Pressure areas Flashcards

1
Q

Define pressure ulcer

A

localised damage to the skin and/or underlying tissue, usually over a bony prominence resulting from sustained pressure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Friction vs shear

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Pressure ulcers risk factors

A

extrinsic:
- excessive uniaxial pressure
- posture
- moisture
- heat
- impact injury
- friction/shear forces
- incontinence

intrinsic:
- incontinence
- infection
- immobility
- sensory loss
- frailty
- disease
- BMI
- poor nutrition

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Where do moisture lesions commonly occur?

A

skin folds, anal cleft, perianal area

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Pressure ulcer grade 1 classification

A

skin is unbroken but inflamed (non-blanchable erythema)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Pressure ulcer grade 2 classification

A

skin is broken to epidermis or dermis
clear blisters can be present

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Pressure ulcer grade 3 classification

A

ulcer extends to subcutaneous fat layer
full-thickness skin break
does not permeate muscle/bone
can have undermining/slough

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Pressure ulcer grade 34 classification

A

ulcer extends to muscle or bone
undermining is likely
bone shows at base

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What is an unstageable pressure ulcer?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What does SSKIN stand for in pressure ulcer prevention?

A

Surface - right mattress etc
Skin inspection
Keep patients moving
Incontinence/moisture - keep patients clean and dry
Nutrition/hydration - right diet and plenty of fluids

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What risk assessment tool assesses risk of pressure ulcers?

A

Waterlow risk assessment tool
should be completed within 6 hours of admission

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

How should pressure ulcers be managed?

A

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

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q
A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly