Pressure SoresAndre Sookdar

Class of 2013

Objectives

• Definition• Epidemiology• Pathogenesis• Risk Factors• Stage & Risk Assessment• Prevention• Management

Definition

• A Pressure sore is a localized injury to the skin or underlying tissue as a result of unrelieved pressure.

• Decubitus Ulcer, bedsore

Epidemiology

• Between 1-3 million US affected• 11 - 18% nursing home residents (2004)• 9 - 60% hospital• 3 - 18% home• Health care expenditure $5 Billion US/year• 1.4 – 2.1 Billion pounds (UK)/year• More than 17,000 lawsuits annually• The longer the patient stays in a hospital

or nursing home the greater the risk

Pathogenesis

Traditional Theory• Prolonged Pressure• Friction• Shearing Forces• Moisture

Pathogenesis

• Pressure: When external pressures are greater than capillary pressure (12-32mmHg) ischaemia results

• Intermittent pressure relief helps prevent ulcer formation

• Friction: Compromise of the protective stratum corneum decreases the pressure required for ischaemia

• The loss of the skin’s ability to act as a barrier further enhances ulcer formation

Pathogenesis

• Shearing Forces: When the patient is raised at an angle > 30˚, shearing forces occur between the deep fascia and the outer skin

• Moisture: Chronic moist environment (incontinence, perspiration) leads to tissue damage and ulcer formation

Pathogenesis

Pathogenesis

• Impairment in lymphathic flow increase in metabolic waste products

• Reperfusion injury• Deformation of tissue cells

Common Sites

• Commonly occurs at bony prominences, e.g. sacrum, greater trochanters, heels, ischial tuberosities

• 95% occur on the caudal aspect of the body; 65% in the pelvic area, 30% on the lower limbs

Intrinsic Risk Factors

Limited Mobility• Spinal cord injury• CVA• Parkinson Disease• Alzheimer Disease• Pain• Fractures• Postsurgical

• Coma or sedation• Arthropathy

Intrinsic Risk Factors

Poor Nutrition• Anorexia• Dehydration• Poor dentition• Poverty or lack of access to food• Dietary Restriction

Intrinsic Risk Factors

Co-morbidities• Diabetes• Depression• Peripheral Vascular

Disease• Decreased pain

sensation• Immunodeficiency• Corticosteroid

effects• Congestive heart

failure• Malignancies• Renal Disease• COPD• Dementia

Intrinsic Risk Factors

Aging skin• Loss of elasticity• Decreased cutaneous blood flow• Changes in dermal pH• Flattening of rete ridges• Loss of subcutaneous fat• Decreased dermal-epidermal blood

flow

Extrinsic Risk Factors

• Pressure from external surface e.g. bed, chair

• Friction from being unable to move well• Shear forces form involuntary

movement• Moisture – bowel or bladder

incontinence, perspiration, wound drainage

National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Classification

• Stage 1 – Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler than adjacent tissue.

National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Classification

• Stage 2 – Partial thickness skin loss, presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open serum-filled blister. Includes tears, tape burns, maceration or excoriation

National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Classification

• Stage 3 – Full thickness skin loss. Fat may be visible but bone, tendon or muscle tissue are not. Slough may be present.

National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Classification

• Stage 4 – Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.

National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Classification

• Unstageable – Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar. Until enough of the base is exposed, the true depth and stage cannot be determined.

National Pressure Ulcer Advisory Panel Pressure Ulcer Staging Classification

• Suspected Deep Tissue Injury – Purple or maroon discoloured intact skin or blood-filled blister due to damaged underlying soft tissue from pressure or shearing forces. The area may be painful, firm, mushy, boggy, wormer or cooler than surrounding tissue

Risk Assessment and Evaluation

• Braden Scale• Push Tool

Braden Scale

• Sensory Perception 1-4• Moisture 1-4• Physical Activity 1-4• Mobility 1-4• Nutrition 1-4• Friction & Shear 1-3• Score 18+ Low risk• 15-18 Mild risk, 13-14 Moderate risk, 10-

12 High risk, below 10 Very High Risk

PUSH Tool

Prevention

Aims• Reduce Pressure and Shearing effects• Reduce Moisture• General Skin Care• Nutrition• Co-morbidities• Involve patient, family, caregivers

Prevention

• Daily skin inspection• Bathing and skin cleaning frequency• Moisturize skin; avoid hot water or harsh

solutions• Assess and treat incontinence; use topical

barriers or absorbent padding when needed• Proper re-positioning frequently; q2hrly for

those bed-bound, q1hrly for those in wheelchairs; self re-positioning every 15 minutes for those in wheelchairs

• Avoid manipulating bony prominences

Prevention

• Practice proper positioning, transferring and turning techniques to avoid friction and shearing forces; lift don’t shift

• Use dry lubricants (cornstarch) or protective coverings to reduce friction injury

• Institute a rehabilitation program to maintain or improve mobility/activity status

• Consider nutritional supplementation/support for nutritionally compromised persons

Prevention

• Use adjunct devices (air mattresses, limb padding) where necessary

• Use pillows or padding to avoid bony prominences such as knees from having direct contact

• Elevate the head of the bed no more than 30˚ unless absolutely necessary

• Monitor and document interventions and outcomes

• Have a fixed repositioning schedule

How might the Leg Ulcer and Thumb Bruises be related?

Management

• Based on Staging and Investigation• Wound swabs and cultures usually show

mixed growth• Blood – CBC, CRP, ESR, Serum

Protein/Albumin• MRI• X-Rays• Ultrasound• Tissue Biopsy – suspect malignancy

Management - AAFP

Dressings

Dressing Type Description Indication Brand Names

Transparent Film Adhesive, semi-permeable, allows vaporization

Stage I and II with light or no exudates

Opsite, Tegaderm

Hydrogel Water/Glycerin based gels on gauze or dressings

Stage II, III, IV; deep ulcers; necrosis & slough

Acryderm, Flexigel, Intrasite

Alginate From Seaweed Stage III, IV with moderate to heavy exudate

Algicell, Algisite, Tegagen

Foam Moist, thermal Insulation

Stage II to IV with varying drainage

Hydrocell, Polyderm

Hydrocolloid Occlusive or semiocclusive; gelatin and pectin

Stage II to IV with sough and necrosis

Dermafilm, Tegaderm

Moistened Gauze Gauze in saline Stage III to IV

Management

• Clean, barrier• Antibiotic where appropriate• Debride necrotic tissue

Complications

• Sepsis, cellulitis, endocarditis, meningitis• Fistula formation• Osteomyelitis, septic arthritis• Sinus tracts• Squamous Cell Carcinoma (Marjolin’s

ulcer)• Amyloidosis• Drug resistant bacteria• Maggot infestation

Conclusion

• Risk • Prevention• Identify early• Manage

The End

Thank You

References

• www.aafp.org• Sussman C, Bates-jensen B. Wound Care:

A Collaborative Practice Manual for Health Professionals 4th Ed Lippincott Williams & Wilkins 2012

• Falabella A, Kirsner R.S. Wound Healing Taylor & Francis Group 2005

• Ruiz J.G. Pressure Ulcers University of Miami Grand Rounds Presentation