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Nursing BN2 > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

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1
Q

A greater understanding of the causes of pressure ulcers is a fundamental issue in preventing them occurring- why is this important?

A

Pressure ulcers cause unnecessary suffering for the patient and can increase hospital stay considerably
They are expensive to treat and to prevent
4% of NHS spending

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2
Q

what is a pressure ulcer

A

“A pressure ulcer is localised injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear. A number of contributing or confounding factors are associated with pressure ulcers.”

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3
Q

where do pressure ulcers occur

A

Over hard bony areas covered by a thin layer of tissue which is in contact with a hard surface e.g. sacrum or heels

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4
Q

describe pressure ulcer aetiology/ pressure ulcer cycle

A

unrelieved pressure starts the cycle
blood vessels occlude, histamine is released, and reactive hyperaemia occurs
there is prolonged pressure damage to microcirculation
the lymphatic system is damaged, cell membranes rupture, toxins are released and there is cell and tissue damage

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5
Q

what are the 4 causes of pressure damage

A

Mechanical Forces
Poor patient handling
Reduced Mobility
Reduced Tissue Tolerance

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6
Q

what are mechanical forces that can cause pressure damage

A
  • Pressure
  • Shear
  • Friction
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7
Q

what can be reasons for reduced mobility which may lead to pressure damage

A
  • Surgery
  • Lower level of consciousness
  • Medication
  • Illness
  • Neurological problems
  • Poor muscle strength
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8
Q

what can cause reduced tissue tolerance

A
  • Poor nutrition
  • Chronic/acute illness
  • Increasing age
  • Poor oxygen perfusion
  • Medication
  • Obesity
  • Emaciation
  • Poor skin care
  • Incontinence
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9
Q

Pressure Ulcers occur due to a combination of both intrinsic and extrinsic factors- what is the difference

A

Intrinsic: Inherent to patient: co-morbidities, existing or previous damage, impairment, age
Extrinsic: environmental/external factors, we can have a positive effect on

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10
Q

examples of intrinsic factors

A
  • Nutritional status
  • Build
  • Age
  • Sensory impairment
  • Incontinence
  • Infection
  • Reduced mobility
  • Circulatory disorders
  • Dehydration
  • Mental status
  • Neurological disease
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11
Q

examples of extrinsic factors

A
  • Pressure
  • Shear
  • Friction
  • Moisture
  • Restricted Mobility
  • Surgery
  • Poor moving and handling
  • Medication
  • Inappropriate positioning
  • Poor hygiene
  • Inappropriate clothing
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12
Q

what is Interface Pressure

A

the pressure of the body pushing down onto a hard surface; usually over a bony prominence

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13
Q

can low pressure for long periods of time cause more or less damage than high pressure for short periods of time and why?

A

Low pressure for long periods of time can cause greater damage than high pressure for short periods of time. Sustained pressure interrupts blood supply to tissues
Lack of oxygen & nutrients from perfusion cause tissue damage & death
Lack of white blood cells increase risk of infection and delay healing

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14
Q

what are shearing forces

A

A stretching force which has a detrimental effect on circulation due to pulling the skeletal frame downwards

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15
Q

how can shearing forces damage skin

A

The skin adheres to hard external surface (bed, trolley, chair)
Leads to tearing of capillaries & damage to circulation
Tissue is pulled in opposing direction to the skeleton
This causes blood vessels to tear and compounds the effects of pressure
Can be caused by poor positioning and manual handling

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16
Q

what is friction, and why is it bad for skin

A

When two surfaces rub together
Detrimental to protective function of the skin
Friction ulcers may develop following repeated episodes
Can lead to eventual epidermal loss
Rubbing of the epidermis across a surface- Epidermis is either removed or damaged
Blister formation

17
Q

what are moisture lesions and how does moisture effect skin integrity

A

Too much moisture negatively affects protective function of the skin
Maceration of the epidermis makes it more susceptible to damage & pressure ulcer development
May be due to incontinence, excessive sweating or wound exudate
Due to the location of moisture lesions, they are often mistaken for pressure ulcers

18
Q

what are risk factors for pressure damage

A
  • Inability to mobilise or change position independently
  • Sensory deficit (e.g. unable to feel pain)
  • Incontinence
  • Serious illness or recent surgery
  • Poor nutritional or fluid intake
  • Very elderly or very young
  • Spinal cord damage
  • Elderly people with illness or injury (e.g. hip fracture)
19
Q

describe how to do pressure ulcer risk assessment (not specific!) and what are 3 examples of risk assessment tools

A

Use a validated tool
Inform patient
Should be carried out at first visit and repeated if any change in condition
To be used alongside clinical judgement

e.g. waterlow, SSKINS, PUDRA

20
Q

what does SSKINS stand for

A 
Skin Inspection 
Support surfaces and equipment requirements 
Keep patients moving 
Incontinence and moisture management 
Nutrition and Hydration Assessment 
Self Care
21
Q

what are surface requirement to reduce risk of pressure damage

A

Pressure redistributing equipment can be used to help reduce the risk of pressure damage.
To reduce interface pressure, the surface contact area must be increased (i.e. spreading the patient’s weight over a greater surface area).

22
Q

describe different types of mattress to reduce risk of pressure damage

A

Foam mattress
-Designed to conform to body shape and redistribute weight over large area.
-Is appropriate for up to grade 2 pressure damage.
Alternating pressure
-Pressure constantly being redistributed

23
Q

what are the principles of equipment selection

A 
cost
level of risk
weight
treatment objectives
acceptability
ease of use and maintenance
24
Q

describe seating in relation to pressure damage

A

If a patient has pressure damage at sacrum or buttocks, they should not be sitting for more than 2 hours (in total) over a 24 hour period.
Chair must be at the correct height
Repositioning is still required.

25
Q

what should a cushion be like to reduce risk of pressure damage

A
  • Conform to patient’s shape 
  • Vary sites of pressure 
  • Improve stability
  • Provide adjustable support 
  • Allow air to circulate
26
Q

describe heel protectors

A

Protects against foot drop – maintains neutral alignment
Redistributes pressure from heel and Achilles tendon
Covers are single patient use.

27
Q

describe Turning Assist Devices

A

-Fits onto a standard single bed – plus special sizes on request
-Automated turning cycle with user-controlled tilt and dwell times
-Very gentle lift (approx 10 minutes) to avoid disturbing sleep
-Whisper-quiet operation (<20db)
-Lifts to 30 degrees
-Does work with alternating
mattresses

28
Q

describe skin releasing

A

This is necessary to ensure the skin is not stretched taut.
Taut skin increases the risk of skin tears which are painful for patient
Skin should be gently released on repositioning, particularly under sacrum, back and shoulders.
Ensure clothing is not stretched, this would cause a ‘hammocking’ effect

29
Q

why is Incontinence and Moisture Management important for skin integrity

A

Faecal incontinence along with urinary incontinence, is considered to increase vulnerability to skin breakdown

Moisture lesions (skin lesions associated with incontinence are not caused by pressure or shear)

Moisture lesions can contribute to the formation of pressure ulcers

30
Q

what are do’s and don’ts of Incontinence and Moisture Management

A
  • Skin should be cleansed using skin cleansing spray or with low pH soap and water.
  • Barrier creams should be used on skin that is not broken
  • Films / sprays can be used on damaged skin.
  • Pat don’t rub skin dry
  • Do not use perfumed soaps/talk
  • Appropriate incontinence pads should be used for patients
  • Flat pads on beds do not provide adequate absorption for patients with continence problems.
31
Q

why is nutrition and hydration important for skin integrity

A

Plays a vital role in prevention and treatment of pressure ulcers
With dehydration skin becomes fragile and its elasticity is reduced, therefore making it more susceptible to breaking down. Pressure damage is difficult to heal if there is poor nutrition and hydration as the supply of nutrients and oxygen to the wound site is reduced, due to the reduced blood volume which leads to poor tissue perfusion.

Nursing BN2 (34 decks)

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