HLT54115 Diploma of Nursing

HLT54115 Diploma of Nursing
HLTENN006 Apply principles of wound management in the clinical
environment
Written Assessment Student Copy
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Read the study guide and the related resources.
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Pressure ulcers
A pressure ulcer (bedsore, decubitus ulcer) is an area of localised damage to the
skin and underlying tissue caused by pressure, shear or friction, Friction and
moisture are the most important factors in the development of superficial skin
breakdown. Pressure and shearing forces have a greater effect on subcutaneous
and muscle tissues. Ulcers can be deep, even with minimal skin breakdown, and
may not be evident until days after injury.214 They commonly form over bony
prominences such as the heels, the malleoli and the sacrum. Pressure ulcers
significantly reduce quality of life and increase care costs, as well as the length of
hospital stay. Prevalence in Australian aged care homes is between 3.4 and 5.4%.
Most pressure ulcers are preventable adverse events.
Prevention
Risk assessment involves examination of the skin, nutritional and general medical
assessment to identify risk factors, and use of a risk assessment tool. Major risk
factors are immobility, sensory loss, impaired cognitive state, urinary and faecal
incontinence, age over 65 years, chronic illness, poor nutritional status, impaired
oxygen delivery to tissues, raised skin temperature, skin dryness and the presence
of pressure, shear or friction forces.
The most commonly used risk assessment tools are the Norton Scale, the Braden
Score, and the Waterlow Risk Assessment.
The Norton Scale is designed to identify the need for preventive pressure care in
older hospital patients/clients and aged care home residents. Each of the five items
is scored from 1 to 4, with a maximum total score of 20. Scores of 14 or less rate the
resident as 'at risk' of developing pressure sores, the lower the score, the greater the
risk. Validity and reliability range from poor to good.
The Norton Scale
Physical
condition
Mental
condition
Activity Mobility Incontinence
Good 4 Alert 4 Ambulant 4 Full 4 Not 4
Fair 3 Apathetic 3 Walk help 3 Slightly limited
3
Occasional 3
Poor 2 Confused 2 Chair bound 2 Very limited 2 Usually/urine 2
Very bad 1 Stupor 1 Bed 1 Immobile 1 Doubly 1
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Preventive strategies to reduce risk factors can be incorporated into care plans for
residents identified as ‘at risk'. Consider
- daily inspection of all pressure points
- protection of skin - routine inspection, moisturisers for dry skin, protect from
moisture (treat incontinence), avoid harsh cleansers
- pressure relieving interventions and devices - pressure relieving positions,
turning schedules, repositioning intervals, reducing contact between bony
prominences and support surfaces, lifting devices and aids, low pressure
support surface for 'at risk' residents, dynamic support surface for high risk
residents
- optimise nutrition and hydration - adequate protein and caloric intake, zinc,
vitamins.
Assessment and management
The ulcer should be assessed and documented daily, based on the depth of tissue
destruction. Stages of pressure ulcer are defined as
Stage 1 - observable pressure related alteration(s) of intact skin whose indicators,
as compared to the adjacent or opposite areas of the body, may include changes in
one or more of the following: skin temperature (warmth or coolness), tissue
consistency (firm or boggy feel) and/or sensation (pain/itching). The ulcer appears as
a defined area of persistent redness if skin is lightly pigmented. In darker skin tones,
the ulcer may appear with persistent red, blue and purple hues
Stage 2 - partial thickness skin loss involving epidermis and/or dermis. The pressure
ulcer is superficial and presents clinically as an abrasion, blister or shallow crater
Stage 3 - full thickness skin loss involving damage or necrosis of subcutaneous
tissue that may extend down to, but not through, underlying fascia. The ulcer
presents clinically as a deep crater with or without undermining of the adjacent tissue
Stage 4 - full thickness skin loss with extensive destruction, tissue necrosis or
damage to muscle, bone or supporting structures (eg. tendon or joint capsule).
Undermining and sinus tracts may also be associated with stage 4 pressure ulcers.
Wound cultures are not indicated unless there is evidence of surrounding cellulitis or
bacteremia. X-rays or bone scans may be indicated to diagnose osteomyelitis in
deep non healing ulcers.229
The differential diagnosis for pressure ulcers includes venous stasis and arterial
ulcers, cancers, traumatic ulcers, neuropathic and infective ulcers, vasculitides and
other skin conditions.
Characteristics by ulcer type for arterial, diabetic, pressure and venous ulcers.
Arterial Diabetic Pressure Venous
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