Pressure Sores

Question 1

In which pts do pressure ulcers / sores develop?

Answer 1

In pts who are unable to move parts of their body due to illness, paralysis or advancing age

Question 2

Where do pressure ulcers / sores typically develop?

Answer 2

bony prominences - e.g. sacrum or heel

Question 3

What factors predispose to the development of pressure uclers / sores?

Answer 3

Malnourishment
incontinence
lack of mobility
pain (reducing mobility)

Question 4

What scoring system is used to SCREEN for pts at risk of developing pressure areas?

Answer 4

Waterlow score

Question 5

What factors does the Waterlow score take into account when screening for pts at risk of developing pressure sores?

Answer 5

BMI
nutritional status
skin type
mobility
continence

Question 6

What findings and present for a GRADE 1 pressure ulcer / sore ? (European Pressure Ulcer Advisory Panel classification system)

Answer 6

Erythema (non-blanchable) of intact skin
discolouration of skin
warmth
oedema
induration or hardness (especially for ppl with darker skin)

Question 7

What findings and present for a GRADE 2 pressure ulcer / sore ? (European Pressure Ulcer Advisory Panel classification system)

Answer 7

Partial thickness skin loss (epidermis and/or dermis)
Superficial ulcer - e.g. abrasion / blister

Question 8

What findings are present for a GRADE 3 pressure ulcer / sore ? (European Pressure Ulcer Advisory Panel classification system)

Answer 8

Full thickness skin loss
damage to OR necrosis of subcutaneous tissue. This can extend down to fascia.

Question 9

What findings and present for a GRADE 4 pressure ulcer / sore ? (European Pressure Ulcer Advisory Panel classification system)

Answer 9

Extensive destruction, tissue necrosis
Damage of muscle / bone / supporting structures and / or full thickness skin loss

Question 10

How would you manage a pressure ulcer / sore?

Answer 10

DRESSING: hydrocolloid dressing and hydrogels- a moist environment aids healing. (AVOID SOAP = drying)

LAB: wound swab often as many colonised w/ bacteria

SURGERY: surgical debridement can help selected wounds

REFER: consider referring to tissue viability nurse

Question 11

How is the decision on whether or not to give systemic antibiotics for a pressure ulcer / sore made?

Answer 11

CLINICAL BASIS
e.g. if there is evidence of surrounding cellulitis