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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.
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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
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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.
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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.
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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.
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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
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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.
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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