Pressure Ulcers Flashcards
What are the parts of a prevention program for pressure ulcers?
Risk assessment, skin assessment, nutrition assessment, preventative skin care, proper positioning, support surfaces, documentation, education
What is the Braden screening tool?
It is the most commonly used pressure ulcer risk assessment
Comprised of six subscales: sensory perception, moisture, activity, mobility, nutrition, friction/shear
Lower Score = Higher risk (15-18 at risk, 13-14 moderate risk, 10-12 high risk, <10 very high risk)
Interventions based on total score or low score in a particular subscale
How is the skin treated?
Keep skin clean and dry daily hygiene moisturize skin, clean immediately after incontinent episodes, use skin protectants keep linens wrinkle free check fit of orthotics
What is the difference between pressure reduction and pressure relief?
Reduction = decreases interface pressure but not necessarily below capillary pressure Relief = decreases pressure below capillary presssure
What is a static device and why would you use it?
Static devices do not move
They reduce pressure by spreading load over large area (only if patient can assume many positions without bearing weight on existing pressure ulcer)
What is a dynamic device and why would you use it?
They move and require motor to operate
Use if patient can not assume a variety of positions without bearing weight on pressure ulcers
Use if pressure ulcer is not healing or if patient fully compresses static support surface
What is a low air loss surface and why would you use it?
It is a series of connected air filled pillows with surface fabrics of low-friction material
Used for large stage III or IV pressure ulcers on multiple turning surfaces
What is a fluidized or high air loss surface and why would you use it?
Silicone coated glass beads (incorporates both air and fluid)
Use when excessive moisture on intact skin; can dry skin and prevent pressure ulcers
What is bottoming out?
Surface becomes totally compressed, often weight related
Use hand check
What are the guidelines for re-positioning in bed?
At least every 2 hours 30 degree turns but keep patients off trochanters Float the heels Use pillows between bony prominences Donuts are DO NOTs HOB < 30 degrees unless contraindicated
What are the guidelines for re-positioning in a chair?
At least every 30 minutes
Do not flop or squeeze into chair
Check ankles and knees
Can alter tilt or recline feature in w/c
What is the difference between prevalence and incidence?
Prevalence = all pressure ulcer cases that an institution sees, regardless of where they started Incidence = the new pressure ulcer cases that developed while in that institution
What is a pressure ulcer?
A localized injury to the skin and/or underlying tissue usually over a bony prominence
(result of pressure and/or shear/friction)
What physiologically occurs with a pressure ulcer?
Capillaries are excluded, thus surrounding tissue has no oxygen or nutrition
Tissue hypoxia worsens, cell death ensues
What is friction and shear and how do they differ?
Friction is a mechanical force exerted when skin is dragged across a coarse surface (it is external)
Shear is a mechanical force that acts on an area of skin parallel to the body surface (it is internal) (major cause of undermining)
