Pressure Ulcers Flashcards
What is an ulcer?
an abnormal break in the epithelial surface
How may pressure ulcers present?
persistently red
blistered, broken or necrotic skin
can extend to underlying structures (cavity) -> muscle and bone
What are risk factors for pressure ulcers?
• immobility - may be secondary to various chronic conditions e.g. dementia, arthritis, fractures, paralysis
What is the cause of pressure ulcers?
pressure or shear force over a bony prominence in presence of numerous risk factors
How would you examine an ulcer?
- site
- number
- surface area
- base
- discharge
- depth
- edge
- sensation
- healing
What is involved in the assessment of an ulcer?
- Cause
- Site/location
- Dimensions of ulcer
- Stage or grade
- Exudate amount and type
- Local signs of infection
- Pain
- Wound appearance
- Surrounding skin
- Undermining/tracking (sinus or fistula)
- Odour
What is involved in the assessment of physical condition?
- Comorbidities
- Nutrition
- Pain
- Continence
- Neurological -> sensory impairment, cognitive impairment, level of consciousness
- Blood supply
- Mobility
- Signs of local or systemic infection
- Medication
- Previous pressure damage
- Psychological and social factors
What classification system is used to grade pressure ulcers?
European Pressure Ulcer Advisory Panel grading system
What is a grade 1 pressure ulcer?
non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin - in whom it may appear blue or purple.
What is a grade 2 pressure ulcer?
partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Surrounding skin may be red or purple.
What is a grade 3 pressure ulcer?
full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia.
What is a grade 4 pressure ulcer?
extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, with or without full-thickness skin loss. Extremely difficult to heal and predispose to fatal infection.
What is an unstageable (depth unknown) pressure ulcer?
full-thickness tissue loss in which the base of the ulcer is covered by slough and/or eschar in the wound bed, resulting in the true depth, and therefore Category/Stage, being unable to be determined.
What investigations are done for pressure ulcers?
- skin biopsy
* ulcer biopsy
What is the management of pressure ulcers?
- treat cause and focus on prevention
- reposition patient to redistribute the pressure
- good nutrition
- appropriate wound management
- pain relief
- debridement of necrotic tissue - non-surgical washing or surgical
- reduce risk factors e.g. smoking
