Transcript Topic 2. Pressure ulcers and pressure mapping

Pressure Ulcers
Pressure Ulcer
Pressure ulcer – Definition
Open sore caused by pressure,
friction, and moisture. These
factors lead to reduced blood flow
to the are and subsequent tissue
death. The most common sites for
pressure ulcer are over bony
Prominences
PU Staging System
 Stage 1
 May include changes in
one or more of the
following:




Skin temperature (warmth
or coolness)
Tissue consistency (firm or
boggy feel)
Sensation (pain, itching)
The ulcer appears as a
defined area of persistent
redness in lightly
pigmented skin, whereas in
darker skin tones, the ulcer
may appear with persistent
red, blue, or purple hues.
PU Staging System
 Stage 2
 Partial thickness skin
loss involving
epidermis, dermis, or
both.
 The ulcer is superficial
and presents clinically
as an abrasion, blister,
or shallow crater.
PU Staging System
 Stage 3
 Full thickness skin loss
involving damage to, or
necrosis of,
subcutaneous tissue
that may extend down
to, but not through,
underlying fascia.
PU Staging System
 Stage 4
 Full thickness skin loss
with extensive
destruction, tissue
necrosis, or damage to
muscle, bone, or
supporting structures
(e.g., tendon, joint,
capsule).
Pressure Ulcer Risk Factors
Extrinsic Factors
Excessive
Pressure
Friction
and Shear
Forces
Pressure
Ulcer
Intrinsic Factors
Immobility
Sensory
Loss
Age
Heat
Poor Nutrition
Moisture
Pressure Ulcer Risk
Factors
 It remains to be determined which, if any, risk factor
by itself increases the risk of PU, which risk factors are
more important than others, and which combinations
of risk factors appear to be the major contributors to
the development of PU.
 However, the literature suggests that a combination of
risk factors, intrinsic and extrinsic, is more likely to
predict the development of PU than any one risk factor
by itself.
Pressure ulcer prevention
 Good skin care
 Visually inspect the skin
 Warm reddened area indicates a possible site of tissue
breakdown
 Time for skin to recover …… !!!
 Modification for the position, schedule, procedure,
equipment, or orthotics is necessary
 If patient can not perform skin inspection by himself, a
care provider should be instructed to perform these
tasks everyday
 Pressure relief
 In bed: change position every …… !!!
 In sitting: every ….. for ……. !!!!!