pressure ulcers

Question 1

define pressure ulcer

Answer 1

localisd injury ot the skin and/or underlying tissue ususally over a bony prominence as a result of

• pressure
• combination with shear
• small, superficial wounds or blisters
• epidermal elements
  covered or filled with necrotic tissue
• deeper tissues
  – fascia
  – muscle
  – bone

Question 2

key diagnostic factors

Answer 2

• presence of risk factors
• use of non-pressure-relieving support surface
• localised skin changes on areas subjected to pressure
• blister/shiny/dry shallow ulcer
• – partial loss of dermis WITHOUT SLOUGH - grade 2 ulcer

Question 3

what are localised skin changes seen on areas subjected to pressure

Answer 3

non-blanching erythema/purple/,arror

• painful
• firm
• mushy
• boggy
• warmer/cooler than adjacent tissue

Question 4

predisposing factors of pressure ulcers

Answer 4

malnourishment
incontinence
lack of mobility
pain (leads to a reduction in mobility)

Question 5

screening tool for pressure ulcers

Answer 5

waterlow

Question 6

grading of ulcers tool name

Answer 6

European Pressure Ulcer Advisory Panel classification system.

Question 7

grade 1 ulcer

Answer 7

Non-blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin

Question 8

grade 2 ulcer

Answer 8

Partial thickness skin loss involving epidermis or dermis, or both. The
ulcer is superficial and presents clinically as an abrasion or blister

Question 9

grade 3 ulcer

Answer 9

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

Question 10

grade 4 ulcer

Answer 10

Extensive destruction, tissue necrosis, or damage to muscle, bone or
supporting structures with or without full thickness skin loss

Question 11

management of pressure uclers

Answer 11

• a moist wound environment encourages ulcer healing. Hydrocolloid dressings and hydrogels may help facilitate this. The use of soap should be discouraged to avoid drying the wound
• wound swabs should not be done routinely as the vast majority of pressure ulcers are colonised with bacteria. The decision to use systemic antibiotics should be taken on a clinical basis (e.g. Evidence of surrounding cellulitis)
• consider referral to the tissue viability nurse
• surgical debridement may be beneficial for selected wounds