Pressure Ulcers Flashcards
1
Q
What is a pressure ulcer?
A
A localized area of tissue necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence
2
Q
What are the 3 classes of patients with the greatest risk of developing a pressure ulcer?
A
- Individuals with spinal cord injuries
- Hospitalized patients
- Individuals in long-term care facilities
3
Q
Pressure ulcers can develop in less than _ hours if the proper conditions prevail
A
2
4
Q
Describe the etiology behind pressure ulcers
A
1) Pressure on any given bony prominence is transmitted to underlying tissues, compressing all structures in between.
2) When the applied pressure is greater than the intracapillary blood pressure, blood flow to soft tissue is obstructed and local tissue ischemia occurs.
3) The pressure also restricts local lymphatic channels which leads to higher concentrations of metabolic wastes and acidosis.
4) If pressure is maintained, capillary permeability increases as does local edema and inflammation.
5)
5
Q
Ischemia causes a decrease in fibrinolysis which leads to what?
A
fibrin deposits within capillaries and interstitial space
6
Q
In patients with pressure ulcers, fibrinolytic activity at the wound border is significantly less than _ mm away
A
9
7
Q
Previously it was thought that there was a critical level of pressure, below which no ulceration would occur. What is that pressure?
A
less than 32 mmHg
No longer believed to be true
8
Q
What 4 individual hemodynamic factors affect the amount of pressure needed to cause a pressure ulcer?
A
- hematocrit
- RBC flexibility
- blood viscosity
- lower temps
9
Q
Is muscle or bone more sensitive than skin to the effects of ischemia due to pressure? Explain why…
A
muscle, because the greatest pressure occurs in the tissue directly over the prominence
10
Q
Pressure ulcers may not develop until - days after the pressure was applied. Why?
A
2-7
Because trauma occurs from the inside out
11
Q
Relief of short-term pressure is followed by blood rich in oxygen and nutrients to flood the ischemic tissues and remove waste products from the area. What is this called and what does it look like?
A
Reactive hyperemia, a localized area of blanchable erythema
12
Q
What is the length of time reactive hyperemia lasts proportional to?
A
the extent of tissue ischemia
13
Q
What are the 7 Risk Factors Contributing to Pressure Ulcers?
A
- Shear
- Excessive moisture
- Impaired mobility
- Malnutrition
- Impaired sensation
- Advanced age
- History of pressure ulcer
14
Q
Shear occurs when a force is applied ____ to the soft tissue
A
parallel
15
Q
What do pressure ulcers with a shearing component look like?
A
a teardrop appearance and undermining is common
16
Q
When does friction occur?
A
When 2 surfaces move across one another
17
Q
How does increased moisture predispose skin to pressure ulcers?
A
- Causing maceration
- Increasing shear
- Increasing friction forces
18
Q
What are 3 things that maceration can be caused by?
A
- Wound drainage
- Perspiration
- Incontinence
19
Q
Urinary incontinence has been shown to increase ulceration __-fold
A
five
20
Q
What are the 3 factors that affect a patient’s mobility?
A
- affecting the ability to move (restricted ROM, limited strength, presence of mechanical devices)
- the desire of a patient to move or change positions (pain or depression)
- the ability to perceive pain (medications, neuron damage)
21
Q
What are the 4 most frequently studied causes of impaired mobility with respect to pressure ulcer development?
A
- Hospitalization
- Fracture
- Spinal cord injury
- Infants/neonates
22
Q
Malnutrition is the __ most common risk factor for development of pressure ulcers
A
2nd
23
Q
Low levels of serum _____ causes interstitial edema and signals the body lacks the protein stores necessary for building and repairing tissues which predisposes the body for ulceration.
A
albumin
24
Q
__% of patients with pressure ulcers are obese
A
53
25
True or False
Hydration plays a role on pressure ulcer development.
True
26
What are 6 examples of cases in which sensation may be impaired leading to an increased risk of pressure ulceration?
- Spinal cord injury
- Spina bifida
- Stroke
- Diabetes mellitus
- Full-thickness burns
- Peripheral neuropathy
27
More than half of patients with pressure ulcers are over __ years old
70
28
Describe why previous pressure ulcers increase the risk of future pressure ulcers
Because the scar tissue that developed can only attain up to 80% of the strength of the original tissue. This alters tolerance to pressure and externally applied loads
29
Low diastolic blood pressures, particularly those less than __ mmHg, may develop pressure-related tissue damage from forces lower than expected or in a shorter period of time.
60
30
How often should a pressure ulcer risk assessment tool be administered in each of the following settings: home health, acute, long-term care?
Home health: every visit
Acute care: every 48 hours
Long-term: every week for the first month
31
What are 3 of the most widely used and researched assessment tools?
- Braden Scale for Predicting Pressure Sore Risk
- Norton Risk Assessment Scale
- Gosnell Pressure Sore Risk Assessment
32
What are the 6 subscales of the Braden scale?
- mobility
- activity
- sensory perception
- skin moisture
- nutritional status
- friction and shear
33
Scores on the Braden scale range from _-__, with lower scores indicating _____ impairment and _____ risk
6-23
greater
higher
34
A score less than __ on the Braden scale is deemed an at-risk patient
18
35
Pressure ulcer risk assessment for pediatric patients can be performed using the Braden _ scale
Q
36
A score less than __ on the Braden Q scale is deemed an at-risk patient
16
37
On the Norton Risk Assessment Scale if a patient scores less than or equal to __ they are considered at risk
16
38
What is the problem with the Norton scale?
It may over predict the incidence of pressure ulcers
39
Higher scores on the Gosnell Pressure Sore Risk Assessment indicate ______ impairment and ____ risk
greater
higher
40
On the Gosnell scale if a patient scores greater than __ they are considered at risk
16
41
What are the 5 arms of pressure ulcer prevention?
- education
- positioning
- mobility
- nutrition
- management of incontinence
42
Patients should not be placed directly on their side, rather a __ degree lateral position should be used
30
43
For every gram decrease in serum albumin levels below normal, the odds of having a pressure ulcer increase __fold
four
44
What does the mnemonic NO ULCERS stand for?
- Nutrition and fluid status
- Observation of skin
- Up and walking or assist with position changes
- Lift, don't drag
- Clean skin and continence care
- Elevate heels
- Risk assessment
- Support surfaces
45
What does the mnemonic SKIN stand for?
- Surface selection
- Keep turning
- Incontinence management
- Nutrition
46
The current staging system was derived from _____ classification system first developed in 1975
Shea's
47
What is the current staging system called?
International NPUAP/EPUAP Pressure Ulcer Classification System
48
Describe a Stage I pressure ulcer
Nonblanchable erythema of intact skin. In individuals with more highly pigmented skin, may appear purple, blue, or violet. May also be characterized by changes in local temperature, tissue consistency, or sensation
49
What tissues are involved in a stage I pressure ulcer?
May be superficial or the first signs of deeper tissue involvement
50
What is the integumentary preferred practice pattern for a stage I ulcer?
B
51
Describe a Stage II pressure ulcer
Superficial ulcer that presents as a shallow crater or blister (intact or ruptured)
52
What tissues are involved in a stage II pressure ulcer?
Partial-thickness ulcer involving the epidermis, dermis, or both
53
What is the integumentary preferred practice pattern for a stage II ulcer?
C
54
Describe a Stage III pressure ulcer
A deep ulcer that presents as a deep crater in which there may be undermining present
55
What tissues are involved in a stage III pressure ulcer?
Full-thickness ulcer involving the epidermis, dermis, and subcutaneous tissue. Ulcer extends to, but not through the underlying fascia (bone/tendon not visible)
56
If a pressure ulcer is found on what 4 body structures it is automatically classified as a stage III ulcer because there is no subcutaneous tissue located there? Therefore a sore in these places cannot be classified as type II
- bridge of the nose
- ear
- occiput
- malleolus
57
What is the integumentary preferred practice pattern for a stage III ulcer?
D
58
Describe a Stage IV pressure ulcer
Deep ulcer with extensive necrosis in which there may be undermining or sinus tracts
59
What tissues are involved in a stage IV pressure ulcer?
Full-thickness ulcer involving the epidermis, dermis, subcutaneous tissue, fascia, and underlying structures such as muscle, tendon, joint capsule, or bone.
60
What is the integumentary preferred practice pattern for a stage IV ulcer?
E
61
Describe an unstageable/unclassified pressure ulcer
A pressure ulcer in which the base is obscured by eschar or slough
62
Describe a deep tissue injury
A local area of purple or maroon discoloration of intact skin or a blood-filled blister that is painful, firm, mushy, boggy, warmer, or cooler than surrounding tissue.
63
What tissues are involved in a deep tissue injury?
unknown
64
What are the 5 benefits of the International NPUAP/ EPUAP PU Classification System?
- Promotes uniform understanding of the depth of tissues involved
- Excellent reliability
- Clinicians must stage pressure ulcers for Medicare reimbursement
- Determines type of support surface to be used
- Can be used for research studies
65
What are the 3 limitations of the International NPUAP/ EPUAP PU Classification System?
- Category/stage I pressure ulcer is not an ulcer by definition
- Clinicians may erroneously “reverse stage” a pressure ulcer to imply the progression of wound healing
- Significant revision of prior system – may take time to adapt to and use correctly
66
Typical characteristics of pressure ulcers are described using the 5PT method, what does this stand for?
- Pain
- Position
- Presentation
- Periwound
- Pulses
- Temperature
67
What are 3 ways to assess pain?
- McGill Pain Questionnaire
- Visual Analog Scale
- Faces Pain Scale
68
Do the vast majority of pressure ulcers occur in the upper or lower body?
lower
69
95% of all pressure ulcers occur in what 5 sites?
- sacrum
- greater trochanter
- ischial tuberosity
- posterior calcaneous
- lateral malleolus
70
What are the most common locations for pressure ulcers while in the supine position?
- posterior heel
- sacrum/coccyx
- scapula
- occiput
- medial humeral epicondyle
- spinous process if emaciated
71
What are the most common locations for pressure ulcers while in the prone position?
- anterior knee
- anterior tibia
- iliac crest
72
What are the most common locations for pressure ulcers while in the sidelying position?
- greater trochanter
- malleolus
- femoral condyle if emaciated
- ear
- lateral humeral epicondyle
73
What are the most common locations for pressure ulcers while in the seated position?
- ischial tuberosity
- greater trochanter if in a sling-like seat
- sacrum/coccyx if in a posterior pelvic tilt
74
Describe the typical wound presentation of a deeper ulcer
Generally covered with black eschar, may have exposed tendon, muscle, capsule, and/or bone, tunneling and undermining are common, and they may even drain profusely
75
Describe the periowund area and possible structural changes that may occur
Typically surrounded by a ring of nonblanchable erythema, localized warmth. Reactive fibrosis and thickening of the surrounding soft tissue is common.
76
Dermatitis is common in what patient type?
incontinent patients with sacral ulcers
77
Why are pulses usually not applicable?
due to proximal ulcer location
78
Pulses are usually normal unless what condition persists?
concomitant PVD
79
Areas of active hyperemia are typically ____ to the touch, whereas necrotic areas are ___.
warm
cool
80
What are the 6 things PU assessment instruments are meant to do?
- Measure changes in wound status
- Evaluate the effectiveness of plan of care
- Document wound severity
- Promote quantification of wound parameters
- Standardize wound assessment
- Facilitate reimbursement
81
What are examples of pressure ulcer assessment instruments?
- Sessing Scale
- Bates-Jensen Wound Assessment Tool (BWAT)
- Pressure Ulcer Scale for Healing
82
Describe the Sessing scale
It is a 7-point observational scale describing wound and periwound characteristics in which scores range from 0-6 with the higher scores representing more severe PU status
83
Describe the Bates-Jensen Wound Assessment Tool (BWAT)
Consists of 13 items describing wound and periwound characteristics including size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, skin color, tissue edema and induration, granulation tissue, and epitheltialization
84
Describe the scoring for the Bates-Jensen Wound Assessment Tool (BWAT)
Each item is rated on a 1 to 5 scale, with a score of 1 indicating tissue health and 5 indicating tissue degeneration
85
Scores for the Bates-Jensen Wound Assessment Tool (BWAT) range from 13-65, with _____ scores representing more severe pressure ulcer status
higher
86
Describe the Pressure Ulcer Scale for Healing (PUSH)
It consists of 3 subscales: surface area, exudate amount, and wound appearance.
87
The Pressure Ulcer Scale for Healing (PUSH) scores range from 8-34 with _____ scores representing more severe pressure ulcer status
higher
88
How long can it be expected for a stage I pressure ulcer to heal?
1-3 weeks
89
How long can it be expected for a stage II pressure ulcer to heal?
days to weeks
90
How long can it be expected for a stage III or IV pressure ulcer to heal?
8-13 weeks
91
Ulcers that do not decrease in size within _ weeks should be reassessed for alternative/adjunctive interventions
2
92
What essentially plays the largest role on the prognosis for pressure ulcer healing?
nutrition
93
What are 3 precautions to keep in mind when managing a patient with a pressure ulcer?
- Pressure ulcer depth can be deceptive
- Probe regularly
- Ensure wound care goals and interventions are consistent with patient’s overall plan of care
94
When should pressure ulcers be cultured for infection?
- they fail to progress in timely manner
| - they show signs/symptoms of infection
95
Wounds with exposed bone and wounds that are deep with purulent or foul-smelling drainage should be assessed for what?
osteomyelitis
96
What are the 5 keys to local wound care for patients with pressure ulcers?
- protect the surrounding skin
- address wound bed
- minimize pressure and shear forces
- educate patient and caregivers
97
What are the 2 keys to protecting the surrounding tissue?
- moisturize dry skin
| - use moisture barriers and skin sealants to protect from excessive moisture
98
Should the pressure ulcer be covered with a moisture-retentive or dry dressing? Give 3 examples why...
moisture-retentive
1) they stay in place better than gauze
2) present a continuum of adsorption capabilities that can be left on for several days
3) they encourage autolytic debridement
99
Can synthetic dressings be used to manage infected wounds?
No
100
What type of wound dressing may assist with odor control?
charcoal
101
Necrotic tissue should be actively debrided if appropriate, in what situation is active debridement not recommended?
In stable, hard, dry, eschar-
| covered wounds in ischemic limbs
102
What does tissue interface pressure refer to?
the amount of pressure between a body part and support surface
103
Generally, __ mm Hg is considered to be the breakdown pressure. Explain why
32, because it exceeds capillary closing pressure in healthy individuals
104
True or False
Pressure-relieving devices are substitutes for turning and repositioning
False
They merely increase the interval between them without risk to skin integrity or wound healing
105
Pressure-_____ devices do not consistently reduce pressure below 23-32 mmHg. Whereas pressure-____ devices decrease pressure below 23 mmHg
reducing
relieving
106
When are pressure-reducing devices appropriate?
When the patient has more than 1 turnable surface
107
What is important to assess in a static support surface?
Ensure that the patient is not "bottoming out" and that there is at least 3/4 to 1 inch of thickness of support material between the patient's body and the support surface
108
Describe dynamic support surfaces
They use currents of air or fluid to redistribute pressure across the body
109
Foam pressure-reducing devices must be at least _ inches thick
4
110
What 4 therapeutic interventions have been proven to be beneficial to wound healing?
- flexibility
- strengthening
- aerobic
- gait
111
What is currently the only adjuvant treatment that is recommended to assist with pressure ulcer healing?
Electrical stimulation
112
What type of surgical closure is recommended in the repair of pressure ulcers?
Musculocutaneous flaps
