Pressure Sores & Nutrition issues

Question 1

Briefly describe the staging/ grading of Pressure Sores?

Answer 1

National Pressure Ulcer Advisory Panel Classification System
Grade I: Non blanching erythema with intact skin. When pressure is applied to erythematous area and then when removed, the skin does not go white.
Grade II: loss of dermis but not full thickness and no slough. Superficial ulcer/ blister
Grade III: Full thickness skin loss with loss of subcutaneous fat but no sign of muscle/ tendon/bone visually/ on palpation. May see tunneling/undermining (erosion to surrounding tissue)
Grade IV: Full thickness tissue loss with visible muscle/ tendon/ bone or on palpation. Common to see tunneling /
undermining.
Grade unknown: Due to slough or eschar (scab) the depth of the ulcer is impossible to ascertain but if wounds are covered in 100% of it are at least stage 3.

Question 2

What are the RF for pressure ulcer development?

Answer 2

poor mobility
older age
reduced tissue perfusion (e.g. PVD)
malnutrition
moisture (e.g. due to unmanaged incontinence)
sensory impairment
cognitive impairment
dehydration
obesity
Assess patient's risk using Waterlow/ Braden tools.

Question 3

What is the simple mantra for Pressure sore prevention?

Answer 3

SSKIN
S: Surface, ensure adequate support
S: skin assessment, early inspection means early detection. Inspect on admission and on repositioning.
K: Keep moving- relieving the Pressure is the most important way to prevent ulcers. routine must be identified for those not independently mobile.
I: incontinence management if this is present
N: Nutrition/ hydration is very important to prevention and management of sores

Question 4

What is the pathophys of a pressure ulcer?

Answer 4

They result from localized external P on the skin causing occlusion of the capillaries and tissue compression leading to:

1. reduced oxygen and nutrients reaching tissues
2. altered soft tissue hydration as fluid is pushed away from viable cells.

P ulcers can predispose to pain and infection which could be life-threatening causing sepsis/ osteomyelitis.

Question 5

How should P ulcers be managed?

Answer 5

1. Expert advice from Tissue Viability Nurse for Stage III/IV
2. Frequent movement of the patient
3. High spec mattress and cushion for wheelchair/ chair to relieve pressure
4. Use pH balanced skin cleaner
5. High protein diet to facilitate healing
6. increased freq of skin assessment
7. Protect from moisture
8. Swab ulcer and only tx with systemic abx if clinical evidence of sepsis, osteomyelitis, spreading cellulitis.
9. Debridement is an option usually autolytic which involves using the body’s own phagocytes to break down necrotic tissue by providing a moist env (moisture retain plaster) to facilitate the process.