Pressure Ulcers Flashcards
What is a pressure ulcer?
A localized injury to the skin and/or underlying tissue. They are painful, odorous, and have drainage!
Where are pressure ulcers usually located? (1)
Usually over a bony prominence
What are pressure ulcers a result of? (less detailed)
They are a result of pressure, or pressure in combination with shear
Where do PrU occur
Ischium - 24% (MOST COMMON per PollEverywhere)
Sacrum - 23%
Trochanter - 15%
Occiput is common area in infants
How prevalent are PrU?
2.3% to 12% in LTC
2.5 million annually
Costs hospitals $40,381 per pressure ulcer? (ranges from 2K to 70K)
How do pressure ulcers develop? (more detailed)
External pressure > capillary perfusion pressure!
- Capillary leakage
- Increased intersititial pressure
Tissue deprived of blood and oxygen –> necrosis
- Muscle and subcutaneous tissue are less tolerant of interruptions in blood flow than skin
- Tip of the iceberg! (happens at a deeper level than we see)
What are external factors than can lead to pressure ulcers? (3)
Shear - distortion along fascial planes
Moisture - and tissue temperature
Friction - strips the epidermis of the stratum corneum and makes skin more susceptible
What are intrinsic factors that can lead to pressure ulcers? (5)
Age (skin changes and muscle loss) Malnutrition Vascular compromise Loss of sensation (SCI) Medications
What should bed be set at?
30 degrees. More than 30 degrees is BAD
What is reactive hyperemia?
Trasnient increase in blood flow following period of ischemia
BLANCHABLE
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What happens if pressure is relieved before a critical time period is reached?
A normal compensatory mechanism -REACTIVE HYPEREMIA - restores tissue nutrition and compensates for compromised circulation
What is a Stage 1 Pressure Ulcer?
Non-blanchable Erythema
An observable pressure related change in area of intact skin when compared to adjacent/comparable area of skin
Can be warm or cool, boggy or firm, painful or itchy
Hard to detect in dark-skinned persons
May indicate “at risk” persons
What is a Stage 2 Pressure Ulcer?
Partial thickness wound that present as abrasion, blister, or shallow crater (epidermis and dermis only). No bruising or slough
(should not be used to classify skin tears, tape burns, incontinence associated dermatitis, maceration, or excoriation)
Stage 3?
Full-thickness - wound with damage or necrosis that may extend down to (but not through) fascia that presents as a deep crater. Fat may be visible but bone, muscle, and tendon ARE NOT EXPOSED! May be slough, undermining, or tunneling. Depending on the area of the body, some Stage III may be shallow (no fat) or super deep (lots of adipose)
Stage IV?
Full-thickness skin loss with extensive necrosis, destruction, damage to underlying structures (muscle, bone, cartilage, tendon, joint capsule, etc) - directly palpable
Undermining and sinus tracts are common; risk for osteomyelitis
What is a unstageable pressure ulcer?
Likely full-thickness; completely covered w/ slough and eschar (cannot be staged unless removed)
DO NOT remove if stable eschar is dry, adherent, and intact (especially on the heels)
Would be a stage 3 or 4 if eschar/slough was not present
What is a deep tissue injury?
Depth is unknown.
Purple / maroon localized area of discolored intact skin
Texture and temperature changes
Blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. May be preceded with other stuff; tough to detect in dark-skinned people. May be a thin blister or eschar present too.
Can you go backwards in the Stages?
No. Once a Stage IV, always a Stage IV. Wound is a “healing Stage IV.”
