Pressure Sores

Question 1

Definition of Pressure sore

Answer 1

Localised injury to the skin/underlying tissue over a bone prominence as a result of pressure +/- shearing

Question 2

What is a stage 1 pressure sore

Answer 2

Non-Blanchable erythema

may be painful, firm, warm

Question 3

What should be done if a stage 1 pressure sore is detected

Answer 3

Risk should be calculated using the Braden score

regular Repositioning should be commenced with care to avoid the affected area

Question 4

What is a stage 2 pressure sore

Answer 4

Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed

Alternatively may be a fluid-filled blister

Question 5

what may present similarly to a stage 2 pressure ulcer

Answer 5

Skin tears
Tape Burns
Incontinence associated dermatitis
Excoriation

Question 6

What is a stage 3 pressure sore

Answer 6

Full-thickness SKIN loss

Subcutaneous fat may be visible but bone, tendon or muscle are NOT exposed or directly palpable

Question 7

What is a stage 4 pressure sore

Answer 7

Full-thickness TISSUE loss

Exposed bone, tendon or muscle

Question 8

What has to be considered in conjunction with a stage 4 pressure sore

Answer 8

Osteomyelitis

Question 9

What is a deep tissue injury

Answer 9

Full-thickness tissue loss obscured by skin material/eschar making it difficult to stage

Question 10

How do you identify a deep tissue injury

Answer 10

Purple/maroon localised area of discoloured skin

Question 11

What is a moisture lesion

Answer 11

Lesion caused by chronic exposure to faecal/urine matter

Question 12

How do you identify a moisture lesion

Answer 12

Skin is wet/shiny

Diffuse irregular redness with irregular distribution of colour, with white areas of maceration

Question 13

What are some risk factors for pressure sores

Answer 13

>65
Decreased mobility
Sensory impairment (diabetic neuropathy) 
Vascular Disease
Decreased Conciousness
Previous History 
Incontinence
Malnutrition
Dehydration

Question 14

What Risk assessment tools are available for assessing pressure sore risk

Answer 14

Braden or Waterloo scores

Question 15

What are the components of a Braden score +what are the thresholds for risk

Answer 15

Mobility 
Friction level (out of 3, rest out of 4) 
Sensory Perception 
Nutritional status
Incontinence/moisture exposure
Special risks

<17 = high risk
17-20 = medium risk
21-23 = low risk

Question 16

How do you manage high-risk pressure sore individuals

Answer 16

2 hourly repositioning (1 hour if sitting)

Question 17

What is the structure of a visual assessment for a pressure sore

Answer 17

Site
Dimension/edge 
Pain
Colour
Exudate? (infection) 
Stage (look at floor, feel base) 
Fistulae/sinus?

Question 18

What does a raised edge indicate for a pressure sore

Answer 18

Malignancy

Question 19

What are the most common locations for a pressure sore

Answer 19

Sacrum
Elbows
Heels
Ears
Hips

Question 20

How do you diagnose a pressure sore

Answer 20

Clinical Diagnosis
Must be:
in a common location
in the presence of risk factors
Painful/Pruitic (in the absence of risk factors)

Question 21

What is the prevention package for pressure sores

Answer 21

SSKIN

Support Surface 
Skin evaluatoin
Keep moving
Incontinence (reassess for moisture lesions)
Nutrition (MUST)

Question 22

What are some management principles for pressure sores

Answer 22

Healing is slow but with adequate pressure distribution, nutrition and appropriate wound management ulcers generally heal

Antiseptic is contraindicated as this kills the healing granulation tissue

Involve tissue viability

Keep everything well documented