Pressure ulcers | Flashcards
What is the definition of a pressure ulcer?
A pressure ulcer is localized injury to the skin
and/or underlying tissue, usually over a bony
prominence, as a result of pressure, or pressure
in combination with shear and/or friction
What are causes of pressure sores (4)?
- Pressure
- Shearing
- Friction
- Mixture
Which 5 areas are most common to get pressure sores?
- Sacrum
- Heel
- Elbow
- Top of ears - glasses/hearing devices/nasal cannulas pressing
- Hips e.g. if laid on side
What is a shearing force?
Pushing or pulling skin means more than 1 layer of skin slides against each other and this can cause damage to these layers or they may become detached from each other all together
How does friction cause a pressure ulcer?
This is where 2 surfaces rub together, so this could be the skin and bed sheets, or a chair cushion etc, or poorly fitting clothing or manual handling aids. Hot, moist skin is likely to experience even more damage from friction than more healthy skin
How does pressure cause a pressure sores?
A perpendicular load of force exerted on a unit of
area (this could be a patients body weight
bearing down on a hip or sacrum)
What are risk factors for pressure sores (8)?
More like to occur in people who:
- Impaired mobility (inc those wearing a prosthesis, body brace or plaster cast)
- Various weaknesses e.g. stroke
- Seriously ill
- Neurologically compromised
- Impaired nutrition
- Poor posture
- Use equipment such as seating or beds that do not provide appropriate pressure relief
- Incontinent - wearing wet pads that are not changed regularly, leading to moisture lesion
How do you screen for pressure sores when a patient comes to hospital (2)?
What time frame does a Waterlow need be done after admission?
- Fully inspect skin
- Check under bandages and dressings
Within 6 hours
How do you grade pressure sores?
Pressure ulcer grading chart
Stage 1 (superficial)
- Skin not broken, but red and not blanching
- Offload pressure
Stage 2 (superficial)
- Skin broken but still superficial
- Offload pressure and dress
Stage 3 (deep) -Penetrates into subcutaneous layer, full thickness skin loss
Stage 4 (deep)
- Full thickness tissue loss to muscle/bone
- Slough (yellow, tan, grey. green, black)
- Need to debride
Unstageable pressure injury
- Dark Eshar
- Can’t stage it until it is debrided.
What is the Waterlow pressure ulcer risk assessment?
- Underweight
- Overweight
- Continence
- Age
- Female
- Medical conditions/drugs
- Surgeries
-> gives you a score and indicates level of risk
What equipment can you use to manage pressure sores (4)?
- Air mattress
- Air cushions
- Prevalon (over foot and offloads pressure off heel)
- Sponge over nasal cannula over ear
What nutrition do you need to give patients in the management of pressure sores?
- Hydrated
- Vitamin C
- High protein/calorie intake including supplements
- Patients with grade 3,4 or complex wound must have a urgent assessment by dieticians
What do you need to take into account of when repositioning patients to manage pressure ulcers (5)?
- Level of dependence
- Waterlow score
- Pre-existing pressure ulcers
- Continence
- Type of mattress
How often do you need to reposition patients with pressure ulcers?
Every 2 hours
What are the overall management steps of pressure ulcers (7)?
- Referral to tissue viability team
- Appropriate dressing and frequency of changes
- Implementation of pressure ulcer prevention plan
- Dietician for stage 3/4
- Equipment
- Education of staff and patients
- Datix - incident reports
