Tissue viability Flashcards
Outline the Waterlow Score
Gives an estimated risk for the development of a pressure sore in a given patient
Areas assessed:
- Build/weight for height
- Skin type/visual risk areas
- Sex and age
- Malnutrition Screening Tool
- Continence
- Mobility
1-64. A total Waterlow score ≥10 indicates risk for pressure ulcer. A high risk score is ≥15. A very high risk exists at scores ≥20.
Define tissue viability
Primarily considers all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration
Prevention and management, and considers the microbiological reasons why some wounds do not heal
Outline primary and secondary healing
PRIMARY = Incised, closed, non-infected, sutured wounds
Disruption of basement membrane, death of small no. of epithelial and CT cells, Minimal clot and granulation tissue – epidermis regenerates, dermis undergoes fibrous repair
SEC = Excisional wound, with tissue loss, separated edges, infected wounds, filled by abundant granulation tissue – grows in from wound margins.
Wound contraction must take place = scab, myofibroblasts
What factors influence tissue healing?
Type, size, location, mechanical stress, blood supply, local foreign bodies
Systemic = age, anaemia, hypoxia, hypovolema, Obesity, DM, Genetic disorders, Drugs, Vit def, Malnutrition
What is the role of the tissue viability team?
Committed to providing support, training and education to clinical staff, patients and carers about maintaining, promoting skin integrity and preventing pressure sores.
The nurses in the tissue viability team can provide specialist advice on all types of wounds, including: pressure ulcers