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Pressure Ulcers

Definition

Pressure Ulcers are localized areas of tissue

necrosis that tend to occur when soft tissue is

compressed between a bony prominence and

an external surface for a prolonged period.

These lesions are also called bedsores,

decubitus ulcers and pressure sores

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Pressure Ulcers

Epidemiology

1-3 million Americans are affected

Health care expenditures: $ 5 billion/year

More than 17,000 lawsuits related to pressureUlcers are filed annually

1 in 4 persons in the USA who died in 1987had a dermal ulcer

Pressure Ulcers develop primarily in elderlypatients

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Pressure Ulcers

Epidemiology

Setting

Hospital 60%

Nursing homes 18%

Home 18%

1/3 of patients undergoing surgery for hip fracturedevelop a pressure ulcer

The longer the patient stays in a nursing home, the

greater the likelihood of developing a pressure ulcer

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THERMODYNAMICS, METABOLISM

AND PRESSURE

Thermodynamic factors - skin/surfaceinterface

As temperature increases, skin becomes more

metabolically active and 02 demands increase With increased pressure, metabolic demands

not able to be met and skin becomes hypoxic

Hypoxic skin more susceptible to breakdown

Adding frictionand shearto already fragileskin is perfect storm

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THE 4 FORCES

1. Pressure: Force applied to soft tissue between

hard surface and bony prominence. When skin

and the underlying tissues are trapped between

bone and a surface such as a wheelchair or bed,blood flow is restricted. This deprives tissue of

oxygen and other nutrients -> tissue death.

2. Friction: Resistance of one body sliding or rollingover another. Making skin more susceptible to

pressure sores.

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PRESSURE AND FRICTION

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3. Shear: This occurs when skin moves in one

direction, and the underlying bone moves in

another. Sliding down in a bed or chair orraising the head of bed more than 30 degrees

is especially likely to cause shearing, which

stretches and tears cell walls and tiny bloodvessels. Especially affected are areas such as

tailbone where skin is already thin and fragile.

4. Strain: Tissue deformation in response topressure

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Pathophysiology

Prolong weight bearing and mechanical shear

forces act on areas of soft tissue overlying

bony prominence > when this pressure

exceeds normal capillary perfusion pressure(32 mm Hg) > occlusion & tearing of small

blood vessels > reduced tissue perfusion >

ischaemic necrosis > Pressure sore.

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Risk factors

Age.Older adults tend to have thinner skin,

making them more susceptible to damagefrom minor pressure. They have less natural

cushioning over their bones. And poor

nutrition, delays wound healing.

Lack of pain perception.Spinal cord

injuries and some diseases cause a loss ofsensation > bedsore is forming.

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=risk-factorshttp://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=risk-factors

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Natural thinness or weight loss.Muscle atrophy andwasting are common in people living with paralysis. If

you lose fat and muscle there is no cushion over yourbones.

Malnutrition. Pressure sores develops if you have apoor diet, especially one deficient in protein, zinc andvitamin C.

Urinary or fecal incontinence.Problems with bladdercontrol can greatly increase risk of pressure soresbecause skin stays moist, making it more likely tobreak down. And bacteria from fecal matter not only

can cause serious local infections but also can lead tolife-threatening systemic complications such as sepsis,gangrene and, rarely, necrotizing fasciitis, a severeand rapidly spreading infection.

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Other medical conditions. diabetes and

vascular diseaseaffect circulation > tissue

damage. Smoking.Smokers tend to develop more

severe wounds and heal more slowly, mainly

because nicotine impairs circulation andreduces the amount of oxygen in blood.

Decreased mental awareness.People whose

mental awareness is lessened by disease,

trauma or medications are often less able to

take the actions needed to prevent or care for

pressure sores.

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Risk Factors

Spinal cord injuries

Traumatic brain injury

Neuromuscular disorders Immobility

Malnutrition

Fecal and urinaryincontinence

Altered level ofconsciousness

Chronic systemic illness

Fractures

Aging skin decreased epidermal

turnover

dermoepidermaljunction flattens

fewer blood vessels Decreased pain

perception

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Pressure ulcerscommonly occur

over the :

Sacrum

Greatertrochanter

Ischial tuberosity

Malleolus

Heel Fibular head

Scapula

Site

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While on a wheelchair a pressure sore develop

on:

- tailbone or buttocks

- shoulder blades and spine

- The backs of arms and legs where they

rest against the chair

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Stages/ classification

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Classification Stage I

1. 1. most superficial,

2. non blanchableredness,does not subside

after pressure is relieved.

3. The skin may be hotter or cooler than normal

4. have an odd texture, or

5. perhaps be painful to the patient.

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STAGE I

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Stage IIis damage to the epidermisextending

into, but no deeper than, the dermis. In this

stage, the ulcer may be referred to as a blisteror abrasion.

The ulcer is superficial and manifest clinically

as an abrasion, blister or shallow crater

http://en.wikipedia.org/wiki/Epidermis_(skin)http://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Blisterhttp://en.wikipedia.org/wiki/Abrasion_(medical)http://en.wikipedia.org/wiki/Abrasion_(medical)http://en.wikipedia.org/wiki/Blisterhttp://en.wikipedia.org/wiki/Dermishttp://en.wikipedia.org/wiki/Epidermis_(skin)

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STAGE II

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STAGE II

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Stage IIIinvolves the full thickness of the skinand may extend into the subcutaneous tissue

layer. This layer has a relatively poor bloodsupply and can be difficult to heal.

The ulcer manifests clinically as a deep crater

with or without undermining of adjacent

tissue

http://en.wikipedia.org/wiki/Subcutaneous_tissuehttp://en.wikipedia.org/wiki/Subcutaneous_tissue

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STAGE III

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STAGE III

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Stage IVis the deepest, extending into themuscle, tendonor even bone.

Full thickness tissue loss with exposed bone,

tendon or muscle. Slough or eschar may bepresent on some parts of the wound bed.Often include undermining and/or tunneling

Depth varies according to anatomic location Exposed bone/tendon usually directly visible

and/or palpable

http://en.wikipedia.org/wiki/Musclehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Bonehttp://en.wikipedia.org/wiki/Tendonhttp://en.wikipedia.org/wiki/Muscle

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STAGE IV

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B

A

Stage 4

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STAGE IV

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Complications

Cellulitis.This causes pain, redness and swelling, all of

which can be severe. Cellulitis can also lead to life-

threatening complications, including sepsis and

meningitis.

Bone and joint infections.These develop when the

infection from a bedsore burrows deep into joints and

bones. Joint infections (septic or infectious arthritis) can

damage cartilage and tissue, whereas bone infections(osteomyelitis) may reduce the function of joints and

limbs.

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=complicationshttp://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=complications

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Sepsis.It occurs when bacteria enters

bloodstream through the broken skin and

spreads throughout the body a rapidly

progressing, life-threatening condition thatcan cause shock and organ failure.

Cancer.This is usually an aggressive carcinoma

affecting the skin's squamous cells.

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Tests and diagnosis

Bedsores are usually unmistakable, even in

the initial stages, but doctor is likely to order

blood tests to check nutritional status and

overall health. Depending on thecircumstances, there may have other tests.

Wound swabC/S

Incision biopsyif malignancy is suspected.

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=tests-and-diagnosishttp://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=tests-and-diagnosis

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Treatments and drugs

Treating bedsores is challenging. Openwounds are slow to heal, and because skinand other tissues have already been

damaged or destroyed, healing is neverperfect.

Requires a multidisciplinary approach

nurses, physician, social worker, physicaltherapist, urologist or gastroenterologist, aneurosurgeon, orthopedic surgeon andplastic surgeon.

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=treatments-and-drugshttp://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=treatments-and-drugs

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TREATMENT OBJECTIVES Identification of problem

Debridement of necrotic tissue

Moist wound care without maceration

Control of infection/bioburden

Management of pain

Pressure redistribution/Offloading

Choice of wound care products is individualpreference as long as above objectives met.

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A) Conservative treatment

Although it may take some time, most stage I

and stage II sores will heal within weeks with

conservative measures. But stage III and stageIV wounds, which are less likely to resolve on

their own, may require surgery.

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1. Changing positions often.Carefully follow the

schedule for turning and repositioning approximately

every 15 minutes if in a wheelchair and at least once

every two hours when in bed. If unable to change

position on own, a family member or other caregiver

must be able to help.

2. Using support surfaces.These are special cushions,

pads, mattresses and beds that relieve pressure on anexisting sore and help protect vulnerable areas from

further breakdown.

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PRESSURE REDISTRIBUTION

http://www.nationalwound.com/images/products/group1/group1_nwc400new.jpg

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3. Cleaning.It's essential to keep woundsclean to prevent infection. A stage I woundcan be gently washed with water and mildsoap, but open sores should be cleaned with a

saltwater (saline) solution each time thedressing is changed. Avoid antiseptics such ashydrogen peroxide and iodine, which candamage sensitive tissue and delay healing.

4. Controlling incontinenceas far as possibleis crucial to helping sores

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5. Removal of damaged tissue (debridement).Toheal properly, wounds need to be free of damaged,

dead or infected tissue. This can be accomplished inseveral ways -

a. Autolytic debridementis autolysiswith the body'sown enzymes.

b. Biological debridement, or maggot debridementtherapy,

c. Chemical debridement, or enzymatic debridement

d. Mechanical debridement

e. Sharp debridementis the removal of necrotic tissuewith a scalpel or similar instrument.

f. Surgical debridement

g. Ultrasound-assisted wound therapy

http://en.wikipedia.org/wiki/Autolysishttp://en.wikipedia.org/wiki/Maggot_therapyhttp://en.wikipedia.org/wiki/Maggot_therapyhttp://en.wikipedia.org/wiki/Maggot_therapyhttp://en.wikipedia.org/wiki/Maggot_therapyhttp://en.wikipedia.org/wiki/Autolysis

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6. Dressings.

7. Oral antibiotics.

8. Healthy diet.

9. Muscle spasm relief

10. Educating the caregiver

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B) Surgical repairby - tissue flap, free flap,

Negative Pressure Wound Therapy

C) Other treatment options

Researchers are searching for more effective

bedsore treatments. Under investigation are

hyperbaric oxygen, electrotherapyand thetopical use of human growth factors.

http://en.wikipedia.org/w/index.php?title=Tissue_flap&action=edit&redlink=1http://en.wikipedia.org/wiki/Free_flaphttp://en.wikipedia.org/wiki/Negative_Pressure_Wound_Therapyhttp://en.wikipedia.org/wiki/Negative_Pressure_Wound_Therapyhttp://en.wikipedia.org/wiki/Free_flaphttp://en.wikipedia.org/w/index.php?title=Tissue_flap&action=edit&redlink=1

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Prevention

Bedsores are easier to prevent than to treat,

but that doesn't mean the process is easy or

uncomplicated. Although wounds can develop

in spite of the most scrupulous care, it'spossible to prevent them in many cases.

http://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=preventionhttp://www.mayoclinic.com/health/bedsores/DS00570/DSECTION=prevention

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Position changesChanging position frequently and consistentlyis crucial to preventing bedsores. Expertsadvise shifting position about every 15

minutes that you're in a wheelchair and atleast once every two hours, even during thenight, if you spend most of your time in bed.

Skin inspectionDaily skin inspections for pressure sores are anintegral part of prevention.

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Nutrition

A healthy diet is important in preventing skin

breakdown and in aiding wound healing

Lifestyle changes

-Quitting smoking,

- Exercise - Daily exercise improves

circulation