Pressure Sores and Rehabilitation Flashcards
Impact of pressure ulcers on the patient
Pain Reduced mobility Infection Septicaemia Osteomyelitis Anxiety Loss of dignity Loss of sleep Loss of appetite
What is a pressure ulcer?
Localise injury to the skin and/or underlying tissue
Usually over a bony prominence
Result of pressure +- shear forces
Shear forces
Constant pull of gravity against the body
Slipping down the bed
Blanch test
Reactive hyperaemia-> normal response to temporary pressure
If not the stages of non blanchable skin
Stage 1
Intact skin Non blanchable redness Less visible on dark skin Painful Firm/soft Warmer "At risk" Commence skin bundle Position patient safely
Stage 2
Partial thickness loss of dermis Shallow open ulcer Pink wound bed No Slough Ruptured blister No bruising
Stage 3
Full thickness tissue loss Subcutaneous fat may be exposed Slough may be present Depth varies by anatomical location Bone and tendon are not visible
Stage 4
Full thickness tissue loss
Exposed bone, tendon or muscle
Undermining and tunnelling
May extend in to supporting structures
Unstagable
Full thickness tissue loss where the depth is obscured by Slough and/or eschar
Suspected deep tissue injury
Purple locals area of intact skin/blood blister
Suggests damage to deeper tissues
Moisture lesions
Wet skin Bony prominence or skin folds Diffuse spots/irregular shape Superficial-partial No necrosis Non uniform redness Irregular edges
Braden scale
SSKIN bundle
Support surface Skin evaluation Keep moving Incontinence Nutrition
Examination of ulcers
Site Measurements Wound description Dressings Photographs
Positioning
30 degree tilt, sacrum ff mattress Heels off loaded Watch out for appliances 2 hourly repositioning Avoid ever positioning the patient on he effected area
