NSG 300 TOPIC 4: PRESSURE ULCERS & WOUND CARE – STUDY
NOTES & Q&A REVIEW
pressure ulcers
a localized injury to the skin and underlying tissue, usually over a bony
prominence. It results from pressure in combination with shear and/or friction.
what are some other names for a pressure ulcer?
Pressure sore, decubitus ulcer, or bed sore
what are the three major elements that cause a pressure ulcer?
pressure intensity (tissue ischemia & blanching)
pressure duration
tissue tolerance
tissue ischemia
If pressure applied over a capillary exceeds normal capillary pressure and the
vessel is occluded for a prolonged time
blanching
Blanching occurs when the normal red tones of skin are absent.
pressure duration
Pressure duration assesses low and extended pressures. Low pressures over a
prolonged time can cause tissue damage. Extended pressure occludes blood flow
and nutrients and contributes to cell death.
tissue tolerance
The ability of tissue to endure pressure depends on the integrity of the tissue and
supporting structures.
what assessment is included for a pressure ulcer?
-wound location
-depth of tissue involvement (staging)
-type and approximate percentage of tissue in wound bed
-wound dimensions (if present include sinus tracts and tunneling)
, -exudate description (if present odor)
-condition of surrounding skin.
what are the risk factors for a pressure ulcer
-Impaired sensory perception
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
stage I
o Intact skin with no blanchable redness of a localized area usually over a bony
prominence
-Discoloration of the skin, warmth, edema, hardness, or pain may also be present.
stage II
o Partial-thickness skin loss involving epidermis, dermis, or both
-Presenting as a shallow open ulcer with a red pink wound bed, without slough.
-May also present as an intact or open/ruptured serum-filled or serosanguineous
filled blister.
-Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising
indicates deep tissue injury.
stage III
o Full-thickness tissue loss with visible fat but bone, tendon, or muscle are not
exposed.
stage IV
o Full-thickness tissue loss with exposed bone, muscle, or tendon
partial thickness wound
Involves the epidermis and the dermis but does not extend through the dermis to
the subcutaneous layer
full thickness wound
NOTES & Q&A REVIEW
pressure ulcers
a localized injury to the skin and underlying tissue, usually over a bony
prominence. It results from pressure in combination with shear and/or friction.
what are some other names for a pressure ulcer?
Pressure sore, decubitus ulcer, or bed sore
what are the three major elements that cause a pressure ulcer?
pressure intensity (tissue ischemia & blanching)
pressure duration
tissue tolerance
tissue ischemia
If pressure applied over a capillary exceeds normal capillary pressure and the
vessel is occluded for a prolonged time
blanching
Blanching occurs when the normal red tones of skin are absent.
pressure duration
Pressure duration assesses low and extended pressures. Low pressures over a
prolonged time can cause tissue damage. Extended pressure occludes blood flow
and nutrients and contributes to cell death.
tissue tolerance
The ability of tissue to endure pressure depends on the integrity of the tissue and
supporting structures.
what assessment is included for a pressure ulcer?
-wound location
-depth of tissue involvement (staging)
-type and approximate percentage of tissue in wound bed
-wound dimensions (if present include sinus tracts and tunneling)
, -exudate description (if present odor)
-condition of surrounding skin.
what are the risk factors for a pressure ulcer
-Impaired sensory perception
-Impaired mobility
-Alteration in LOC
-Shear
-Friction
-Moisture
stage I
o Intact skin with no blanchable redness of a localized area usually over a bony
prominence
-Discoloration of the skin, warmth, edema, hardness, or pain may also be present.
stage II
o Partial-thickness skin loss involving epidermis, dermis, or both
-Presenting as a shallow open ulcer with a red pink wound bed, without slough.
-May also present as an intact or open/ruptured serum-filled or serosanguineous
filled blister.
-Presents as a shiny or dry shallow ulcer without slough or bruising. Bruising
indicates deep tissue injury.
stage III
o Full-thickness tissue loss with visible fat but bone, tendon, or muscle are not
exposed.
stage IV
o Full-thickness tissue loss with exposed bone, muscle, or tendon
partial thickness wound
Involves the epidermis and the dermis but does not extend through the dermis to
the subcutaneous layer
full thickness wound
