Tissue viability

Question 1

Outline the Waterlow Score

Answer 1

Gives an estimated risk for the development of a pressure sore in a given patient

Areas assessed:

• Build/weight for height
• Skin type/visual risk areas
• Sex and age
• Malnutrition Screening Tool
• Continence
• Mobility

1-64. A total Waterlow score ≥10 indicates risk for pressure ulcer. A high risk score is ≥15. A very high risk exists at scores ≥20.

Question 2

Define tissue viability

Answer 2

Primarily considers all aspects of skin and soft tissue wounds including acute surgical wounds, pressure ulcers and all forms of leg ulceration

Prevention and management, and considers the microbiological reasons why some wounds do not heal

Question 3

Outline primary and secondary healing

Answer 3

PRIMARY = Incised, closed, non-infected, sutured wounds

Disruption of basement membrane, death of small no. of epithelial and CT cells, Minimal clot and granulation tissue – epidermis regenerates, dermis undergoes fibrous repair

SEC = Excisional wound, with tissue loss, separated edges, infected wounds, filled by abundant granulation tissue – grows in from wound margins.

Wound contraction must take place = scab, myofibroblasts

Question 4

What factors influence tissue healing?

Answer 4

Type, size, location, mechanical stress, blood supply, local foreign bodies

Systemic = age, anaemia, hypoxia, hypovolema, Obesity, DM, Genetic disorders, Drugs, Vit def, Malnutrition

Question 5

What is the role of the tissue viability team?

Answer 5

Committed to providing support, training and education to clinical staff, patients and carers about maintaining, promoting skin integrity and preventing pressure sores.

The nurses in the tissue viability team can provide specialist advice on all types of wounds, including: pressure ulcers