ABSTRACT
Fig. 55-1 Pressure-distribution maps (in mm Hg) of a male figure. A, Supine. B, Prone. C, Sitting with feet hanging freely. D, Sitting with feet supported.
A
B
C
D
• Vascular disease Diabetes, peripheral vascular disease, and smoking decrease tissue perfusion and
predispose to necrosis. • Anemia Decreased wound healing capabilities Weakness or fatigue that leads to prolonged immobilization
• Malnutrition Diminished ability to heal wounds Vitamin supplementation only effective if truly deficient
• Altered level of consciousness Loss of protective reflexes or voluntary movements to off-load pressure
BRADEN SCALE n Most commonly used n Subscales
• Sensory perception • Skin moisture • Activity • Mobility • Friction and shear • Nutritional status
n Minimum value of 6 n Maximum value of 23 n Subscales of sensory perception, mobility, moisture, and friction and shear most predictive n Lower scores indicate increased risk for developing pressure ulcers. n Threshold scores for pressure sore development
• Tertiary care facilities: 16 • Veteran’s hospitals: 19 • Skilled nursing care facilities: 18
• Can be seen within 30 minutes and usually resolves after 1 hour • Can be difficult to detect in dark-skinned patients
n Stage II: Partial-thickness skin loss that presents clinically as a blister, abrasion, or shallow open ulcer. • 2-6 hours of pressure • Erythema lasts more than 36 hours.
