Pressure sores Flashcards
What is a pressure sore
a localised injury to the skin and/or underling tissue over a bony prominence as a result of pressure, or pressure in combination with shear
Describe stage 1 pressure sores
Non-blanchable erythema
Dark skin may appear purple
Must commence a skin bundle and avoid positioning the patient on the affected area whenever possible
Describe stage 2 pressure sores
Partial thickness
Shiny or dry, shallow ulcer WITHOUT slough or bruising
Describe stage 3 pressure sores
Full thickness tissue loss
Subcutaneous fat may be visible, but bone, tendon and muscle are NOT exposed
Slough may be present, but does not obscure the depth of tissue loss
may include undermining or tunneling
Describe stage 4 pressure sores
Full thickness tissue loss with exposed bone, tendon or muscle
Slough or escar may be present
Osteomyelitis likely
Often includes undermining or tunneling
Depth varies with anatomical location
When is a deep tissue injury difficulf to stage?
ull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed
either stage 3 or 4 (can tell once enough slough/eschar is removed)
What points towards deep tissue injury?
Depth is obscured by slough or area of unbroken skin with underlying dark patches suggesting necrosis
Purple localised area
Blood filled blister
Area may be preceded by painful, firm, mushy, warm or cool tissue
What are moisture lesions
Caused by chronic exposure to moisture. Skin appears red and macerated and is extremely painful
Which test is used for testing for pressure sore
BLANCH test
literally see if the area blanches. If not, there is pressure damage
What should be assessed for in somebody with suspected pressure sore
Pain or oedema in the area
Warmer or cooler temperature over bony prominence
Hardened area
Broken skin
What are intrinsic risk factors for pressure sores
Reduced mobility Vascular disease Sensory imparment Severe chronic or terminal illness Reduced level of consciousness The very young or very old (poorer circulations)
Previous history of pressure damage (weak skin)
Malnutrition
Dehydration
Acute illness
Hip replacement surgery
Which factors exacerbate pressure sores?
Medication (hypnotics, sedatives, inotropes)
Moisture to skin
What is the risk assessment for pressure sores
Braden Risk Assessment Tool:
All adult services within 2 hrs of admission
Reassess at least weekly, and more often if low score
Describe braden scores
16 or less means risk
10 or less means higher risk
Describe the Pressure Ulcer Assessment
Cause of ulcer Site/location Photography Dimensions of ulcer Pain and/or odour Exudate and signs of local infection Stage - fistulae/sinus
