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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
Q

Of patients with PUs, more than ____ are over ___ years old.

A

Half, 70

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26
Q

What are some reasons for increased risk of PUs with age?

A
  • 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
Q

Why does a history of previous PU increase risk for another PU?

A

Scar tissue only attains up to 80% strength of original tissues

28
Q

What are some less common risk factors for PUs?

A
  • ischemia-reperfusion injuries
  • low diastolic pressure
  • smoking
  • diabetes-related microvascular changes
  • polypharmacy
  • psychosocial factors
  • increased skin temperature
  • Alzheimer’s, Parkinson’s, RA
29
Q

What are the 3 most widely used risk assessment tools for PUs?

A

1) Braden Scale for Predicting Pressure Sore Risk
2) Norton Risk Assessment Scale
3) Gosnell Pressure Sore Risk Assessment

30
Q

What are the 6 subclass of the Braden scale?

A

1) mobility
2) activity
3) sensory perception
4) skin moisture
5) nutritional status
6) friction and shear

31
Q

What is the scoring for Braden?

A

Ranges from 6-23, with lower scores indicating greater impairment/higher risk. Score

32
Q

What is the additional criteria added to the pediatric Braden Q?

A

tissue perfusion/oxygenation, score is ranged 7-28, with 16 deemed at-risk

33
Q

What are the 5 subscales for the Norton?

A

1) physical condition
2) mental condition
3) activity
4) mobility
5) incontinence

34
Q

What are the Norton deductions?

A
  • diabetes
  • hypertension
  • low hematocrit, hemoglobin, album
  • fever
  • 5+ medications
  • change in mental status in last 24 hours
35
Q

What is the scoring for Norton? What is the main issue with it?

A

Each rated 1-4, low scores = greater impairment. Score

36
Q

What are the 5 subclass for Gosnell?

A

1) Mental status
2) continence
3) mobility
4) activity
5) nutrition

37
Q

What are the 5 arms of PU prevention?

A

1) Education
2) Positioning
3) Mobility
4) Nutrition
5) Management of Incontinence

38
Q

NO ULCERS

A 
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
Q

SKIN

A 
S= surface selection
K= keep turning
I= incontinence management
N= nutrition
40
Q

Category/Stage I

A

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
Q

Category/Stage II

A

Superficial ulcer that presents as shallow crater without slough or bruising. May be ruptured or intact blister. Partial thickness involving epidermis/dermis/both

42
Q

Category/Stage III

A

Deep ulcer that presents as deep crater, may have undermining/tunneling. Full thickness involving epidermis/dermis, subcutaneous. Bone/tendon not visible.

43
Q

Category/Stage IV

A

Deep ulcer with extensive necrosis, often undermining or sinus tracts. Full thickness involving fascia, muscle, tendon, joint capsule, bone

44
Q

Unstageable/Unclassified

A

If base is obscured by eschar or slough. Will be III or IV

45
Q

Suspected Deep Tissue Injury

A

Purple/maroon discoloration of blood filled blister. Area may be painful, firm, mushy, boggy or warmer or cooler. May become eschar covered.

46
Q

Benefits of Classification System

A
  • promotes uniform understanding
  • excellent reliability
  • must stage for medicare reimbursement
  • determines support surface
  • can be used for research
47
Q

Limitations of Classification System

A
  • stage I ulcer is not ulcer
  • people may “reverse stage”
  • may take time to adapt
48
Q

What does the 5PT Method include?

A 
Pain
Position
Presentation
Periwound
Pulses
Temperature
49
Q

What are some ways to assess pain?

A

McGill Pain Questionnaire
Visual Analog Scale
Faces Pain Scale

50
Q

Where do 95% of PUs occur?

A

Sacrum, greater trochanter, ischial tuberosity, posterior calcaneus, lateral malleolus

51
Q

What are the common location for PU’s while supine?

A 
Occiput
Scapula
Medial Epicondyle
Spinous process
Sacrum/coccyx
Posterior heel
52
Q

What are the common location for PU’s while prone?

A

Iliac crest
Anterior knee
Anterior tibia

53
Q

What are the common location for PU’s while side-lying?

A 
Mallelus
Medial and lateral femoral condyles
Greater trochanter
Lateral epicondyle
Ear
54
Q

What are the common location for PU’s while sitting?

A

Sacrum/coccyx
Ischial tuberosity
Greater trochanter

55
Q

What are the main feature to look for in the preowned area?

A

nonblanchable erythema
mottled appearance
ring of inflammation around ulcer
dermatitis

56
Q

What is the common temperature like in PUs?

A

Increased –> reactive hyperemia

Decreased –> ischemia

57
Q

Why are PU assessment instruments necessary?

A
  • measure changes in wound status
  • evaluate effectiveness of care
  • document wound severity
  • promote quantification of wound parameters
  • standardize wound assessment
  • facilitate reimbursement
58
Q

Sessing Scale

A

7-point observational scale describing wound and periwound

Score ranges 0-6 (0 = normal)

59
Q

Bates-Jenson Wound Assessment Tool (WBAT)

A

13 items rated 1-5. Higher score indicated increased severity

60
Q

Pressure Ulcer Scale for Healing (PUSH)

A

3 subscales, limited research

61
Q

Estimated pressure ulcer healing rates: I, II, III, IV

A

I = 1-3 weeks
II = days to weeks
III and IV = 8-13 weeks

62
Q

Pressure ulcers should be reassessed every _____ weeks for alternative interventions.

A

2 weeks

63
Q

What are PT precautions for PU PT interventions?

A
  • 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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