Tissue Viability Flashcards
What is a pressure ulcer?
A pressure injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure, or pressure in combination with shear.
What grading system is used to document and classify ulcers in the UK?
In the UK all pressure ulcers are documented and graded using the international recognised grading system EPUAP
Describe the EUPAP grading system of pressure ulcers?
Category/Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones.
Category/Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ ruptured serum-filled or sero-sanginous filled blister.
Category Stage III: Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss.
Category/Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunnelling. Can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule)
What causes pressure ulcers vs moisture lesions?
Pressure injury
Evidence/history of pressure, shear or friction
Moisture lesion
Skin obviously moist, history of incontinence
Where are pressure injuries located compared to moisture lesions?
Pressure
Usually over a bony prominence unless compressed with equipment such as catheter or oxygen mask
Moisture
Not over a bone, frequently in the natal cleft and/or over buttocks. May present as ‘kissing’ or copy lesion with the shape /pattern on both buttocks
What shape are pressure injuries compared to moisture lesions?
Pressure
Usually distinct shape with obvious edges, 1 or 2 wounds
Moisture
Frequently multiple wounds with diffuse edges
How deep are pressure ulcers compared to moisture lesions?
Pressure
From superficial to deep, may be down to bone
Moisture
Usually superficial – unless it becomes infected
Are pressure ulcers and moisture lesions necrotic?
Pressure
Frequently necrotic tissue present as hypoxia causes necrosis
Moisture
No necrosis
How do the edges of pressure lesions differ to moisture lesions?
Pressure
Distinct edges, may be rolled or raised in chronic stages
Moisture
Edges may be difficult to determine;
How is the risk of pressure ulcers assessed?
Use the Waterlow scoring system to assess risk used by the tissue viability team
What are the extrinsic risk factors for pressure ulcers?
Extrinsic risk factors
• Pressure
• Shear (when skin is being pulled in 2 different directions – i.e skin ‘stuck’ to sheet and gravity pulling body down)
• Friction (the rubbing together of two surfaces)
• Moisture
What are the intrinsic risk factors for pressure ulcers?
Intrinsic risk factors • Reduced mobility • Impaired sensation • Acute/Chronic/Palliative illness • Pyrexia • Medication –Steroids • Age • Level of consciousness and cognitive state • Dehydration • Incontinence • History of pressure ulcers • Pain – preventing repositioning • Vascular disease • Malnutrition
Why do pressure ulcers occur?
As patient age their skin becomes much thinner as the dermis shrinks. As well as this the amount of blood vessels, collagen and nerve endings decrease resulting in skin that is very vulnerable and unable to protect the body. In addition, elderly people are not able to detect temperature changes readily making them more susceptible to the cold and hypothermia.
How are pressure ulcers managed and prevented?
All those at risk of pressure ulcers should be repositioned or encouraged to move regularly. In those at high risk it should be every 2 hours and those without high risk every 4-6 hours.
What factors influence wound healing?
Severity – type, shape, depth, moisture, pain and location
Age – reduced elasticity corresponds to longer healing times
Weight – often due to strained cardiovascular function that compromising tissue oxygenation
Diet – need foods high in protein, zinc, copper and vitamins and staying well hydrated
Behaviour – Mobility, smoking, drinking, poor sleep and not staying clean
Medical History – low blood pressure, incontinence, vascular disease, oedema cause slow healing
Drug History – Medication e.g. steroids and anticoagulants
Infection – any infection will stall healing
