Pressure Ulcers

Question 1

who most commonly gets pressure ulcers

Answer 1

people who are immobile
SCI
neuropathy
sedentary elderly

Question 2

what are the primary forces involved in pressure sores

Answer 2

shear,pressure and friction

Question 3

which force is the most dangerous and why

Answer 3

shear forces are the most dangerous because they are difficult to see and stop; they happen underneath the skin

Question 4

how do pressure ulcers heal

Answer 4

by secondary closure; collagen fills in the area but muscle or bone loss is not replaced

Question 5

what is the best way to heal an ischial pressure ulcer

Answer 5

stay in bed SIDELYING positioning

Question 6

what is our role in wound care

Answer 6

prevention of new wounds
education on hydration
recommending foot wear

Question 7

what is the purpose of debridement

Answer 7

clean the wound

Question 8

what is mechanical debridement

Answer 8

use of outside force to remove dead tissue

Question 9

what is sharp debridement

Answer 9

used when the body needs an extra boost to heal but more complicatiions/risks are seen with this

Question 10

what is enzymatic debridement

Answer 10

applied to the surface of necrotic tissue and digests devitaized tissue

Question 11

what is autolytic dbridement

Answer 11

uses dressings to maintain optimum environment for healing

promotes re-hydration of dead tissue

Question 12

What are the causes of pressure ulcers

Answer 12

Dryness-
– atrophy and thinning of epithelial and
fatty layers of tissue
• Thinning skin and atrophy of muscle results in
– more prominent bony protuberances
Loss of elasticity
– 2° to shrinkage of collagen and elastin
• Weakening of juncture between
– dermis and epidermis
• Sebaceous glands and secretions
decreased-dry easily torn skin
-pressure and shear

Question 13

what type of force is pressure

Answer 13

it is a perpendicular force on an area causing ischemia and hypoxia

Question 14

what do pressure forces cause

Answer 14

-Capillary vessels to collapse
– Thrombosis occurs
– Deficient tissue nutrition
– Build up of waste products
– Tissue necrosis

Question 15

how long until certain pressure forces occur

Answer 15

Hyperemia- observed after approx 30
minutes
• Ischemia- 2-6 hrs of continuous
compression
• Necrosis- after 6 hours of continuous
compression
• Ulceration can develop over hours or
several days

Question 16

what can cause shear forces

Answer 16

head elevated >30°
• Reclined chair
• Transfers
• Bed positioning

Question 17

risk factors for pressure ulcers

Answer 17

Age
• Moisture
• ↓ Mobility
• ↓ Sensation
• Friction/shear
• Confined to bed/chair
• Nutrition/hydration
• Braden/ Gosnell scales

Question 18

predictors of acute skin failure

Answer 18

PAD
• Mechanical ventilation >72 hrs
• Respiratory failure
• Liver failure
• Severe sepsis/shock

Question 19

characteristics of DTI

Answer 19

Discolored intact skin
• Damage to underlying
tissue
• Boggy or mushy
• Warmer than adjacent
skin
• Maybe a blood filled
blister
• Caused by pressure or
shear

Question 20

Stage 1 characteristics

Answer 20

Skin intact
• Change of color of epidermis
– Reddening of epidermis (Lightly pigmented
skin)
– Red, blue or purple in darkly pigmented skin
• Non-blanchable-
– color change doesn’t change when pressed
upon
• Skin temp changes-
– warm or cool
• Pain

Question 21

Stage II characteristics

Answer 21

–Partial thickness loss involving the
epidermis
– May penetrate into the dermis, but
not through it
–Wound bed is pink, moist, free of
necrotic tissue
–Presents as an abrasion, or
shallow ulcer

Question 22

Stage III Characteristics

Answer 22

Full thickness loss through dermis
to subcutaneous fat
• Fat may be visible, but bone, tendon,
muscle aren’t exposed
• May include slough, undermining,
tunneling

Question 23

Stage IV characteristics

Answer 23

Full thickness, with exposed bone,
tendon or muscle
• Slough or eschar may be present
• Undermining or tunneling often
• infection often present
• Wound base is not painful

Question 24

Unstageable characteristics

Answer 24

Full thickness tissue loss
– Base of ulcer is covered by eschar or
slough
– Full depth of wound is unable to be
determined

Question 25

What process do pressure ulcers heal by

Answer 25

secondary closure; Collagen fills in the area, muscle or bone
loss is not replaced

Question 26

treatment of pressure ulcers

Answer 26

Relieve the pressure
– Improve mobility
– Dressings
– Debridement
– Education
– Pressure relieving devices
– Nutrition
– Keep dry
– Eliminate shear forces

Question 27

how does static pressure reduction work

Answer 27

Does not require electricity to function
– Reduces pressure by spreading the
load over a larger area
– Examples- foam, air or gel mattress
overlays, water filled mattresses

Question 28

how does dynamic support work

Answer 28

Require a motor or electricity to operate

– Example- alternating air mattress

Question 29

what factors affect healing of pressure ulcers

Answer 29

DM- doubles chance for infection
• BMI
– > 30-doubles chance for infection
– >35, triples chance for infection
Duration of surgical procedure
• Tension/stress on surgical site
• Age
• Co-morbidities
• Immunocompromised
Medications
– Anti-inflammatory
– Steroids
– Antimitotic for cancer treatment
– Radiation therapy

Question 30

what are the signs of infection

Answer 30

Erthema
• Warmth
• Edema
• ↑ pain
• Odor
• ↑ temperature

Question 31

what is a dehisced wound

Answer 31

surgical wound closure disruption

it heals by tertiary intention