Pressure Ulcers Flashcards
who most commonly gets pressure ulcers
people who are immobile
SCI
neuropathy
sedentary elderly
what are the primary forces involved in pressure sores
shear,pressure and friction
which force is the most dangerous and why
shear forces are the most dangerous because they are difficult to see and stop; they happen underneath the skin
how do pressure ulcers heal
by secondary closure; collagen fills in the area but muscle or bone loss is not replaced
what is the best way to heal an ischial pressure ulcer
stay in bed SIDELYING positioning
what is our role in wound care
prevention of new wounds
education on hydration
recommending foot wear
what is the purpose of debridement
clean the wound
what is mechanical debridement
use of outside force to remove dead tissue
what is sharp debridement
used when the body needs an extra boost to heal but more complicatiions/risks are seen with this
what is enzymatic debridement
applied to the surface of necrotic tissue and digests devitaized tissue
what is autolytic dbridement
uses dressings to maintain optimum environment for healing
promotes re-hydration of dead tissue
What are the causes of pressure ulcers
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
what type of force is pressure
it is a perpendicular force on an area causing ischemia and hypoxia
what do pressure forces cause
-Capillary vessels to collapse – Thrombosis occurs – Deficient tissue nutrition – Build up of waste products – Tissue necrosis
how long until certain pressure forces occur
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
what can cause shear forces
head elevated >30°
• Reclined chair
• Transfers
• Bed positioning
risk factors for pressure ulcers
Age • Moisture • ↓ Mobility • ↓ Sensation • Friction/shear • Confined to bed/chair • Nutrition/hydration • Braden/ Gosnell scales
predictors of acute skin failure
PAD • Mechanical ventilation >72 hrs • Respiratory failure • Liver failure • Severe sepsis/shock
characteristics of DTI
Discolored intact skin • Damage to underlying tissue • Boggy or mushy • Warmer than adjacent skin • Maybe a blood filled blister • Caused by pressure or shear
Stage 1 characteristics
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
Stage II characteristics
–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
Stage III Characteristics
Full thickness loss through dermis to subcutaneous fat • Fat may be visible, but bone, tendon, muscle aren’t exposed • May include slough, undermining, tunneling
Stage IV characteristics
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
Unstageable characteristics
Full thickness tissue loss – Base of ulcer is covered by eschar or slough – Full depth of wound is unable to be determined
What process do pressure ulcers heal by
secondary closure; Collagen fills in the area, muscle or bone
loss is not replaced
treatment of pressure ulcers
Relieve the pressure – Improve mobility – Dressings – Debridement – Education – Pressure relieving devices – Nutrition – Keep dry – Eliminate shear forces
how does static pressure reduction work
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
how does dynamic support work
Require a motor or electricity to operate
– Example- alternating air mattress
what factors affect healing of pressure ulcers
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
what are the signs of infection
Erthema • Warmth • Edema • ↑ pain • Odor • ↑ temperature
what is a dehisced wound
surgical wound closure disruption
it heals by tertiary intention
