Pressure ulcers

Question 1

What are the main locations for pressure ulcers (3)

Answer 1

Sacrum
Coccyx
Heels

Question 2

What are the features of a Stage 1 pressure ulcer (2+4)

Answer 2

Non-blanchable erythema (skin intact)
Usually over bony prominence

Possibly: 
Painful
Firm/soft
Warmer
Bluish tinge

NB Darker skin appears bluish/purple + poss not visible blanching

Question 3

What are the features of a Stage 2 pressure ulcer (4)

Answer 3

Shallow open ulcer (partial thickness dermis loss)
Red/pink wound bed
W/o slough

OR present as intact filled blister

Question 4

What are the features of a Stage 3 pressure ulcer (4)

Answer 4

Full thickness of dermis loss
Subcut fat visible but not bone/tendon/muscle
± Slough (doesn’t obscure depth of tissue loss)

Poss undermining/tunneling

Question 5

What are the features of a Stage 4 pressure ulcer (3)

What is a common complication

Answer 5

Full thickness dermis loss + exposed bone/tendon/muscle
± Slough / eschar
Often includes undermining and tunnelling

Osteomyelitis is a common complication

Question 6

How is a pressure ulcer defined as ‘unstageable’

Answer 6

Actual depth completely obscured by slough/eschar

Question 7

What are the features of moisture lesions/ulcers (2)

How do they occur

Answer 7

Skin appears macerated
Extremely painful

Caused by chronic exposure to urine/faecal matter

Question 8

List the intrinsic RFs for pressure ulcers (11)

Answer 8

↓ Mobility
↓Consciousness/sedation
Sensory impairment (neuro disorders, SC injury, DM)
Older people undergoing hip replacement surgery

Previous history of pressure damage (weak skin)
Vascular disease (↓blood flow)
Very young / very old (poorer circulations)

Severe chronic/terminal illness
Malnutrition
Dehydration
Acute illness

Question 9

What are the extrinsic RFs for pressure ulcers

Answer 9

Anything that can cause injury/pressure/shear/friction

Question 10

What are the categories considered in a Braden Score (6)

Answer 10

Sensory Perception
Moisture
Activity
Mobility
Nutrition
Friction/Shear

Question 11

What Braden scores constitute high/medium/low risk of pressure sores?
How is each risk level managed?

Answer 11

≤16 = high-risk → Red skin bundle (2hrly repositioning)
17-20 = medium-risk → Amber skin bundle (check/4hrs)
21-23 = low-risk

Question 12

What is a SSKIN bundle?

+ other things involved in management (2)

Answer 12

Support surface
Skin evaluation (blanche test)
Keep moving
Incontinence
Nutrition

Photography / approp wound management

Question 13

What blood tests could be considered in preventing pressure sores? (2)
What meds should be avoided/minimised (4)

Answer 13

Anaemia / Albumin (affect wound healing)

Hypnotics/sedatives (sleepy/immobile)
Analgesics (reduce normal stimulus to relieve pressure)
Inotropes (periph vasocon)
NSAIDs (impair inflamm response)

Question 14

What tool is used to calculate nutrition risk?

Answer 14

MUST

1. BMI score
2. % unplanned wt loss score
3. Acute disease effect score
4. Add scores + calc risk of malnutrition
5. Use local guidelines

(Score 1 = med-risk; >1 = high risk → dietician referral)

Question 15

When is an NG tube given in malnutrition?

Answer 15

Transient cause e.g. stroke / surgery
NOT dementia (swallowing probs)