pressure ulcers Flashcards
What is a localized injury to the skin and or underlying tissue, over a bony prominence as a result of pressure ?
Pressure ulcer
Can you reverse stage an ulcer
Never
What does a stage 2 pressure ulcer look like
pink, partial thickness and painful to touch
how many hours of sustained pressure can the skin tolerate before tissue ischemia sets in.
2-6 hours
What can cause a pressure ulcer
Pressure
What does a suspected deep tissue injury look like ?
Intact skin that is purple or maroon in a localized area, can have a blood filled blister.
What does a stage 4 pressure ulcer look like?
Full thickness tissue loss with bone, tendon and muscle exposed. Slough or escar in some areas of the wound bed. Have undermining and tunneling.
Moisture of the skin can lead to
tissue softening and maturation
What does a stage 3 pressure ulcer look like
full thickness tissue loss, subcuq fat can be visible No bone, tendon, or muscle are exposed. Slough present but does not obscure the depth of the tissue loss.
For a stage 3/4 pressure ulcer what type of dressing?
- For highly exudative wounds, use highly absorptive dressing or packing, calcium alginate 2. Wounds with necrotic debris must be debrided Debridement can be autolytic, mechanical (wet to moist), or surgical 3. Shallow, clean wounds can be dressed with hydrocolloid wafers, semipermeable foam, or polyurethane film 4. Deep wounds can be packed with gauze; if the wound is deep and highly exudative, an absorptive packing should be used
Do you debried an escar wound?
No leave it alone.
What would a stage 1 pressure ulcer look like?
Intact skin with nonblanchable redness of the localized area. over a bony prominence.
What does a suspected deep tissue injury feel like on the skin?
painful to touch, firm , mushy skin, can be boggy, tissue can be warm or cooler can precede color change.
name the body prominence that a pressure ulcer can occur.
elbow, inner knee, back of head, ears, lower back and buttocks, heels
For a stage 2 pressure ulcer what type of dressing?
Hydrocolloid wafers Semipermeable foam dressing Polyurethane film
What will a stage 1 pressure ulcer feel like on the skin?
Firm and painful to touch, warm or cooler then surrounding tissue .
What are Extrinsic factors that can lead to a pressure ulcer
Shearing, frictional, moisture
You can only stage a pressure ulcer wound if you can
visualize the wound base
Stage 4 pressure ulcer increases the risk of
osteomyelitis
For a stage 1 pressure ulcer or suspected deep tissue injury what type of dressing?
Polyurethane film Hydrocolloid wafer Semipermeable foam dressing
increased hydro static pressure reduces?
arterial inflow leads to tissue ishemia
Unstagable ulcer how would you treat it?
debride before deciding on further therapy
Intrinsic factors that can lead to a pressure ulcer
nutritional debilitation, age, low B/P, stress, smoking, elevated body temp, miscellaneous factors
Shearing forces lead to what type of pressure ulcer
full thickness ulcer
How many stages for a pressure ulcer
5
name the #1 and 2 areas for pressure ulcers
sacrum and heels
How can nutritional debilitation lead to pressure ulcer formation
Low protein intake and albumin in the blood leads to poor wound healing.
What would a stage 2 pressure ulcer look like ?
Partial thickness loss of the dermis presenting as a shallow open ulcer with a red pink wound bed without slough or bruising. Can be serum filled blister
what is an unstageable ulcer
Wound bed is obscure ( can not see) covered with eschar.
Frictional forces lead to what type of pressure ulcer
partial thickness
For a heel ulcer with escar how would you treat ?
Do not remove eschar on heel ulcers because it can help promote healing (eschar in other locations should be debrided)
do pressure ulcers have stages
yes
