| Questions about risk factors and risk assessment |
| 2 - The risk factors for developing PU are: immobility, incontinence, inadequate nutrition, and altered level of consciousness (T) |
15 (93.7) |
9 (90) |
9 (90) |
12 (100) |
27 (93.1) |
28 (100) |
| 3 - All patients at risk for PU should have systematic skin inspection at least once a week (F) |
12 (75) |
7 (70) |
6 (60) |
11 (91.6) |
13 (44.8) |
22 (78.5) |
| 7 - All patients should be assessed on admission to the hospital for risk of developing PU (T) |
15 (93.7) |
9 (90) |
10 (100) |
12 (100) |
29 (100) |
28 (100) |
| 16 - In the patient with the presence or risk of PU, the head end of the bed should not be raised more than 30 degrees if there is no medical contraindication (T) |
8 (50) |
4 (40) |
6 (60) |
1 (8.3) |
11 (37.9) |
10 (35.7) |
| 26 - Every patient who does not ambulate should be submitted to risk assessment for the development of PU (T) |
16 (100) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
28 (100) |
| 27 - Patients and families should be educated about the causes and risk factors for developing PU (T) |
16 (100) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
27 (96.4) |
| 40 - The development of educational programs in the institution can reduce the incidence of PU (T) |
15 (93.7) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
28 (100) |
| 41 - Hospitalized patients need to be assessed for the risk of PU only once during their hospitalization (F) |
14 (87.5) |
10 (100) |
10 (100) |
12 (100) |
27 (93.1) |
28 (100) |
| Skin and tissue assessment questions |
| 1 - PU stage/category 1 is defined as intact skin with hyperemia of a localized area, which does not show visible whitening or the color differs from the surrounding area (T) |
15 (93.7) |
10 (100) |
10 (100) |
12 (100) |
25 (86.2) |
23 (82.1) |
| 6 - A stage 3 PU is partial skin loss, involving the epidermis (F) |
14 (87.5) |
9 (90) |
7 (70) |
12 (100) |
20 (68.9) |
22 (78.5) |
| 9 - Stage/category 4 PUs have full thickness skin loss and tissue loss with exposure or direct palpation of fascia, muscle, tendon, ligament, cartilage, or bone (T) |
16 (100) |
10 (100) |
10 (100) |
12 (100) |
29 (100) |
27 (96.4) |
| 20 - Stage 2 PUs have full thickness skin loss (F) |
9 (56.2) |
6 (60) |
8 (80) |
11 (91.6) |
15 (53.5) |
16 (57.1) |
| 31 - PUs are sterile wounds (F) |
15 (93.7) |
9 (90) |
6 (60) |
12 (100) |
21 (72.4) |
24 (85.7) |
| 33 - A blister in the calcaneal region should not be a cause for concern (F) |
15 (93.7) |
9 (90) |
10 (100) |
12 (100) |
26 (89.6) |
27 (96.4) |
| 38 - Stage 2 PUs can be extremely painful as a result of exposure of the nerve endings (T) |
7 (43.7) |
10 (100) |
3 (30) |
11 (91.6) |
17 (58.6) |
20 (71.4) |
| Preventive Skin Care Questions |
| 4 - The use of hot water and soap can dry out the skin and increase the risk for PU (T) |
12 (75) |
9 (90) |
5 (50) |
11 (91.6) |
20 (68.9) |
26 (92.8) |
| 5 - It is important to massage the regions of bony prominences if they are hyperemic (F) |
14 (87.5) |
8 (80) |
8 (80) |
12 (100) |
16 (55.1) |
26 (92.8) |
| 8 - Creams, transparent dressings, and extra-thin hydrocolloid dressings help protect the skin from the effects of friction (T) |
15 (93.7) |
10 (100) |
9 (90) |
12 (100) |
27 (93.1) |
27 (96.4) |
| 21 - The skin of the patient at risk for PU must remain clean and moisture-free (T) |
16 (100) |
9 (90) |
10 (100) |
12 (100) |
27 (93.1) |
28 (100) |
| 22 - Measures to prevent new lesions do not need to be taken continuously when the patient already has PU (F) |
16 (100) |
9 (90) |
10 (100) |
12 (100) |
28 (96.5) |
27 (96.4) |
| 23 - Movable sheets or liners should be used to transfer or move patients who cannot move themselves (T) |
14 (87.5) |
8 (80) |
10 (100) |
12 (100) |
27 (93.1) |
28 (100) |
| 25 - In the patient with a chronic condition who cannot move by himself, rehabilitation should be started including orientation on the prevention and treatment of PU (T) |
15 (93.7) |
10 (100) |
10 (100) |
12 (100) |
29 (100) |
28 (100) |
| 28 - The regions of bony prominences can be in direct contact with each other (F) |
15 (93.7) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
28 (100) |
| 30 - The skin, when macerated by moisture, is more easily damaged (T) |
16 (100) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
28 (100) |
| 32 - A skin region with PU scarring may be damaged more quickly than healthy skin (T) |
14 (87.5) |
9 (90) |
9 (90) |
11 (91.6) |
29 (100) |
26 (92.8) |
| 34 - A good way to decrease the pressure in the heel area is to keep them elevated off the bed (T) |
16 (100) |
9 (90) |
10 (100) |
12 (100) |
26 (89.6) |
27 (96.4) |
| 35 - Every care to prevent or treat PU does not need to be recorded (F) |
14 (87.5) |
9 (90) |
9 (90) |
9 (75) |
27 (93.1) |
28 (100) |
| 36 - Shear is the force that occurs when the skin adheres to a surface and the body slides (T) |
14 (87.5) |
9 (90) |
8 (80) |
11 (91.6) |
28 (96.5) |
25 (89.2) |
| 37 - Friction can occur when moving the patient on the bed (T) |
16 (100) |
9 (90) |
10 (100) |
12 (100) |
27 (93.1) |
28 (100) |
| 39 - In the incontinent patient, the skin should be cleaned at the time of elimination and at routine intervals (T) |
16 (100) |
9 (90) |
10 (100) |
12 (100) |
28 (96.5) |
28 (100) |
| Question about nutritional assessment and treatment |
| 10 - An adequate dietary intake of protein and calories should be maintained during illness/hospitalization (T) |
16 (100) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
27 (96.4) |
| Questions about repositioning and early mobilization |
| 11 - Patients who are confined to bed must be repositioned every three hours (F) |
15 (93.7) |
9 (90) |
7 (70) |
12 (100) |
21 (71.4) |
26 (92.8) |
| 12 - A timed bed change schedule should be used for each patient with or at risk for PU (T) |
16 (100) |
9 (90) |
10 (100) |
12 (100) |
28 (96.5) |
27 (96.4) |
| 15 - In the lateral decubitus position, the patient with or at risk for PU should be at a 30-degree angle to the bed mattress (T) |
14 (87.5) |
8 (80) |
9 (90) |
11 (91.6) |
23 (79.3) |
24 (85.7) |
| 17 - The patient who does not move by himself must be repositioned every two hours when sitting in a chair (F) |
6 (37.5) |
7 (70) |
6 (60) |
9 (75) |
8 (27.5) |
17 (60.7) |
| 18 - The patient with limited mobility and who can change body position without help should be instructed to perform pressure relief every 15 minutes while sitting in the chair (T) |
11(68.7) |
10 (100) |
7 (70) |
11 (91.6) |
17 (58.6) |
24 (85.7) |
| 24 - Mobilization and transfer of patients who cannot move by themselves should always be performed by two or more people (T) |
15 (93.7) |
9 (90) |
10 (100) |
12 (100) |
29 (100) |
28 (100) |
| Support surface questions |
| 13 - Water or air gloves relieve the pressure on the heels (F) |
12 (75) |
9 (90) |
7 (70) |
12 (100) |
15 (51.7) |
27 (96.4) |
| 14 - Water-wheel or air-wheel cushions help prevent PU (F) |
11 (68.7) |
9 (90) |
6 (60) |
11 (91.6) |
12 (41.3) |
22 (78.5) |
| 19 - The patient with limited mobility and who can remain in the chair should have a seat cushion for the protection of the region of the bony prominences (T) |
9 (56.2) |
8 (80) |
8 (80) |
11 (91.6) |
28 (96.5) |
27 (96.4) |
| 29 - Every patient at risk for developing PU should have a mattress that redistributes pressure (T) |
15 (93.7) |
10 (100) |
10 (100) |
12 (100) |
28 (96.5) |
26 (92.8) |
