Pressure Ulcers Flashcards
What is a stage one pressure ulcer?
NON-BLANCHING ERYTHEMA
Intact skin with non blanchable redness of a localised area may be painful, have blush tinge or feel warmer
What is a stage two pressure ulcer?
PARTIAL THICKNESS
partial thickness with loss of dermis as a shallow open ulcer with red/pink wound bed, without slough
may be intact or open/ruptured serum-filled blister
What is a stage three pressure ulcer?
FULL THICKNESS
Full thickness tissue loss with a loss of subcutaneous fat, some of which may still be visible but bone, tendon or muscle is not visible of directly palpable. Slough may be present
What is a stage four pressure ulcer?
FULL THICKNESS
Full thickness tissue loss with bone exposed, tendon or muscle visible or palpable. Slough or eschar may be present and there may be tunnelling and undermining.
Stage 4 ulcers extend into muscle and/or fascia, tendon or joint capsule, making osteomyelitis a high risk factor
What is a suspected deep tissue injury?
- skin is intact
- purple localised area of discoloured intact skin or blood filled booster due to damage of underlying soft tissue from pressure and/or shear
- a thin blister may develop over a dark wound bed
What is a moisture lesion?
NOT a pressure ulcer
redness or partial thickness skin loss involving the epidermis, upper dermis or both
What is a moisture lesion caused by?
excessive moisture to the skin from faeces, urine or sweat
What are the important contributors to pressure ulcers?
limited movement sensory impairment malnutrition dehydration obesity cognitive impairment urinary and faecal impairment reduced tissue perfusion
How do pressure ulcers form?
Result from localised external pressure on the skin causing occlusion of the capillaries and tissue compression. Which leads to decreased oxygen and nutrients reaching the tissues and altered soft tissue hydration as the fluid is pushed away from viable cells
When are pressure ulcers reported as clinical incidents?
Stage 2, 3 and 4
When are pressure ulcers reported as serious incidents?
Stage 3 and 4
How are pressure ulcers further classified?
Acquired or inherited
Avoidable or unavoidable (95% are avoidable)
How is the patients risk of pressure ulcers predicted?
Waterlow or Braden tools
How are pressure ulcers prevented?
Skin bundles - SSKIN
What are the components of the SSKIN bundles
S - support surface - a pressure redistributing support surface
S - skin assessment - on admission
K - keep moving - repositioning regime
I - incontinence and moisture - continence assessment
N - nutrition and hydration - nutritional assessment
