tracts, or infection
    May curl at edges
    May injure fragile skin upon removal
    Contraindicated for wounds with packing
    Moistened gauze2×2- or 4×4-inch square of gauze soaked in saline for packingMay be used for stage 3 and 4 ulcers and for deep wounds, especially those with tunneling or underminingAccessible
    Must be remoistened often
    Time-consuming to apply
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    19 . Silver-impregnated dressings are an option for
    A) all wounds.
    B) infected or heavily colonized wounds.
    C) only wounds with little or no exudate.
    D) patients who require long-term wound care.

    PREVENTION AND TREATMENT

    Silver-impregnated dressings are a treatment option for infected or heavily colonized wounds or wounds that are at increased risk for infection [89]. Silver has an antimicrobial effect on a broad spectrum of organisms and has been shown to reduce the bacterial count in wounds [83]. Sustained-release sliver dressings are toxic to bacteria and fungi but do not adversely affect healthy wound tissue [85]. However, silver-resistant organisms do exist, and the judicious use of sliver is advised, similar to the approach adopted with antibiotics [83]. It is recommended that the use of silver dressings be limited to a two- to four-week period [83].

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    20 . Which medications should be avoided as much as possible for routine pain management in patients with pressure ulcers?
    A) Opioids
    B) NSAIDs
    C) Acetaminophen
    D) Both B and C

    PREVENTION AND TREATMENT

    For mild-to-moderate pain, nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen may be used. Opioids should be avoided as much as possible, as the sedative effects boost immobility; however, they may be necessary during dressing changes and/or debridement.

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    21 . Direct contact electrical stimulation therapy should be considered for the management of
    A) unstageable ulcers.
    B) deep tissue injuries.
    C) recalcitrant stage 1 ulcers.
    D) stage 3 and stage 4 ulcers.

    PREVENTION AND TREATMENT

    This therapy consists of the placement of a high-voltage, pulsed electrical current onto the wound bed (direct) or near the wound (induced), usually once daily for several weeks. The electrical settings (e.g., the polarity, amplitude and voltage, amperage) are established according to wound and patient characteristics. The Institute for Clinical Systems Improvement recommends considering the use of direct contact electrical stimulation in the management of recalcitrant stage 2 as well as stage 3 and 4 pressure injuries to facilitate wound healing [114].

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    22 . Which of the following is a thermal effect of therapeutic ultrasound that may be beneficial for patients with pressure ulcers?
    A) Increased collagen elasticity
    B) Speeds up inflammatory process
    C) Increased release of growth factors
    D) Increased muscle and joint stiffness

    PREVENTION AND TREATMENT

    THERMAL AND NON-THERMAL EFFECTS OF THERAPEUTIC ULTRASOUND

    ThermalNon-Thermal
    Increased collagen elasticity
    Decreased muscle and joint stiffness
    Decreased pain
    Decreased muscle spasm
    Increased oxygen transport
    Hyperemia
    Speeds up inflammatory process
    Increases release of growth factors
    Fibroblast and endothelial cell proliferation
    Increased collagen production
    Accelerated angiogenesis
    Better organization of collagen matrix
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    23 . According to the algorithm for the treatment of pressure ulcers, management of a stage 3 ulcer with necrotic tissue consists of
    A) applying protective dressings, as needed.
    B) cleansing the wound and applying a moist dressing.
    C) debridement, cleansing the wound, and use of a moist-to-absorbent dressing.
    D) cleansing the wound, applying topical antibiotics, and using a moist-to-absorbent dressing.

    PREVENTION AND TREATMENT

    ALGORITHM FOR THE TREATMENT OF PRESSURE ULCERS

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    24 . The Pressure Ulcer Scale for Healing (PUSH) tool assesses what three domains of the pressure ulcer to determine wound progression?
    A) Size, odor, and color
    B) Comorbidities, pain, and tissue in wound bed
    C) Size, exudate amount, and tissue in wound bed
    D) Wound location, signs of infection, and exudates

    WOUND MONITORING

    Reverse staging of pressure ulcers is not an acceptable approach to gauging the level of wound healing. Healed pressure ulcers do not replace lost muscle, subcutaneous fat, or dermis [89]. Tools that appropriately measure degrees of healing include the Bates-Jensen Wound Assessment Tool and the Pressure Ulcer Scale for Healing (PUSH) tool [82,95]. The Bates-Jensen Wound Assessment Tool has thirteen variables that provide a composite picture of the status of the wound [82]. The PUSH tool uses scores in three domains (i.e., size, exudate amount, and tissue type) to indicate improvement or deterioration of the ulcer (Table 5) [103]. When using this tool, surface area is calculated by multiplying the greatest length (head to toe) by the greatest width (side to side) in centimeters. After removal of the dressing and before applying any topical agent to the ulcer, the amount of exudate is estimated as none, light, moderate, or heavy. Finally, the type(s) of tissue present in the wound bed is evaluated (i.e., necrotic, slough, granulation, epithelial, or closed). A score of 0 on the PUSH tool indicates the wound has healed, whereas the highest score of 17 indicates wound degeneration [82]. Results of the assessment should be recorded; a decrease in score over time indicates improvement.

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    25 . A wound base that appears clean and uniformly red or pink in color
    A) may be exposed tendon.
    B) should be kept dry at all times.
    C) usually heals by secondary intention.
    D) indicates a need for more frequent dressing changes.

    WOUND MONITORING

    WOUND BASE COLOR DESCRIPTIONS

    ColorDescription and Clinical Implications
    Red
    Clean and uniformly pink to red in color.
    Usually heals by secondary intention.
    Dressings need to be changed less often, but the wound should be moist at all times.
    Yellow
    Varies from ivory to canary yellow or even green in color, depending on whether or not infection is present.
    Caution: Tendon may appear as yellow or white.
    The goal of care is to manage exudate and remove slough through surgical, sharp, mechanical, enzymatic, or autolytic debridement.
    Not all yellow is detrimental to healing; granulation grows through yellow fibrin.
    Black or brown
    Ranges in color from dark brown and gray to black.
    The goal for most individuals is to remove the necrotic tissue by surgical, sharp, enzymatic, or autolytic debridement.
    Where there is no drainage or there is boggy surrounding tissue, leave the hard, dry eschar or black scab intact on the lower legs, feet, or heels of individuals whose healing potential is compromised by inadequate circulation. It provides a protective covering for the wound.
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    26 . Circumferential erythema and/or induration up to 2 cm from the wound are indicative of
    A) cellulitis.
    B) septic shock.
    C) Marjolin ulcer.
    D) necrotizing fasciitis.

    WOUND MONITORING

    The condition of the surrounding skin surface up to 4 cm from the edge of the wound circumferentially must also be assessed and documented. Its characteristics should be noted, particularly color and integrity [85]. Maceration from excessive drainage may indicate that the dressing used is not appropriate and a different product is needed. Circumferential erythema and/or induration up to 2 cm from the wound are indicative of cellulitis.

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    27 . Which of the following is NOT one of the elements in the quick Sequential Organ Failure Assessment (qSOFA) tool?
    A) Altered mentation
    B) Elevated bilirubin (>2 mg/dL)
    C) Systolic blood pressure 100 mm Hg or greater
    D) Respiratory rate of 22 breaths per minute or less

    COMPLICATIONS

    Working from a model derived from a large inpatient data base, the sepsis task force was able to identify, and validate, a simple "bedside" clinical measure that can be used to identify which patients with suspected infection are at risk for developing sepsis. Designated the qSOFA (for quick SOFA), this measure consists of three elements [128]:

    • Respiratory rate ≥22/min

    • Altered mentation

    • Systolic blood pressure ≤100 mm Hg

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    28 . The first sign of Marjolin ulcer is
    A) flu-like illness.
    B) abrupt resolution of the wound.
    C) change in the character of the wound.
    D) a decrease in drainage and an increase in odor.

    COMPLICATIONS

    The first sign of Marjolin ulcer is a change in the character of the wound. Drainage increases, and the odor of the drainage becomes putrid. In some cases, there is frank bleeding. Diagnosis is made after histologic examination of a specimen removed from the ulcer, usually at the time of a flap closure. Confirmation of the diagnosis requires a preoperative tissue biopsy; wedge biopsy is the method of choice.

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    29 . To be considered unavoidable, a pressure ulcer must develop
    A) after a delay in detection or diagnosis.
    B) while a patient is being cared for at home.
    C) in spite of timely, appropriate interventions.
    D) in a patient being cared for in an acute care facility.

    MEDICO-LEGAL ASPECTS OF ULCER CARE

    As noted, despite best patient care and treatment, not all pressure ulcers are avoidable [76]. In long-term care, the NPUAP defines an unavoidable ulcer as one that occurs even though "the facility had evaluated the individual's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with individual needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate" [111]. However, most pressure ulcers are avoidable, and in acute care, an ulcer is considered a never event. The decision of whether an ulcer is avoidable or not is made on the basis of an assessment of care and patient characteristics; it may not be made prior to ulcer development [111].

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    30 . Which of the following factors may lead to a determination of neglect?
    A) Poor documentation
    B) Inadequate nutrition
    C) Inadequate prevention
    D) All of the above

    MEDICO-LEGAL ASPECTS OF ULCER CARE

    FACTORS LEADING TO A DETERMINATION OF NEGLECT

    Inadequate prevention
    Poor documentation
    Inadequate nutrition
    Inadequate medical care
    No family notification
    Poor care planning
    Wound severity and outcome
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