Pressure Sores

Question 1

Where do pressure sores typically develop?

Answer 1

Over bony prominences - sacrum, heel

Question 2

What factors predispose to the development of pressure ulcers?

Answer 2

Malnourishment
Incontinence
Lack of mobility
Pain - reduced mobility

Question 3

What score is used to screen for patients who are at risk of developing pressure areas?

Answer 3

Waterlow score

Question 4

What is the Waterlow score marked out of?

Answer 4

Out of 30

10= at risk 
15= high 
20= very high

Question 5

What criteria is taken into account for the waterlow score?

Answer 5

Sex and age
Skin type e.g like tissue paper, dry, oedematous, clammy, broken area
Continence
Build/ weight for height
Mobility
Malnutrition screening tool
Special risks- tissue malnutrition, neurological deficit, recent surgery or trauma

Question 6

If ulcer looks inflamed and red, what should be done?

Answer 6

Swab
Antibiotics - flucloxacillin 
X-ray to see if bone involved 
Bloods - FBC, CRP, U+E 
May need blood culture if thinking sepsis

Question 7

Pressure ulcers can be graded from…

Answer 7

1 to 4

Question 8

How should pressure ulcers be managed?

Answer 8

• Moist environment encourages healing e.g hydrocolloid dressings and hydrogels may facilitate this. Avoid soap - dries out wound
• swabs should not be done routinely as majority are colonised
• use of antibiotics taken on clinical basis e.g is there evidence of surrounding cellulitis
• consider referral to tissue viability nurse
• surgical debridement may be beneficial

Question 9

What comes under tissue malnutrition in the waterlow score?

Answer 9

Terminal cachexia 
Multiple organ failure
Single organ failure
PVD
Anaemia 
Smoking

Question 10

What comes under neurological deficit in waterlow score?

Answer 10

Diabetes, CVS, MS
Motor/sensory
Paraplegia