Pressure Ulcers

Question 1

Risk factors for pressure ulcer development
-how to screen for risk

Answer 1

Patients who are unable to move due to
-illness
-paralysis
-age

Malnourishment
Incontinence - urinary, fecal
Lack of mobility
Pain => reduced mobility

Waterlow score - looks at
-BMI
-nutritional status
-skin type
-mobility
-continence

Question 2

Grading pressure ulcers

Answer 2

Grade 1
-non blanchable erythema
-intact skin
-discolouration, warmth, edema, induration, hardness if looking at darker skin

Grade 2
-partial thickness skin loss of epidermis/dermis
-superficial ulcer, abrasion or blister

Grade 3
-full thickness skin loss => to SC tissue but not to underlying fascia

Grade 4
-destruction or damage to muscle, bone, supporting structures
-with/without full thickness skin loss

Question 3

Management

Answer 3

Initial assessment can be done by DNs in the community

Ulcer healing - moist dressing (hydrocolloid dressings, hydrogels)
-avoid soap - can dry wound
Wound swabs should only be done if there are signs of cellulitis
-can treat with ABx
If complex wound => refer to tissue viability
Surgical debridement