Pressure Ulcers Flashcards
What is the biggest risk factor for PU?
immobilization is a bigger risk factor than decreased sensation
pts who move less then 20 times in sleep are at biggest risk
What are 4 key risk factors for PU?
pressure, shear, friction, moisture
What is shear?
parallel force displaces internal tissues and laterally deforms
happening beneath skin by sliding on the bed, skin stays but underlying tissues move
What is etiology of pressure related cell death?
- pressure
- ischemia
- acidosis
- inflammation
- increased cap perm and edema
- local tissue anoxia
- necrosis
What is reactive hyperemia?
reaction to pressure as body sends massive amount of blood to compensate for circulation loss
What is normal capillary blood flow?
25-32 mmHg
What are modern theories as to why pressure ulcers form?
inverse pressure-time relationship (2 hours) More pressure will result in faster ulcer development
individual hemodynamic factors
body location and body tissue type
Where is the most pressure in the body?
most tissue damage occurs deep at the bone
What are risk factors contributing to PU?
shear- moving up and down in bed excessive moisture, incontinence impaired, prolonged mobility malnutrition- 15% body loss impaired sensation advanced age history of pressure ulcer
What are typical pt diagnoses who develop PU?
spinal cord pts, cognitive impairments, neuro disorders, diabetes, obese/thin
How many areas are on the Braden scale?
6
When assessing a new pts skin who is at risk for PU what five things should you look at?
- temperature (cold skin may already have damage)
- color
- moisture level
- turgor (tenting)
- skin integrity
What are the four levels on skin breakdown?
hyperemia- with 30 mins, redness dissipates within 1 hr after relief
ischemia- after 2-6 hours skin deeper in skin color as its trying to heal, dissipates within 36 hours
necrosis- after 6 hours, bluegrey color cool to touch dissipates at individual level
ulceration- may occur 2 weeks after necrosis
What is biggest area for incidence?
sacral, coccyx
How often should pressure ulcers be reassessed?
weekly
What is important remember about pressure ulcer staging?
once a wound is staged can only stage to higher level not lower
even if wound is healing it will never be documented as an earlier staged wound “pts has healing stage 2 ulcer”
What is a deep tissue injury?
purple or marooned area, intact skin or filled blood blister
technically not stagable but will become stage 4 PU
What is a PU stage 1?
non blanchable erythema over bony prominence
may be superficial or first sign of DTI
What is stage 2 PU?
superficial to partial thickness depth, loss of dermis, red pink wound bed and without slough or bruising
What are 3 P’s of stage 2 PU?
pink, partial and painful
ex. blister, abrasion, shallow crater
What is a stage 3 PU?
involves epidermis all the way to subcutaneous tissue (depth depends on how much in area)
bone and tendon not visible
crater with or w/o undermining, tunneling
What could be present to make it stage 3?
slough/necrotic tissue
avg. length of healing 3-4 months
What is stage 4 PU?
full thickness which goes down to muscle bone tendons
avg healing 120 days
What are “5PT” characteristics of PU?
pain, position, presentation (NPUAP), periwound, pulses, and temp
What are norms for Braden scale?
under 18 at low risk
15-16 at risk, 50-60% chance of getting stage 1
13-14- mod risk 65-90% of getting stage 2 or deeper
10-12 high risk
9 or less very high risk
What other risk factors will move them up the Braden scale?
fever, diastolic under 60, hemodynamic instability or advanced age
What are PT interventions?
remove pressure with positioning, trapeze bar, wound management, lifting out of bed not dragging, ROM/splinting, therex, EDUCATION
T/F: The researchers strongly recommend the use of e-stim vs laser for healing of pressure ulcers?
TRUE
What are positioning recommendations for pts?
decrease shear- HOB less than 30 degrees, avoid semi-fowler
decrease friction- heel/elbow pads
decrease stress on bony prominences
What is the pressure number for tissue breakdown?
32 mmHG
What is a category 1 support surface?
preventive type intervention, pressure redistribution surface, foam, gel, water
the pt can move some but not enough
What is medicare criteria for category 1 surface?
patient is completely immobile or pt has limited mobility or any stage PU on the trunk or pelvis along with atleast one criteria: impaired nutrition, incontinence, altered sensory, compromised circulatory
What is a category 2 support surface?
dynamic, pressure redistribution, therapetic intenrvention
alternating pressure mattress or low air loss mattress
What is medicare criteria for stage 2?
multiple stage 2 PU on trunk or pelvis and
pt on comprehensive tx program for stage 1 PU for ovr a month or
pts ulcer remained same or worse over past month or
large or multiple stage 3-4 or
recent skin graft on ulcer within 60 days and
pt was on 2 or 3 support surface prior to recent DC from hospital or nursing facility
What is category 3 support surface?
air fluidized bed, provides low friction and shear environment
What are medicare requirements for stage 3 SS?
needs: stage 3 or 4 PU, bedridden, MD order
