Pressure Ulcers Flashcards
Pressure ulcers are also known as
- bedsores
- decubitus ulcer
Pressure ulcer etiology
tissue ischemia and/or necrosis that occurs as a result of soft tissue compression between hard objects such as bony prominences and external surfaces
Iceberg effect
starts under the surface of the skin before anything is seen above the surface
NPUAP stands for
National Pressure Ulcer Advisory Panel
NPUAP definition of a pressure ulcer
localized injury to skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and/or friction.
Pressure ulcers - presentation
- over bony prominences
- oval or round
- frequently very painful
- can be superficial to deep - necrotic tissue possible
- infection common
NPUAP staging
- for pressure ulcers only (not arterial, venous, or diabetic)
- indicates deepest level of damage
- reverse staging is not a true indication of the healing process
Alternatives to backstaging
- Pressure Ulcer Scale for Healing (PUSH)
- Bates-Jensen Wound Assessment Tool
- Sussman Wound Healing Tool
Pressure ulcers - plan of care
- Remove or reduce the pressure
- Debride non-viable tissue
- Treat any infection
- Protect the wound from contamination
- Address moisture / continence issues
- Correct nutrition / hydration deficits
- Manage shear / friction
- Patient / caregiver education
- Dressings to promote moist wound healing
DTI stands for
Deep Tissue Injury
Pressure ulcers - risk factors
- Nutritional deficits
- Immobility
- Incontinence
- Sensory impairment
- Chronic or critical illness
- Impaired cognition
What is the most popular standardized risk assessment for pressure ulcers?
Braden
What is the score range of the Braden?
6-23
- lower score indicates greater risk
Pressure ulcers - medical complications
- repeated wounding
- infection
- death
What are some ways to remove or reduce pressure when caring for a pressure ulcer?
- turning off of wound(s) frequently
- splints or other positioning devices
- support surface as indicated
