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Chapter 12 Integ > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

1
Q

Localized Area of tissue necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence is known as

A

Pressure ulcer (or any wound caused by unrelieved pressure or a combination or pressure and shear forces)

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2
Q

What types of patient possess the greatest risk?

A
  1. SCI
  2. Hospitalized pts.
  3. patients in Long term care facilities
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3
Q

T/F as pressure is increased, the duration required for formation of a pressure ulcer decreases.

A

T (pressure and time have an inverse relationship)

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4
Q

What areas possess the greatest risk for developing a pressure ulcer?

A

Over bony prominences (note that muscle is more sensititive than skin)

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5
Q

What is defined as localized area of blanchable erythema?

A

Reactive Hyperemia

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6
Q

List the Risk Factors of Pressure Ulcer Formation?

A
  1. Shear Forces
  2. Malnutrition
  3. Excessive Moisture
  4. Impaired Mobility
  5. Impaired Sensation
  6. Adavanced Age
  7. History of Pressure Ulcer
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7
Q

What is the number 1 cause for pressure ulcer Formation?

A
  1. Immobility
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8
Q

Define Shear force

A

force that is parallel to soft tissue

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9
Q

What nutritional fact is correlated with severity and development of pressure ulcer?

A

low serum albulim (hypoalbuminemia causes interstitial edema and signals that the body lacks the protein stores necessary for building and repairing tissues)

**ALSO considered the 2nd most common risk factor.

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10
Q

What populations would be at risk to developing impaired sensation?

A

-SCI, spina bifida, stroke, DM, full-thickness burn, peripheral neuropathy.

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11
Q

50% of patients who are ____years old possess a greater risk due to their advanced age

A

70 years old. Age related changes include changes in the Dermis and Epidermis, decrease collagen and elastin, decrease tissue strength and stiffness and decrease ability to fight infection

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12
Q

History of Pressure Ulcers: Scar tissue only attains_____% of strength of original tissue

A

80%

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13
Q 
Braden Scale 
List the
Range of Score
Meaning of Scores
Reliability of Scores
Subscales
A

Scores Range from 6-23, lower scores indicate GREATER impairment and higher risk

an at risk patient : cut off score: 18
less than 13 high risk
13-14 mod risk
15-18 mild risk
High Inter-rater Reliability

Sub Scales:

  1. Mobility
  2. Acitivity
  3. Sensory Perception
  4. Skin moisture
  5. Nutritional stat
  6. Friction and shear

(there is also a braden for peds)

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14
Q 
Nortion Risk Assessment
List the
Range of Score
Meaning of Scores
Reliability of Scores
Subscales
A

Scale rate 1-4, LOWER scores mean greater risk of PU development
Range: 5-20
Cut off: scores less than 16 considered at risk
Reliability; may overpredict indicidence or pressure ulcers

Subscales:

  1. Physical condition
  2. Mental condition
  3. Acitvitiy
  4. Mobility
  5. Incontinence

there is also a Norton plus pressure scale (that deducts points for co-morbidities and for patients on 5 or more medications)

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15
Q

Declining NORTON Scores parrallel a decline in

A

patient medical status

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16
Q 
GOSNELL PRESSURE SORE RISK ASSESSMENT
List the
Range of Score
Meaning of Scores
Reliability of Scores
Subscales
A

Sub Scales

  1. Mental Status
  2. continence
  3. Mobility
  4. Acitivity
  5. Nutirition

Range 5-20, 16 cut off score. HIGHER SCORES indicate greater risk.

Least Research done on this tool

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17
Q

NPUAP Pressure Ulcer Classification

Stage 1

A

Non Blanchable erythema of intact skin
May be superificial or first sign of deeper tissue involvement

May INDICATE person is at risk for pressure ulcer

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18
Q

NPUAP Pressure Ulcer Classification

Stage 2

A

Superficial ulcer that presents as shallow crater

Partial-thickness ulcer involving the epidermis, dermis or both

19
Q

NPUAP Pressure Ulcer Classification

Stage 3

A

Deep ulcer that presents as deep crater, may have undermining or tunneling.

Full thickness skin loss involving epidermis, dermins, and subcutaneous tissue. Bone and tendon are not visible or palpabable

20
Q

NPUAP Pressure Ulcer Classification

Stage 4

A

Deep ulcer with extensive necrosis, often has undermining or sinus tracts

Full-thickness skin loss involving the epidermis, dermis, subcutaneous tissue, fascia and underlying structures sucha as muscle, tendon bone..capsule

21
Q

NPUAP Pressure Ulcer Classification

Unstageable/Unclassified

A

A pressure ulcer should be described as unstageable if the base is obsured or identifiable by eschar or slough.

Full-thickness will be in the category of 3 or 4

22
Q

NPUAP Pressure Ulcer Classification

Suspected Deep Tissue

A

Blood filled blister (tissue involvement is unknown)

local area looks purple or maroon, painful mushy or boggy area

23
Q

Stage 3-4 ulcers do not______

A

HEAL! they will close but the tissue damage is done. WIll not have the same integrity as prior to damage. Max 80% normal tissue strength after closing

24
Q

List 3 Benefits of NPUAP/EPUAP

A
  1. Promotes uniform understanding of depth of involved tissue
  2. Clinicians must stage PUs for Medicare Reimbursment
  3. Can be used for research
25
Q

List 2 Limitations of NPUAP/EPUAP

A
  1. Stage 1 PU is not an ulcer by definition

2. Clinicans may erroneously reverse stage to imply progression, but can’t do that

26
Q

5 PT in Pressure Ulcers

Pain

A

Just note that Stage 1 PU may be tender not painful

and patient with Neuro deficits may not perceive pain

27
Q

5 PT in Pressure Ulcers

Position

A

Sacrum, greater troch, ishcial tub, posterior cal, lateral mal.

majority lower half of body and over bony prominences

28
Q

5 PT in Pressure Ulcers

Presentation

A

patients with full-thickness pressure ulcers are more likely to have multiple ulcers

29
Q

5 PT in Pressure Ulcers

Periwound

A

No-blanchable
Mottled
RIng of Inflammation around ulcer
Dermatitis

30
Q

5 PT in Pressure Ulcers

Pulses

A

Normal (n/a)

31
Q

5 PT in Pressure Ulcers

Temperature

A

Increased in areas of reactive hyperemia

Decreased in areas of Ischemia

32
Q 
Sessing Scale
List the
Use
Range of Score
Meaning of Scores
Reliability of Scores
A
  1. 7 point obesrvational scale describing wound and periwound
  2. range 0-6
  3. Used in clinic and Research
  4. HiGHER SCORES represent more sever pressure ulcer status.
33
Q

How does a clinican assess change over time using the sessing scale?

A

reassessment score is subtracted from initial score. A positive value indicates improvement

34
Q 
Bates-Jensen Wound Assessment Tool (BWAT)
List the
Use
Range of Score
Meaning of Scores
Reliability of Scores
A

Describes Wound and Periwound characterisitics
13 items

rated 1-5
RANGE: 13-65

Higher scores means increased severity

Reliable and valid tool

10 minutes

35
Q 
Pressure Ulcer Scale for Healing (PUSH)
List the
Use
Range of Score
Meaning of Scores
Reliability of Scores
A

**Requires less than 5 minutes to complete

Total score from 8-34

HIGHER score means increased serverity

LIMITED RESEARCH

36
Q

Prognosis for pressure ulcers (remember very slow healing)

  1. Category 1:
  2. Category 2:
    3: Category 3/4:
A
  1. 1-3 weeks
  2. days to weeks
  3. average of 8-13 weeks, can take months
37
Q

Full thickness are more likely to be______and if a patient has a better baseline they have a _____healing rate.

A

infected, faster

38
Q

PT interventions:

Name 2 main interventions

A

70-90% of PT interventions can be maanged conservatively.
through:
1. Dietary consult
2. Positioning

39
Q

List 3 Precuations of PU

A
  1. Pressure ulcer depth can be decpetive
  2. Probe regularly
  3. Ensure wound care goals and interventions are consitent with POC (clincian must acknowledge that not all pressure ulcers can be healed and that wound closure may not be consistenc with overall POC, like for terminal patient)
40
Q

List 4 guidelines for Managing PU

A
  1. Control pressure and shear forces, by shifting weight every 2 hours and while lying down. 15 min while sitting
  2. take care of skin, daily skin checks, wash with mild soap and water temp shouldn’t be very hot
  3. take care of ulcer, wear bandages as instructed
  4. Control meds by taking them as prescribe.

All patients should eat a well balanced diet and take supplements as directed. make sure to educate patient and caregiver

41
Q

What is considered to be “breakdown pressure”

42
Q

Pressure reducing devices do not reduce pressure below____

A

23-33 mmHg

43
Q

Pressure-relieving devices decrease pressure below____

44
Q

Medicare and Medicaid support Surface Classification
Category 1:
Category 2:
Category 3

A
  1. Mattresses and mattress overlays
  2. Speciality mattresses pressure reducing: Foam, low air..alt. air.
  3. Air fluidized beds

Chapter 12 Integ (2 decks)

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