Pressure sores Flashcards
What is the rough cost of pressure sores to the NHS per annum?
£1.5 billion
Where do pressure ulcers normally occur on the body?
Over bony prominences
What are the two ways pressure sores can occur?
Due to pressure or pressure with shear force (i.e. sliding down a bed)
What is the scale of pressure sores severity?
0-4
What is a stage 0 pressure sore?
Normal reactive hyperaemia (increase of blood flow) due to pressure
What is a stage 1 pressure sore?
Non-blanchable erythema
What is a stage 2 pressure sore?
Partial thickness skin loss
What is a stage 3 pressure sore?
Full thickness skin loss
What is a stage 4 pressure sore?
Full thickness tissue loss
How can you tell the difference between a stage 0 and stage 1 pressure sore?
Stage 1 will not blanch under pressure (i.e. you cannot push the blood out)
Which stage of pressure sore are normal (i.e. not damage has occurred)?
Only stage 0
What do stage 1 pressure sores look like?
Darkly pigmented
Can have a bluish tinge
Is a stage 1 pressure sore firm or soft?
It can be both
Is a stage 1 pressure sore painful?
It may be
At what stage of pressure sore is the pt “at risk” regardless of the Braden score?
Stage 1
How deep does a stage 2 pressure sore go down to?
About midway through the dermis
How can a stage 2 pressure sore present?
A shallow open ulcer
with a red/pink wound bed
without slough
OR
An intanct or open/ruptured
serum-filled
blister
Do stage 2 ulcers have bruising and explain why?
No bruising
as this indicates deep tissue injury
What should stage 2 ulcer not be used to describe?
Skin tears
Tape burns
incontinence associated dermatitis
Excoriation
How deep does a stage 3 skin ulcer go?
Goes down to fat but not as deep as
bone, tendon or muscle
What is slough?
A yellow fibrinous tissue
that consists of fibrin, pus, and proteinaceous material
What stages of pressure ulcers can include tunnelling and undermining?
Stage 3 and 4
How is a stage 3 pressure ulcer described?
Full thickness skin loss
What is a stage 4 pressure ulcer?
Full thickness tissue loss with exposed
bone tendon or muscle
What stages of pressure sore can have slough?
Stages 3 + 4
What is eschar?
a slough
produced by: a thermal burn
a corrosive chemicals
or by gangrene.
Which stage of pressure sore can eshcar be present in?
Stage 4
What can prevent a wound being staged?
If the wound if obscured by slough or eschar
If a wound is unstagable due to obstruction by eschar or slough then what stages must it be?
It must be either a stage 3 or 4
What is a common mimic of a pressure ulcer?
A moisture lesion
What is a moisture lesion?
An area of irritation due to prolonged exposure to
moisture/water/urine
What categories can be used to differentiate pressure ulcers and moisture lesions?
Location
Shape
Edges
Depth
Colour
Necrosis
How do pressure ulcers and moisture lesions vary in location?
Pressure ulcers - over bony prominence
Moisture lesion - maybe over bony prominence but also:
in skin folds
anal cleft
peri-anal area
How do pressure ulcers and moisture lesions vary in shape?
Pressure uclers - circular or regular shape and
limited to one spot
Moisture lesion - diffuse/ irregular shape or
linear shape in cleft and skin folds
How do pressure ulcers and moisture lesions vary in depth?
Pressure ulcer - if ≥ grade 2 then will be deeper than moisture ulcers
Moisture lesion - only as deep as superficial dermis
How do pressure ulcers and moisture lesions vary in necrosis
Moisture ulcers have no necrosis
or eschar
How do pressure ulcers and moisture lesions vary in their colour?
Pressure ulcers can be: red, yellow, green, black (think traffic lights)
Moisture ulcers have varying shades of red and
maceration (pink or white)
What is maceration?
softening
and turning white of the skin
due to being consistently wet
What are the types of risk screening tool for pressure ulcers?
Braden scale
Glamorgan scale
Cubbin and jackson scale
When is the Braden scale used?
For all adult services
within 2 hours of admission
What score on the braden scale makes a person at risk of pressure sores?
≤16
When should the Braden scale be repeated for a pt?
Weekly or
if a change in condition (EWS, post-op etc)
When is the Glamorgan scale for pressure ulcers ued?
All children’s services within 2 hours
When is a child “at risk” according to the Glamorgan scale?
≥10
When is the Cubbin and Jackson pressure sore risk screening tool used?
All critical care services within 6 hours
At what score is a pt at risk according to the Cuubbin and Jackson scale?
≤40
Explain how the Braden tool is used in a clinical context?
It is only a guide and should not overshadow clinical judgement.
consider comorbidities
If a patient has existing damage they are already “at risk”
As soon as you notice a skin ulcer (even at stage 1) what should you commence?
A SSKIN bundle
Avoid positions pt on affected area
What does the SSKIN bundle include?
Support surface
Skin evaluation
Keep moving
Incontinence
Nutrition
As part of the SSKIN bundle how should you support the surface?
Provide a special mattress and cushion
As part of the SSKIN bundle how should you do the skin evaluation?
Assess the skin when repositioning and
record a blanch test
As part of the SSKIN bundle how should you keep the pt moving?
Reposition 2hrly (if not marked you can do 3hrly)
Record each time you reposition
As part of the SSKIN bundle what should you do regarding incontinence?
Assess for moisture lesions
As part of the SSKIN bundle how should you keep an eye on nutrition?
Use the Malnutrition Universal Screening Tool (MUST) tool
What stages of pressure sore require a wound care plan?
≥stage 2
In a wound care plan for pressure ulcers what should you record?
The site of the wound
The dimentions of the wound (LxWxD)
A description of the wound
Dressings used for the wound
If a patient is admitted to or discharged from hospital with a wound what should you do?
Take a picture
Is it better for a patient with a pressure sore to be in bed or in a chair?
In bed, but you must still reposition 2hrly
What conditions can increase the risk of pressure sores?
Poor nutrition
Incontinence
