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bHCE > Pressure sores > Flashcards

Pressure sores Flashcards

1
Q

What is the rough cost of pressure sores to the NHS per annum?

A

£1.5 billion

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2
Q

Where do pressure ulcers normally occur on the body?

A

Over bony prominences

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3
Q

What are the two ways pressure sores can occur?

A

Due to pressure or pressure with shear force (i.e. sliding down a bed)

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4
Q

What is the scale of pressure sores severity?

A

0-4

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5
Q

What is a stage 0 pressure sore?

A

Normal reactive hyperaemia (increase of blood flow) due to pressure

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6
Q

What is a stage 1 pressure sore?

A

Non-blanchable erythema

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7
Q

What is a stage 2 pressure sore?

A

Partial thickness skin loss

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8
Q

What is a stage 3 pressure sore?

A

Full thickness skin loss

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9
Q

What is a stage 4 pressure sore?

A

Full thickness tissue loss

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10
Q

How can you tell the difference between a stage 0 and stage 1 pressure sore?

A

Stage 1 will not blanch under pressure (i.e. you cannot push the blood out)

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11
Q

Which stage of pressure sore are normal (i.e. not damage has occurred)?

A

Only stage 0

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12
Q

What do stage 1 pressure sores look like?

A

Darkly pigmented

Can have a bluish tinge

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13
Q

Is a stage 1 pressure sore firm or soft?

A

It can be both

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14
Q

Is a stage 1 pressure sore painful?

A

It may be

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15
Q

At what stage of pressure sore is the pt “at risk” regardless of the Braden score?

A

Stage 1

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16
Q

How deep does a stage 2 pressure sore go down to?

A

About midway through the dermis

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17
Q

How can a stage 2 pressure sore present?

A

A shallow open ulcer

with a red/pink wound bed

without slough

OR

An intanct or open/ruptured

serum-filled

blister

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18
Q

Do stage 2 ulcers have bruising and explain why?

A

No bruising

as this indicates deep tissue injury

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19
Q

What should stage 2 ulcer not be used to describe?

A

Skin tears

Tape burns

incontinence associated dermatitis

Excoriation

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20
Q

How deep does a stage 3 skin ulcer go?

A

Goes down to fat but not as deep as

bone, tendon or muscle

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21
Q

What is slough?

A

A yellow fibrinous tissue

that consists of fibrin, pus, and proteinaceous material

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22
Q

What stages of pressure ulcers can include tunnelling and undermining?

A

Stage 3 and 4

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23
Q

How is a stage 3 pressure ulcer described?

A

Full thickness skin loss

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24
Q

What is a stage 4 pressure ulcer?

A

Full thickness tissue loss with exposed

bone tendon or muscle

25
Q

What stages of pressure sore can have slough?

A

Stages 3 + 4

26
Q

What is eschar?

A

a slough

produced by: a thermal burn

a corrosive chemicals

or by gangrene.

27
Q

Which stage of pressure sore can eshcar be present in?

A

Stage 4

28
Q

What can prevent a wound being staged?

A

If the wound if obscured by slough or eschar

29
Q

If a wound is unstagable due to obstruction by eschar or slough then what stages must it be?

A

It must be either a stage 3 or 4

30
Q

What is a common mimic of a pressure ulcer?

A

A moisture lesion

31
Q

What is a moisture lesion?

A

An area of irritation due to prolonged exposure to

moisture/water/urine

32
Q

What categories can be used to differentiate pressure ulcers and moisture lesions?

A

Location

Shape

Edges

Depth

Colour

Necrosis

33
Q

How do pressure ulcers and moisture lesions vary in location?

A

Pressure ulcers - over bony prominence

Moisture lesion - maybe over bony prominence but also:

in skin folds

anal cleft

peri-anal area

34
Q

How do pressure ulcers and moisture lesions vary in shape?

A

Pressure uclers - circular or regular shape and

limited to one spot

Moisture lesion - diffuse/ irregular shape or

linear shape in cleft and skin folds

35
Q

How do pressure ulcers and moisture lesions vary in depth?

A

Pressure ulcer - if ≥ grade 2 then will be deeper than moisture ulcers

Moisture lesion - only as deep as superficial dermis

36
Q

How do pressure ulcers and moisture lesions vary in necrosis

A

Moisture ulcers have no necrosis

or eschar

37
Q

How do pressure ulcers and moisture lesions vary in their colour?

A

Pressure ulcers can be: red, yellow, green, black (think traffic lights)

Moisture ulcers have varying shades of red and

maceration (pink or white)

38
Q

What is maceration?

A

softening

and turning white of the skin

due to being consistently wet

39
Q

What are the types of risk screening tool for pressure ulcers?

A

Braden scale

Glamorgan scale

Cubbin and jackson scale

40
Q

When is the Braden scale used?

A

For all adult services

within 2 hours of admission

41
Q

What score on the braden scale makes a person at risk of pressure sores?

A

≤16

42
Q

When should the Braden scale be repeated for a pt?

A

Weekly or

if a change in condition (EWS, post-op etc)

43
Q

When is the Glamorgan scale for pressure ulcers ued?

A

All children’s services within 2 hours

44
Q

When is a child “at risk” according to the Glamorgan scale?

A

≥10

45
Q

When is the Cubbin and Jackson pressure sore risk screening tool used?

A

All critical care services within 6 hours

46
Q

At what score is a pt at risk according to the Cuubbin and Jackson scale?

A

≤40

47
Q

Explain how the Braden tool is used in a clinical context?

A

It is only a guide and should not overshadow clinical judgement.

consider comorbidities

If a patient has existing damage they are already “at risk”

48
Q

As soon as you notice a skin ulcer (even at stage 1) what should you commence?

A

A SSKIN bundle

Avoid positions pt on affected area

49
Q

What does the SSKIN bundle include?

A

Support surface

Skin evaluation

Keep moving

Incontinence

Nutrition

50
Q

As part of the SSKIN bundle how should you support the surface?

A

Provide a special mattress and cushion

51
Q

As part of the SSKIN bundle how should you do the skin evaluation?

A

Assess the skin when repositioning and

record a blanch test

52
Q

As part of the SSKIN bundle how should you keep the pt moving?

A

Reposition 2hrly (if not marked you can do 3hrly)

Record each time you reposition

53
Q

As part of the SSKIN bundle what should you do regarding incontinence?

A

Assess for moisture lesions

54
Q

As part of the SSKIN bundle how should you keep an eye on nutrition?

A

Use the Malnutrition Universal Screening Tool (MUST) tool

55
Q

What stages of pressure sore require a wound care plan?

A

≥stage 2

56
Q

In a wound care plan for pressure ulcers what should you record?

A

The site of the wound

The dimentions of the wound (LxWxD)

A description of the wound

Dressings used for the wound

57
Q

If a patient is admitted to or discharged from hospital with a wound what should you do?

A

Take a picture

58
Q

Is it better for a patient with a pressure sore to be in bed or in a chair?

A

In bed, but you must still reposition 2hrly

59
Q

What conditions can increase the risk of pressure sores?

A

Poor nutrition

Incontinence

bHCE (18 decks)

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