Pressure sores Flashcards
What is a pressure sore?
Pressure ulcers occur when area of skin or tissue are damaged due to being placed under pressure causing impairment to blood supply
- develop in patients who are unable to move their body due to illness, paralysis or advancing age
- typically over bony prominences like sacrum or heel
what are some risk factors for developing pressure sores?
- seriously ill
- neurological condition
- impaired mobility
- impaired nutrition
- incontinence: urinary or faecal
- pain and affect on mobility
- poor posture or deformity
- poor equipment
- increasing age
what is a grade 1 pressure sore?
non blanchable erythema, intact skin, discolouration of skin, warmth, erythema or hardness
what is a grade 2 pressure sore?
partial thickness skin loss involving epidermis or dermis, ulcer superficial and presents as abrasion or blister
what is grade 3 pressure sore?
full thickness skin loss, damage to or necrosis of subcutaneous tissue that may extend to underlying fascia
what is a grade 4 pressures sore?
extensive destruction, tissue necrosis, damage to muscle, bone or supporting structures with or without full thickness skin loss
how are pressure sores assessed?
- use finger palpation - erythema or discolouration blanch-able
- Waterlow score - screen for patients who are at risk of developing pressure areas
- Braden scale
how are pressure sores managed?
- change position at least every 6h
- moist wound environment with hydrocolloid dressings, soap discouraged
- wound was swab not routine
- abx
- tissue viability
- surgical debridement
what impairs wound healing?
- oxygenation
- infection
- foreign body
- venous insufficiency
- age, gender
- stress
- ischaemia
- diseases - jaundice, DM, fibrosis, uraemia
- obesity
- medications - NSAIDs, steroids, chemo
- immunocompromised
- nutrition
