Pressure Ulcers Flashcards
What is a pressure ulcer?
Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply.
Typically they occur in a person confined to bed or a chair by an illness and as a result they are sometimes referred to as ‘bedsores’, or ‘pressure sores’.
What causes pressure ulcers?
Pressure ulcers develop through the interplay of 4 main factors: pressure, shear, friction, and moisture.
Pressure is clearly the most important factor and both the duration and intensity of pressure are important.
What are the risk factors for pressure ulcers?
- Immobility
- Sensory impairment
- Older age
- Surgery
- Intensive care stay
- Malnourishment
- Incontinence
- Pain (leading to a reduction in mobility)
- History of previous pressure ulcers
- Environmental factors e.g. the likelihood of developing pressure damage is greatly influenced by the nature of the surface on which the patient has been sitting or lying
Where do pressure ulcers commonly occur?
Pressure ulcers occur most commonly over bony prominences and are caused principally by unrelieved interfacial pressure.
Commonly occur in:
- Heels
- Ankles
- Hips
- Sacrum
What screening tools are used to assess pressure ulcers?
A number of tools have been developed for the formal assessment of risk for pressure ulcers. The three most widely used scales are the:
- Braden Scale
- Norton Scale
- Waterlow Scale
Briefly describe the Braden Scale
The Braden Scale for Predicting Pressure Sore Risk was developed to foster early identification of patients at risk for forming pressure sores.
The scale is composed of six subscales:
- Sensory perception
- Skin moisture
- Activity
- Mobility
- Friction and ahear
- Nutritional status
Each iten is scored between 1 and 4 guided by a descriptor. The lower the score the greatest the risk.
Briefly describe the Norton Scale
A scale used to predict the likelihood a patient will develop pressure ulcers. The patient is rated from 1 (low risk) to 4 (high risk) using the following five criteria:
- Physical condition
- Mental condition
- Activity
- Mobility
- Incontinence
Briefly describe the Waterlow Scale
The Waterlow consists of seven items: build/weight, height, visual assessment of the skin, sex/age, continence, mobility, and appetite, and special risk factors, divided into tissue malnutrition, neurological deficit, major surgery/trauma and medication.
The tool identifies three ‘at risk’ categories,
- A score of 10-14 indicates ‘at risk’
- A score of 15-19 indicates ‘high risk’
- A score of 20 and above indicates very high risk
Briefly describe grade 1-4 of pressure ulcers by the European Pressure Ulcer Advisory Panel classification system
Grade 1
Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin.
Grade 2
Partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
Grade 3
Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4
Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss.
What factors need to be documented when conducting a skin assessment?
Offer adults who have been assessed as being at high risk of developing a pressure ulcer a skin assessment by a trained healthcare professional. The assessment should take into account any pain or discomfort reported by the patient and the skin should be checked for:
- Skin integrity in areas of pressure
- Colour changes or discoloration
- Variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin)
Briefly describe the management of pressure ulcers
Treatment for all patients should include pressure relief, good hygiene practice, and skin care, particularly in the sacral region.
Briefly describe the role of pressure reducing aids and repositioning in managing pressure ulcers
Pressure relief is critical to pressure ulcer treatment and is achieved through repositioning and use of an appropriate support surface. Patients should not be positioned on their wound.
In many institutions, repositioning every 2 hours is the standard of care for at-risk individuals.
Appropriate pressure-reducing aids, including mattresses and wheelchair or seat cushions, should be immediately provided.
Briefly describe the role of hygiene, cleaning and dressing pressure ulcers
The aim of topical treatment is to achieve a clean wound bed, an essential precursor to healing. If erythema or pus are seen, a wound swab may be taken to obtain evidence of infection.
The presence of excess moisture may exacerbate damage caused by frictional or shear force, so it is important to ensure that the skin of incontinent patients is regularly cleansed and dried and protective creams applied as appropriate.
When may surgery be indicated in a patient with a pressure ulcer?
Surgery may be considered in patients whose ulcers are not healing with conservative therapy or when rapid closure is desirable.
What are the complications of pressure ulcers?
- Sepsis
- Cellulitis
- Osteomyelitis
- Mortality
