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Practice topics Exam 2 > Pressure Ulcers > Flashcards

Pressure Ulcers Flashcards

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1
Q

Pressure Ulcers - AKA

A

Decubitus ulcers
Pressure sores
Pressure ulcers
Now = pressure injury

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2
Q

Definition (WOCN guidelines)

A

Area of localized tissue destruction caused by the compression of soft tissue over a bony prominence and an external surface for a prolonged period of time

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3
Q

Definition (other)

A

An ischemic response with resulting soft tissue death caused by sustained pressure and/or often physical forces generally found over bony prominences

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4
Q

Who is the primary source for getting information on pressure injury

A

National pressure ulcers advisory panel (NPUAP)

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5
Q

How does the NPAUP define a pressure injury

A

Localzed damage to the skin or underlying soft tissue - injury occurs as a result of intense or prolonged pressure or pressure in combo with shear

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6
Q

What is a required factor in pressure ulcer development

A

Pressure

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7
Q

What else (besides pressure) is required for pressure ulcer development

A

Perpendicular load or force exerted on a given, localized area

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8
Q

Pressure effects - what pressure will effectively obstruct blood flow within a capillary bed

A

More than 32 mmHg

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9
Q

Pressure effects - what is the most sensitive to limited blood flow

A

Muscle and fat

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10
Q

Pressure effects - greatest force is delivered at what

A

tissue/bone interface

Greatest at the apex of the force and is less to either side

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11
Q

Capillary hydrostatic pressure diagram

A

Venous blood - capillary hydrostatic pressure is lower at 20 mmHg
Arterial is higher at 30 mmHg

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12
Q

Tissue susceptibility - Time and Pressure have what relationship

A

INVERSE

The greater the pressure, the less time it needs to produce an injury

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13
Q

Extrinsic factors

A

Friction
Shear
Moisture
Irritants

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14
Q

Extrinsic factors - Friction is what

A

Resistance to motion in a parallel direction relative to the border between surfaces
Think pulling body part over sheets

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15
Q

Extrinsic factors - Shear is what

A

Force per unit exerted parallel to the plane
Blood vessels are effected
Irregular wound shape, with undermining

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16
Q

Extrinsic factors - Moisture

A

Variety of causes

  • Wound drainage
  • Incontinence (urinary and fecal)
  • Sweating (sacrum is huge)
  • Liquid spills
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17
Q

Extrinsic factors - Moisture produces what

A

Maceration!

Losing layer of the epidermis and increase risk of infection

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18
Q

Intrinsic factors

A 
Age
Smoking
Infections 
Immunocompromised conditions
Obesity
Medications
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19
Q

Intrinsic factors - Age

A

As we get older - BM flattens out, changes in blood vessels (weaker)
Younger = heal faster but they don’t have good temp regulation and not all the protective factors are there yet

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20
Q

Intrinsic factors - infections

A

changes in pH which makes it harder for the skin to be healthy

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21
Q

Intrinsic factors - obesity

A

increase pressure points on soft tissue

Skin folds on skin folds that weight a lot

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22
Q

Intrinsic factors - medications

A

usually antibiotics

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23
Q

Other factors (maybe intrinsic?)

A

Degree ob mobility
Presence of existing pressure sores
Hydration
Mental status

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24
Q

Presence of predisposing pathologies

A 
DM
Neuro disorders - MS, ALS, Parkinsons
PVD
CHF
Spinal cord injuries
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25
CMS regulations (1)
A resident who enters a facility without pressure sores does not develop pressure sore unless their clinical condition demonstrates that they were unavoidable
26
CMS regulations (2)
A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing
27
Risk classification scales
Norton scale Braden scale Gosnell scale Waterlow scale
28
Common features in the risk classification systems
``` Level of mobility Mental status General physical condition (including comorbidities) Level of continence Nutritional status Existence or previous skin breakdown ```
29
Braden scale - describe
6 subscales most rated from 1-4 Friction and shear rated 1 to 3 Scores 6 to 23
30
Braden scale - risk levels
milde - 15 - 18 moderate - 13-14 high - 10-12 very high - 9 or below
31
Physical characteristics of pressure injuries (ulcers)
``` Size and depth Location Shape Drainage Odor Eschar/Necrotic tissue Undermining/Tunneling ```
32
Staging of pressure ulcers - stage definitions from who
NPUAP
33
Staging of pressure ulcers - NPUAP - Deep tissue injury
Persistent non-blanchable deep red, maroon or purple discoloration Color is key when differentiating with stage 1
34
Staging of pressure ulcers - NPUAP - Stage 1
Intact skin with a localized area of non blanchable erythema which may appear differently in darkly pigmented skin Color changes DO NOT include purple or maroon!!! More of a red color
35
Staging of pressure ulcers - NPUAP - Stage 2
Partial thickness skin loss with exposed dermis | Disrupted BM - might see blisters
36
Staging of pressure ulcers - NPUAP - Stage 3
Full thickness skin loss in which adipose (fat) is visible in the ulcer and granulation tissue and rolled round edges are often also present Might see undermining and tunneling
37
If slough or eschar obscures the extent of tissue loss it is what stage
UNSTAGEABLE!
38
Staging of pressure ulcers - NPUAP - Stage 4
``` Full thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament cartilage or bone in the ulcer Slough or eschar might be visible Rolled edges (epibole), tunneling, or undermining are common ```
39
Staging of pressure ulcers - NPUAP - Unstageable
Full thickness and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar
40
Staging of pressure ulcers - NPUAP - If slough or escahr is removed - what stage?
3 or 4 | Stable eschar on the heel or ischemic limb should NOT be softened or removed
41
You can NOT stage a pressure ulcer unless
you can see the base!
42
Reverse staging
IS NOT A THING! Staging is used to define the depth of a pressure ulcer Staging should NOT be used to define improvement
43
Location - always check
Pressure areas | Weight bearing
44
Clinical signs of infection
Drainage/Color Devitalized tissue Tunneling/Undermining Physical characteristics
45
Clinical signs of infection - Drainage/color - Gray/Cream
You probably do not have an infection
46
Clinical signs of infection - Drainage/color - bright yellow
Might be staph infection
47
Clinical signs of infection - Drainage/color - Green and sweet smelling
Might be a pseudomonas infection - | Pseudomonas is more easily transmitted in air particles!
48
Clinical signs of infection - Drainage/color - Rust red
May indicated strep infection
49
Clinical signs of infection - Devitalized tissue
Black | Eschar - usually firm/hard, tightly adhered to wound bed
50
What is eschar
Protein and collagen fibers adhering together as non-living tissue and forms a covering (eschar)
51
Clinical signs of infection - Undermining/Tunnel/Track
Cavity or channel underneath the dermis/epidermis | Undermining (cavity), Tunnel (channel)
52
Clinical signs of infection - physical characteristics - tricolor
Red - clean, healthy, granulation tissue Yellow - exudate, needs to be removed Black - necrotic tissue or eschar
53
Evaluating pressure ulcers
Bates Jensen Wound Assessment Tool (BJWAT) Pressure sores status tool (PSST) Wound healing scale (WHS) Sussman Wound healing tool (SWHT)
54
Evaluating pressure ulcers - Sussman Wound healing tool (SWHT)
Two parts 10 descriptors associated with tissue healing - present or absent Description of wound location healing phase depth Ongoing development
55
Evaluating pressure ulcers - Bates Jensen Wound Assessment Tool (BJWAT)
13 items (1 best, 5 worst) 10 minutes 2 none scored items (location and shape - just for tracking) Reliable and valid Requires training Might be difficult to use to determine change
56
Evaluating pressure ulcers - PUSH
National pressure ulcer advisory panel 3 subscales - surface area, exudate amount, wound appearance Requires training Might be able to track wound changes effectively Recent work shows it has good validity and strong reliability
57
Creation of a healing environment
Enhance soft tissue mobility and promote healing | PREVENTION is key!
58
Healing environment
``` Pressure relief! Continence Nutrition Mobility Education ```
59
Pressure redistribution devices - overlays
Support surfaces that are positioned on top of other surfaces Foam, static air filled, alternating air filled, gel filled, water filled
60
Surgical treatment
Debridement Myocutaneous flaps Reconstructive surgery (pay more attn to BVs and nerves)
61
Primary treatment
``` PREVENTION! Identify risk Maintain skin integrity Treat potential or underlying causes Pressure relief Education of patient and care givers ```

Practice topics Exam 2 (15 decks)

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