Pressure sores:

Question 1

Outline the grading of pressure sores:

Answer 1

Grade 1 - Intact skin (erythema)
Grade 2 - Partial thickness skin loss - epidermis +/- dermis -> abrasion/blister
Grade 3 - Full thickness skin loss -> subcutaneous tissue
Grade 4 - Facia/muscle/bone - extensive destructive necrosis

Question 2

Give 5 RF for pressure sores:

Answer 2

• Coma
• Neuro-impairment (stroke, SCI, spina bifida)
• Surgery
• Impaired mobility
• Diabetes

Question 3

Give the principles of pressure sore management:

Answer 3

(SSKIN)

S - Surface: patients have right support
S - Skin inspection: early detection
K - Keep your patients moving
I - Incontinence/moisture: clean and dry
N - Nutrition/hydration: correct diet and lots of fluid

Question 4

What are the benefits of a moist wound environment?

Answer 4

• ^ rate of epithelial migration
• ^ Collagen synthesis
• Speeds wound contraction
• decrease length of inflammatory phase

Question 5

Outline the steps of wound healing:

Answer 5

1) Vascular response:
- vasoconstriction
- Coagulation cascade

2) Inflammatory response:
- Vasodilation
- Neutrophil and macrophage infiltration
- Slough formation (dead cells)

3) Proliferative stage (day 2-3):
- Fibroblasts (secrete GAG and collagen)
- Granulation (angiogenesis)

3) Maturation (slows down ~20 day)

Question 6

Outline the strength of the wound at 1 week,, 4 weeks and 3 months:

Answer 6

1 week - 10%
4 weeks - 70%
3 months - 80%

Question 7

Give two potential abnormal resolutions of wounds:

Answer 7

• Chronic wound

- Keloid scar

Question 8

Give the 3 different types of wound management/intention:

Answer 8

Primary intention:

• Only little or no tissue loss
• Linear scar - suturing/glueing

Secondary intention;

• Wound edges unopposed
• Wound granulates = broadening of scar

Tertiary intention:

• Wound purposefully left open - ?infection
• Cleaned, debrided, observed (surgically closed)

Question 9

Give 4 general factors and 4 local factors affecting wound healing:

Answer 9

General:

• Elderly
• Diabetes
• Malnutrition
• Immunosuppression

Local:

• Site
• Infection
• Oedema
• Vascular insufficiency

Question 10

What differentiates venous, arterial and neuropathic ulcers from each other?

Answer 10

Venous:
- Shallow, granulated base
- Irregular borders, impaired venous return
(Occurs due to WBC being trapped in capillaries -> inflam mediators released -> tissue damage)

Arterial:

• Distal sites (trauma/pressure), deeper, necrotic base
• Defined borders
• Painful

Neuropathic (diabetic):

• Over areas of abnormal pressure, secondary to joint deformities
• Peripheral neuropathy context
• Painless

Question 11

What investigation would perform in those with pressure ulcers?

Answer 11

Venous -

• duplex USS (incompetence at SFJ)
• ABPI
• Swabs

Arterial:

• ABPI (0.9-0.8 = mild, 0.8-0.5 =moderate, <0.5 = severe)
• Duplex USS

Neuropathic:

• Blood glucose/HbA1c
• Serum B12
• ABPO +/- duplex USS
• 10g monofilament sensation assessment

Question 12

What is the management of venous ulcers?

Answer 12

• Leg elevation + exercise
• Lifestyle ( Decrease weight)
• Compression bandage
• Dressing/emollients

Question 13

What is the management for arterial ulcers?

Answer 13

Medical:

• Statin
• Aspirin
• Diabetes control

Surgical:

• Angioplasty
• Bypass grafting
• Skin graft

Question 14

What is the management of Neuropathic pressure ulcers?

Answer 14

• Diabetic foot clinic
• HbA1c
• Lifestyle
• regular chiropody/foot care
• Swabs