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CP2 - HCOLL > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

1
Q

Components protecting the skin against damage (5)

A 
Pacinian corpuscles 
pH 4-6 (optimum for flora) 
Sebum - antimicrobial + sealant 
Langerhans cells - APC
Capillary vascular bed
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2
Q

Factors leading to a pressure ulcer (9)

A 
Limited movement 
Sensory impairment 
Malnutrition 
Dehydration 
Obesity 
Cognitive impairment 
Urinary + fetal incontinence 
Reduced tissue perfusion 
Poor circulation
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3
Q

Define pressure ulcer

A

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.

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4
Q

Common locations of P ulcers (7)

A 
Back of head 
Elbows 
Sacrum 
Iliac 
Hips 
Medial malleolus 
Lateral malleolus
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5
Q

Stage 1 Pressure ulcer

A

Non-blanchable erythema

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6
Q

Features Stage 1 pressure ulcer

A

Intact skin
Non-blanchable redness
May be painful, firm, soft, warm or w/ blue tinge

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7
Q

What is a stage 2 pressure ulcer?

A

Partial thickness

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8
Q

Features of a stage 2 pressure ulcer?

A

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

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9
Q

What is a stage 3 pressure ulcer?

A

Full thickness skin loss

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10
Q

Features of a stage 3 pressure ulcer

A

SCt fat may be visible
Slough or eschar may be present
May have tunelling

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11
Q

What is a stage 4 pressure ulcer?

A

Full thickness tissue loss

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12
Q

Features stage 4 pressure ulcer?

A

Exposed bone, tendon or muscle
Slough/eschar may be present
Can extend into mm or supporting fascia, tendon or joint capsule
Osteomyelitis likely

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13
Q

Features of U ulcer (unclassified)

A

Full thickness tissue loss w/ unknown depth

Will either be stage 3 or 4

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14
Q

What is a suspected deep tissue injury?

A

Depth unknown skin intact

Purple area of skin/blood filled blister

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15
Q

How quickly should a Braden scale occur on admission?

A

Within 6 hours

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16
Q

Braden scale: High risk

A

<16 - red skin bundle

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17
Q

Braden scale: Med risk

A

17-20 - amber skin bundle

18
Q

Braden scale: Low risk

A

21-23

19
Q

What does the braden scale take into account?

A 
Sensory proprioception 
Moisture 
Activity 
Mobility 
Nutrition 
Friction/shear
20
Q

Which stage ulcers should be reported as clinical incidents?

A

2,3,4

21
Q

Acquired pressure ulcer

A

If it occurs within a care facility

22
Q

Inherited pressure ulcer

A

Pt moves into facility w/ ulcer already evident

23
Q

What % p ulcers are avoidable

A

95%

24
Q

What are moist lesions?

A

Caused by excessive moisture to skin from urine, faeces, sweat

25
Q

Location - P ulcer vs moisture lesion

A

PU: Over bony prominence
ML: Over bony prom or in skin folds

26
Q

Shape: P ulcer vs Moisture lesion

A

PU: Circular/regular shape. Limited to one spot.
ML: Diffuse/regular. Linear shape in clefts/folds

27
Q

Depth: P ulcer vs Moisture lesion

A

PU: Partial to full thickness
ML: Superficial

28
Q

Necrosis: Pressure ulcer vs moisture lesion

A

PU: Present in full thickness P damage
ML: No necrosis or eschar

29
Q

Edges: P ulcer vs Moisture lesion

A

PU: Distinct, regular. Raised edges if chronic
ML: Diffuse, irregular edges

30
Q

Colour - P ulcer vs Moisture lesion

A

PU: Red, yellow, green, black
ML: Ununiform redness, pink/white - maceration

31
Q

Consequences of P ulcers (8)

A 
Pain 
Reduced mobility 
Infection 
Sepsis/osteomyelitis 
Anxiety 
Loss dignity/self-esteem 
Loss sleep
Loss appetite
32
Q

SSKIN Bundle

A 
Support surface 
Skin evaluation 
Keep moving 
Incontinence 
Nutrition
33
Q

How to position heels for P ulcer

A

Off-load using pillow

Orthotic boots, dermal heat pads

34
Q

How often should @ risk patients be repositioned?

A

Every 2 hrs

35
Q

If no markings on the skin, how often should patients be repositioned?

A

Every 3 hrs

36
Q

How should incontinence be managed in relation to moisture lesions

A

Pads + pants checked @ every reposition

Barrier creams if req

37
Q

Why is nutrition important in relation to pressure ulcers?

A

Poor nutrition linked to skin breakdown + healing

38
Q

Which 2 aspects of blood impact wound healing?

A

Albumin

Anaemia (Hb)

39
Q

What do the Tissue viability services provide help/advice for?

A

Appropriate repositioning regimes
All suspected stage 3,4 PU
PU staging
Wound Mx

40
Q

Topical AM therapy for ulcers (3)

A

Ag
Honey
I dress

41
Q

When should you use systemic AB in P ulcers?

A

If deep infection or sepsis are suspected

CP2 - HCOLL (13 decks)

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