Wound care and pressure ulcers

• Pressure ulcer classification - stage 1

  Non blanchable erythema of intact skin
• Pressure ulcer classification - stage 2

  partial thickness of skin loss that involves the epidermis or dermis (or both)
• Pressure ulcer classification - stage 3

  full thickness skin loss and damage or necrosis of subcutaneous tissue that may extend to, but not through, underlying fascia
• Pressure ulcer classification - stage 4

  full thickness skin loss associated with extensive deconstruction, tissue necrosis or damage to muscle bone or supporting structures such as tendons or joint capsules
• Pressure ulcer classification - limitations

  stage 1 pressure ulcers are difficult and are often misdiagnosed on darker pigmented skin
• layers of skin

  Epidermis

  Dermis

  Subcutaneous tissue

  Muscle
• Basic components of pressure ulcer care

  Debridement of necrotic tissue as needed on initial and subsequent assessment

  Cleansing the wound initially and with each dressing change

  Preventing diagnosis and treatment of infection

  Using a dressing that keeps the ulcer bed moist and the surrounding intact tissue dry
• pathogenesis

  The origin and development of a disease
• Pathogenesis of pressure ulcers 


  Fiction

  Shearing forces

  Moisture

  Pressure
• Risk assessments for pressure ulcers

  Braden scale

  Waterlow score
• pressure ulcer care -4 basic components

  1. debridement of necrotic tissue as needed on initial and subsequent assessment
  2. cleansing the wound initially and with easy dressing change
  3. prevention, diagnosis and treatment of infection
  4. using a dressing that keeps the ulcer bed moist and the surrounding intact tissue dry