Pressure Ulcers Flashcards
1
Q
Risk Factors for Pressure Ulcers
A
IMMOBILITY
decreased sensation
moisture
friction or shearing
decreased arterial flow
abnormally low or high BMI
2
Q
Prevention of Pressure Ulcers:
A
Pressure must be relieved 3-4x/hr in a recumbent position or every 15-20 minutes while sitting.
SKin inspected and kept clean/dry
Scales: Braden or Norton
3
Q
Pressure Ulcer: Stage 1
Definition and Treatment
A
- Stage 1: Nonblanchable erythema. Reversible with intervention
- discoloration
- warmth
- edema
- induration (firming or hardening of tissues 2nd to edema)
- Treatment
- virgorous pressure, friction, moisture alleviating measures required
4
Q
Pressure Ulcer: Stage 2
Definition and Treatment
A
- Stage 2: partial thickness skin loss, Epidermis and Dermis are involved
- abrasion
- blister
- shallow crater
- Treatment
- dermis exposed - no infection - app dressings
- similar pressure
- friction
- moitsure-alleviating measures for stage 1
5
Q
Pressure Ulcer: Stage 3
Definition and Treatment
A
- Stage 3: full thickness skin defect extending into the fat layer but not through fascia
- Treatment
- subcutaneous tissue exposed -
- debridement necrotic tissue
- dressings
- advanced pressure alleviating measures
6
Q
Pressure Ulcer: Stage 4
Definition and Treatment
A
- Stage IV: Full-thickness skin defect that extends beyond fascia and into muscle. Other structures are exposed. Ulcer may extend down to and include bone destruction
- Treatment
- Extends beyond fascia
- debridement
- appropriate dressings
- advanced pressure alleviation
- surgery and grafting more likely at this stage
7
Q
Pressure Ulcer: Unstageable
Definition and Treatment
A
- Unstageable: term used it wound is obscured by necrotic tissue
- Treatment
- if wound is infected or no healing occurs in 2 weeks then antibacterial agents or a treatment modality may be indicated
