Wound Care and Skin Integrity in Rehabilitation Flashcards

A patient with paraplegia develops a stage 3 pressure injury over the ischial tuberosity. Which factor is the PRIMARY cause of ischial pressure injuries in wheelchair users?

Answer: Sustained pressure exceeding capillary closing pressure during prolonged sitting

Ischial pressure injuries in wheelchair users result from sustained pressure exceeding capillary closing pressure (~32 mmHg), causing tissue ischemia during prolonged sitting.

A CRRN is staging a wound with slough covering 70% of the wound bed. The visible tissue appears to reach subcutaneous fat. Which pressure injury stage is CORRECT?

Answer: Unstageable

When slough or eschar obscures the wound base and prevents accurate depth assessment, the injury is classified as unstageable until the wound bed is debrided.

Which pressure redistribution surface is MOST appropriate for a patient with multiple stage 2 pressure injuries who requires full-time bed rest?

Answer: Low-air-loss or alternating pressure mattress system

Low-air-loss or alternating pressure mattress systems provide superior pressure redistribution for high-risk patients with existing injuries compared to passive foam surfaces.

A patient with diabetes and a neuropathic plantar foot ulcer is in wound rehabilitation. Which offloading device is considered the GOLD STANDARD for plantar foot ulcer healing?

Answer: Total contact cast (TCC)

The total contact cast (TCC) is the gold standard for offloading diabetic neuropathic foot ulcers because it distributes pressure over the entire foot and ensures compliance.

A wound care nurse is selecting a dressing for a stage 3 pressure injury with moderate exudate and a clean, granulating base. Which dressing type is MOST appropriate?

Answer: Alginate or foam dressing to maintain moist wound healing while managing exudate

Alginate and foam dressings absorb moderate-to-heavy exudate while maintaining the moist environment proven to optimize wound healing and granulation tissue formation.

A rehabilitation patient with spinal cord injury is being taught pressure relief techniques for wheelchair use. Which frequency of pressure relief is RECOMMENDED to prevent ischial pressure injuries?

Answer: Every 15–30 minutes for at least 1–2 minutes

Pressure relief maneuvers every 15–30 minutes for 1–2 minutes are the standard SCI guideline to restore tissue perfusion and prevent ischial pressure injuries.