Pressure areas Flashcards
Define pressure ulcer
localised damage to the skin and/or underlying tissue, usually over a bony prominence resulting from sustained pressure
Friction vs shear
friction = force of rubbing 2 surfaces against one another
shear = gravity force pushing down on a patient’s body with resistance between the patient’s body and the surface
Pressure ulcers risk factors
extrinsic:
- excessive uniaxial pressure
- posture
- moisture
- heat
- impact injury
- friction/shear forces
- incontinence
intrinsic:
- incontinence
- infection
- immobility
- sensory loss
- frailty
- disease
- BMI
- poor nutrition
Where do moisture lesions commonly occur?
skin folds, anal cleft, perianal area
Pressure ulcer grade 1 classification
skin is unbroken but inflamed (non-blanchable erythema)
Pressure ulcer grade 2 classification
skin is broken to epidermis or dermis
clear blisters can be present
Pressure ulcer grade 3 classification
ulcer extends to subcutaneous fat layer
full-thickness skin break
does not permeate muscle/bone
can have undermining/slough
Pressure ulcer grade 34 classification
ulcer extends to muscle or bone
undermining is likely
bone shows at base
What is an unstageable pressure ulcer?
full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, grey, green or brown) and/or eschar (tan, brown or black) in the wound bed
What does SSKIN stand for in pressure ulcer prevention?
Surface - right mattress etc
Skin inspection
Keep patients moving
Incontinence/moisture - keep patients clean and dry
Nutrition/hydration - right diet and plenty of fluids
What risk assessment tool assesses risk of pressure ulcers?
Waterlow risk assessment tool
should be completed within 6 hours of admission
How should pressure ulcers be managed?
address nutrition and hydration
pressure redistribution devices
dressings
antibiotics rarely indicated - indicated if systemic sepsis, spreading cellulitis or underlying osteomyelitis
consider debridement if necrotic tissue
