PRESSURE ULCERS Flashcards
What are the main risk factors for developing pressure ulcers?
- Malnourishment
- Incontinence (urinary and fecal)
- Lack of mobility
- Pain (leads to reduced mobility)
What is the Waterlow score used for?
The Waterlow score is used to screen patients at risk of developing pressure ulcers. It includes factors like body mass index, nutritional status, skin type, mobility, and continence.
Over which body parts do pressure ulcers typically develop?
Pressure ulcers typically develop over bony prominences such as the sacrum or heel.
What is the classification system used for grading pressure ulcers?
The European Pressure Ulcer Advisory Panel classification system.
What are the findings in a Grade 1 pressure ulcer?
- Non-blanchable erythema of intact skin
- May include discolouration, warmth, oedema, induration, or hardness, particularly in individuals with darker skin.
What are the findings in a Grade 2 pressure ulcer?
- Partial thickness skin loss involving the epidermis or dermis (or both).
- The ulcer is superficial and may present as an abrasion or blister.
What are the findings in a Grade 3 pressure ulcer?
Full thickness skin loss with damage or necrosis of subcutaneous tissue, possibly extending down to but not through underlying fascia.
What are the findings in a Grade 4 pressure ulcer?
- Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full thickness skin loss.
How should pressure ulcers be managed in terms of wound care?
- A moist wound environment is encouraged for healing.
- Hydrocolloid dressings and hydrogels may be used.
- Soap should be avoided to prevent drying the wound.
When should wound swabs be taken for pressure ulcers?
Wound swabs should not be done routinely, as most pressure ulcers are colonized with bacteria. Systemic antibiotics should be considered only based on clinical evidence (e.g., surrounding cellulitis).
When should a patient with a pressure ulcer be referred to a specialist?
Referral to a tissue viability nurse should be considered for specialized management.
When might surgical debridement be beneficial for pressure ulcers?
Surgical debridement may be beneficial for selected wounds, especially if they show extensive necrosis or other complications.
