WEEK 8: Pressure Ulcers Flashcards
where do pressure ulcers mostly happen?
At bony prominences
Differentiate between primary- and secondary-intention wound healing as well as tertiary intention
1) Primary: wound edges of a clean surgical incision remain closed together
2) Secondary: wounds are left open and allowed to heal by scar formation
3) Tertiary (aka delayed primary intention or closure): occurs when surgical wounds are not closed immediately but left open for 3-5 days to allow edema or infection to diminish then the wound edges are sutured or stapled closed
When would we use secondary intention?
Pressure ulcers, lost a lot of tissues or when the edges of the wound can’t be brought together
Define granulation tissue
Its viable tissue that’s red to pink and moist
Define eschar tissue
Black, brown or tan tissue in the wound
Explain factors that promote or impair normal wound healing
- Increase blood circulation
- Nutrition and hydration: immune system
- Moisture (urinary or fecal incontinence compromises the protective barrier of the skin aka moisture from doo doo can thin out the skin)
- Pressure off loading: key element to skin breakdown
- Age
What are the stages of wound
Stage 1: non blanchable erythema skin intact
- Intact skin with darkened areas
Stage 2: Partial thickness skin loss with exposed dermis
- Wound bed is Bright red/pink and may have serum blister
- No slough or granulation
- Associated with moisture, skin tears and medical devices
Stage 3: full thickness skin loss
- Adipose and granulation present. Slough and eschar visible
- May have undermining and tunneling
- Bones are NOT exposed though
Stage 4: full thickness tissue loss
- Exposed fascia, muscle, tendons etc
- Slough and eschar present
- Undermining and tunneling often present
Deep tissue injury: intact or not intact skin with unblanchable deep red or maroon discolouration revealing blood filled blister.
- Pain and temp changes
Unstageable pressure injury: full thickness skin and tissue loss where the loss cannot be determined due to obscure slough (beige) and eschar(black)
- Once eschar or slough is removed, may reveal stage 3 or 4
How do we prevent skin ulcers?
1) Early identification of at risk patients
2) Early implementation of prevention strategies
3) Perform risk assessment on entry to the health care setting and repeat on scheduled basis or when a significant change in the patients condition is noted
4) Inspect the pt’s skin and bony prominences daily
Describe the criteria/items in performing a wound assessment
- Location
- Type of wound (surgical, pressure, trauma)
- Extent of tissue involvement (stage the wound)
- Type and percentage of tissue in wound base (granulation, eschar, slough )
- Wound size
- Wound exudate (drainage amount, colour and consistency)
- Presence of odour (odour may indicate infection)
- Wound edge (wound edges rolled, jagged or smooth)
- Periwound area (redness, temperature and look of surrounding skin)
- Pain (evaluate patient pain)
- Tunneling and undermining
Describe guidelines for prevention of skin breakdown.
- Turn and reposition patient
- Specialized beds and mattresses to redistribute pressure over the entire body to prevent excess pressure over bony prominences
- Uses approaches that minimize friction and shear
- Adequate nutrition to prevent and treat pressure ulcers
Discuss the valid and reliable tools for assessing a patient’s risk for pressure injuries…BRADEN SCALE
- Braden scale : Maximum score is 23, indicating little or no risk. A score of ≤16 indicates “at risk”; ≤9 indicates very high risk.
- Norton scale
NOTE: risk assessments are performed on people who have 1 or more risk factors present.
What tool can we use to reduce pressure on areas?
pillow bridging
