1 |
Stage I Pressure Ulcer is defined as intact, with hyperemia of a localized area, which has no visible whitening or differs in color from the surrounding area. |
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2 |
The risk factors for the development of Pressure Ulcer are: immobility, incontinence, inadequate nutrition and alteration of the level of consciousness. |
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3 |
All patients at risk for Pressure Ulcer should have systematic skin inspection at least weekly. |
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4 |
Using hot water and soap can dry out the skin and increase the risk of Pressure Ulcer. |
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5 |
It is important to massage the regions of bony prominences if they are hyperemic. |
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6 |
A stage III Pressure Ulcer is a partial loss of skin, involving the epidermis. |
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7 |
All patients should be assessed on admission to the hospital for risk of developing a Pressure Ulcer. |
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8 |
Creams, clear dressings and extra-fine hydrocolloid dressings help protect the skin against the effects of friction. |
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9 |
Pressure Ulcers, in stage IV, present total loss of skin with intense destruction and tissue necrosis or damage to muscles, bones or supporting structures. |
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10 |
An adequate dietary intake of protein and calories should be maintained during illness/hospitalization. |
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11 |
Patients who are confined to bed should be repositioned every 3 hours. |
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12 |
A scale with times for changing positions should be used for each patient with or at risk of Pressure Ulcer. |
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13 |
Water or air gloves relieve heel injuries. |
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14 |
Donut shaped water or air cushions help prevent Pressure Ulcer. |
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15 |
In the lateral decubitus position, the patient with the presence of Pressure Ulcer or at risk for the same must remain at an angle of 30 degrees in relation to the bed mattress. |
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16 |
In patients with Pressure Ulcer or at risk for it, the head of the bed should not be raised at an angle greater than 30 degrees, if there is no medical contraindication. |
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17 |
Patients who cannot move on their own should be repositioned every 2 hours when sitting in the chair. |
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18 |
The patient with limited mobility and who can change body position without assistance should be instructed to relieve pressure every 15 minutes while sitting in the chair. |
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19 |
The patient with limited mobility and who can remain in the chair must have a cushion on the seat to protect the bony prominences region. |
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20 |
Stage II Pressure Ulcers show full-thickness skin loss. |
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21 |
The patient’s skin at risk for Pressure Ulcer must remain clean and free of moisture. |
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22 |
Measures to prevent new injuries do not need to be adopted continuously when the patient already has a Pressure Ulcer. |
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23 |
Movable sheets or bed linen should be used to transfer or move patients who cannot move on their own. |
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24 |
Mobilization and transfer of patients who cannot move on their own should always be performed by two or more people. |
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25 |
In the patient with a chronic condition who cannot move independently, rehabilitation should be initiated and include guidance on Pressure Ulcer prevention and treatment. |
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26 |
Every patient who cannot walk should be submitted to risk assessment for the development of Pressure Ulcer. |
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27 |
Patients and family members should be advised about the causes and risk factors for the development of Pressure Ulcer. |
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28 |
The regions of bony prominences can be in direct contact with each other. |
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29 |
Every patient at risk for developing Pressure Ulcer should have a mattress that redistributes pressure. |
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30 |
The skin, when macerated by moisture, is more easily damaged. |
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31 |
Pressure Ulcers are sterile wounds. |
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32 |
A region of skin scarred by Pressure Ulcer may be injured more quickly than intact skin. |
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33 |
A blister in the heel region should not be a cause for concern. |
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34 |
A good way to decrease pressure in the heel region is to keep the heels elevated from the bed. |
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35 |
All precautions to prevent or treat Pressure Ulcers do not need to be registered. |
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36 |
Shear is the force that occurs when skin adheres to a surface and the body slides. |
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37 |
Friction may occur when moving the patient on the bed. |
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38 |
Stage 2 Pressure Ulcers can be extremely painful due to the exposure of nerve endings. |
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39 |
In the patient with incontinence, the skin must be cleaned at the time of eliminations and at routine intervals. |
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40 |
The development of educational programs in the institution can reduce the incidence of pressure ulcers. |
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41 |
Hospitalized patients need to be assessed for risk of Pressure Ulcer only once during their stay |
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