Pressure Ulcers Flashcards
***What is a pressure ulcer? (AKA Decubitus ulcers, Bedsores, Pressure sores)
Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of unrelieved external pressure greater than arterial capillary pressure with or without additional shear
Pressure: the force that is applied perpendicular to the surface of the skin causing compression of the underlying tissue and blood vessels.
Shear: one layer of tissue slides horizontally over another causing deformation of adipose and muscle tissue which disrupts blood flow
***CAUSES VASCULAR INFLOW IMPAIRMENT AND RESULTANT LOCAL ISCHEMIA AND TISSUE DAMAGE
What are the common sites of development?
Sacrum (#1) Heels (#2) Scapula Ischial tuberosities Greater trochanters Lateral malleoli
***What are the intrinsic risk factors?
Limited mobility
Poor nutrition
Comorbidities (DM, depression, vascular stuff, cancer, dementia, COPD)
Aging skin
***What are the extrinsic risk factors?
Pressure from hard surface
Friction or shear
Moisture
How do you assess pressure ulcers?
Number Location Size (length x width x depth), usually in centimeters Exudate Odor Sinus tracts Necrosis or eschar formation Tunneling Infection Healing (granulation, epithelialization) Wound margins
***What is a stage 1 ulcer?
Stage 1 = intact skin w/ non-blanchable redness of a localized area usually over a bony prominence.
***What is a stage 2 ulcer?
Stage 2 = partial thickness loss of dermis presenting as a shallow open ulcer with red pink wound bed, without slough (may also present as a blister).
***What is a stage 3 ulcer?
Stage 3 = Full thickness skin loss. Subcutaneous fat may be present but bone, tendon or muscle is not exposed.
***What is a stage 4 ulcer?
Stage 4 = Full thickness tissue loss with exposed bone, tendon or muscle.
• Often include undermining and tunneling
• Increased risk of osteomyelitis or osteitis
What is an unstageable ulcer?
Unstageable = Full thickness tissue loss in which the base of the ulcer is completely covered by slough (yellow, tan, gray, green or brown) and/or eschar in the wound bed.
• Must see the true depth of the wound to determine stage
What are descriptions of exudate?
Exudates:
-None – base and dressing dry
-Slight – small amount in center of dressing
-Moderate – contained within the dressing
-Copius – extends beyond dressing onto clothing or bed linen
Exudate types:
-Serous – thin, watery, clear or straw colored
-Serosanguinous – thin, pale red to pink
-Purulent – thick, opaque, tan, yellow to green and may have offensive odor
What are the signs and symptoms of infection?
- Redness, warmth and induration of adjacent tissues
- Pain or tenderness
- Dysmorphic and/or friable granulation
- Unusual odor
- Purulent exudates
- System signs (fever, chills, sweats)
***How do you correctly classify the staging of an ulcer during the healing process?
DO NOT REVERSE STAGE
-Original stage but with healing descriptors
Examples: Stage 3, granulating or Stage 2, epithelializing
-If pressure ulcer reopens in the same anatomical site, it retains its original staging – e.g. “once a Stage 4, always a Stage 4”
***What is the first step in treatment of a pressure ulcer?
REDUCE PRESSURE!
How do you clean ulcers w/o cellulitis?
Stage 1: Apply protective dressings, as needed
Stage 2: Apply moist dressing, such as a transparent film; clean the wound
Stage 3 or 4: Apply moist to absorbent dressing, such as hydrogel, foam or alginate; consider surgical consultation as needed; clean the wound initially and at each dressing stage.
How do you clean ulcers w/ cellulitis?
- Local infection: topical antibiotics. If no improvement after 2-4 weeks, obtain tissue culture and consider osteomyelitis
- Systemic infection: systemic antibiotics.
How do you treat necrotic tissue?
- Perform debridement (remember, not if stable eschar on heel)
- Sharp if advancing cellulitis or sepsis present
- Autolytic, enzymatic, mechanical or biological if non-urgent
Describe the different types of debridement.
- Sharp debridement: sterile scalpel or scissors
- Mechanical debridement: wet-to-dry dressings, hydrotherapy, wound irrigation, whirlpool baths
- Autolytic debridement: body’s own process of getting rid of dead tissue and keeping healthy (recommended when complete wound healing is not the primary goal)
- Enzymatic debridement: streptokinase or streptodornase preps or bacterial-derived collagenases
- Biological debridement: larval or maggot therapy
What should you NOT clean wounds with and why?
Do not clean wounds with antiseptic agents (betadine, hydrogen peroxide, acetic acid) because they destroy granulation tissue.
What are NOT pressure ulcers?
Skin tears Venous ulcers Neuropathic ulcers Arterial insufficiency ulcers Surgical wounds
