Pressure Ulcers- Quiz 3 Flashcards
What are pressure ulcers also known as?
Decubitus ulcer or bed sore
what are pressure ulcers caused by?
ischemia that develops from sustained pressure on the tissues
- high pressure for short duration
- low pressure for long duration
_______ are most affected by pressure ulcers
bony prominences
what are 6 contributing factors of pressure ulcers?
- amount of force applied
- duration of force
- direction of force
- friction force
- shear force
- moisture level
what are 3 type of patients that are at risk for pressure ulcers
- bed/chair bound
- impaired ability to weight shift/reposition
- altered mental status (unable to report areas of pressure)
how does size of pt affect pressure ulcers
Thin-> more prominent bones
Overweight->increased pressure on WB surfaces
Which areas are most affected in Supine? (6)
- back of head
- scapular spines
- spinous processes
- elbows
- sacrum
- heels
Which areas are most affected in Side-lying? (7)
- Ear/side of head
- acromion process
- rib
- iliac crest
- greater trochanter
- medial/lateral femoral condyle
- malleoli
Which areas are most affected in Sitting? (6)
- spinous processes
- greater trochanter
- ischial tuberosity
- sacrum/coccyx
- heels
- toes
Which areas are most affected in prone? (8)
- chin/cheek/ear
- anterior iliac crest
- Acromion process
- patella
- tibial crests
- toes
- genitals in men
- breast tissue in women
What are the stages of pressure ulcers
suspected deep tissue injury (DTI), stage 1-4, unstageable
Stage DTI for pressure ulcers
- localized areas of discoloration (purple/maroon) under intact skin
- blood-filled blister
- damage to underlying soft tissue
Stage 1 for pressure ulcers
-presents as intact, reddened skin
-doesn’t blanch
-may be painful, firm, soft, warmer or cooler compared to adjacent skin
NOTE: challenging to stage in pts with darker pigmented skin
Stage 2 for pressure ulcers
- shallow open ulcer
- may be shiny or dry
- partial thickness loss of dermis
- red, pink wound bed without slough or bruising
- can have intact, fluid-filled blister covering
Stage 3 for pressure ulcers
- Full-thickness loss of dermal tissue
- Subcutaneous fat may be visible
- No bone, tendon, or muscle exposed
- May include undermining or tunneling but not common
- Slough (necrotic tissue) may be present but doesn’t obscure depth of tissue loss
- Depth varies by anatomical location
