Pressure Area Care

Question 1

Consequences of skin damage

Answer 1

cost
prolonged stay in hospital
infection
immobility
DVT

Question 2

patient groups vulnerable to skin damage

Answer 2

cardia and orthopaedic surgery because patient is in supine position for long time

Question 3

what causes pressure ulcers

Answer 3

obstruction of blood vessels in soft tissues. Leads to hypoxia. Persistent hypoxia can cause tissue necrosis

Question 4

Skin damage can occur due to:

Answer 4

**UNRELIEVED pressure (external pressure inhibits arterial inflow leading to ischemia. Venous outflow is also inhibited resulting in increased venous capillary pressure which causes tissue oedema. Body can withstand high pressure for a very short time. It is when pressure is not relieved that ulcer will develop

**Shearing. Skin stays stationary and underlying tissues move, eg reverse trendelenberg

**Friction. skin moves across a surface like a sheet. Don’t pull patient down table without moving sheet with them

**Moisture: wether due to incontinence, sweating, wound exudate

Question 5

Intraoperative Factors for pressure ulcer formation

Answer 5

• Anaesthesia - lead to peripheral dilation - decreasing CO, leading to hypotension and reduced tissue pefusion
• Duration of surgery
• Position
• Extrinsic factors
• Intrinsic factors

Question 6

Extrinsic factors for pressure ulcer formation

Answer 6

Pressure
Moisture
Shearing
Friction

Question 7

Intrinsic factors for pressure ulcer formation

Answer 7

• Age: loss of integrity of skin due to loss of collagen and not well hydrated, loss of sensation
• Hydration/nutrition status : Malnutrition leads to dry papery skin. Lack of protein - skin doesn’t repair well. Dehydration
• Immobility. paralysis, pain, MS patients skin may be poor
• Pathophysiology: Diabetic patients skin more prone to pressure ulcers. Also chronic cardiac failure, COAD, Autoimmune disease-loss of sensation

Question 8

Six stages of pressure sore

Answer 8

Suspected deep tissue injury. localised area of discoloured intact skin or blood filled blister. Area around painful, firm/mushy, warmer or cooler compared to adjacent tissue

Stage 1: Intact skin with non blancheable redness of localised area usually over a bony prominence
Stage 2: partial thickness loss of dermis. shallow open ulcer without slough or intact or open blister with serum
Stage 3. Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle not exposed
Stage 4. Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be on some parts of wound bed

UNSTAGEABLE: Full thickness tissue loss. Base of ulcer covered by slough or eschar. Until slough and or eschar removed true depth and therefore stage undetermined

Question 9

Pressure Ulcer Prevention

Answer 9

Pre-assess patient and plan ( not always poss. Consider, age, height/weight, nutritional status, pre-existing medical conditions, mobility waterlow score)

• ensure correct positioning
• pressure reducing/relieving equipment, gel pads, mattresses
• keep patient warm and dry
• Keep patient hydrated and normotensive
• Ensure no one leans on patient
• Observe risk areas and document