Pressure Ulcers Flashcards
Pressure Ulcers - AKA
Decubitus ulcers
Pressure sores
Pressure ulcers
Now = pressure injury
Definition (WOCN guidelines)
Area of localized tissue destruction caused by the compression of soft tissue over a bony prominence and an external surface for a prolonged period of time
Definition (other)
An ischemic response with resulting soft tissue death caused by sustained pressure and/or often physical forces generally found over bony prominences
Who is the primary source for getting information on pressure injury
National pressure ulcers advisory panel (NPUAP)
How does the NPAUP define a pressure injury
Localzed damage to the skin or underlying soft tissue - injury occurs as a result of intense or prolonged pressure or pressure in combo with shear
What is a required factor in pressure ulcer development
Pressure
What else (besides pressure) is required for pressure ulcer development
Perpendicular load or force exerted on a given, localized area
Pressure effects - what pressure will effectively obstruct blood flow within a capillary bed
More than 32 mmHg
Pressure effects - what is the most sensitive to limited blood flow
Muscle and fat
Pressure effects - greatest force is delivered at what
tissue/bone interface
Greatest at the apex of the force and is less to either side
Capillary hydrostatic pressure diagram
Venous blood - capillary hydrostatic pressure is lower at 20 mmHg
Arterial is higher at 30 mmHg
Tissue susceptibility - Time and Pressure have what relationship
INVERSE
The greater the pressure, the less time it needs to produce an injury
Extrinsic factors
Friction
Shear
Moisture
Irritants
Extrinsic factors - Friction is what
Resistance to motion in a parallel direction relative to the border between surfaces
Think pulling body part over sheets
Extrinsic factors - Shear is what
Force per unit exerted parallel to the plane
Blood vessels are effected
Irregular wound shape, with undermining
Extrinsic factors - Moisture
Variety of causes
- Wound drainage
- Incontinence (urinary and fecal)
- Sweating (sacrum is huge)
- Liquid spills
Extrinsic factors - Moisture produces what
Maceration!
Losing layer of the epidermis and increase risk of infection
Intrinsic factors
Age Smoking Infections Immunocompromised conditions Obesity Medications
Intrinsic factors - Age
As we get older - BM flattens out, changes in blood vessels (weaker)
Younger = heal faster but they don’t have good temp regulation and not all the protective factors are there yet
Intrinsic factors - infections
changes in pH which makes it harder for the skin to be healthy
Intrinsic factors - obesity
increase pressure points on soft tissue
Skin folds on skin folds that weight a lot
Intrinsic factors - medications
usually antibiotics
Other factors (maybe intrinsic?)
Degree ob mobility
Presence of existing pressure sores
Hydration
Mental status
Presence of predisposing pathologies
DM Neuro disorders - MS, ALS, Parkinsons PVD CHF Spinal cord injuries
CMS regulations (1)
A resident who enters a facility without pressure sores does not develop pressure sore unless their clinical condition demonstrates that they were unavoidable
CMS regulations (2)
A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing
Risk classification scales
Norton scale
Braden scale
Gosnell scale
Waterlow scale
Common features in the risk classification systems
Level of mobility Mental status General physical condition (including comorbidities) Level of continence Nutritional status Existence or previous skin breakdown
Braden scale - describe
6 subscales most rated from 1-4
Friction and shear rated 1 to 3
Scores 6 to 23
Braden scale - risk levels
milde - 15 - 18
moderate - 13-14
high - 10-12
very high - 9 or below
Physical characteristics of pressure injuries (ulcers)
Size and depth Location Shape Drainage Odor Eschar/Necrotic tissue Undermining/Tunneling
Staging of pressure ulcers - stage definitions from who
NPUAP
Staging of pressure ulcers - NPUAP - Deep tissue injury
Persistent non-blanchable deep red, maroon or purple discoloration
Color is key when differentiating with stage 1
Staging of pressure ulcers - NPUAP - Stage 1
Intact skin with a localized area of non blanchable erythema which may appear differently in darkly pigmented skin
Color changes DO NOT include purple or maroon!!!
More of a red color
Staging of pressure ulcers - NPUAP - Stage 2
Partial thickness skin loss with exposed dermis
Disrupted BM - might see blisters
Staging of pressure ulcers - NPUAP - Stage 3
Full thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and rolled round edges are often also present
Might see undermining and tunneling
If slough or eschar obscures the extent of tissue loss it is what stage
UNSTAGEABLE!
Staging of pressure ulcers - NPUAP - Stage 4
Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament cartilage or bone in the ulcer Slough or eschar might be visible Rolled edges (epibole), tunneling, or undermining are common
Staging of pressure ulcers - NPUAP - Unstageable
Full thickness and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar
Staging of pressure ulcers - NPUAP - If slough or escahr is removed - what stage?
3 or 4
Stable eschar on the heel or ischemic limb should NOT be softened or removed
You can NOT stage a pressure ulcer unless
you can see the base!
Reverse staging
IS NOT A THING!
Staging is used to define the depth of a pressure ulcer
Staging should NOT be used to define improvement
Location - always check
Pressure areas
Weight bearing
Clinical signs of infection
Drainage/Color
Devitalized tissue
Tunneling/Undermining
Physical characteristics
Clinical signs of infection - Drainage/color - Gray/Cream
You probably do not have an infection
Clinical signs of infection - Drainage/color - bright yellow
Might be staph infection
Clinical signs of infection - Drainage/color - Green and sweet smelling
Might be a pseudomonas infection -
Pseudomonas is more easily transmitted in air particles!
Clinical signs of infection - Drainage/color - Rust red
May indicated strep infection
Clinical signs of infection - Devitalized tissue
Black
Eschar - usually firm/hard, tightly adhered to wound bed
What is eschar
Protein and collagen fibers adhering together as non-living tissue and forms a covering (eschar)
Clinical signs of infection - Undermining/Tunnel/Track
Cavity or channel underneath the dermis/epidermis
Undermining (cavity), Tunnel (channel)
Clinical signs of infection - physical characteristics - tricolor
Red - clean, healthy, granulation tissue
Yellow - exudate, needs to be removed
Black - necrotic tissue or eschar
Evaluating pressure ulcers
Bates Jensen Wound Assessment Tool (BJWAT)
Pressure sores status tool (PSST)
Wound healing scale (WHS)
Sussman Wound healing tool (SWHT)
Evaluating pressure ulcers - Sussman Wound healing tool (SWHT)
Two parts
10 descriptors associated with tissue healing - present or absent
Description of wound location healing phase depth
Ongoing development
Evaluating pressure ulcers - Bates Jensen Wound Assessment Tool (BJWAT)
13 items (1 best, 5 worst)
10 minutes
2 none scored items (location and shape - just for tracking)
Reliable and valid
Requires training
Might be difficult to use to determine change
Evaluating pressure ulcers - PUSH
National pressure ulcer advisory panel
3 subscales - surface area, exudate amount, wound appearance
Requires training
Might be able to track wound changes effectively
Recent work shows it has good validity and strong reliability
Creation of a healing environment
Enhance soft tissue mobility and promote healing
PREVENTION is key!
Healing environment
Pressure relief! Continence Nutrition Mobility Education
Pressure redistribution devices - overlays
Support surfaces that are positioned on top of other surfaces
Foam, static air filled, alternating air filled, gel filled, water filled
Surgical treatment
Debridement
Myocutaneous flaps
Reconstructive surgery (pay more attn to BVs and nerves)
Primary treatment
PREVENTION! Identify risk Maintain skin integrity Treat potential or underlying causes Pressure relief Education of patient and care givers
