Pressure Ulcers Flashcards
What are pressure sores?
Localized injuries to the skin and underlying tissue caused by prolonged pressure on certain areas of the body.
What are common locations for pressure sores?
- Sacrum
- Coccyx
- Heels
- Hips
What is the pathophysiology of pressure sores?
- Ischaemic changes: compression of the capillaries leading to cell death and ulceration
-
Reperfusion Injury: influx of blood upon relief from pressure causing further damage
*** Tissue distortion: **continuous mechanical stress distorts and damages cells
What are the risk factors for developing pressure sores?
- Immobility
- Malnutrition
- Incontinence
- Sensory impairment
What are the underlying causes of pressure sores?
- Prolonged pressure over bony prominences
- Shearing forces
- Excessive moisture
- Aging skin
What characterizes Stage 1 of ulceration?
Non-blanchable redness of intact skin, which may feel warm and have a different consistency compared to adjacent skin.
What characterizes Stage 2 of ulceration?
Partial-thickness loss of dermis presenting as a shallow open ulcer or intact/ruptured serum-filled blister.
What characterizes Stage 3 of ulceration?
Full-thickness tissue loss where subcutaneous fat is visible but bone, tendon, and muscle are not exposed.
What characterizes Stage 4 of ulceration?
Full-thickness tissue loss with exposed bone, tendon, or muscle, possibly with slough or eschar.
What is an unstageable ulcer?
Full-thickness tissue loss where actual depth is** obscured by slough** and/or eschar.
What is a suspected deep tissue injury?
Purple or maroon localized area of discolored intact skin due to damage of underlying soft tissue.
What is the Levine technique in wound swabbing?
Rotate over a 1cm area of the wound bed for 5 seconds.
What blood tests are important in the investigation of pressure sores?
- FBC
- U&Es
- CRP
- Albumin - (low albumin = poor nutrition which can impead healing)
What are the components of pressure sore management?
- Prevention + risk assessment
- Dressings
- Pressure-relieving devices e.g. pressure reliving matress
- Pain management
- Severe management
What scales assess the risk of pressure sores?
- Braden Scale
- Waterlow Scale
What types of dressings are used for pressure sores?
- Alginate for exuding wounds
- Hydrocolloid for non-exuding/mildly exuding wounds
What are examples of pressure-relieving devices?
- Mattresses
- Cushions
What complications can arise from pressure sores?
- Infections
- Sepsis
- Necrotizing fasciitis
- Long term: MSK deformities, cancerous changes (Marjolin’s ulcers)
What are differential diagnoses for pressure sores?
- Diabetic ulcers
- Venous stasis ulcers
- Ischaemic ulcers
Fill in the blank: Regularly assess pain level and provide _______.
[analgesia]
True or False: Aging skin is more elastic compared to younger skin.
False
Fill in the blank: Full-thickness tissue loss in which actual depth is completely obscured is known as _______.
[unstageable]
