Complex Care Flashcards
What are pressure ulcers?
Pressure ulcers may present as persistently red, blistered, broken or necrotic skin and may extend to underlying structures - eg, muscle and bone.
What is the aetiology of pressure ulcers?
A pressure ulcer may be caused by pressure, shear, friction or a combination of these.
What are the risk factors for pressure ulcers?
Pressure ulcers are caused by pressure and/or shear forces over a bony prominence in the presence of a number of risk factors, the most important of which is immobility. Others include malnoursishment, incontinence and pain leading to immobility.
Which medical conditions increase the risk of pressure ulcers?
Other conditions that increase the risk include:
- Alzheimer’s disease.
- Cardiovascular disease.
- Diabetes mellitus.
- Chronic obstructive pulmonary disease (COPD).
- Hip fracture and hip surgery.
- Heart failure.
- Deep vein thrombosis.
- Limb paralysis.
- Lower limb oedema.
- Malignancy.
- Parkinson’s disease.
- Rheumatoid arthritis.
- Urinary tract infections.
What is the waterlow scale?
Risk assessment tools often uses include the Norton, Braden and the Waterlow scales.
The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas. It includes a number of factors including body mass index, nutritional status, skin type, mobility and continence.
Where do pressure ulcers most commonly develop?
Pressure ulcers can develop in any area of the body. In adults, damage usually occurs over bony prominences, such as the sacrum.
How are pressure ulcers assessed?
Pressure ulcers and the person’s general physical condition are very closely related and the two should be assessed together.
Health status includes:
- Comorbidities.
- Nutrition.
- Pain.
- Continence.
- Neurological (sensory impairment, level of consciousness, cognitive status).
- Blood supply.
- Mobility.
- Signs of local or systemic infection.
- Medication.
- Previous pressure damage.
- Psychological and social factors.
- Ulcer assessment
What is involved in the ulnar assessment?
Ulcer assessment: should be supported by photography (calibrated with a ruler) and tracings.
Ulcer assessment should include: Cause of ulcer. Site/location. Dimensions of ulcer. Stage or grade Exudate amount and type. Local signs of infection. Pain. Wound appearance. Surrounding skin. Undermining/tracking (sinus or fistula). Odour.
What is the classification of pressure ulcers?
Grade 1: non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin - in whom it may appear blue or purple.
Grade 2: partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Surrounding skin may be red or purple.
Grade 3: full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4: extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Extremely difficult to heal and predispose to fatal infection.
Unstageable (depth unknown): full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
What is the management of pressure ulcers?
Patients with extensive superficial pressure ulcers, Grade 3 or 4 pressure ulcers or those that are deteriorating should be referred to a specialist service.
A moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
Wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
Consider referral to the tissue viability nurse
Surgical debridement may be
beneficial for selected wounds
Repositioning of the patient.
Treatment of concurrent conditions which may delay healing.
Pressure-relieving support surfaces such as beds, mattresses, overlays or cushions.
Patients with identified Grade 1 pressure ulcers are at a significant risk of developing more severe ulcers and should receive interventions to prevent deterioration.
Pain relief such as paracetamol but not NSAIDs (it increases peripheral oedema and is inappropriate). Malnutrition can adversely affect wound healing.
When is surgical debridement indicated for pressure ulcers?
An assessment of the need to debride a pressure ulcer in adults should be undertaken, which takes into consideration:
- The amount of necrotic tissue.
- The grade, size and extent of the pressure ulcer.
- Patient tolerance.
- Any comorbidities.
What are the types of debridement?
Debridement may be autolytic, mechanical (allowing a dressing to become moist and then wet before manually removing the dressing), or surgical.
For deep pressure ulcers not responding to standard care, surgery can offer a rapid closure for some patients. This is usually undertaken by plastic surgeons and often involves creating rotational flaps.
The presence of devitalised tissue delays the healing process.
What is autolytic debridement?
Superficial pressure ulcers may benefit from autolytic debridement techniques, which use the body’s own enzymes and moisture to rehydrate, soften and liquefy hard eschar and slough.
Autolytic debridement can be achieved with the use of occlusive or semi-occlusive dressings which maintain wound fluid in contact with the necrotic tissue.
NICE recommends that the Debrisoft® pad can be an option for debridement in wound management in the community.
How can pressure ulcers be prevented?
SSKIN- support surface, skin inspection, keep moving, incontinence and nutrition.
Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.
Pressure redistributing equipment should be used.Eliminate any source of excess moisture due to incontinence, perspiration or wound drainage.
Reduce underlying risk factors such as poor nutrition. Education and training - e.g., mobility, positioning, skin care, use of equipment - for patients and their carers.
Consider the use of emollients if the skin is dry or barrier products if the skin is excessively moist.People at high risk of developing pressure ulcers should use higher-specification foam mattresses rather than standard hospital foam mattresses.
Medical grade sheepskins are associated with a decrease in pressure ulcer development. A polyurethane foam dressing can be applied to bony prominences (eg, heels, sacrum) for the prevention of pressure ulcers in anatomical areas frequently subjected to friction and shear.
