Pressure Injuries and Pressure Care

Transcription

1 Pressure Injuries and Pressure Care Multiple choice Questions (with answers) Contents Segment 1 Pressure Injuries and Pressure Care... 2 Segment 2 Anatomy of the Skin... 4 Segment 3 How pressure injuries occur... 6 Segment 4 Index Risk... 8 Segment 5 Assessment Segment 6 Prevention Segment 7 Your role Segment 8 Pressure area Development Segment 9 Potential Pressure Injury Areas

2 Segment 1 Pressure Injuries and Pressure Care 1) Where is a Pressure injury usually located? a. You will find them at the site of joints b. You will find them at fatty sites c. They are only ever found on the buttocks d. Over bony prominence areas e. On a persons weaker side 2) How is a pressure injury described? a. As a localised injury to the skin and / or underlying tissue b. An injury that needs pressure placed over it to heal c. An infection that spreads throughout the skin originating from a pressure point d. Skin erosion caused by pressure e. Bruising or damage to the skin from pressure impact such as walking into a wall 3) Which ones of these is NOT a cause of pressure injury? a. Damage from unrelieved pressure b. Poor blood flow c. Damage from walking into objects d. Chaffing and rubbing of the skin e. These are all forms of pressure injuries 4) A pressure injury will not do what? a. Grow b. Blanch c. Heal d. Get infected e. Cause pain 5) A pressure injury will generally be what colours? a. White or Red b. Black or Blue / Purple c. Red or Blue / Purple d. Yellow or white e. Black or Red 6) What may be happening under the skin of a pressure area? a. A cavity could be forming b. Infection c. Skin becoming thick d. Become a storage site for fatty tissue e. Pressure injuries only effect the top layers of the skin 7) What can prevent pressure injuries? a. Nothing can prevent pressure injuries b. Wrapping padding around the client 2

3 c. Keeping the client moving often d. Good nursing care e. Plenty of calcium in the diet 8) What can pressure injuries be a sign of? a. The client is not getting up and moving like they were told to b. The client is not consuming enough calcium c. The client is a smoker d. The client is not consuming enough water e. The client may be getting neglected or abused 9) Which of the following is another term used for pressure injuries? a. Bed sores b. Pressure sores c. Pressure ulcers d. Pressure areas e. All of the above 10) How long can pressure injuries take to develop? a. Sudden impact b. A matter of minutes c. A matter of hours d. Half a day e. A day or 2 11) How often do you need to ensure a person is turned or moved? a. Every hour b. Every 2 hours c. Every 3 hours d. Every 4 hours e. Every 5 hours 12) What is the first indication of a pressure injury? a. A change of colour to the area b. Warmth in the area c. Coolness in the area d. Blotching in the area e. Skin breakdown over the area 3

4 Segment 2 Anatomy of the Skin 1) Which of the following is the role of skin? a. Protects internal organs b. Heat regulation c. Sensation d. Making Vitamin D e. All of the above 2) How many main layers are there to skin? a. 1 b. 2 c. 3 d. 4 e. 5 3) The outermost layer of the skin is called what? a. Dermis b. Epidermis c. Peridermis d. Subcutaneous e. Shell 4) Skin gets its toughness from a protein called what? a. Keratin b. Elastin c. Collagen d. Amyloid e. Fibronectin 5) How many layers are there to the epidermis? a. 1 b. 2 c. 3 d. 4 e. 5 6) How long does it take for the new cells to reach the surface of the skin? a. 24 hours b. 48 hours c. 1 week d. 2 weeks e. 1 month 4

5 7) The dermis layer contains what? a. Collagen and Elastin b. Collagen and Keratin c. Elastin and Amyloid d. Elastin and Keratin e. Keratin and Amyloid 8) The epidermis and dermis combined are called what? a. Subcutaneous b. Cutaneous c. Skin barrier d. 1 st layer of skin e. Dual layer 9) The subcutaneous layer stores what? a. The ends of the pain receptors b. Red blood cells c. White blood cells d. Most of the bodies fat e. Keratin 10) Why is skin thinner over joints? a. It is not thinner over the joints b. Because of the wear and tear to the inside of the skin c. Because it would be difficult to bend if there was thick skin at joints d. Because there are no organs needing protection e. Because the insertion points of muscle to bone make it difficult for skin to develop there 5

6 Segment 3 How Pressure Injuries Occur 1) Pressure injuries can be grouped into how many main themes? a. 2 b. 3 c. 4 d. 5 e. 6 2) What type of injury is caused by the body squashing the skin and blocking blood flow to the tissue? a. Prolonged unrelieved pressure b. Shearing c. Friction d. Tourniquet e. Impact 3) What is the term used when the skin moves one way but the bone moves the other way? a. This is impossible to happen b. Friction c. Sliding pressure d. Distortion e. Shearing 4) When do friction injuries happen? a. When a person is left in the same position for a while b. When you drag a person up the bed without a slid sheet c. When two surfaces rub together like moving up and down the bed d. When a person has something around their body too tight cutting of circulation e. When something has scratched their body like a finger nail 5) When is skin more susceptible to damage? a. If skin is too moist b. If skin is too dry c. If skin has no hair d. a and b e. a and c 6) What will happen if blood cannot flow through an area due to pressure applied? a. Cell death can occur b. A build-up of blood near the area will occur c. People stop feeling pain in that area as the nerve cells die d. The person will experience pins and needles sensation e. The area will get cold causing discomfort to the person 6

7 7) How can you prevent pressure injuries from occurring? a. Keeping a person sitting up not lying down b. Moving or turning a person regularly c. Getting a person to get up and walk around regularly d. Keeping a person warm e. There is nothing you can do to prevent pressure injuries from occurring 8) What is the term used to describe skin that has become soft and separated or to waste away? a. Cyanosed b. Slough c. Shearing d. Distortion e. Macerate 7

8 Segment 4 Index Risk 1) Who is at risk of developing a pressure injury? a. Elderly people b. Frail people c. People with limited mobility d. All of the above e. Anyone can develop a pressure injury if seated for more than 2 hours 2) Who will do a risk assessment to determine how likelihood a client could develop a pressure injury? a. The client will tell you b. The assigned health care worker c. A registered nurse d. An occupational therapist e. A physical therapist 3) Which of the following is NOT a type of scale used to determine how likely a pressure injury could occur? a. Braden scale b. Glasgow scale c. Norton scale d. Waterlow scale e. Glamorgan scale 4) How many categories are assessed using the Braden scale? a. 3 b. 4 c. 5 d. 6 e. 7 5) Which of the following is NOT a category assessed in the Braden scale? a. Sensory perception b. Moisture c. Activity d. Mobility e. Temperature 6) Which scale system scores risk from 1-4 to ascertain likelihood of pressure injuries? a. Norton scale b. Braden scale c. Waterlow scale d. Glasgow scale e. Glamorgan scale 8

9 7) Which scale system is used for children? a. Norton scale b. Braden scale c. Waterlow scale d. Glasgow scale e. Glamorgan scale 8) Why does a health care worker need to know what assessments are done for pressure injury risk? a. Because a health care worker will be required to complete the assessments b. So the health care worker sound knowledgeable when talking to medical staff c. It will help the care worker know what information to pass on to the registered nurse when doing cares d. The healthcare worker does not need to know about the assessments scales other than they exist e. So the health care worker can further explain the assessment to the client 9

10 Segment 5 Assessment 1) What is vital for the care and prevention of pressure injuries? a. A sound assessment b. Adequate training c. A compliant patient d. The right equipment e. Supervision of a registered nurse 2) When doing an assessment where is the first place to start? a. The head b. The feet c. With a clinical history d. Whatever order is comfortable for you e. Checking medications 3) What information would you require when obtaining a clinical history? a. Current illnesses b. Past health issues c. Any illness that could impact current health d. Medications e. All of the above 4) Which of the following is NOT part of a skin assessment? a. Colour b. viscosity c. Integrity d. Temperature e. Dryness 5) What is a key indicator that a person is at risk for pressure injuries? a. Weight b. Medications c. Diabetes d. Mobility e. Age 6) Name two other assessments that are key to determining risk of pressure injuries: a. Nutritional and continence b. Cardiac and continence c. Mental health and nutritional d. Cardiac and nutritional e. Cardiac and mental health 10

11 7) Which of the following in NOT an example of an external factor influencing the likelihood of pressure injuries? a. The person spends a lot of time in bed b. The person spends all their time in bed c. The person is uncoordinated when walking d. The person is reliant on people to move them e. The person spends a lot of time in a wheelchair 8) What other factor is important to consider when assessing the level of risk for pressure injuries? a. Illness such as stroke or COPD b. Poor blood flow c. Skin sensation d. Frail e. All of the above 9) If the person has had a pressure injury in the past, this would indicate what? a. That they do not look after themselves very well b. They are more likely to get another pressure injury c. That they are less likely to get another pressure injury d. That they need a softer bed e. That people have failed to adequately care for them 10) How does weight impact a person s risk of pressure injuries? a. They are more likely to get pressure injuries if they are over weight b. They are more likely to get pressure injuries if they are under weight c. They are less likely to get pressure injuries if they are overweight d. They are less likely to get pressure injuries if they are underweight e. If they are over or underweight it increases the likelihood of pressure injuries 11) How can equipment cause pressure injuries? a. They cannot cause pressure injuries b. It is only when they are not used properly that injuries can occur c. Only heavy / metal equipment can cause pressure injuries while things like oxygen tubes are fine d. Anytime equipment is against the skin for a period of time pressure injuries can happen e. Equipment is unsafe to use with anybody who is at risk of pressure injuries 11

12 Segment 6 Prevention 1) After a client has been assessed by a registered nurse, what is the next thing that should happen if there is a risk of pressure injury? a. The client should be prescribed creams that work to protect skin b. The client should be prescribed medication that works to protect skin c. A care plan should be developed d. The bed should be positioned correctly to reduce pressure e. They should have a high pressure risk notice made for their room 2) Which of the following would you expect to see in a care plan? a. Timeframes for moving a person b. Schedule for completing skin checks c. Equipment list to use d. Nursing interventions e. All of the above 3) What is the common timeframe for moving a patient? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 6 hours e. Every 8 hours 4) If you notice redness over an area when turning a patient, how soon should you report it? a. Immediately b. Check it at the next turn to see if it has changed, then report c. No need to report, but it needs to be written in notes d. Monitor it for changes over the course of your shift then report at the end of shift e. Redness happens all the time, you only need to report it if the skin is breaking down 5) What can be used as a heel protection device for people that are bed bound? a. Specially designed heal pads b. Slippers c. A pillow d. A foot spa e. Heals are not much of a concern as the skin is thick 6) Which of the following is NOT a reactive surface product? a. Device that periodically redistributes pressure b. Gel c. Memory foam square d. Air inflated device e. Sheepskin heal pad 12

13 7) When does a person no longer need to be turned? a. When the gel is applied b. When using a memory foam bedding is being used c. When any active surface products are being used d. When any reactive surface products are being used e. A person always needs to be turned regardless of products 8) How should you move a person up the bed? a. Two people put their hands under their arms and drag them up b. Two people lift and shuffle them up c. Get the person to help you move them up the bed d. Use a sliding sheet to move a person up the bed e. Any of the above options are appropriate 13

14 Segment 7 Your role 1) Who develops the care plan? a. The health care assistant b. The Registered Nurse c. The family of the client d. The GP e. A gerontologist 2) What is the key aspect of your role? a. To design a care plan b. To assess the effectiveness of the care plan c. To critique the care plan d. To follow the care plan e. To do what you think should be done 3) What do you need to document? a. What you think should be done b. What you are planning to do c. What you have done d. What you thought you did well e. What the client thought you did well 4) What do you need to observe when doing cares? a. Red areas on the skin b. Moisture of the skin c. Dryness of the skin d. If a person is showing signs of dehydration e. All of the above 5) How does moisture on the skin cause pressure injuries? a. It does not cause pressure injuries; the skin needs to be moist b. It does not cause pressure injuries but it does make it more susceptible due to softening and macerating the skin c. Moisture acts as a suction pulling the skin to objects increasing the risk of pressure injuries d. Moisture erodes the skin away e. Moisture bloats the skin causing more pressure between the bone the object 6) What type of soap should be used on older adults skin? a. Soap free products b. A soap that contains antiseptic c. Strong smelling soap d. Soap with moisturiser e. Whatever is most cost effective 14

15 7) What is the most effective measure for preventing pressure injuries? a. A good barrier cream b. Keep them lying or sitting still c. A good quality pillow and mattress d. Turning or moving the person regularly e. A healthy diet 8) How often should a person be moved or turned? a. Every ½ hour b. Every hour c. Every 2 hours d. Every 3 hours e. Every 6 hours 9) Besides the turning chart, what two other charts are useful tools to use in the prevention of pressure injuries? a. Fluid balance and Food intake b. Fluid balance and Medication c. Medication and Food intake d. Food Intake and Cleaning e. Medication and Cleaning 10) Which is the most common place for a pressure injury? a. Shoulder, Elbow, Sacral b. Shoulder, hip, Stomach c. Elbow, Stomach Sacral d. Sacral, Shoulder, Stomach e. Hips, Stomach, Sacral 11) How can you protect a persons knees from rubbing together? a. Knees are not a problematic area so this is not a concern b. As long as they have been moisturised it is fine c. The person should be positioned on their back with their legs apart d. A wedge that keeps their legs apart can be used e. A pillow between their legs can be used 15

16 Segment 8 Pressure Area Development 1) How many stages of development are there with pressure injuries? a. 3 b. 4 c. 5 d. 6 e. 7 2) A pressure injury is the result of what? a. Clothing being too tight b. Banging against objects c. Old age skin deterioration d. Rubbing an area too roughly e. Intense pressure on an area 3) If you see redness that does not blanch when you touch it, what stage of pressure area development is present? a. 1 b. 2 c. 3 d. 4 e. 5 4) If you can see yellow fatty tissue and a layer of the skin is missing what stage of pressure area injury is apparent? a. 2 b. 3 c. 4 d. 5 e. 6 5) If the ulcer has rolled edges and there is beginning to be dead tissue what stage of pressure injury is a person in? a. 1 b. 2 c. 3 d. 4 e. 5 6) If the skin is blistering, what stage of pressure area injury is a person in? a. 1 b. 2 c. 3 d. 4 e. 5 16

17 7) When the wound extends down to the muscle, bones and fascia, what stage of pressure injury is present? a. 2 b. 3 c. 4 d. 5 e. 6 8) What does blanching mean? a. The skin bounces back after being pressed within 2 seconds b. A red area will go dark when touched c. A red area will go white when touched d. There will be no touch sensation felt when touched e. When you lightly pinch the skin it will go back down within 2 seconds 9) During stage one, what may you see happen with the skin? a. Redness b. Change in sensation c. Change in temperature d. Firmness e. All of the above 10) What is mean if there is tunnelling? a. You are in stage 4 of pressure injury b. You can see underlayers of fat or muscle c. You can see to the bone d. It is difficult to ascertain how deep the ulcer is e. All of the above 11) What would there likely be a lot of in stage 3 and 4 of pressure injury? a. Fluid b. granulation c. blistering d. blanching e. Scabbing 12) A pressure injury will not heal while there is the presence of what? a. Granulation b. Blanching c. Scabbing d. Puss e. Blistering 17

18 13) How does healing take place? a. From the bottom up b. From the top down c. Healing will not take place after stage 3 d. By packing the wound e. Healing will take place naturally when there is no longer pressure on the area 14) Who should do wound dressings? a. Any health care assistant b. Any trained health care assistant c. Anyone including family d. A district health nurse e. A registered nurse 18

19 Segment 9 Potential Pressure Injury Areas 1) Any skin that is dry or cracking is what? a. Has already begun to become a pressure injury b. In imminent danger of a pressure injury c. Is at risk of a pressure injury d. Is a low risk of being a pressure injury e. Will not turn into a pressure injury 2) What type of skin is likely to macerate? a. Dry skin b. Cracking skin c. Skin with a low ph d. Moist skin e. Thin skin 3) What should you avoid doing when moving a person? a. Rubbing them b. Lifting them c. Taking pressure off the area too quickly d. Using a slide sheet e. Using pillows to adjust them 4) What is the most important thing to look out for when moving a person? a. Pain b. Redness c. Warmth in the area d. Hardness e. All of the above 5) What should you do if you suspect a pressure injury may be at risk of forming? a. Monitor it for the duration of your shift b. Let the Registered nurse know c. Document it d. a and c e. b and c 19