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 SystemStage 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.

Stage 2Partial 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 3Full 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 4Full thickness skin

loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule).

PU Staging System

Extrinsic Factors

Friction and Shear

Forces

Heat

Moisture

Excessive Pressure

Intrinsic Factors

Poor Nutrition

Age

Sensory Loss

Immobility

PressureUlcer

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 preventionGood skin careVisually 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 necessaryIf 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 ……. !!!!!