Pressure Ulcer Flashcards
What is the definition of a pressure ulcer?
Pressure ulcer: A localized area of tissue injury/necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence, often due to a combination of pressure, shear, friction, and moisture.
What are the primary risk factors contributing to pressure ulcers?
Risk factors: Shear, excessive moisture, impaired mobility, malnutrition, impaired sensation, advanced age, and history of pressure ulcers.
Define shear in the context of pressure ulcers.
Shear: Refers to forces applied tangentially over an area of tissue, causing deformation, ischemia, and potential reperfusion injury.
Define friction in relation to pressure ulcers.
Friction: Resistance to motion when two surfaces move across each other, increasing the risk of skin breakdown.
How does moisture contribute to the development of pressure ulcers?
Moisture: Predisposes skin to pressure ulcers by causing maceration, increasing shear, and enhancing friction forces.
What are the stages of pressure ulcers according to the International NPUAP/EPUAP classification system?
Stages:
- Stage I: Non-blanchable erythema of intact skin.
- Stage II: Partial thickness loss of dermis.
- Stage III: Full thickness tissue loss without exposed bone, tendon, or muscle.
- Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle.
- Unstageable: Base obscured by eschar or slough.
- Suspected Deep Tissue Injury: Localized discolored intact skin or blister.
What is the Braden Scale used for?
Braden Scale: A risk assessment tool for predicting pressure sore risk, with scores ranging from 6 to 23, where lower scores indicate higher risk.
What is the Norton Risk Assessment Scale?
Norton Scale: Assesses pressure ulcer risk based on physical condition, mental state, activity, mobility, and incontinence.
- A score ≤16 indicating risk.
What are common characteristics of Stage I pressure ulcers?
Stage I: Non-blanchable erythema, intact skin, and possible changes in temperature, firmness, or sensation.
What are the risk factors for impaired mobility leading to pressure ulcers?
Impaired mobility risk factors:
- weakness
- sedation
- depression
- hospitalization
- fractures
- spinal cord injury
What role does malnutrition play in pressure ulcer development?
Malnutrition: Contributes to pressure ulcer severity due to low serum albumin levels and inadequate hydration, affecting tissue repair.
What is the PUSH tool used for?
PUSH Tool: Assesses pressure ulcer healing using subscales for wound area, exudate amount, and appearance, with scores ranging from 8 to 34.
Differentiate between Stage III and Stage IV pressure ulcers.
Stage III: Full thickness tissue loss without exposed bone, tendon, or muscle, may have slough or tunneling.
Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle, often with necrosis or sinus tracts.
What are some advanced risk factors for pressure ulcers beyond physical causes?
Advanced risk factors: Ischemia-reperfusion injuries, polypharmacy, low diastolic pressure, psychosocial factors, smoking, increased skin temperature, and diabetes-related changes.
What interventions can be used to prevent pressure ulcers?
Interventions: Offloading, managing moisture, ensuring proper nutrition, repositioning, and using specialized support surfaces.
What is the significance of Stage I pressure ulcers being non-blanchable?
Non-blanchable: Indicates sustained capillary occlusion and the beginning of tissue damage, distinguishing it from reactive hyperemia.
What differentiates a mucosal membrane pressure injury from a skin-based pressure ulcer?
Mucosal membrane injuries: Result from medical devices and cannot be staged using the skin pressure ulcer classification system due to different histology.
What are the benefits of the International NPUAP/EPUAP classification system?
Benefits: Promotes understanding of tissue involvement, ensures reliability, supports Medicare reimbursement, aids research, and guides support surface selection.
What is undermining in pressure ulcers, and in which stages is it common?
Undermining: Tissue destruction under intact skin edges, commonly seen in Stage III and Stage IV pressure ulcers.
What are the characteristics of suspected deep tissue injuries?
Deep tissue injuries: Purple/maroon discolored intact skin or blood-filled blister, possibly firm, mushy, boggy, warmer, or cooler than surrounding tissue.
What interventions are specific to Stage III pressure ulcers?
Stage III interventions: Fill dead space, pack undermining/tunneling areas, use antimicrobials for high bioburden, and apply alginate for high exudate.
How does advanced age contribute to the development of pressure ulcers?
Advanced age: Increases risk due to skin changes, higher comorbidity rates, and reduced regenerative capacity.
What are examples of medical devices that cause device-related pressure injuries?
Examples: Oxygen tubing, nasotracheal tubes, cervical collars, external fixators, splints, IV tubing, urinary catheters, and compression devices.
What are the steps for managing exudate in pressure ulcers?
Managing exudate: Use appropriate dressings like alginate, apply antimicrobial agents for infection control, and ensure proper dressing changes to minimize accumulation.
How do shear and friction forces differ in the development of pressure ulcers?
Shear: Tangential forces causing tissue deformation and ischemia.
Friction: Surface resistance leading to superficial skin damage.
What are the components of the ‘5PT’ method for pressure ulcer assessment?
5PT: Pain, Position, Presentation, Periwound, Pulses, and Temperature are assessed to determine ulcer characteristics.
What types of dressings are appropriate for Stage I and II pressure ulcers?
Stage I and II dressings: Film dressings to prevent shear and allow observation, or composite foam for added padding and moisture control.
What is the expected healing time for a Stage II pressure ulcer with appropriate interventions?
Stage II healing time: Approximately 23 days if pressure is relieved and proper care is provided.
What therapeutic exercises can help prevent pressure ulcers in patients with impaired mobility?
Therapeutic exercises: Flexibility exercises to reduce contractures, strengthening exercises for transfers and weight shifts, and aerobic exercises to improve mobility.
How is electrical stimulation used in the treatment of pressure ulcers?
Electrical stimulation: Promotes wound healing by enhancing cellular activity, increasing blood flow, and reducing inflammation.
What are the primary goals of intervention for pressure ulcers?
Goals: Offload affected areas, perform wound care, debride necrotic tissue, fill dead space, control exudate, decrease microbial load, and pad/protect the wound.
What is the purpose of pulsatile lavage with suction in pressure ulcer treatment?
Pulsatile lavage with suction: Cleanses necrotic wounds by removing debris and bacteria, promoting a clean wound bed for healing.
What role does nutrition play in pressure ulcer prognosis?
Nutrition: Better baseline nutrition correlates with faster healing and reduced risk of complications, emphasizing the importance of protein and hydration.
What are common peri-wound structural changes in pressure ulcers?
Peri-wound changes: Non-blanchable erythema, mottling, a ring of inflammation, and dermatitis are common findings around the ulcer site.
What are characteristics of Stage IV pressure ulcers?
Stage IV: Full thickness tissue loss with exposed bone, tendon, or muscle, often accompanied by necrosis, undermining, or sinus tracts.
How do clinicians assess the depth of a pressure ulcer?
Depth assessment: Based on the extent of tissue involvement using staging systems, with depth changes described as ‘healing’ rather than reversed staging.
What interventions are recommended for device-related pressure ulcers?
Device-related ulcer interventions: Reposition devices, use padding, and inspect frequently to prevent and treat ulcers related to medical devices.
What is negative pressure wound therapy, and when is it used for pressure ulcers?
Negative pressure wound therapy: Used after surgical debridement to promote healing by creating a vacuum that removes exudate and reduces bacterial load.
What are the benefits of musculocutaneous flaps in surgical interventions for pressure ulcers?
Musculocutaneous flaps: Provide vascularized tissue bulk to fill defects, protect underlying structures, and enhance healing after excisional debridement.
How do aerobic exercises assist in pressure ulcer prevention?
Aerobic exercises: Improve cardiovascular endurance, mobility, and activity levels, reducing the risk of ulcer development by enhancing overall circulation and function.
