Pressure Sores Flashcards
(22 cards)
Definition of Pressure sore
Localised injury to the skin/underlying tissue over a bone prominence as a result of pressure +/- shearing
What is a stage 1 pressure sore
Non-Blanchable erythema
may be painful, firm, warm
What should be done if a stage 1 pressure sore is detected
Risk should be calculated using the Braden score
regular Repositioning should be commenced with care to avoid the affected area
What is a stage 2 pressure sore
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed
Alternatively may be a fluid-filled blister
what may present similarly to a stage 2 pressure ulcer
Skin tears
Tape Burns
Incontinence associated dermatitis
Excoriation
What is a stage 3 pressure sore
Full-thickness SKIN loss
Subcutaneous fat may be visible but bone, tendon or muscle are NOT exposed or directly palpable
What is a stage 4 pressure sore
Full-thickness TISSUE loss
Exposed bone, tendon or muscle
What has to be considered in conjunction with a stage 4 pressure sore
Osteomyelitis
What is a deep tissue injury
Full-thickness tissue loss obscured by skin material/eschar making it difficult to stage
How do you identify a deep tissue injury
Purple/maroon localised area of discoloured skin
What is a moisture lesion
Lesion caused by chronic exposure to faecal/urine matter
How do you identify a moisture lesion
Skin is wet/shiny
Diffuse irregular redness with irregular distribution of colour, with white areas of maceration
What are some risk factors for pressure sores
>65 Decreased mobility Sensory impairment (diabetic neuropathy) Vascular Disease Decreased Conciousness Previous History Incontinence Malnutrition Dehydration
What Risk assessment tools are available for assessing pressure sore risk
Braden or Waterloo scores
What are the components of a Braden score +what are the thresholds for risk
Mobility Friction level (out of 3, rest out of 4) Sensory Perception Nutritional status Incontinence/moisture exposure Special risks
<17 = high risk 17-20 = medium risk 21-23 = low risk
How do you manage high-risk pressure sore individuals
2 hourly repositioning (1 hour if sitting)
What is the structure of a visual assessment for a pressure sore
Site Dimension/edge Pain Colour Exudate? (infection) Stage (look at floor, feel base) Fistulae/sinus?
What does a raised edge indicate for a pressure sore
Malignancy
What are the most common locations for a pressure sore
Sacrum Elbows Heels Ears Hips
How do you diagnose a pressure sore
Clinical Diagnosis Must be: in a common location in the presence of risk factors Painful/Pruitic (in the absence of risk factors)
What is the prevention package for pressure sores
SSKIN
Support Surface Skin evaluatoin Keep moving Incontinence (reassess for moisture lesions) Nutrition (MUST)
What are some management principles for pressure sores
Healing is slow but with adequate pressure distribution, nutrition and appropriate wound management ulcers generally heal
Antiseptic is contraindicated as this kills the healing granulation tissue
Involve tissue viability
Keep everything well documented
