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Practice topics Exam 2 > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

1
Q

Pressure Ulcers - AKA

A

Decubitus ulcers
Pressure sores
Pressure ulcers
Now = pressure injury

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2
Q

Definition (WOCN guidelines)

A

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

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3
Q

Definition (other)

A

An ischemic response with resulting soft tissue death caused by sustained pressure and/or often physical forces generally found over bony prominences

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4
Q

Who is the primary source for getting information on pressure injury

A

National pressure ulcers advisory panel (NPUAP)

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5
Q

How does the NPAUP define a pressure injury

A

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

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6
Q

What is a required factor in pressure ulcer development

A

Pressure

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7
Q

What else (besides pressure) is required for pressure ulcer development

A

Perpendicular load or force exerted on a given, localized area

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8
Q

Pressure effects - what pressure will effectively obstruct blood flow within a capillary bed

A

More than 32 mmHg

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9
Q

Pressure effects - what is the most sensitive to limited blood flow

A

Muscle and fat

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10
Q

Pressure effects - greatest force is delivered at what

A

tissue/bone interface

Greatest at the apex of the force and is less to either side

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11
Q

Capillary hydrostatic pressure diagram

A

Venous blood - capillary hydrostatic pressure is lower at 20 mmHg
Arterial is higher at 30 mmHg

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12
Q

Tissue susceptibility - Time and Pressure have what relationship

A

INVERSE

The greater the pressure, the less time it needs to produce an injury

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13
Q

Extrinsic factors

A

Friction
Shear
Moisture
Irritants

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14
Q

Extrinsic factors - Friction is what

A

Resistance to motion in a parallel direction relative to the border between surfaces
Think pulling body part over sheets

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15
Q

Extrinsic factors - Shear is what

A

Force per unit exerted parallel to the plane
Blood vessels are effected
Irregular wound shape, with undermining

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16
Q

Extrinsic factors - Moisture

A

Variety of causes

  • Wound drainage
  • Incontinence (urinary and fecal)
  • Sweating (sacrum is huge)
  • Liquid spills
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17
Q

Extrinsic factors - Moisture produces what

A

Maceration!

Losing layer of the epidermis and increase risk of infection

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18
Q

Intrinsic factors

A 
Age
Smoking
Infections 
Immunocompromised conditions
Obesity
Medications
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19
Q

Intrinsic factors - Age

A

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

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20
Q

Intrinsic factors - infections

A

changes in pH which makes it harder for the skin to be healthy

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21
Q

Intrinsic factors - obesity

A

increase pressure points on soft tissue

Skin folds on skin folds that weight a lot

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22
Q

Intrinsic factors - medications

A

usually antibiotics

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23
Q

Other factors (maybe intrinsic?)

A

Degree ob mobility
Presence of existing pressure sores
Hydration
Mental status

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24
Q

Presence of predisposing pathologies

A 
DM
Neuro disorders - MS, ALS, Parkinsons
PVD
CHF
Spinal cord injuries
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25
Q

CMS regulations (1)

A

A resident who enters a facility without pressure sores does not develop pressure sore unless their clinical condition demonstrates that they were unavoidable

26
Q

CMS regulations (2)

A

A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing

27
Q

Risk classification scales

A

Norton scale
Braden scale
Gosnell scale
Waterlow scale

28
Q

Common features in the risk classification systems

A 
Level of mobility
Mental status
General physical condition (including comorbidities)
Level of continence
Nutritional status
Existence or previous skin breakdown
29
Q

Braden scale - describe

A

6 subscales most rated from 1-4
Friction and shear rated 1 to 3
Scores 6 to 23

30
Q

Braden scale - risk levels

A

milde - 15 - 18
moderate - 13-14
high - 10-12
very high - 9 or below

31
Q

Physical characteristics of pressure injuries (ulcers)

A 
Size and depth
Location
Shape
Drainage
Odor
Eschar/Necrotic tissue
Undermining/Tunneling
32
Q

Staging of pressure ulcers - stage definitions from who

A

NPUAP

33
Q

Staging of pressure ulcers - NPUAP - Deep tissue injury

A

Persistent non-blanchable deep red, maroon or purple discoloration
Color is key when differentiating with stage 1

34
Q

Staging of pressure ulcers - NPUAP - Stage 1

A

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

35
Q

Staging of pressure ulcers - NPUAP - Stage 2

A

Partial thickness skin loss with exposed dermis

Disrupted BM - might see blisters

36
Q

Staging of pressure ulcers - NPUAP - Stage 3

A

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

37
Q

If slough or eschar obscures the extent of tissue loss it is what stage

A

UNSTAGEABLE!

38
Q

Staging of pressure ulcers - NPUAP - Stage 4

A 
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
39
Q

Staging of pressure ulcers - NPUAP - Unstageable

A

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

40
Q

Staging of pressure ulcers - NPUAP - If slough or escahr is removed - what stage?

A

3 or 4

Stable eschar on the heel or ischemic limb should NOT be softened or removed

41
Q

You can NOT stage a pressure ulcer unless

A

you can see the base!

42
Q

Reverse staging

A

IS NOT A THING!
Staging is used to define the depth of a pressure ulcer
Staging should NOT be used to define improvement

43
Q

Location - always check

A

Pressure areas

Weight bearing

44
Q

Clinical signs of infection

A

Drainage/Color
Devitalized tissue
Tunneling/Undermining
Physical characteristics

45
Q

Clinical signs of infection - Drainage/color - Gray/Cream

A

You probably do not have an infection

46
Q

Clinical signs of infection - Drainage/color - bright yellow

A

Might be staph infection

47
Q

Clinical signs of infection - Drainage/color - Green and sweet smelling

A

Might be a pseudomonas infection -

Pseudomonas is more easily transmitted in air particles!

48
Q

Clinical signs of infection - Drainage/color - Rust red

A

May indicated strep infection

49
Q

Clinical signs of infection - Devitalized tissue

A

Black

Eschar - usually firm/hard, tightly adhered to wound bed

50
Q

What is eschar

A

Protein and collagen fibers adhering together as non-living tissue and forms a covering (eschar)

51
Q

Clinical signs of infection - Undermining/Tunnel/Track

A

Cavity or channel underneath the dermis/epidermis

Undermining (cavity), Tunnel (channel)

52
Q

Clinical signs of infection - physical characteristics - tricolor

A

Red - clean, healthy, granulation tissue
Yellow - exudate, needs to be removed
Black - necrotic tissue or eschar

53
Q

Evaluating pressure ulcers

A

Bates Jensen Wound Assessment Tool (BJWAT)
Pressure sores status tool (PSST)
Wound healing scale (WHS)
Sussman Wound healing tool (SWHT)

54
Q

Evaluating pressure ulcers - Sussman Wound healing tool (SWHT)

A

Two parts
10 descriptors associated with tissue healing - present or absent
Description of wound location healing phase depth
Ongoing development

55
Q

Evaluating pressure ulcers - Bates Jensen Wound Assessment Tool (BJWAT)

A

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

56
Q

Evaluating pressure ulcers - PUSH

A

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

57
Q

Creation of a healing environment

A

Enhance soft tissue mobility and promote healing

PREVENTION is key!

58
Q

Healing environment

A 
Pressure relief!
Continence
Nutrition
Mobility
Education
59
Q

Pressure redistribution devices - overlays

A

Support surfaces that are positioned on top of other surfaces
Foam, static air filled, alternating air filled, gel filled, water filled

60
Q

Surgical treatment

A

Debridement
Myocutaneous flaps
Reconstructive surgery (pay more attn to BVs and nerves)

61
Q

Primary treatment

A 
PREVENTION!
Identify risk
Maintain skin integrity
Treat potential or underlying causes
Pressure relief
Education of patient and care givers

Practice topics Exam 2 (15 decks)

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