Pressure sores Flashcards
What is the epidemiology of pressure sores?
Cost the UK £1.4-2 billion per year
A comparative study of patients with pressure ulcer in the UK, US & Canada demonstrated prevalence in hospitalised patients of 4.7% to 32.1%
In patients in community care the prevalence ranged from 4.4% to 33.0% and was 4.6% to 20.7% in patients in nursing homes
Among elderly patients being seen by a GP in the UK, an overall incidence rate of 0.58 ulcers per 100 person- rates were considerably higher in people >85yrs
What is the definition of a pressure sore?
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 shear forces occur due to the constant pull of gravity against the body, and results in the patients’ body gradually slipping down the bed, chair or trolley
What is a stage 1 pressure sore?
Non-blanchable erythema
o Intact skin over a non-blanchable redness of a localised area usually over a bony prominence
o Darkly pigmented skin will appear purple or bluish rather than red may not have visible blanching
o Area may be painful, firm, soft, warmer, bluish tinge
o Patients should be considered at risk regardless of the Braden score
o Must commence a skin bundle and avoid positioning the patient on the affected area whenever possible
What is a stage 2 pressure sore?
Partial thickness
o Partial thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed, without slough
o May also present as an intact or ruptured serum-filled blister
o Presents as a shiny or dry shallow ulcer without slough or bruising (indicates deep tissue injury)
o This stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis or excoriation
What is a stage 3 pressure sore?
Full thickness skin loss
Full thickness tissue loss- subcutaneous fat may be visible, but bone, tendon or muscle are not exposed
Slough may be present, but does not obscure the depth of tissue loss, may include undermining and tunnelling
The depth of a stage 3 pressure ulcer varies by anatomical location
Bone/tendon is not visible or directly palpable
What is a stage 4 pressure sore?
Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present
Ulcers can extend into muscle and/or supporting structures (eg. fascia, tendon or joint capsule) making osteomyelitits likely
Often includes undermining or tunnelling
The depth of a stage 4 pressure ulcer varies with anatomical location
When is a deep tissue injury suspected?
Purple or maroon localised area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear
The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue
Deep tissue injury may be difficult to detect in individuals with dark skin tones- evolution may include a thin blister over a dark wound bed, the wound may further evolve and become covered by thin eschar
Evolution may be rapid exposing additional layers of tissue even with optimal treatment
What is a moisture lesion?
Caused by chronic exposure to urine/faecal matter leading to skin appearing macerated
extremely painful for the patient
What are the features of a moisture lesion?
Shining wet skin
May be over a bony prominence or in skin folds, anal cleft, peri-anal redness/skin irritation
Diffuse superficial spots or irregular shape. Linear shape in cleft and skin folds
Superficial depth
No necrosis or eschar present
Diffuse, irregular edges
Redness that isn’t uniformly distributed. Pink ro white maceration
How is the skin tested?
Using the blanch test caused by chronic exposure to urine/faecal matter leading to skin appearing macerated extremely painful for the patient
Assess for:
Pain or oedema in the area
Warmer or cooler temperature over a bony prominence
Hardened area
Broken skin
What are intrinsic risk factors?
Reduced mobility or immobility
Vascular disease (reduced blood flow)
Sensory impairment (neurological disorders, spinal cord injury lead to lack of stimulus to relieve pressure
Severe chronic or terminal illness
Reduced level of consciousness
Either the very young or the old (poorer circulations)
Previous history of pressure damage (weak skin)
Malnutrition
Dehydration
Older people undergoing hip replacement surgery
Acute illness
What are the extrinsic risk factors?
All factors that are involved that can cause injury, pressure, shearing and friction will eventually lead to tissue damage
Exacerbating conditions- medication (hypnotics, sedatives, inotropes) or moisture to skin
What is the Braden risk assessment tool?
all adult services within 2hrs of admission- reassess at least weekly and upon change of condition
Score 16 or less- high risk – 2hrly repositioning (red skin bundle)
Score 17-20- medium risk (amber skin bundle)
Score 21-23- low risk
Sensory perception
Moisture
Activity
Mobility
Nutrition
Friction and shear
1-4: 1- worst, no 4 for friction and shear
What are the other risk assessment tools for pressure sores not in the elderly?
Glamorgan scale: all children’s services within 2hrs of admission- score 10 or over are at risk
Cubbin & Jackson: all critical care services within 6hrs of admission- score 40 or less are at risk
What is pressure ulcer assessment?
Cause of ulcer Site/location Photography Dimensions of ulcer Pain and/or odour Exudate & signs of local infection Stage – fistulae/sinus
