Pressure Ulcers

Question 1

What is the biggest risk factor for PU?

Answer 1

immobilization is a bigger risk factor than decreased sensation

pts who move less then 20 times in sleep are at biggest risk

Question 2

What are 4 key risk factors for PU?

Answer 2

pressure, shear, friction, moisture

Question 3

What is shear?

Answer 3

parallel force displaces internal tissues and laterally deforms

happening beneath skin by sliding on the bed, skin stays but underlying tissues move

Question 4

What is etiology of pressure related cell death?

Answer 4

1. pressure
2. ischemia
3. acidosis
4. inflammation
5. increased cap perm and edema
6. local tissue anoxia
7. necrosis

Question 5

What is reactive hyperemia?

Answer 5

reaction to pressure as body sends massive amount of blood to compensate for circulation loss

Question 6

What is normal capillary blood flow?

Answer 6

25-32 mmHg

Question 7

What are modern theories as to why pressure ulcers form?

Answer 7

inverse pressure-time relationship (2 hours) More pressure will result in faster ulcer development
individual hemodynamic factors
body location and body tissue type

Question 8

Where is the most pressure in the body?

Answer 8

most tissue damage occurs deep at the bone

Question 9

What are risk factors contributing to PU?

Answer 9

shear- moving up and down in bed
excessive moisture, incontinence
impaired, prolonged mobility
malnutrition- 15% body loss
impaired sensation
advanced age
history of pressure ulcer

Question 10

What are typical pt diagnoses who develop PU?

Answer 10

spinal cord pts, cognitive impairments, neuro disorders, diabetes, obese/thin

Question 11

How many areas are on the Braden scale?

Answer 11

6

Question 12

When assessing a new pts skin who is at risk for PU what five things should you look at?

Answer 12

1. temperature (cold skin may already have damage)
2. color
3. moisture level
4. turgor (tenting)
5. skin integrity

Question 13

What are the four levels on skin breakdown?

Answer 13

hyperemia- with 30 mins, redness dissipates within 1 hr after relief

ischemia- after 2-6 hours skin deeper in skin color as its trying to heal, dissipates within 36 hours

necrosis- after 6 hours, bluegrey color cool to touch dissipates at individual level

ulceration- may occur 2 weeks after necrosis

Question 14

What is biggest area for incidence?

Answer 14

sacral, coccyx

Question 15

How often should pressure ulcers be reassessed?

Answer 15

weekly

Question 16

What is important remember about pressure ulcer staging?

Answer 16

once a wound is staged can only stage to higher level not lower

even if wound is healing it will never be documented as an earlier staged wound “pts has healing stage 2 ulcer”

Question 17

What is a deep tissue injury?

Answer 17

purple or marooned area, intact skin or filled blood blister

technically not stagable but will become stage 4 PU

Question 18

What is a PU stage 1?

Answer 18

non blanchable erythema over bony prominence

may be superficial or first sign of DTI

Question 19

What is stage 2 PU?

Answer 19

superficial to partial thickness depth, loss of dermis, red pink wound bed and without slough or bruising

Question 20

What are 3 P’s of stage 2 PU?

Answer 20

pink, partial and painful

ex. blister, abrasion, shallow crater

Question 21

What is a stage 3 PU?

Answer 21

involves epidermis all the way to subcutaneous tissue (depth depends on how much in area)

bone and tendon not visible

crater with or w/o undermining, tunneling

Question 22

What could be present to make it stage 3?

Answer 22

slough/necrotic tissue

avg. length of healing 3-4 months

Question 23

What is stage 4 PU?

Answer 23

full thickness which goes down to muscle bone tendons

avg healing 120 days

Question 24

What are “5PT” characteristics of PU?

Answer 24

pain, position, presentation (NPUAP), periwound, pulses, and temp

Question 25

What are norms for Braden scale?

Answer 25

under 18 at low risk 15-16 at risk, 50-60% chance of getting stage 1 13-14- mod risk 65-90% of getting stage 2 or deeper 10-12 high risk 9 or less very high risk

Question 26

What other risk factors will move them up the Braden scale?

Answer 26

fever, diastolic under 60, hemodynamic instability or advanced age

Question 27

What are PT interventions?

Answer 27

remove pressure with positioning, trapeze bar, wound management, lifting out of bed not dragging, ROM/splinting, therex, EDUCATION

Question 28

T/F: The researchers strongly recommend the use of e-stim vs laser for healing of pressure ulcers?

Answer 28

TRUE

Question 29

What are positioning recommendations for pts?

Answer 29

decrease shear- HOB less than 30 degrees, avoid semi-fowler decrease friction- heel/elbow pads decrease stress on bony prominences

Question 30

What is the pressure number for tissue breakdown?

Answer 30

32 mmHG

Question 31

What is a category 1 support surface?

Answer 31

preventive type intervention, pressure redistribution surface, foam, gel, water the pt can move some but not enough

Question 32

What is medicare criteria for category 1 surface?

Answer 32

patient is completely immobile or pt has limited mobility or any stage PU on the trunk or pelvis along with atleast one criteria: impaired nutrition, incontinence, altered sensory, compromised circulatory

Question 33

What is a category 2 support surface?

Answer 33

dynamic, pressure redistribution, therapetic intenrvention alternating pressure mattress or low air loss mattress

Question 34

What is medicare criteria for stage 2?

Answer 34

multiple stage 2 PU on trunk or pelvis and pt on comprehensive tx program for stage 1 PU for ovr a month or pts ulcer remained same or worse over past month or large or multiple stage 3-4 or recent skin graft on ulcer within 60 days and pt was on 2 or 3 support surface prior to recent DC from hospital or nursing facility

Question 35

What is category 3 support surface?

Answer 35

air fluidized bed, provides low friction and shear environment

Question 36

What are medicare requirements for stage 3 SS?

Answer 36

needs: stage 3 or 4 PU, bedridden, MD order