Pressure sores Flashcards
Definition of a pressure sore?
An area of localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.
A number of contributing or compounding factors is associated with pressure ulcers; the significance of all these factors is yet to be elucidated.
How does pressure or shear cause sores?
Unrelieved pressure: disruption to microcirculation causing tissue hypoxia and tissue breakdown.
Shearing forces: poor lifting or repeated slipping down the bed, causes distortion of the microcirculation and severing of tiny blood vessels leading to tissue breakdown.
Common sites for pressure sores?
occiput elbows sacrum coccyx hips heels
Be careful with medical devices as they can cause pressure sores.
Brief definition of pressure sores grade 1 - 4?
1: Non-blanchable erythema
2: Partial thickness
3: - Full thickness skin loss
- Unstageable
- Suspected deep tissue injury (SDTI)
4: Full thickness tissue loss
Describe a Grade 1 pressure sore?
Non-blanchable erythema:
Intact skin with non-blanchable redness of a localised area usually over a bony prominence. Darkly pigmented skin may not have visible blanching: its colour may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
Describe a Grade 2 pressure sore?
Partial thickness:
Partial thickness of dermis presenting as a shallow open ulcer with a red pink wound bed without slough. May also present as an intact or open/ruptured serum filled or sero-sanginuous filled blister. Presents as a shiny or dry shallow ulcer without slough
*this should not be used to describe skin-tears, tape-burns, incontinence associated dermatitis, maceration or excoriation.
Describe Grade 3 pressure sores?
Full thickness skin 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 Grade 3 ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Grade 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Grade 3 ulcer. Bone / tendon is not visible or directly palpable.
Suspected deep tissue injury (SDTI): Purple or marron localised area of discolouration with intact skin suggesting underlying deeper tissue damage.
Describe a Grade 4 pressure sore?
Full thickness tissue loss with exposed bone, tendon, muscle. Slough or eschar may be present. Often includes undermining and tunnelling. The depth of a Grade 4 ulcer varies as well. Grade 4 ulcers can extend into the muscle and or supporting structures (eg fascia, tendon or joint capsule) making osteomyelitis or osiers likely. Exposed bon/muscle is visible or directly palpable.
Who can be at risk of a pressure ulcer?
Anyone but especially:
Children
Disabled
the elderly
women in labour
All patients should be risk assessed
What pressure ulcer risk assessment tools should be used for each patient group?
Paediatric and neonate - Adapted Braden Score
Adults - Waterlow score
Maternity - Adapted Waterlow score
What parameters are scored in the Waterlow score?
Build/weight/heigh Ages/ sex Continence Tissue malnutrition Skin type Mobility Appetitie Neurological deficit Major surgery/ trauma
Sores vary for each category, scoring over 10 means high risk.
When should you reassess pressure ulcer risk assessments?
- within 6 hours of admission
- as the patient condition changes
- on transfer
- or at least weekly
What headings come under the SSKIN bundle?
S - Surface S - Skin Assessment K - Keep moving and repositioning I - Incontinence Management N - Nutrition and hydration
What happens in Skin Assessment of SSKIN bundle?
LOOK and FEEL Persistent erythema Non-blanching erythema Blister Scaring
Heat
Tenderness
Change in tissue consistency
What is MASD and IAD?
MASD - Moisture Associated Skin Damage - damage form urine, faeces, sweat or exudate.
IAD - Incontinence Associated Dermatitis - damage caused by urine / faecal incontinence.
This is different from pressure sores but can increase the risk of pressure ulceration.
Skin folds, diffuse, kissing ulcer, no necrosis, irregular.
What happens in the K of SSKIN bundle?
Keep moving and repositioning:
Waterlow 10-14: change position at least every 6 hours.
Waterlow >15: change position at least every 4 hours
What happens in I of SSKIN bundle?
Incontinence management
Consider:
- regular toileting
- bottles / bed pan
- commode
- penile sheath
- bowel management system
All incontinent patients should be washed with Aqueous Cream and apply Sereprep spray as barrier.
Follow IAD algorithm. Consider referral to Continence service.
What does N stand for in the SSKIN bundle?
Nutrition and hydration
Nutritional assessment as per guideline. If unable to weigh patient then complete Mid Upper Arm Circumference (MUAC).
Refer for assessment by a dietitian
Offer nutritional supplement
Ensure adequate hydration
What does S stand for on SSKIN?
Surface
High spec foam mattress should be standard.
Use dynamic support surface patient has a pressure ulcer of foam isn’t sufficient to redistribute pressure.
A pressure relieving mattress does not replace reposting the patient.
Check Dynamic equipment every shift to ensure no faults.
Discuss risk of heel pressure ulcer and consider: pillows, repose boots / wedge, derma, Devon heel protectors.
Correct size and height of chair helps distribute pressure. Consider maximum of 2 hours.
What do you report on Barts DATIX re pressure sores?
Pressure Ulcers:
on admission or develop during care. Any deterioration.
Continence Management:
Incontinence Associated Moisture lesions on admission, or during stay.
Skin Trauma:
Any traumatic wounds.
