Pressure Ulcers Flashcards by Owen Honroth

pressure ulcers are described as

localized area of tissue necrosis

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what are pressure injuries

compression of soft tissue between firm surface and bony prominences

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patients at greatest risk of pressure ulcers

SCI injuries
hospitalized pts
long-term pts

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medical device injury

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

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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

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explain the process of cell death when considering pressure

stages include:

pressure
ischemia
acidosis
inflammation
permeability and edema
tissue anoxia
necrosis

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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

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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

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what is reactive hypermia

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

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what external factors/forces increase likelihood of pressure injuries

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

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what is common in appearance in shear force injuries

teardrop appearance
- strip stratum corneum

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what does excessive moisture do to the skin

maceration
increased shear
increased friction forces

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what causes maceration

wound drainage
perspiration
incontenince

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malnutrition is the ____ most common risk factor for _____

second
pressure injuries

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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%

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what are the scales used to assess risk of pressure ulcer

braden scale
norton risk assessment

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what does the braden scale measure

mobility
activity
sensory perception
skin moisture
nutrition
friction/shear

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

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

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what is the Braden Q score

pediatric patient braden scale
7-28

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

implementation of a turning schedule

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what does the norton scale measuere

physical condition
mental condition
activity
mobility
incontenince

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

5-20
≤16 = at risk

lower = more at risk

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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