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.
