S1L1: Pressure Ulcers Flashcards
Wound caused by unrelieved pressure to the dermis and underlying structures
Pressure Ulcers
Pressure ulcers are common in:
Common in individuals who are immobilized for a long period of time
Clinical presentation
First clinical sign of pressure ulceration
blanchable erythema
Clinical presentation
Progression to () abrasion, (), or shallow ()
Progression to superficial abrasion, blister, or shallow crater
Clinical presentation
When full-thickness skin is lost,
(1) Ulcer appear as __
(2) Bleeding is ___
(3) Tissues are ____ and ___
Ulcers appear as deep carter, bleeding is minimal, and tissues are indurated and warm
T/F: Tunneling or undermining is often present. Thus, affectation continues to deepen extending to the dermis, hypodermis, muscle, then exposing the bone
True
Develop commonly to six primary bone areas which are:
o (1) Sacrum
o (2) Coccyx
o (3) Greater trochanter
o (4) Ischial tuberosity
o (5) Calcaneus (heel)
o (6) Lateral Malleolus
Pressure is present especially when pt. is in what position?
Supine
It is important to reposition/turn the patient every ___ hrs
2 hours
Stages of Pressure Ulcer:
Non-blanchable erythema with intact skin
Stage 1
Stages of Pressure Ulcer:
Partial thickness skin loss with exposed dermis
Stage 2
Stages of Pressure Ulcer:
Full-thickness skin loss no slough or necrosis Until fat layer or hypodermis
Stage 3
Stages of Pressure Ulcer:
Full-thickness skin and tissue loss Until muscle/bone
Stage 4
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Suspected Deep
Tissue Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
The area may be preceded by tissue that
is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.
Suspected Deep
Tissue Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Deep tissue injury may be difficult to detect in individuals with dark skin tones.
Suspected
Deep Tissue
Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Evolution may include a thin blister over a dark wound bed.
Suspected Deep
Tissue Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
The wound may further evolve and become covered by thin eschar.
Suspected Deep
Tissue Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Evolution may be rapid, exposing additional layers of tissue even with optimal treatment
Suspected Deep
Tissue Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Intact skin with nonblanchable redness of a localized area usually over a bony prominence.
Stage 1
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Redness in the area but still has blanching
Suspected
Deep Tissue
Injury
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Extends up to the epidermis
Stage I
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.
Stage I
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
Stage I
T/F: Stage I may be difficult to
detect in individuals with dark skin tones
True
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
May indicate ‘at risk’ persons (a heralding
sign of risk)
Stage I
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Partial-thickness skin loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.
Stage II
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
May also present as an intact or
open/ruptured serum-filled blister
Stage II
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Presents as a shiny or dry shallow ulcer
without slough or bruising (bruising
indicates suspected deep tissue injury)
Stage II
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
This stage should not be used to describe
skin tears, tape burns, perineal dermatitis,
maceration, or excoriation
Stage II
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Full-thickness tissue loss. Subcutaneous fat
(hypodermis) may be visible, but bone,
tendon, and muscle are not exposed
Stage III
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Slough may be present but does not obscure the depth of tissue loss.
Stage III
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
May include undermining and tunneling.
Stage III
T/F: The depth of a Stage Ill pressure ulcer varies by anatomical location.
True
The bridge of the nose, ear, occiput, and malleoli do not have subcutaneous tissue and Stage Ill ulcers can be _____. In contrast, areas of significant adiposity can develop extremely _______ Stage Ill pressure ulcers
Shallow
Deep
T/F: In Stage 3, Bone/tendon is visible or directly palpable.
False: Bone/tendon is not visible or directly palpable.
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Full-thickness tissue loss with exposed bone, tendon, or muscle.
Stage IV
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Slough or eschar may be present on some parts of the wound bed.
Often include undermining and tunneling.
Stage IV
T/F: The depth of a Stage IV pressure ulcer varies by anatomical location.
True
T/F: In stage 4, the bridge of the nose, ear, occiput, and malleoli do not have subcutaneous tissue and these ulcers are deep.
False: The bridge of the nose, ear, occiput, and malleoli do not have subcutaneous tissue and these ulcers can be shallow.
Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon, or joint capsule) making ______ possible.
Osteomyelitis
T/F: In stage 4, Exposed bone/tendon is visible or directly palpable.
True
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound.
Unstageable
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined.
Unstageable
PRESSURE ULCER STAGING CRITERIA REVISED BY NPUAP
Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover and should not be removed
Unstageable
Sites of predilection for pressure ulcers:
Supine (5)
Occiput
Scapula
Elbows
Sacrum
Heels
Sites of predilection for pressure ulcers:
Sidelying (8)
side of the head (ear),
shoulder (acromion process),
Hip (iliac crest),
greater trochanter
spine
knees (if on top of each other can develop pressure ulcer at medial condyle)
leg (head ng fibula)
ankle (lateral malleolus and side of calcaneus)
Sites of predilection for pressure ulcers:
Prone (9)
cheek and ear
breast (for women)
elbows
ribs
hip bones (ASIS, or if masyadong naka protrude yung iliacus natin)
genitalia (male)
thighs
knees
toes
Sites of predilection for pressure ulcers:
Long sitting (6)
Back of head
shoulders
sacrum
lower hip bones (ischial tuberosities)
heels
toes
Sites of predilection for pressure ulcers:
Short sitting (5)
Shoulders
Sacrum
Hips
Lower hip bones (ischial tuberosities)
Feet
Note: kaya chairs are at the midthoracic area para di nakasandal and magkaroon ng problems sa scapula area.
