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Integumentary > Chapter 12 - Pressure Ulcers > Flashcards

Chapter 12 - Pressure Ulcers Flashcards

1
Q

What is a pressure ulcer?

A

A localized area of tissue necrosis that develops when soft tissue is compressed between a firm surface and underlying bone prominence

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2
Q

Who is at the greatest risk for developing a pressure ulcer?

A
  • spinal cord injury patients
  • hospitalized patients
  • patients in long term care facilities
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3
Q

What is the etiology of pressure ulcers?

A 
Pressure
Ischemia
Acidosis
Inflammation
Increased capillary permeability and edema
Local tissue anoxia
Necrosis
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4
Q

What are the 3 main factors that contribute to pressure ulcer formation?

A

1) inverse pressure-time relationship
2) individual hemodynamic factors
3) body location

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5
Q

What are the risk factors for pressure ulcer formation?

A 
Shear
Excessive moisture
Impaired mobility
Malnutrition
Impaired sensation
Advanced age
History of pressure ulcers
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6
Q

What is shear?

A

Force parallel to soft tissue, may have teardrop appearance. Undermining is common, caused by friction

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7
Q

Why does moisture predispose skin to PUs?

A
  • causes maceration
  • increases shear
  • increases friction forces

*can also be lack of moisture (anhydrous)

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8
Q

What are some causes for maceration to occur?

A
  • wound drainage
  • perspiration
  • incontinence
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9
Q

How can impaired mobility predispose skin to PUs?

A

Affects patient ability to move (limited ROM, strength, infants), desire to move (pain and depression), and ability to perceive to pain (medications and UMN and LMN lesions)

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10
Q

What is the capillary closing pressure?

A

13-32 mmHg

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11
Q

Which tissue is the least tolerant to compression? Why?

A

Muscle- it has the highest metabolic demand. More sensitive to ischemia due to pressure cone.

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12
Q

T/F: Pressure ulcers may not appear for several days after the pressure is applied.

A

True, may not appear for 2-7 days due to extensive deep tissue damage without any clinical signs/symptoms

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13
Q

What is reactive hyperemia?

A

Follows short-term pressure relief, when ischemic tissues are flooded with blood rich in oxygen, nutrients, and vasodilators and waste is removed. “Blancable erythema” aka will turn white with pressure

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14
Q

T/F: Friction can directly cause pressure ulcers.

A

False- it can strip away the stratum corner though which can make the skin more susceptible to pressure ulcers.

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15
Q

Which form of moisture poses the most significant problem?

A

Incontinence due to the bacteria and acidity of urine and feces. Urinary incontinence increases risk 5-fold, those with bowel are more at risk than urine

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16
Q

T/F: Wet skin is more resistant to bacteria than dry skin.

A

False

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17
Q

T/F: There is a direct correlation between impaired mobility and pressure ulcer development.

A

True

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18
Q

Individuals who reposition themselves less than ___ times per night are at increased risk for pressure ulcer development.

A

20 times

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19
Q

What are the most frequently studied causes of impaired mobility with respect to pressure ulcer development?

A
  • hospitalization
  • fractures
  • SCI
  • infants, neonates
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20
Q

What are the best predictors for PU’s in an individual with an SCI?

A
  • over 40
  • young age of injury
  • complete SCI
  • lengthy hospitalization
  • low education level
  • alcohol abuse
  • previous ulcer
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21
Q

Why are infants and neonates more at risk for PU development?

A
  • fragile skin
  • inability to reposition themselves
  • medical tubes
  • high frequency oscillatory ventilation devices
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22
Q

Poor nutrition, specifically low _______ levels contribute to PU development and correlate with severity.

A

Serum albumin

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23
Q

T/F: Malnutrition is the most common risk factor for PU development.

A

False- second most under impaired mobility

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24
Q

What are examples of conditions that would cause impaired sensation?

A
  • SCI
  • spina bifida
  • stroke
  • diabetes
  • full thickness burns
  • peripheral neuropathy
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25
Of patients with PUs, more than ____ are over ___ years old.
Half, 70
26
What are some reasons for increased risk of PUs with age?
- Age-related skin changes (decreased elastin/collagen, tissue strength/stiffness, loss of dermal vasculature, flattening of dermal-epidermal junction, thinning of dermis/epidermis, decreased sebaceous gland secretion, increased skin permeability, slow cell replacement rate) - decreased ability to fight infection - comorbidities
27
Why does a history of previous PU increase risk for another PU?
Scar tissue only attains up to 80% strength of original tissues
28
What are some less common risk factors for PUs?
- ischemia-reperfusion injuries - low diastolic pressure - smoking - diabetes-related microvascular changes - polypharmacy - psychosocial factors - increased skin temperature - Alzheimer's, Parkinson's, RA
29
What are the 3 most widely used risk assessment tools for PUs?
1) Braden Scale for Predicting Pressure Sore Risk 2) Norton Risk Assessment Scale 3) Gosnell Pressure Sore Risk Assessment
30
What are the 6 subclass of the Braden scale?
1) mobility 2) activity 3) sensory perception 4) skin moisture 5) nutritional status 6) friction and shear
31
What is the scoring for Braden?
Ranges from 6-23, with lower scores indicating greater impairment/higher risk. Score
32
What is the additional criteria added to the pediatric Braden Q?
tissue perfusion/oxygenation, score is ranged 7-28, with 16 deemed at-risk
33
What are the 5 subscales for the Norton?
1) physical condition 2) mental condition 3) activity 4) mobility 5) incontinence
34
What are the Norton deductions?
- diabetes - hypertension - low hematocrit, hemoglobin, album - fever - 5+ medications - change in mental status in last 24 hours
35
What is the scoring for Norton? What is the main issue with it?
Each rated 1-4, low scores = greater impairment. Score
36
What are the 5 subclass for Gosnell?
1) Mental status 2) continence 3) mobility 4) activity 5) nutrition
37
What are the 5 arms of PU prevention?
1) Education 2) Positioning 3) Mobility 4) Nutrition 5) Management of Incontinence
38
NO ULCERS
``` N= nutrition and fluid status O= observation of skin U= up walking/assist with position changes L= lift, don't drag C= clean skin and continence care E= elevate heels R= risk assessment S= support surfaces ```
39
SKIN
``` S= surface selection K= keep turning I= incontinence management N= nutrition ```
40
Category/Stage I
Nonblanchable erythema Area may be painful, warmer, cooler, firmer, softer May be superficial or first sign of deeper tissue involvement. May indicate person at risk for pressure ulcer.
41
Category/Stage II
Superficial ulcer that presents as shallow crater without slough or bruising. May be ruptured or intact blister. Partial thickness involving epidermis/dermis/both
42
Category/Stage III
Deep ulcer that presents as deep crater, may have undermining/tunneling. Full thickness involving epidermis/dermis, subcutaneous. Bone/tendon not visible.
43
Category/Stage IV
Deep ulcer with extensive necrosis, often undermining or sinus tracts. Full thickness involving fascia, muscle, tendon, joint capsule, bone
44
Unstageable/Unclassified
If base is obscured by eschar or slough. Will be III or IV
45
Suspected Deep Tissue Injury
Purple/maroon discoloration of blood filled blister. Area may be painful, firm, mushy, boggy or warmer or cooler. May become eschar covered.
46
Benefits of Classification System
- promotes uniform understanding - excellent reliability - must stage for medicare reimbursement - determines support surface - can be used for research
47
Limitations of Classification System
- stage I ulcer is not ulcer - people may "reverse stage" - may take time to adapt
48
What does the 5PT Method include?
``` Pain Position Presentation Periwound Pulses Temperature ```
49
What are some ways to assess pain?
McGill Pain Questionnaire Visual Analog Scale Faces Pain Scale
50
Where do 95% of PUs occur?
Sacrum, greater trochanter, ischial tuberosity, posterior calcaneus, lateral malleolus
51
What are the common location for PU's while supine?
``` Occiput Scapula Medial Epicondyle Spinous process Sacrum/coccyx Posterior heel ```
52
What are the common location for PU's while prone?
Iliac crest Anterior knee Anterior tibia
53
What are the common location for PU's while side-lying?
``` Mallelus Medial and lateral femoral condyles Greater trochanter Lateral epicondyle Ear ```
54
What are the common location for PU's while sitting?
Sacrum/coccyx Ischial tuberosity Greater trochanter
55
What are the main feature to look for in the preowned area?
nonblanchable erythema mottled appearance ring of inflammation around ulcer dermatitis
56
What is the common temperature like in PUs?
Increased --> reactive hyperemia | Decreased --> ischemia
57
Why are PU assessment instruments necessary?
- measure changes in wound status - evaluate effectiveness of care - document wound severity - promote quantification of wound parameters - standardize wound assessment - facilitate reimbursement
58
Sessing Scale
7-point observational scale describing wound and periwound | Score ranges 0-6 (0 = normal)
59
Bates-Jenson Wound Assessment Tool (WBAT)
13 items rated 1-5. Higher score indicated increased severity
60
Pressure Ulcer Scale for Healing (PUSH)
3 subscales, limited research
61
Estimated pressure ulcer healing rates: I, II, III, IV
I = 1-3 weeks II = days to weeks III and IV = 8-13 weeks
62
Pressure ulcers should be reassessed every _____ weeks for alternative interventions.
2 weeks
63
What are PT precautions for PU PT interventions?
- PU depth can be deceptive - probe regularly - ensure wound care goals/interventions are consistent with patient's overall POC

Integumentary (6 decks)

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