Pressure Ulcers

Question 1

What are the risk factors that contribute to the development of a pressure ulcer?

Answer 1

• General health
• Age/ sex
• Reduced mobility
• Sensory impairment
• Body weight
• Posture
• Circulation

Question 2

Skin inspection

Answer 2

• Top to toe
• Skin folds
• Under any medical devices e.g urinary catheters
• Inspect daily for those at high risk
• Not appropriate for all such as those with no risk factors but everyone should be offered a skin inspection.

Question 3

What to look for when inspecting the skin

Answer 3

• Blanching erythema
• Non-blanching erythema
• Blistering
• Localised heat, oedema and induration (hardening)
• Purple/ maroon localised discolouration or coolness.

Question 4

Category 1

Answer 4

• Intact skin with non-blanching erythema usually over a bony prominence.
• Changes in sensation, temperature, or firmness may precede visual changes.

Question 4

Category 2

Answer 4

• Partial-thickness loss of skin with exposed dermis.
• Wound bed is visible, pink or red, moist, without non-removable slough.
• May present as an intact or ruptured serum-filled blister.

Question 5

Category 3

Answer 5

• Full thickness loss of skin
• Bone, tendon or muscles are not exposed.
• Slough or necrosis may be present.
• Varies by anatomical location such as the back of the head and malleolus which do not have subcutaneous tissue and these ulcers can be shallow.

Question 6

Category 4

Answer 6

• Full thickness tissue loss with exposed tendon, muscle, bone or palpable bone.
• Slough or necrosis may be present.
• Often includes undermining/ tunnelling
• The depth depends on anatomical location which do not have subcutaneous tissue and these ulcers can be shallow.

Question 7

Unstageable (depth unknown)

Answer 7

• Full thickness tissue loss in which the depth is obscured by slough or necrosis.
• The true depth cannot be determined until enough slough or necrosis is removed but it will be category 3 or 4.
• Stable (dry, adherent, intact without erythema)

Question 8

Deep tissue injury (DTI)

Answer 8

• Intact or non-intact purple/ maroon area of discolouration or blood-filled blister.
• Pain and temperature change
• Evolution may be rapid exposing additional layers of tissue even with optimal treatment or may resolve without tissue loss.

Question 9

Device related pressure ulcer

Answer 9

• Differ from classic pressure ulcer in aetiology and location.
• Not usually over bony prominences, often on mucosal membranes
• May not be round but may resemble the shape of the device.
• Can occur because of poorly fitting medical devices, insufficient protection and lack of repositioning the device.

Question 10

How to prevent pressure ulcers?

Answer 10

• Circulation (move the patient to improve circulation).
• Provide mattress that relieves pressure
• Provide pressure redistributing gel
• The use of slide sheets