Pressure sores and undernutrition Flashcards
How often should patients swap sides to avoid pressure sores
every 2 hours
Common places for pressure sores
sacrum
heel
greater trochanter
Grades of pressure sore
Stage I non blanching erythema over intact skin
Stage II partial thickness skin loss
Stage III full thickness skin loss extending to fat
Stage VI Destruction of bone, muscle, tendons
Prevention of pressure sores
- Alternating pressure air mattress (APAM)
- Pressure-relieving mattress/cusion
- Turning chart
How long does it take for grade I,II sores to heal
around 2 wks
How long does it take for grade III,IV sores to heal
months
Debridement of pressure sores
Surgically - cutting away necrotic tissue Medically - topical enzymes eg streptokinase - or occlusive dressing allowing body enzymes to digest material in wound
Effect of moisture on pressure sores
Moist areas thin the skin predisposing to sores
But moisture helps healing
Use hydrocolloid gel on ulcer every 3-5 days
Undernutrition def
BMI<20
BMI<15
How to measure height in elderly where they cant stand straigth
use arm span from fingers on one side to the other
Albumin levels a good indicative of nutrition status
- albumin is an active phase protein
- low in illness, severe leg ulcers, cellulitis or nephrotic syndrome
Malnutrition assessment score
MUST score
Components of MUST
I. BMI score
(>20=0, 18.5-20=1, <18.5=2)
II. unplanned wt loss last 3-6 mo
(<5% =0, 5-10 % =1 , >10% =2)
III. acute disease effect
( pt acutely ill and has been or likely to be no or minimal nutritional intake for >5days =2)
MUST score results
0 - low risk
1 medium
2 or more high
Medium risk MUST score mx
Document dietary intake for 3 days if in hospital or care home- if no improvement after 3 days
- refer to dietician
