11] Pressure Ulcers Flashcards
Etiology of pressure ulcers
Capillaries are occluded and the tissue around is has no oxygen or nutrition —> this turns into tissue hypoxia which leads to cell death
Shear is?
Internal
Major cause of undermining
Shearing
Doing what causes increased shear forces
Elevating head of bed
How do we stage pressure ulcers?
NPUAP which describes the deepest level of tissue destroyed
Stage 1 pressure injury
Intact skin with non-blanchable redness
Stage 2 pressure injury
Partial thickness loss of dermis presenting as shallow open ulcer with a red pink wound bed
2 characteristics stage 2 pressure injuries can present as
Intact OR open/ruptured serum filled blister
Stage 3 pressure injury
Full thickness- can see fat but BTM are not exposed;s slough may be present but does not obscure depth of tissue loss
What stage does undermining and tunneling start in?
Stage 3 pressure injury
Stage 4 pressure injury
Full thickness and you see MTB
Stage 5 pressur einjury
Unstageable! Full thickness where base is covered by slough and/or Eschar
Stage 6 pressure injury
Suspected deep tissue injury where its purple with intact skin or blood filled blister
The area may be precededby tissue that is painful,
firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Stage 6- suspected deep tissue injury
Pressure ulcer healing
Eschar —> slough —> granulation —> epithelialization
What is a Kennedy terminal ulcer
Specific pressure ulcer characterized by rapid onset and rapid tissue breakdown — SKIN FAILURE
When do Kennedy terminal ulcers develop
Within 2-4 weeks before dying
Where does Kennedy terminal ulcers happen and what shape
Sacrum/coccyx and are pear or butterfly shaped that can be purple, red blue or black with irregular borders
Patho fo Kennedy ulcer
Blood shunts away from skin to vital organs
►Monitors healing or deterioration
►Uses minimal number of assessment parameters
►Reliable
►Easy to use
Documenting change : PUSH tool
Stage 1 healing time
14 days
Stage 2 healing time
45 days
Stage 3 healing time
90 days
Stage 4 healing time
120 days
With PI you want to manage
Incontinence
Cleansing interventions
Remove devitalized tissue and decerase bacterial burden
Intervention- debride
Sharp
Enzymatic
Autolytic
Intervention- dressings
Create moist environment for wound healing
►Most commonly used pressure ulcer risk assessment
Braden
6 subscales of Braden
Sensory perception Moisture Activity Mobility Nutrition Friction/shear
Scoring for Braden
►Lower score = higher risk
15-18 = at risk 13-14 = moderate risk 10-12 = high risk <10 = very high risk
Decreases interface pressure but not necessarily below capillary pressure
Pressure reduction
Decreases of pressure below capillary pressures
Pressure relief
do not move, reduce pressure by spreading load over large area
Static devices
Use if a patient cannot assume a variety of
positions without bearing weight on pressure ulcers,
If pressure injury is not healing, or
If patient fully compresses static support
surface
Dynamic devices
Use if a patient can assume variety of positions without bearing weight on existing pressure ulcer
Static devices
Goes over foam or regular bed
Overlay
Move; require motor to operate
Dynamic devices
Series of connected air filled pillows with surface fabrics of low-friction material
Low air loss
What PI would you use low air loss for?
Stage 3 or 4 on multiple turning surfaces
Use when excessive moisture on intact skin; can dry skin and prevent pressure injury
Fluidized or high air loss (silicone coated glass beds that has air and fluid)
Assessing performance of support surfaces
Bottoming out
Bunching in gel mattress
Deflating air mattress
Standard repositioning measures in BED (6)
Every 2 hours while in bed 30 degree turns but keep pt off trochanter Float heels Pillows b/w bony prominences HOB less than 30 Donuts are DO NOTS
Standard repositioning in chair
Every 30 min
all pressure ulcers cases in an institution whether admitted with or occurring during the stay
Prevalence
The new pressure ulcer cases developed within the institution
Incidence
Heel ulcer prevention protected what structures
Peroneal nerve and Achilles’ tendon contracture
Use what to prevent sacral pressure ulcers in ICU because it does what
Silicone based dressing b/c it reduces shear, friction and excess moisture
Stage 1 treatment
Relieve pressure and protect the area
Stage 2 pressure ulcer
Partial thickness- there isnt too much drainage and a thin film, hydrocolloid foam or gel can be used
Stage 3/4 PI
Full thickness- depending on amount of drainage you could use hydrocolloid, foam, gel, or calcium alginate
Treatment for necrotic tissue slough or Eschar
Enzymatic debridement
If ulcer becomes infect, what might you do for dressing
Dressing with silver
