LO6- Pressure Ulcers Flashcards
What are some risk factors for pressure ulcers?
Malnu
What causes pressure ulcers?
Prolonged pressure on a section of the skin, particularly at bony prominences.
Medical devices putting pressure on the skin can also cause pressure ulcers to form. Shearing pressure also decreases pressure injuries
How do pressure ulcers form?
Prolonged pressure on the skin between bony prominences and an external surface reduces blood supply in the area
This results in a pressure injury
How many stages are there for pressure sores?
Stage 1 to 4
Assess the extent of the pressure ulcer
What are some risks for pressure ulcers forming?
Poor nutrition- (intake and cachexic states, causes poor skin integrity)
Mobile
Neurological deficits (can’t shift weight or loss to sensation to the area, spinal injuries, stroke)
Continence
Decreased skin integrity- e.g. atrophic due to steroids
Diabetes- decreased sensation glove and stocking and decreased perfusion
Incontinence
Activities causing friction and shearing- e.g. sliding in the bed
What assessment tool is used to assess the risk of developing a pressure ulcer?
Waterlow Risk Assessment
What does the Waterlow risk assessment do?
Considers the risk of developing pressure ulcers, the following risk factors are assessed: Nutrition Neurological deficits Immobility Incontinence- irritation to the skin Skin appearance- e.g. is it atrophic Medication Weight
Why do neurological issues increase the risk of developing pressure ulcer?
Reduced sensation to the area reducing the sensation of needing to move
Reduces motor function could result in prolonged pressure on an area of the skin
Which drugs can cause skin atrophy?
Steroids
What are some common sites for pressure ulcers?
Over bony prominences Heels + Ankles Hips Sacral Area back Elbows Shoulders Inside/outside of knee Occipital area Ear
Anywhere where there is pressure on the body
What are some risk factors for developing pressure ulcers?
Malnutrition Immobility Neurological deficits Diabetes Incontinence Pre-existing skin atrophy- e.g. with steroids Smoking Peripheral vascular disease Anaemia
What is a stage 1 pressure ulcer?
Skin in tack
Discolored with non-blanching erythema
What is a stage 2 pressure ulcer?
Skin is not longer in tact
Partial thickness skin loss with unceration
Limited to the epidermis and dermis
No involvement of subcutaneous tissue
What is a stage 3 ulcer?
Ulceration into the subcutaneous tissue
Full loss of epidermis and dermis
Rolled edges
Bone, tendon and muscle not visible
What is a stage 4 ulcer?
Full thickness damage through the subcutaneous tissue meaning that bone, tendon or muscle is visible
