Pressure Ulcers Flashcards
pressure ulcers are described as
localized area of tissue necrosis
what are pressure injuries
compression of soft tissue between firm surface and bony prominences
patients at greatest risk of pressure ulcers
SCI injuries
hospitalized pts
long-term pts
medical device injury
pressure injury not at bony prominence, typically induced by a medical device
explain the relationship of pressure and time in the etiology of pressure injuries
inverse
- more likely for a ulcer at higher pressures for lower time intervals
explain the process of cell death when considering pressure
stages include:
pressure
ischemia
acidosis
inflammation
permeability and edema
tissue anoxia
necrosis
explain the formation of pressure injuries in terms of the pressure/duration relationship for those less tolerant to hemodynamic changes
these pts will be more likely to have pressure injuries due to their intolerance of hemodynamic changes
- higher pressures will cause ulcers occur in a shorter amount of time
explain the timeline of pressure injuries in relation to the application of pressure
may not develop until 2-7 days after
- extensive skin damage could occur before clinical signs are present
what is reactive hypermia
localized area of blanchable erythema
- length of time is proportional to extent of tissue ischemia
what external factors/forces increase likelihood of pressure injuries
shear
excessive moisture
impaired mobility
nutrition
impaired sensation
older
hx of pressure injuries
what is common in appearance in shear force injuries
teardrop appearance
- strip stratum corneum
what does excessive moisture do to the skin
maceration
increased shear
increased friction forces
what causes maceration
wound drainage
perspiration
incontenince
malnutrition is the ____ most common risk factor for _____
second
pressure injuries
when pressure ulcer is healed, how strong is the new tissue laid at that site is considered? what to consider when treating repeated wounds
80% strength of the 100% healthy tissue
- each new layer of tissue is then 80% of the original 80%
what are the scales used to assess risk of pressure ulcer
braden scale
norton risk assessment
what does the braden scale measure
mobility
activity
sensory perception
skin moisture
nutrition
friction/shear
scoring of the braden scale? what is a significant score on it
6-23
<18 is deemed at risk
lower = worse
what is the Braden Q score
pediatric patient braden scale
7-28
what does a <18 on the braden signify for therapists/nurses
implementation of a turning schedule
what does the norton scale measuere
physical condition
mental condition
activity
mobility
incontenince
scoring of norton scale? significant value? what is a better vs worse score?
5-20
≤16 = at risk
lower = more at risk
what is something to consider when scoring the norton?
criteria that deduct points
what criteria deduct points on the norton scale
diabetes
HTN
5+ medication
AMS
low blood work
when in sidelying, how should patients be positioned to avoid pressure ulcers
at a 30° angle
pillows over bony prominences
what is used to stage pressure injuries
NPUAP Pressure Injury system
stage 1 on the NPUAP description
nonblanchable erythema
intact skin
may be painful, different temp, and different firmness than periwound
stage 2 NPUAP is described by
superficial ulcer
shallow crater
no slough, eschar or bruising
may have a blister
stage 3 NPUAP description
deep ulcer
undermining or tunneling may be present
stage 4 NPUAP description
deep ulcer with extensive necrosis
undermining / sinus tracts common
unstageable wounds are considered as
wounds in which the base is obscured by eschar or slough
what stages of the NPUAP scale are typically unstageable
3 and 4
benefits of the NPUAP system
describes level of tissue involvement
guides appropriate intervention
universally accepted and understood among disciplines
medicare requirements
limitations of the NPUAP
nomenclature
numerical labelling - implies predictable progression
what is problematic about the nomenclature of the NPUAP system
does not provide etiology of the wound just pressure
pressure injury is often seen at these sites
sacrum
greater troch
ischial tuberosity
posterior calcaneus
lateral malleolus
periwound of pressure injuries are described as
mottled
necrotic +/- ring of inflammation
reactive fibrosis and thickening
what is a typical cause of dermatitis
incontinence
how to determine dermatitis vs periwound
blanchable skin will be periwound
nonblanchable is dermatitis
relationship between distal leg pressure injuries and peripheral vascular disease
> 80% of pts with pressure ulcers on the heel have PVD
visual cues of deep tissue injury due to pressure
purple/maroon bruising of intact skin or blister
- indicated muscle necrosis
if pressure ulcers are present distally what is indicated
ABI testing
stages of healing are described as
stage 1 = 1 to 3 wks
stage 2 = ≥ 23 days
stage 3 = 8 to 13 wks
what should a therapist not do often in pressure ulcer healing
culturing (unless indication of infection)
- infections uncommon in stage 1-2
foam pressure surfaces are indicated in
stage 1/2 injuries
foam pressure advantages
cheap
light weight
maintenance free
ease of transfers
disadvantages of foam pressure surfaces
degrade easily (≤3 years)
increase tissue temperature
easily soiled
not very involved/effective
air fluidized support surfaces are described as
powered reactive support surfaces that generally consist of silicone beads within a gore-tex sheet
description of fluid filled pressure devices
multiple chambers filled with air gel or water
advantages of fluid filled pressure devices
pressure/shear reduction
soilproof
maintain temperature of tissue
better for larger individuals
disadvantages of fluid-filled pressure devices
must be monitored carefully
gel/fluid may get dispersed
may pop/puncture
advantages of air-fluidized support
dynamic
control moisture / temperature
good for self repositioning by the patient
disadvantages of air fluidized support
expensive
noisy
high maintenance
can make PT transfers difficult
why can gait training be very beneficial in pressure wound treatment
amputees typically are at a higher risk for pressure ulcers at attachment of orthotic
when is e-stim indicated in treatment of PI
recalcitrant stage 2
typical stage 3 & 4
