Pressure Sores

Question 1

Definition

Answer 1

Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis or advancing age. They typically develop over bony prominences such as the sacrum or heel.

Question 2

Risk factors

Answer 2

Malnourishment
Incontinence: urinary and faecal
Lack of mobility
Pain (leads to a reduction in mobility)

Question 3

Grading

Answer 3

WATERLOW SCORE:
Grade 1: Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin
Grade 2: Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister
Grade 3: Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4: Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss

Question 4

Symptoms

Answer 4

• Redness and blanching
• Swelling and oedema around ulcer
• Pain and tenderness
• Ulceration with/out exudate

Question 5

Diagnosis

Answer 5

Clinical diagnosis

Question 6

Treatment

Answer 6

● A moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
● Wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. Consider Abx.
● Consider referral to the tissue viability nurse
● Surgical debridement may be beneficial for selected wounds

Question 7

Aetiology

Answer 7

• External pressure
• Shear forces
• Friction
• Impaired mobility