Pressure Ulcers and Wounds

• decreased ability to
• equalize blood supply when moving lying to standing position.
• Caused by decreased circulating fluid volume
• and pooling of blood in lower extremities.
• Results in decreased venous return; decreased cardiac output and
• decreased BP

• Changes or injury to vessel walls+Hypercoagulabilityof the blood + venus stasis
• can lead to DVTs

• Critically ill
• Hypercoagubility; history of DVT
• Age; air travel
• Malignancy
• Pregnancy
• Immobilizing illness
• Orthopedic procedure
• Not known (???)

• Superficial
• thrombophlebitis

Localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear

Intact skin with nonblanchable redness of a localized area usually over a bony prominence

• Partial thickness loss of dermis
• Shallow open ulcer
• Red, pink wound bed NO SLOUGH
• May also be intact or
• open/ruptured serum-filled blister

• Full thickness tissue loss
• Sub Q tissue may be visible, but not bone and muscle
• Slough may be present but can still see depth of tissue loss
• May include undermining or tunneling

• Full thickness tissue loss with
• Exposed bone, muscle or tendons
• Slough or eschar may be present in part of wound
• Often includes tunneling and undermining

• Full thickness tissue loss
• Base of ulcer wound bed covered in slough and/or eschar