Pressure Sores Flashcards
What are pressure ulcers?
Pressure ulcers develop in patients who are unable to move parts of their body due to illness, paralysis, or advancing age.
Where do pressure ulcers typically develop?
They typically develop over bony prominences such as the sacrum or heel.
What factors predispose to the development of pressure ulcers?
Factors include malnourishment, incontinence (urinary and faecal), lack of mobility, and pain (which leads to a reduction in mobility).
What is the Waterlow score?
The Waterlow score is widely used to screen for patients who are at risk of developing pressure areas.
What factors does the Waterlow score include?
It includes body mass index, nutritional status, skin type, mobility, and continence.
What are the findings for Grade 1 pressure ulcers?
Non-blanchable erythema of intact skin. Discolouration, warmth, oedema, induration, or hardness may also be indicators.
What are the findings for Grade 2 pressure ulcers?
Partial thickness skin loss involving epidermis or dermis, presenting clinically as an abrasion or blister.
What are the findings for Grade 3 pressure ulcers?
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
What are the findings for Grade 4 pressure ulcers?
Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.
What promotes ulcer healing?
A moist wound environment encourages ulcer healing.
What types of dressings may help facilitate ulcer healing?
Hydrocolloid dressings and hydrogels may help facilitate healing.
What should be discouraged in wound management?
The use of soap should be discouraged to avoid drying the wound.
Should wound swabs be done routinely for pressure ulcers?
No, wound swabs should not be done routinely as most pressure ulcers are colonised with bacteria.
When should systemic antibiotics be considered?
The decision to use systemic antibiotics should be taken on a clinical basis, such as evidence of surrounding cellulitis.
Who should be considered for referral in pressure ulcer management?
Consider referral to the tissue viability nurse.
