Condition- Pressure Sores

Question 1

What is a pressure sore?

Answer 1

Damage to the skin, usually over a bony prominence as a result of pressure

Question 2

List some risk factors for the development of a pressure sore?

Answer 2

• Immobility
• Old age
• Impaired sensation: neuropathy (DM)
• PVD
• Malnourishment
• Incontinence

Question 3

State two parts of the body that pressure ulcers often form at

Answer 3

The sacrum

The heel

Question 4

List some signs that indicate infection of the pressure ulcer?

Answer 4

• Fever
• Erythema
• Foul smelling
• Exudate

Question 5

Which classification system is used for determining the severity of pressure sores?

Answer 5

The Waterlow Score

Question 6

State the 4 different levels of the Waterlow Score (the classification system used for Pressure Sores)

Answer 6

1. LOCALISED SKIN CHANGES: erythematous, non-blanching, warmth, oedema, firm/boggy
2. SHALLOW OPEN WOUND- blister/shiny or dry ulcer
3. FULL THICKNESS SKIN LOSS- may contain slough, but no bone or muscle involvement
4. FULL THICKNESS + MAJOR TISSUE INVOLVEMENT- exposed bone/ muscle

Question 7

What complication might you need to watch out for in full thickness pressure ulcers with bone/ msucle involvement

Answer 7

Osteomyelitis