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Integ > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

1
Q

pressure ulcers are described as

A

localized area of tissue necrosis

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2
Q

what are pressure injuries

A

compression of soft tissue between firm surface and bony prominences

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3
Q

patients at greatest risk of pressure ulcers

A

SCI injuries
hospitalized pts
long-term pts

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4
Q

medical device injury

A

pressure injury not at bony prominence, typically induced by a medical device

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5
Q

explain the relationship of pressure and time in the etiology of pressure injuries

A

inverse
- more likely for a ulcer at higher pressures for lower time intervals

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6
Q

explain the process of cell death when considering pressure

A

stages include:

pressure
ischemia
acidosis
inflammation
permeability and edema
tissue anoxia
necrosis

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7
Q

explain the formation of pressure injuries in terms of the pressure/duration relationship for those less tolerant to hemodynamic changes

A

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
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8
Q

explain the timeline of pressure injuries in relation to the application of pressure

A

may not develop until 2-7 days after
- extensive skin damage could occur before clinical signs are present

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9
Q

what is reactive hypermia

A

localized area of blanchable erythema
- length of time is proportional to extent of tissue ischemia

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10
Q

what external factors/forces increase likelihood of pressure injuries

A

shear
excessive moisture
impaired mobility
nutrition
impaired sensation
older
hx of pressure injuries

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11
Q

what is common in appearance in shear force injuries

A

teardrop appearance
- strip stratum corneum

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12
Q

what does excessive moisture do to the skin

A

maceration
increased shear
increased friction forces

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13
Q

what causes maceration

A

wound drainage
perspiration
incontenince

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14
Q

malnutrition is the ____ most common risk factor for _____

A

second
pressure injuries

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15
Q

when pressure ulcer is healed, how strong is the new tissue laid at that site is considered? what to consider when treating repeated wounds

A

80% strength of the 100% healthy tissue

  • each new layer of tissue is then 80% of the original 80%
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16
Q

what are the scales used to assess risk of pressure ulcer

A

braden scale
norton risk assessment

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17
Q

what does the braden scale measure

A

mobility
activity
sensory perception
skin moisture
nutrition
friction/shear

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18
Q

scoring of the braden scale? what is a significant score on it

A

6-23
<18 is deemed at risk
lower = worse

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19
Q

what is the Braden Q score

A

pediatric patient braden scale
7-28

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20
Q

what does a <18 on the braden signify for therapists/nurses

A

implementation of a turning schedule

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21
Q

what does the norton scale measuere

A

physical condition
mental condition
activity
mobility
incontenince

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22
Q

scoring of norton scale? significant value? what is a better vs worse score?

A

5-20
≤16 = at risk

lower = more at risk

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23
Q

what is something to consider when scoring the norton?

A

criteria that deduct points

24
Q

what criteria deduct points on the norton scale

A

diabetes
HTN
5+ medication
AMS
low blood work

25
Q

when in sidelying, how should patients be positioned to avoid pressure ulcers

A

at a 30° angle
pillows over bony prominences

26
Q

what is used to stage pressure injuries

A

NPUAP Pressure Injury system

27
Q

stage 1 on the NPUAP description

A

nonblanchable erythema
intact skin
may be painful, different temp, and different firmness than periwound

28
Q

stage 2 NPUAP is described by

A

superficial ulcer
shallow crater
no slough, eschar or bruising
may have a blister

29
Q

stage 3 NPUAP description

A

deep ulcer
undermining or tunneling may be present

30
Q

stage 4 NPUAP description

A

deep ulcer with extensive necrosis
undermining / sinus tracts common

31
Q

unstageable wounds are considered as

A

wounds in which the base is obscured by eschar or slough

32
Q

what stages of the NPUAP scale are typically unstageable

A

3 and 4

33
Q

benefits of the NPUAP system

A

describes level of tissue involvement

guides appropriate intervention

universally accepted and understood among disciplines

medicare requirements

34
Q

limitations of the NPUAP

A

nomenclature
numerical labelling - implies predictable progression

35
Q

what is problematic about the nomenclature of the NPUAP system

A

does not provide etiology of the wound just pressure

36
Q

pressure injury is often seen at these sites

A

sacrum
greater troch
ischial tuberosity
posterior calcaneus
lateral malleolus

37
Q

periwound of pressure injuries are described as

A

mottled
necrotic +/- ring of inflammation
reactive fibrosis and thickening

38
Q

what is a typical cause of dermatitis

A

incontinence

39
Q

how to determine dermatitis vs periwound

A

blanchable skin will be periwound
nonblanchable is dermatitis

40
Q

relationship between distal leg pressure injuries and peripheral vascular disease

A

> 80% of pts with pressure ulcers on the heel have PVD

41
Q

visual cues of deep tissue injury due to pressure

A

purple/maroon bruising of intact skin or blister

  • indicated muscle necrosis
42
Q

if pressure ulcers are present distally what is indicated

A

ABI testing

43
Q

stages of healing are described as

A

stage 1 = 1 to 3 wks
stage 2 = ≥ 23 days
stage 3 = 8 to 13 wks

44
Q

what should a therapist not do often in pressure ulcer healing

A

culturing (unless indication of infection)
- infections uncommon in stage 1-2

45
Q

foam pressure surfaces are indicated in

A

stage 1/2 injuries

46
Q

foam pressure advantages

A

cheap
light weight
maintenance free
ease of transfers

47
Q

disadvantages of foam pressure surfaces

A

degrade easily (≤3 years)
increase tissue temperature
easily soiled
not very involved/effective

48
Q

air fluidized support surfaces are described as

A

powered reactive support surfaces that generally consist of silicone beads within a gore-tex sheet

49
Q

description of fluid filled pressure devices

A

multiple chambers filled with air gel or water

50
Q

advantages of fluid filled pressure devices

A

pressure/shear reduction
soilproof
maintain temperature of tissue
better for larger individuals

51
Q

disadvantages of fluid-filled pressure devices

A

must be monitored carefully
gel/fluid may get dispersed
may pop/puncture

52
Q

advantages of air-fluidized support

A

dynamic
control moisture / temperature
good for self repositioning by the patient

53
Q

disadvantages of air fluidized support

A

expensive
noisy
high maintenance
can make PT transfers difficult

54
Q

why can gait training be very beneficial in pressure wound treatment

A

amputees typically are at a higher risk for pressure ulcers at attachment of orthotic

55
Q

when is e-stim indicated in treatment of PI

A

recalcitrant stage 2
typical stage 3 & 4

Integ (12 decks)

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