Pressure ulcers

Question 1

What are pressure ulcers

Answer 1

localised damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device

Question 2

Give 4 RFs for pressure ulcers

Answer 2

• Immobility
• > 70
• Recent surgery
• Malnutrition

Question 3

What are the early indications of tissue damage/ wound formation

Answer 3

Localised skin changes on areas subjected to pressure
* painful
* firm/mushy, warmer/ cooler than adjacent tissue

Question 4

What indicates a stage 2 pressure ulcer

Answer 4

A blister or shiny/dry shallow open wound involving partial loss of dermis without slough

Question 5

What indicates a stage 3 pressure ulcer

Answer 5

Full-thickness wound possibly containing some slough with no bone tendon or muscle involvement/exposure

Question 6

What indicates a stage 4 pressure ulcer

Answer 6

Full-thickness tissue loss with exposed bone, tendon, or muscle possibly containing slough or eschar on some parts of the wound bed

Question 7

What does slough in a wound indicate

Answer 7

Unclean or stagnant wound environment hindering healing and increasing infection risks

Question 8

What suggests infection of a wound

Answer 8

• Localised tenderness and warmth around wound
• Increased exudate
• Development of odour
• Sudden deterioration of wound/ patient

Question 9

How are pressure ulcers managed

Answer 9

• Pressure relief - repositioning every 2h
• Good hygiene practice
• Analgesia

Question 10

How are deep ulcers treated

Answer 10

• debridement of necrotic tissue
• surgical debridement and reconstruction with flap formation