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Integumentary > Lesson 4: Pressure Ulcers > Flashcards

Lesson 4: Pressure Ulcers Flashcards

1
Q

Pressure Ulcers

A

localized area of tissue injury/ necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence

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2
Q

What are pressure ulcers a result of?

A

pressure, or pressure in combination with shear and/or friction.

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3
Q

Who is at greatest risk for a pressure ulcer?

A

Individuals with spinal cord injuries
Hospitalized patients
Individuals in long-term care facilities

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4
Q

Pressure ulcers formation a result of:

A

Inverse pressure–time relationship
Individual hemodynamic factors
Body location

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5
Q

Etiology of Pressure Ulcers

A

Areas overlying bony prominences are at greatest risk for ulcerations
Muscle more sensitive to pressure than skin
Pressure ulcers may not develop for days after the pressure was applied

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6
Q

Reactive hyperemia

A

localized area of blanchable erythema

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7
Q

Risk Factors Contributing

to Pressure Ulcers

A 
Shear
Excessive moisture
Impaired mobility
Malnutrition
Impaired sensation
Advanced age
History of pressure ulcer
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8
Q

Shear:

A

force parallel to soft tissue

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9
Q

Appearance of shear:

A

teardrop appearance

undermining common

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10
Q

Friction:

A

two surfaces moving across one another

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11
Q

How does moisture predispose skin to pressure ulcers?

A

Causing maceration
Increasing shear
Increasing friction forces

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12
Q

Maceration by be caused by:

A

Wound drainage
Perspiration
Incontinence
Anhydrous skin also at risk

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13
Q

What is the second most common risk factor in PU?

A

malnutrition

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14
Q

Malnutrition

A

Low serum albumin levels and/or hydration
Correlated with ulcer severity
Patient may be underweight, normal weight,
or obese

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15
Q

Reduced Mobility

A

Weakness, sedation, depression

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16
Q

Who is reduced mobility frequently studied in?

A

Hospitalization
Fracture
Spinal cord injury
Infants/neonates

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17
Q

Impaired Sensation

A

Unable to detect pain of ischemic tissue damage caused by pressure

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18
Q

Examples of impaired sensation:

A 
Spinal cord injury
Spina bifida
Stroke
Diabetes mellitus
Full-thickness burns
Peripheral neuropathy
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19
Q

Advanced Age

A

More than half of patients with pressure ulcers are over 70 years old
Age-related skin changes
Increased rate of comorbidities

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20
Q

Previous Pressure Ulcer

A

Scar tissue only attains up to 80% strength of the original tissue
Scar tissue alters tolerance to pressure and externally applied loads

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21
Q

Additional Risk Factors for PU:

A 
Ischemia-reperfusion injuries
Polypharmacy
Low diastolic pressure
Psychosocial factors
Smoking
Increased skin temperature
Diabetes-related microvascular changes
Alzheimer’s disease, Parkinson’s disease, RA
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22
Q

Pressure Ulcer Risk Assessment Tools

A

Screening devices

Should have high specificity and sensitivity, be easy to use, and be linked to interventions

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23
Q

The most widely used and researched tools for PU:

A

Braden Scale for Predicting Pressure Sore Risk
Norton Risk Assessment Scale
Gosnell Pressure Sore Risk Assessment

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24
Q

Braden Scale

A

High interrater reliability
Braden Q scale for pediatric patients
Scores range from 6 to 23, with lower scores indicating greater impairment and higher risk

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25
Q

At risk score in Braden Scale:

A

less than 18

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26
Q

Six indicators in Braden Scale:

A 
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction or shear
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27
Q

Norton Risk Assessment Scale

A

May overpredict incidence of pressure ulcers

Each scale is rated 1 to 4, with lower scores indicating greater risk of pressure ulcer development

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28
Q

At risk score in Norton Risk Assessment:

A

less than or equal to 16

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29
Q

Gosnell Pressure Sore Risk Assessment

A

Each scale is rated 1 to 5, with 1 being the least impaired
16 is the critical cut-off score
Least researched tool

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30
Q

Five subscales of Gosnell Pressure Sore Risk Assessment:

A

mental status, continence, mobility, activity, and nutrition

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31
Q

Interdisciplinary interventions for pressure ulcer prevention

A

Prevention

  • education
  • positioning
  • mobility
  • nutrition
  • management of incontinence
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32
Q

NO ULCERS

A 
Nutrition and fluid status
Observation of skin
Up and walking or assist with position change
Lift, don't drag
Clean skin and continence care
Elevate heels
Risk assessment
Support surfaces
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33
Q

SKIN

A

Surface selection
Keep turning
Incontinence management
Nutrition

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34
Q

Stage I PU:

A

Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Area may be painful, warmer, cooler, firmer, softer than surrounding tissue

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35
Q

Tissues involved in stage I:

A

May be superficial

May be first sign of deeper tissue involvement

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36
Q

Stage II PU:

A

Superficial ulcer
Shallow crater without slough or bruising
May be ruptured or intact blister

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37
Q

Tissues Involved in Stage II:

A

Partial thickness (epidermis, dermis, or both)

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38
Q

Stage III PU:

A

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

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39
Q

Tissues involved in Stage III PU:

A 
Full thickness (epidermis, dermis, subcutaneous tissue)
Bone/tendon not visible
40
Q

Stage IV PU:

A

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
Deep ulcer with extensive necrosis

41
Q

Tissues involved in Stage IV PU:

A

Full thickness

Underlying deep tissue exposed

42
Q

Unstageable PU:

A

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

43
Q

Tissues involved in unstageable PU:

A

Full thickness

Will be category III or IV

44
Q

DEEP TISSUE INJURY

A

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

45
Q

Intervention Goals for PU:

A

Off loading
Fill dead space
Control exudate
Decrease microbial load

46
Q

Goals for Stage 1 and 2 PU:

A

film dressings to prevent sheer allow oxygen to get to area, but block bacteria/contaminants, autolytic debridemen

47
Q

Limitations of Classification System:

A

Category/stage I pressure ulcer is not an
ulcer by definition
Clinicians may erroneously “reverse stage” a pressure ulcer
Significant revision of prior system – may take time to adapt to and use correctly

48
Q

Benefits of Classification System:

A

Promotes uniform understanding of the depth of tissues involved
Excellent reliability
Clinicians must stage pressure ulcers for Medicare reimbursement
Determines type of support surface to be used
Can be used for research studies

49
Q

“5PT” Method

A 
Pain
Position
Presentation
Periwound
Pulses
Temperature
50
Q

Pain:

A

McGill Pain Questionnaire, Visual Analog Scale, Faces Pain Scale
Category I pressure ulcers may be tender instead of painful
Patients with neurological deficits may not perceive pain
Patients who are unable to communicate may demonstrate pain by grimacing, withdrawal, or moaning

51
Q

Position:

A

Majority on lower half of body over boney prominence
Areas of outside pressure:
casts, tubing, shoes

52
Q

Where are 95% of PU located:

A

sacrum, greater trochanter, ischial tuberosity, posterior calcaneous, lateral malleolus

53
Q

Pressure Ulcers: Common Sites

A 
Ischial tuberosities
Greater trochanters
Sacrum/ Coccyx
Lateral malleoli
Heels
Olecranons
Medial femoral condyles
Occiput
54
Q

The most common sites for PU while seated:

A

ischial tuberosity, greater trochanter if in a sling-like seat, and sacrum/coccyx if in a posterior pelvic tilt

55
Q

Presentation

A

International NPUAP/EPUAP Ulcer Classification System provides detailed descriptions
Patients with full-thickness pressure ulcers more likely to have multiple ulcers

56
Q

Periwound and Structural Changes

A

Nonblanchable erythema
Mottled
Ring of inflammation around ulcer
Dermatitis

57
Q

Pulses

A

Usually not applicable due to proximal ulcer location

Usually normal unless concomitant PVD

58
Q

Temperature

A

Increased in areas of reactive hyperemia

Decreased in areas of ischemia

59
Q

PU Assessment Instruments

A

Measure changes in wound status
Evaluate the effectiveness of plan of care
Document wound severity
Promote quantification of wound parameters
Standardize wound assessment
Facilitate reimbursement

60
Q

Sessing Scale

A

7-point observational scale describing wound and periwound characteristics
Scores range from 0 to 6
Used in clinic and research settings

61
Q

Sessing scale stage 0:

A

normal skin, but at risk

62
Q

Sessing scale stage 1

A

skin completely closed

may lack pigmentation or may be reddened

63
Q

Sessing scale stage 2

A

wound edges and center are filled in

Surrounding tissues are intact and not reddened

64
Q

Sessing scale state 3

A

wound bed filling with pink granulation tissue
slough present
free of necrotic tissue
minimum drainage and odor

65
Q

Sessing scale stage 4

A

moderate to minimal granulating tissue
slough and minimal necrotic tissue
moderate drainage and odor

66
Q

Sessing scale stage 5

A

presence of heavy drainage and odor; eschar and slough

surrounding skin reddened or discolored

67
Q

Sessing scale stage 6:

A

breaks in skin around primary ulcer
purulent drainage, foul odor, necrotic tissue or/and eschar
may have septic symptoms

68
Q 
Bates-Jensen Wound 
Assessment Tool (BWAT)
A

Formerly the Pressure Sore Status Tool (PSST)
13 items
Rated 1 to 5 scale
Describe wound and periwound characteristics
Total scores range from 13 to 65
Higher scores indicate increased severity
Reliable and valid
Used in clinic and research settings

69
Q 
Pressure Ulcer Scale 
for Healing (PUSH)
A

3 subscales
Wound surface area, exudate amount, appearance
Total score ranges from 8 to 34
Higher scores indicate increased severity
Limited research

70
Q

Prognosis for Pressure Ulcer Healing

A

Pressure ulcers heal very slowly

Expected ulcer healing time with appropriate interventions

71
Q

Category I ulcers heal:

A

within 1-3 weeks

72
Q

Category II ulcers heal:

A

within days to weeks

73
Q

Category III and IV ulcers heal:

A

take an average of 8–13 weeks

74
Q

Precautions For PT:

A

Pressure ulcer depth can be deceptive
Probe regularly
Ensure wound care goals and interventions are consistent with patient’s overall plan of care

75
Q

Request for Further Medical Testing

A

Culture Wounds
Assess for osteomyelitis
Early surgical consult for patients with deep pressure ulcers

76
Q

Culture wounds

A

That fail to progress in timely manner

That show signs/symptoms of infection

77
Q

Assess for osteomyelitis

A

Wounds with exposed bone

Deep wounds with purulent or malodorous drainage

78
Q

Keys to Local Wound Care

A 
protect surrounding tissue
address wound bed
minimize pressure and shear
support surface technology
educate patient and caregivers
79
Q

Protect the Surrounding Tissue

A

Moisturize dry skin

Use moisture barriers and skin sealants to protect

80
Q

Address Wound Bed

A

Choose dressings to provide a moist wound bed
Debride necrotic tissue if appropriate
Control infection
Charcoal dressings control odor

81
Q

Do not debride:

A

stable, hard, dry, eschar-

covered wounds in ischemic limbs

82
Q

What is breakdown pressure?

A

32 mmHg

83
Q

What should pressure be reduced to?

A

23mmHg-32mmHg

presure relieving: under 23mmHg

84
Q

Minimize Pressure and Shear:

A

Tissue interface pressures
Pressure-reducing devices
Pressure-relieving devices
Static and dynamic support surfaces

85
Q

Support Surface Technology

A

Must consider all surfaces patient will be on
Bed, commode, chair, car seat, etc.
Consider patient’s needs
Pressure redistribution, shear reduction, continence, temperature and moisture control
Consider patient mobility
Ability to reposition, transfer
Consider patient status
Deformities, body weight, tissue status, risk for recurrence

86
Q

Category 1 support surface:

A

Mattresses and mattress overlays

87
Q

Category 2 support surface:

A

Specialty mattresses

Pressure-reducing foam, alternative air, low air loss

88
Q

Category 3 support surface:

A

Air-fluidized beds

89
Q

Educate Patient and Caregivers

A

Wound etiology
Intervention strategies
Risk factor modification
Guidelines for pressure ulcers

90
Q

Therapeutic Exercise

A

Flexibility exercise to minimize contractures
Strengthening exercise
Assist with mobility, transfers, and weight shifts
Pelvic floor and abdominal muscle strengthening to assist management of incontinence
Aerobic Exercise
Improves cardiovascular endurance for improving mobility and activity

91
Q

Functional Training

A

Gait training
Transfers and bed mobility
Emphasize minimizing friction and shear
Protect intact skin and any existing pressure ulcers

92
Q

Electrotherapeutic Modalities

A 
Pulsatile lavage with suction
If no evidence of healing with standard care:
Electrical stimulation
Ultraviolet
Ultrasound
Negative pressure wound therapy
93
Q

Medical Testing

A

Wound culture
Bone scan
Malnutrition

94
Q

Medical Interventions

A 
Manage risk factors
Malnutrition
Anemia
Diabetes
Incontinence
Pharmacological interventions
Pain 
Infection
95
Q

Surgical Interventions

A

Debridement
Musculocutaneous flaps
Highly vascular
Provide tissue bulk to fill defect and provide padding
Drain in place for 1 week
Avoid pressure and shear post-operatively
Monitor temperature/color/capillary refill

Integumentary (18 decks)

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