Pressure Ulcers Flashcards
Components protecting the skin against damage (5)
Pacinian corpuscles pH 4-6 (optimum for flora) Sebum - antimicrobial + sealant Langerhans cells - APC Capillary vascular bed
Factors leading to a pressure ulcer (9)
Limited movement Sensory impairment Malnutrition Dehydration Obesity Cognitive impairment Urinary + fetal incontinence Reduced tissue perfusion Poor circulation
Define pressure ulcer
Localised damage to skin/ +//or underlying skin, usually over bony prominence, resulting from sustained P. Damage can be intact skin or open ulcer + may be painful.
Common locations of P ulcers (7)
Back of head Elbows Sacrum Iliac Hips Medial malleolus Lateral malleolus
Stage 1 Pressure ulcer
Non-blanchable erythema
Features Stage 1 pressure ulcer
Intact skin
Non-blanchable redness
May be painful, firm, soft, warm or w/ blue tinge
What is a stage 2 pressure ulcer?
Partial thickness
Features of a stage 2 pressure ulcer?
Loss of dermis –> shallow open ulcer w/ red pink wound bed
May be intact r ruptured w/ serum-filled blister
Shiny or dry shallow ulcer W/O slough/bruising
What is a stage 3 pressure ulcer?
Full thickness skin loss
Features of a stage 3 pressure ulcer
SCt fat may be visible
Slough or eschar may be present
May have tunelling
What is a stage 4 pressure ulcer?
Full thickness tissue loss
Features stage 4 pressure ulcer?
Exposed bone, tendon or muscle
Slough/eschar may be present
Can extend into mm or supporting fascia, tendon or joint capsule
Osteomyelitis likely
Features of U ulcer (unclassified)
Full thickness tissue loss w/ unknown depth
Will either be stage 3 or 4
What is a suspected deep tissue injury?
Depth unknown skin intact
Purple area of skin/blood filled blister
How quickly should a Braden scale occur on admission?
Within 6 hours
Braden scale: High risk
<16 - red skin bundle
Braden scale: Med risk
17-20 - amber skin bundle
Braden scale: Low risk
21-23
What does the braden scale take into account?
Sensory proprioception Moisture Activity Mobility Nutrition Friction/shear
Which stage ulcers should be reported as clinical incidents?
2,3,4
Acquired pressure ulcer
If it occurs within a care facility
Inherited pressure ulcer
Pt moves into facility w/ ulcer already evident
What % p ulcers are avoidable
95%
What are moist lesions?
Caused by excessive moisture to skin from urine, faeces, sweat
