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Flashcards in Preventing pressure ulcers Deck (27)
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1
Q

Define a pressure ulcer

A

Pressure injury to the skin and or underlying tissue especially over a bony prominence especially as a result of pressure or pressure in combination with shear

2
Q

What is the difference in the cause between pressure ulcers and moisture lesions?

A

PU: history of pressure, friction, shear
ML: skin moist (sweat, urine or faeces) or history of incontinence

BUT remember that a patient may have both a pressure ulcer and moisture lesion in a similar area, so can co-exist

3
Q

What is the difference in the position between pressure ulcers and moisture lesions?

A

PU: area over bony prominence or compression eg oxygen mask, plaster cast, crutches
ML: natal cleft, or buttocks, copy lesions on both side of the body, not usually over bony prominences

4
Q

What is the difference in the shape between pressure ulcers and moisture lesions?

A

PU: distinct shape with obvious edges, 1 or 2 wounds
ML: multiple wounds with diffuse edges

5
Q

What is the difference in the depth between pressure ulcers and moisture lesions?

A

PU: may be down to bone
ML: Usually superficial – unless it becomes infected

6
Q

What is the difference in the presence of necrosis between pressure ulcers and moisture lesions?

A

PU: Frequently necrotic tissue present as hypoxia
causes necrosis
ML: No necrosis

7
Q

What is the difference in the edges between pressure ulcers and moisture lesions?

A

PU: Distinct edges, may be rolled or raised in
chronic stages
ML: Edges may be difficult to determine, jagged edges
are seen in moisture lesions that have been
subjected to friction

8
Q

Which bony prominences are most suceptible to pressure ulcers?

A
  • Sacrum
  • Ischial tuberosity
  • Heels
9
Q

Other than bony prominences, where/how else can pressure ulcers form?

A
  • Plaster casts
  • Splints
  • Arm slings
  • Clutches
  • Under glasses
  • Around nose with nasal cannulae
  • Other areas depending on the position of the pt eg their shoulder or knee if lying on their side
10
Q

Explain the different theories of how pressure ulcers form

A
  • top to bottom: Pressure ulcer develops on the skin and then progresses backwards towards the bone
  • bottom to top: But also could be the bone applying pressure to the skin, so ischaemia could develop at the bone end and then progress outwards, explains the cone shape of ulcers
  • reperfusion injury: an ulcer could form due to a series of small reperfusion injuries over time (due to repeated hypoxia and reperfusion) or could exacerbate an injury that has already formed
11
Q

Explain the pathophysiology of pressure ulcers

A

where the pressure is greater than that in the tissue perfusion pressure (which is capillary pressure) over a long period of time. If the pressure is not removed, it will go down into the bone

12
Q

What shape are pressure ulcers from superficial to deep?

A

Cone shaped - widest part near the bone and near surface it is small

13
Q

Why is older skin more predisposed to breakdown?

A
  • The epidermis (outer layer) gets thinner, so the skin is more susceptible to damage from mild injury
  • Flattening out of the dermo-epidermo junction (part between the epidermis and dermis), which makes it more fragile and susceptible to shear forces
  • Reduction in the thickness of the dermis by 20% - this reduces the number of blood vessels, nerve endings and therefore less ability to protect the body from damage
14
Q

List 3 functions of skin

A
  1. sensation
  2. temperature control
  3. moisture retention
15
Q

How can a pressure ulcer present?

A
  • Non blanching erythema
  • superficial skin loss

Remember that the amount of redness can be very small compared to the damage underneath

16
Q

How can you categorise the risk factors for forming a pressure ulcer?

A

intrinsic or extrinsic (ie pt or environmental factors)

17
Q

List some intrinsic factors for development of pressure ulcers

A
  • Reduced mobility
  • Impaired sensation
  • Currently ill, pyrexia
  • Steroids – cause skin thinning
  • Increasing age - affects skin functioning
  • Dehydration
  • Incontinence
  • Previous pressure sores
  • Pain – interfering with staff moving them around, or repositioning themselves
  • Vascular disease
  • Reduced nutritional levels – especially if very thin
  • Reduced level of consciousness and cognitive state
18
Q

List the extrsinsic factors for development of pressure ulcers

A
  • Pressure - sufficient to cause ischaemia and for an extended period eg 30 mins
  • Shear - skin moving in opposite directions
  • Friction
  • Moisture
19
Q

What scoring system would you use to estimate whether someone is at risk of developing pressure ulcers?

A

Waterlow score

20
Q

What are the aspects taken into consideration as part of the Waterlow score?

A

BMI
Skin type (eg tissue paper, dry, pyrexia, broken)
Sex and age
Weight loss and nutrition
continence
mobility
Tissue malnutrition (PVD, cachexia, multiple organ failure, anaemia, smoking)
Neurological deficit (diabetes, MS, stroke, motor or sensory deficit, paraplegia)
Major surgery

21
Q

How are ulcers graded?

A

Grade 1-4 (1 is most superficial, 4 most severe and deep)

22
Q

What is a grade 1 ulcer?

A

Considered superficial
- Non-blanchable erythema of intact skin
(white skin: persistent redness, darker skin: blue or purple discolouration of skin)
- May be warm, swollen, indurated or hard
- May be painful or itching

23
Q

What is a grade 2 ulcer?

A

considered superficial

  • partial thickness loss involving epidermis, dermis or both
  • may present as an abrasion or a blister
  • no bruising (but if blister is bruised or filled with blood, then considered deep)
24
Q

What is a grade 3 ulcer?

A

Considered deep

  • full thickness skin loss
  • subcutaneous fat may be visible through bone, but if the area is shallow without adipose tissue anyway, such as the bridge of the nose, then the ulcer can still be grade 3
  • tendon, muscle and bone are not exposed

Some guidelines also contain the following as grade 3:

  • full thickness tissue loss with actual depth of the ulcer obscured by slough (yellow, orange, grey, green, brown, black) or eschar - slough should be removed, but eschar should not as it is the body’s natural barrier
  • until the slough is removed, it is difficult to tell the true depth and therefore whether it is grade 3 or 4
25
Q

What is a grade 4 ulcer?

A

considered deep

  • full thickness tissue loss with exposed bone or tendon
  • can extend into muscle and joint capsule
26
Q

How would you treat/prevent pressure ulcers?

A
  • movement and repositioning; encourage patients to be independent
  • air matresses
27
Q

How often is it recommended to reposition patients?

A
  • at risk: every 4 hours

- not at risk: every 6 hours