Pressure Ulcers Flashcards
Pathophysiology of Pressure Ulcers:
-injury to the skin because of constant pressure due to impaired mobility
-Pressure results in
1. reduced BF,
2. causes cell death
3. skin breakdown
4. open wound
-open ulcers can become infected
other names for Pressure Ulcers:
-decubitus ulcers, bed sores
Pressure ulcer locations
-Typically located over bony prominences
Braden Scale:
Pressure Ulcer clinical presentation:
- swelling
- Pus-like drainage
- Skin feels warmer than other areas
-Tender Areas
What assessments would you run for pressure ulcers?
-Nutritional Screening
-determine stage (depth)
- asses for exudate, odor, necrosis
Patient recommendations for Nutrition:
-high protein
-vitamin C
-Zinc
The stage is determined by…
(Depth)
stage 1
stage 2
stage 3
stage 4
m/c stage in pressure ulcers:
stage 1
-skin is intact
-change in color
common locations for pressure ulcers:
- Lower back
-glute
-heel
-shoulder
Stage 2 pressure ulcer
- involve the epidermis and maybe into the dermis
- break in the skin integrity
-discharge
stage 3 pressure ulcer
-Full-thickness tissue lost
- extends into the subcutaneous tissue
presence of necrotic makes the upgrade from 2 to 3
stage 4 pressure ulcer
-extends into bone or muscle
Treatment of Pressure ulcer
-Prevention
1. Pressure reduction
2. repositioning
3. support surfaces
4. cleaning, bandage, debridement
More big picture (phone a friend)
- Wound care team
1. PCP
2. wound care team
3. Nursing
common age for pressure ulcer:
65>, 70% occurrence
