Pressure Ulcers Flashcards
Assessment; 6 classifications; 4 stages; Wound Cleansing; Wound Debridement; Wound Dressings
Classification 1
Suspected deep tissue injury is the first category. Although not considered a stage, it pertains to an area of discolored but intact skin caused by damage to underlying tissue.
Classification 2/ Stage 1
Stage I is defined as non-blanchable redness caused by pressure typically over a bony prominence.
Classification 3/ Stage 2
Stage II involves partial-thickness skin loss with a visible ulcer or fluid-filled blister.
Classification 4/ Stage 3
Stage III involves full-thickness tissue loss without exposed muscle or bone and the possibility of undermining or tunneling.
Classification 5/ Stage 4
Stage IV involves full-thickness tissue loss with exposed bone, muscle, the possibility of undermining or tunneling, and sometimes eschar (black scab-like material) or slough (white, yellow dead tissue).
Classification 6
The final category of the NPUAP system is the “unstageable” variety of ulcers whose stage cannot be determined because eschar or slough obscures the wound.
The Braden Scale
..is the most commonly used assessment tool for determining pressure ulcer risk. This scale incorporates six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. Scores range from 6 to 23, with a cutoff score of 18 for most adults. The lower the score, the greater the risk for pressure ulcer formation.
Assessment
Note visually perceived changes, temperature and textural changes, and odors.
Visual- location, shape, size, colors, exudate, bleeding, any tissure that impairs healthing (necrosis, erythematous or infected tissue, tunneling, undermining, edema) and any tissure that helps with healing (granulating tissue, clean wound edges). Note the condition of the peri wound skin.
In addition, assess the psychosocial impact and the patient’s response to the wound.
Wound measurements are recorded as length, width, and depth in millimeters or centimeters. Tunnels and areas of undermining should be measured separately and individually.
Wound Cleansing
Be sure to assess and treat for pain before and after the wound cleansing, if needed. Clean out debris with a liquid solution (often normal saline). Methods incldue passive, mechanical and pressurized irrigation.
Passive Irrigation
Passive irrigation is a method that involves a solution and gravity. The solution is introduced in a top-to-bottom fashion to allow it to flow by gravity along the full length of the wound to the absorbent pad beneath the patient. This allows micro-organisms, tissues, and any unwanted materials to run down and away from the wound gradually for better overall wound cleansing. Top-to-bottom irrigation can sometimes eliminate the need for mechanical cleansing with a gauze pad.
Mechanical Irrigation
Mechanical cleansing involves the use of gauze and a cleansing solution to clean contaminated wound areas. Excessive scrubbing of a wound can be painful, however, and can also cause further injury.
Pressurized Irrigation
Some wounds require pressurized solutions for adequate cleansing coverage. Most wound solutions delivered at 8 psi via a syringe or a catheter can achieve this.
Basics of Wound Debridement
There are several different types of debridement, or removal of nonviable tissue. Mechanical debridement can be achieved with wound irrigation or wet-to-dry gauze dressings; when the dressings are removed, the tissue adhered to the gauze is also removed. Wet-to-dry dressings are nonselective, possibly removing both nonviable as well as healthy tissue. Autolytic debridement uses the wound’s own fluids to self-digest nonviable tissue through the use of dressings that facilitate this. Chemical debridement can be achieved using topical enzymes. Surgical debridement involves the use of a scalpel, scissors, or other instruments to remove devitalized tissue.
Basics of Wound Dressings
Dressing choices are vast and largely determined by the type of wound you are treating and the available materials. Dressing types range from simple dry gauze dressings to complex medication-impregnated bandages used for specific types of wounds. Assess the requirements for the particular wound, including the degree and amount of exudate, any infection, any necrotic (dead) tissue, size and depth, and other factors. Some bandages are meant to be used with creams, chemicals, powders, and other topical agents. In any case, do not put a bandage on a wound without knowing how it will affect the wound and how it is going to heal the wound. Consult a wound care specialist to choose a dressing with specific properties that best optimize wound healing.
