Week 4: Pressure Ulcers Flashcards
What is a localized area of tissue necrosis that develops when soft tissue is compressed between a firm surface and underlying bony prominence?
Pressure ulcer
What is the greatest risk for pressure ulcers?
IMMOBILITY
Which populations are at most risk for pressure ulcers?
individuals with spinal cord injuries, hospitalized patients, individuals in long-term care facilities
What is the capillary closing pressure?
13-32 mmHG
Pressure ulcers are a result of:
inverse pressure-time relationship, individual hemodynamic factors, and body location
____ is more sensitive to pressure than _____
Muscle, skin
What is a localized area of blanchable erythema?
reactive hyperemia
What predisposes skin to PU by causing maceration, increasing shear, and increasing friction forces?
moisture
What is a force parallel to soft tissue?
shear
What is two surfaces moving across one another
friction
What shape is produced by shear forces?
teardrop
What is the second most common risk factor?
malnutrition
more than _____ of patients with PUs are over 70 years old.
half
Scar tissue only attains up to ____% of the strength of the original tissue
80%
What are the most widely used screening tools for screening of pressure ulcers?
Braden Scale for Predicting Pressure Sore Risk
Norton Risk Assessment Scale
Gosnell Pressure Sore Risk Assessment
What are different ways of classifying pressure ulcers?
Integumentary Preferred Practice Patterns
Shea Staging System
International NPUAP/EPUAP Pressure Ulcer Classification System
What are the benefits of the International NPUAP/EPUAP PU Classification System?
- Promotes uniform understanding of the depth of tissues involved
- Excellent reliability
- Clinicians must stage pressure ulcers for Medicare reimbursement
- Determines type of support surface to be used
- Can be used for research studies
What tissues are involved in a stage 1 PU?
may be superficial or may the the first sign of deeper tissue involvement
What tissues are involved in a stage 2 PU?
partial thickness (epidermis and/or dermis)
What tissues are involved in a stage 3 PU?
full thickness (epidermis, dermis, and subcutaneous)… bone or tendon not visible
What tissues are involved in a stage 4 PU?
full thickness with underlying deep tissue exposed
Practice pattern for Stage II PU?
C
Practice pattern for Stage III PU?
D
What tissues are involved in unstageable ulcers?
full thickness (III or IV)
What are certain PUs unstageable?
base obscured by eschar or slough
What are some limitations of the NPUAP/EPUAP PU Classification System?
Stage I is not an ulcer by definition, clinicians may erroneously reverse stage a pressure ulcer, significant revision of prior system (takes time to adapt)
What is the 5PT method of characterizing pressure ulcers?
Pain, Position, Presentation, Periwound, Pulses, Temperature
What are the areas at most risk when a patient is lying supine?
Posterior heel, sacrum/coccyx, spinous process, medial humeral epicondyle, scapula, occiput
What are the areas at most risk when a patient is lying sidelying?
Malleolus, medial and lateral femoral condyles, greater trochanter, lateral humeral epicondyle, ear
What are the areas at most risk when a patient is lying prone?
Anterior tibia, anterior knee, ASIS
What are the areas at most risk when a patient is seated?
Sacrum/coccyx, ischial tuberosity, greater trochanter
95% of pressure ulcers are located over:
sacrum, greater troch, ischial tub, posterior calcaneous, lateral malleolus
Temperature is increased in areas of _______ and decreased in areas of ______.
reactive hyperemia, ischemia
What are the major observational scales of pressure ulcers?
Sessing, Bates-Kensen Wound Assesment Tool (WBAT), Pressure Ulcer Scale of Healing (PUSH)
How long does a Stage I PU take to heal?
1-3 weeks
How long does a Stage II PU take to heal?
days to weeks
How long does a Stage III or IV PU take to heal?
average of 8-13 weeks
Ulcers that do not decrease in size within ____ weeks should be reassessed for alternative/adjunctive interventions.
2 weeks
What should be done with sounds that fail to progress in a timely manner and that show signs/symptoms of infection?
culture
What should be done with wounds that have exposed bone or with deep wounds with purulent or malodorous drainage?
assess for osteomyelitis
