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Pressure sores Flashcards

(59 cards)

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1
Q

What is the rough cost of pressure sores to the NHS per annum?

A

£1.5 billion

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2
Q

Where do pressure ulcers normally occur on the body?

A

Over bony prominences

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3
Q

What are the two ways pressure sores can occur?

A

Due to pressure or pressure with shear force (i.e. sliding down a bed)

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4
Q

What is the scale of pressure sores severity?

A

0-4

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5
Q

What is a stage 0 pressure sore?

A

Normal reactive hyperaemia (increase of blood flow) due to pressure

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6
Q

What is a stage 1 pressure sore?

A

Non-blanchable erythema

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7
Q

What is a stage 2 pressure sore?

A

Partial thickness skin loss

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8
Q

What is a stage 3 pressure sore?

A

Full thickness skin loss

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9
Q

What is a stage 4 pressure sore?

A

Full thickness tissue loss

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10
Q

How can you tell the difference between a stage 0 and stage 1 pressure sore?

A

Stage 1 will not blanch under pressure (i.e. you cannot push the blood out)

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11
Q

Which stage of pressure sore are normal (i.e. not damage has occurred)?

A

Only stage 0

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12
Q

What do stage 1 pressure sores look like?

A

Darkly pigmented

Can have a bluish tinge

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13
Q

Is a stage 1 pressure sore firm or soft?

A

It can be both

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14
Q

Is a stage 1 pressure sore painful?

A

It may be

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15
Q

At what stage of pressure sore is the pt “at risk” regardless of the Braden score?

A

Stage 1

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16
Q

How deep does a stage 2 pressure sore go down to?

A

About midway through the dermis

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17
Q

How can a stage 2 pressure sore present?

A

A shallow open ulcer

with a red/pink wound bed

without slough

OR

An intanct or open/ruptured

serum-filled

blister

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18
Q

Do stage 2 ulcers have bruising and explain why?

A

No bruising

as this indicates deep tissue injury

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19
Q

What should stage 2 ulcer not be used to describe?

A

Skin tears

Tape burns

incontinence associated dermatitis

Excoriation

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20
Q

How deep does a stage 3 skin ulcer go?

A

Goes down to fat but not as deep as

bone, tendon or muscle

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21
Q

What is slough?

A

A yellow fibrinous tissue

that consists of fibrin, pus, and proteinaceous material

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22
Q

What stages of pressure ulcers can include tunnelling and undermining?

A

Stage 3 and 4

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23
Q

How is a stage 3 pressure ulcer described?

A

Full thickness skin loss

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24
Q

What is a stage 4 pressure ulcer?

Study These Flashcards
A

Full thickness tissue loss with exposed

bone tendon or muscle

25
What stages of pressure sore can have slough?
Stages 3 + 4
26
What is eschar?
a slough produced by: a thermal burn a corrosive chemicals or by gangrene.
27
Which stage of pressure sore can eshcar be present in?
Stage 4
28
What can prevent a wound being staged?
If the wound if obscured by slough or eschar
29
If a wound is unstagable due to obstruction by eschar or slough then what stages must it be?
It must be either a stage 3 or 4
30
What is a common mimic of a pressure ulcer?
A moisture lesion
31
What is a moisture lesion?
An area of irritation due to prolonged exposure to moisture/water/urine
32
What categories can be used to differentiate pressure ulcers and moisture lesions?
Location Shape Edges Depth Colour Necrosis
33
How do pressure ulcers and moisture lesions vary in location?
Pressure ulcers - over bony prominence Moisture lesion - maybe over bony prominence but also: in skin folds anal cleft peri-anal area
34
How do pressure ulcers and moisture lesions vary in shape?
Pressure uclers - circular or regular shape and limited to one spot Moisture lesion - diffuse/ irregular shape or linear shape in cleft and skin folds
35
How do pressure ulcers and moisture lesions vary in depth?
Pressure ulcer - if ≥ grade 2 then will be deeper than moisture ulcers Moisture lesion - only as deep as superficial dermis
36
How do pressure ulcers and moisture lesions vary in necrosis
Moisture ulcers have no necrosis or eschar
37
How do pressure ulcers and moisture lesions vary in their colour?
Pressure ulcers can be: red, yellow, green, black (think traffic lights) Moisture ulcers have varying shades of red and maceration (pink or white)
38
What is maceration?
softening and turning white of the skin due to being consistently wet
39
What are the types of risk screening tool for pressure ulcers?
Braden scale Glamorgan scale Cubbin and jackson scale
40
When is the Braden scale used?
For all adult services within 2 hours of admission
41
What score on the braden scale makes a person at risk of pressure sores?
≤16
42
When should the Braden scale be repeated for a pt?
Weekly or if a change in condition (EWS, post-op etc)
43
When is the Glamorgan scale for pressure ulcers ued?
All children's services within 2 hours
44
When is a child "at risk" according to the Glamorgan scale?
≥10
45
When is the Cubbin and Jackson pressure sore risk screening tool used?
All critical care services within 6 hours
46
At what score is a pt at risk according to the Cuubbin and Jackson scale?
≤40
47
Explain how the Braden tool is used in a clinical context?
It is only a guide and should not overshadow clinical judgement. consider comorbidities If a patient has existing damage they are already "at risk"
48
As soon as you notice a skin ulcer (even at stage 1) what should you commence?
A SSKIN bundle Avoid positions pt on affected area
49
What does the SSKIN bundle include?
Support surface Skin evaluation Keep moving Incontinence Nutrition
50
As part of the SSKIN bundle how should you support the surface?
Provide a special mattress and cushion
51
As part of the SSKIN bundle how should you do the skin evaluation?
Assess the skin when repositioning and record a blanch test
52
As part of the SSKIN bundle how should you keep the pt moving?
Reposition 2hrly (if not marked you can do 3hrly) Record each time you reposition
53
As part of the SSKIN bundle what should you do regarding incontinence?
Assess for moisture lesions
54
As part of the SSKIN bundle how should you keep an eye on nutrition?
Use the Malnutrition Universal Screening Tool (MUST) tool
55
What stages of pressure sore require a wound care plan?
≥stage 2
56
In a wound care plan for pressure ulcers what should you record?
The site of the wound The dimentions of the wound (LxWxD) A description of the wound Dressings used for the wound
57
If a patient is admitted to or discharged from hospital with a wound what should you do?
Take a picture
58
Is it better for a patient with a pressure sore to be in bed or in a chair?
In bed, but you must still reposition 2hrly
59
What conditions can increase the risk of pressure sores?
Poor nutrition Incontinence

bHCE (18 decks)

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