how to prevent & cure pressure ulcers home mobility & park house solutions

How to Prevent & Cure Pressure Ulcers

Home Mobility & Park House Solutions

Overview

• Pressure Ulcer– Definition– Causes– Predisposing Risk Factors– Grades– Effects on Patient

• Solutions– Risk Assessment– Skin Wound Protocol

Pressure UlcerCauses of Pressure Ulcer Development

Pressure

Pressure UlcerWhat is Pressure Ulcer?

• A localized area of cellular damage resulting from:– Direct pressure: skin and other tissues are directly

compressed between bone and another surface (bed, chair). Tissue damage will depend on intensity and duration of exposure to pressure.

– Shearing: tissues are wrenched in opposite directions, resulting in disruption or angulations of capillary blood vessels.

– Friction: skin rubs against another surface (sheet) causing epidermis to be stripped away.

• Also called Pressure Sores, Decubitus Ulcers or Bed Sores

Pressure UlcerBony Prominences at Risk

Pressure UlcerPredisposing Risk Factors

• Level of Mobility

• Nutrition

• Continence

• Medication

• Concurrent disease

• Age

Pressure Ulcer Grades of Ulcers

Two Hours …

… That’s what it takes to develop a pressure ulcer.

Pressure UlcerGrades of Ulcers

Grade 1

Epidermis

Dermis

Subcutaneous Fat

Muscle

Bone

Redness that does not disappear when pressure is applied


Grade 2


Grade 3


Grade 4


Very Fast Process

Very Slow Process

Grade I: 14 Days

Grade II: 45 days

Grade III: 90 days

Grade IV: 120 Days

Pressure UlcerEffects on Patient

• Pain

• Systemic illness

• Reduced self-esteem

• Altered body image

• Delayed rehabilitation measures

• Amputation

• Death

Pressure Ulcer

Solution

Pressure UlcerRisk Assessment

• Why?– Because we can prevent Pressure Ulcers– Because we can cure Pressure Ulcers

• To Whom?– All person with reduced mobility / activity or sedated

• When?– Admission– Regular Intervals– Change in patient conditions– During day and night

Pressure UlcerRisk Assessment

• Benefits?– Act as aid-memory– Target preventive care– Effective use of scarce resources– Provide quantifiable data of audit– Provides objective criteria to base care

pathways

• How?– Use Risk Assessment Tools

Pressure UlcerRisk Assessment Tools

• Braden

• Gosnell

• PSPS (Lowthian)

• Norton

• Walsall

• Douglas

• Knoll

• Medley

• N.P.R.U

• Waterlow

Pressure UlcerSkin Wound Protocol

• Pressure Reduction

• Pressure Relief

• Incontinence Care

• Nutrition Consult

• Moisturize Skin

• Positioning

• Wound Care


Pressure Reduction

Pressure Ulcer Pressure Reduction

• Reduce the intensity of pressure and shear : Blood irrigation occlusion diminish O2 flows in tissue– Intensity is determined by contact surface (mattress

or cushion). When the surface is increased, pressure is more evenly redistributed decreasing pressure.

– Avoid several tissue layers because they increase the pressure

– Avoid anything that reduces the size of the pressure surface (ring cushions)

• Should be combined with scheduled alternated repositioning of the patient.


• Pressure Reduction can be done through specialized mattresses / Cushions

• Static Mattresses are non electric system that reduces intensity of the pressure and shear by increasing contact surface

• Overlay is placed over standard mattress and has the same effect as static mattress

• The nature and composition of the material modify the form and the consistency of the mattress that is subject to patient body pressure.


Different Materials:– Water– Static Air– Gel– Fiber– Foam

• CMHR: Combustion Modified High Resilient

• Visco-elastic


Water Mattress Advantages:

• Cheap

• Distributes weight evenly

Water Mattress Disadvantages:

• A spontaneous or assisted change in the positioning is more difficult favours longer period in the same position higher risk of pressure ulcer development.


Water Mattress Disadvantages:• Very difficult to position the patient in Lateral

Decubitus @ 30° (this position is recommended for long stay periods) Low comfort and increased pressure higher risk of pressure ulcer development.

• Cannot be used on profiling beds (electrical) because of the weight of the mattress and the bed inclination

• Cold sensation from the water patient discomfort


Water Mattress Disadvantages:• Extremely heavy weight can causes back

injury to carer• The mattress can break inundation

unpleasant situation for both patient and carer.• Rocking effect may cause dizziness to

predisposed patients• Not durable• Requires a second mattress below


Static Air Mattress Advantages:• Easy use: once filled with air, it does not require an

electric pump.• Heat build up and moisture are greatly reduced, due to

the air holes throughout the mattress. • Light weight.• Best in its class for seating (cushions); however should

be thick enough to prevent bottoming effect Static Air Mattress Disadvantages:• Contact surface is not increased enough to reduce

pressure.• Not durable• Requires a second mattress below


Gel Mattress Advantages:• Comfortable• Viscous gel migrates through sectioned bladders

to relieve pressure around bony prominences.

Gel Mattress Disadvantages:• Contact surface is not increased enough to

reduce pressure.• Gel can dissociate and loose all its properties.• Not durable


Fiber Mattress advantages:• High quality patient comfort• Lasting durability• Easy Maintenance• Body is enveloped by the fiber• Used for very frail bony patients• Light weightFiber Mattress Disadvantages:• Pressure reducing properties are not enough• Rocking effect may cause dizziness to predisposed

patients• Requires a second mattress below


Foam Mattress CMHR advantages:• Longer useful life than non-HR foam• High tear strength• Ability of material to revert to its original shape after pressure

optimal lying comfort • Easy Maintenance• More Supple • Moulds body shape Maximize weight distribution Reduce

pressure• Extremely fire retardant, complies to institutional regulatory

standards Foam Mattress HR Disadvantages:• Used for Low to Medium risk patients only


Foam Mattress Visco-Elastic advantages:• Best in its class for static mattresses. • High quality patient comfort• Lasting durability• Easy Maintenance• Moulds the body allowing patient immersion thus

increasing the contact surface and decreasing the pressure.

• High Memory Foam


Foam Mattress Visco-Elastic advantages:• Heat sensitive property allows the top of the

mattress to be more supple whereas the deeper parts remains firm for a proper support. This maintains the physiological position of the patient maximizing the weight distribution.

• Used for Medium to High Risk Patient


Cover of the mattress is very important and should provide the following:

• Two way stretch Reduce friction and sheer effects.

• Elastic, otherwise it will limit the capacity of the mattress to reduce pressure

• Vapor Permeable evacuate heat patient comfort

• Fire Retardant Fire safety patient safety


• Water Resistant Prevent fluid contamination patient hygiene & safety

• Concealed Zip Fastening Prevent fluid contamination patient hygiene & safety

• Fully Fitted moulds to the shape of the bed Reduce friction and sheer effects

• Detachable cover machine washable easy to clean patient hygiene

Pressure Ulcer Skin Wound Protocol

Pressure Relief

Pressure UlcerPressure Relief

• Purpose is to reduce the duration of pressure and shear by changing the points of pressure.

• Pressure Relief can be done in two ways:– Scheduled alternated positioning– Specialized mattresses


• Scheduled alternated positioning– Change the position of the patient in a way that body

prominences at risk (points of pressure) are different.– Frequency per 24 hours/day, 7 days/week:

Laying Position• Every two hours if no pressure reduction mattress is used

Almost impossible to manage.• Every four hours when a good and appropriate pressure

reduction mattress is usedSeating Position• Every one hour if no pressure reduction cushion is used • Every two hours when a good and appropriate pressure

reduction cushion is used


• Specialized Mattresses are electric system that reduces the duration of the pressure and shear.

• Consist of an inflatable mattress and an electric pump.

• Overlay is placed over standard mattress and has the same effect as an active mattress.

• The cells / compartments of the mattress inflates and deflates in alternation.

• The form of the mattress, that is subject to patient body pressure, changes due to external factors (air pump).


• Differentiation points:– Pump characteristics– Availability of an “intelligent” feed-back

system– Diameter of the cells – Distinct compartments– Additional facilities– Cell structure– Cover


• Pump characteristics:– Quiet– Lightweight and Compact– Clear user instructions – Snap fit connectors, color coded – Adjustable pressure control (better if it is automatic)– Audio – visual alarms– Different settings: Pulsate, Therapy & Static– Comfort control


• Pump characteristics:– Equalized cell pressure when mattress is

disconnected from power unit (transport / power failure)

– Duration of the pressure: 9 to 10 minutes cycle.

– External fusibles to protect the pump from current fluctuations.


• Availability of an “intelligent” feed-back system :– Senses movement of patient– Automatic adjustment to individual patient

weight and position– Optimum pressure is delivered at all times

regardless of body mass.– Back-Raise sensor for semi-recumbent

position push more air in torso section for better support prevents bottoming-out


• Diameter of the cells :– Small cells (less then 10 cm) even when

inflated to the maximum, do not allow the body to elevates enough above the deflated cells.

– Cells larger then 10 cm are recommended.


• Distinct compartments:– Individual cells easy replacement– Tri zonal: comfort for head, torso & heel– Sloping heel section

• Additional Facilities:– Timed static facility– Static facility for fast transfer– CPR facility near head section for faster deflation– Intubation's facility


• The cell structure - number and form:– Double layer cell structure is more efficient then single

layer.

– Cells are linked between each others by series of 3 and same cycle is applied for both layers simultaneously:

1st max. inflation, 2nd half inflation, 3rd total deflation

1st half inflation, 2nd max. inflation, 3rd half inflation

1st total deflation, 2nd half inflation, 3rd max. inflation


• Cover :– Two way stretch Reduce friction and sheer effects.– Elastic maintain reduction property of mattress. – Vapor Permeable evacuate heat patient comfort– Fire Retardant Fire safety patient safety– Water Resistant Prevent fluid contamination patient

hygiene & safety– Concealed Zip Fastening Prevent fluid contamination

patient hygiene & safety – Fully Fitted moulds to the shape of the bed Reduce friction

and sheer effects– Detachable cover easy cleaning– Hoses covered as per disinfections properties


• Special mattresses:– Fluidized Air: Mattress is composed of silicom

particles inside a synthetic cover. When hot air is injected the silicon particles liquefies.

– Low air-loss: Reduce humidity build-up to to the air-loss.


Fluidized Air Advantages: • The body is totally immersed in the mattress which

maximizes the contact surface between the body and the mattress

• Excellent system for treating burns or wounds with high exudates.

Fluidized Air Disadvantages: • Very expensive• Extremely difficult to clean• Cannot be moved from 1 patient to another before a

special cleaning process has taken place.


Low Air loss Advantages: • Designed to provide very high degree of comfort • Constant air flow will help dry up wounds• Separate mattress system can be easily moved

from patient to patient and from bed to bed.• Easy to clean and decontaminate


Incontinence Care

Pressure Ulcer Incontinence Care

• Clean skin at time of soiling

• Provide quick drying surface (under pads) to the skin.

• Avoid hot water and too much soap while bathing.


Nutrition Consult

Pressure Ulcer Nutrition Consult

• Diet should have adequate calories and protein, vitamins and mineral supplements.

• Consult your dietician and doctor.• There is no direct link between bad

nutrition and pressure ulcer prevention however nutrition optimization ameliorates the general condition of the patient and helps the cicatrisation process.


Moisturize Skin

Pressure Ulcer Moisturize Skin

• Maintain good hygiene

• Wash with mild soap and warm water, rinse well and pat dry carefully and gently.

• Use moisturizers for dry skin

• Minimize environmental factors leading to dry skin (Low humidity, cold air)

• Do not massage skin over bony parts of the body (can damage tissue)


Positioning

Pressure Ulcer Positioning

• The intensity of the pressure is determined by the weight of the patient, his positioning and the hardness of the material he is seated in.

• The contact surface depends on the positioning: Surface redistribution of pressure Pressure


• Some facts:– In laying position: Avoid bottoming effect where the

patient is not sustained by the mattress but lies directly on the sub-adjacent surface, specially for obese patients.

– With a simple manual verification, we should not feel patient body.


• Some facts:– In laying position: when the bed head is

elevated, the pressure and shear effects increase.

– In seating position, the weight is redistributed in a small surface: more pressure then laying position.

– In seating position, a lateral or vertical inclination increases the pressure.

Pressure UlcerPositioning

• Dorsal Decubitus– Head and legs of the bed are elevated 30°:

maximum reduction of pressure and shear.– Preferred positioning for long periods.

http://www.health.fgov.be/vesalius/factory/publication/decubitus/fr/semifowler.htm


• Lateral Decubitus– Body forms a 30° angle with the mattress aided by a 30° cushion– The sacrum should not be under pressure.– Above leg is positioned behind the other one, tilted 30° at the

level of the hip and 35° at the level of knee.– Positioning can be made more comfortable with cushions– Use of inflatable cushions is not

recommended due to the effect of shear.

http://www.health.fgov.be/vesalius/factory/publication/decubitus/fr/lat%C3%A9ral30.htm


• Alternated positioning– Use as often as possible

Dorsal Decubitus positioning

– Alternate with lateral Decubitus positioning

• When using appropriate pressure reducing mattress, the schedule can be every 4 hours instead of 2 hours.

12

1

2

3

4

5

6

7

8

9

10

11

Semi-Fowler 30° - 30°30° 30°

L R

30°

Lat. 30°

Nom :

Mobilisation alternée

http://www.health.fgov.be/vesalius/factory/publication/decubitus/fr/horaire.htm


• Seating position in bed– Limit seating positions in bed because it is the cause

of shearing.– Preferred position is 60° but should be limited in

duration.– Use this position only for eating time.


• Ventral Decubitus– Should be used with soft mattress for comfort– To prevent pressure on feet, either place a cushion or remove

end of bed and slide down patient so that feet are outside mattress.

– Should observe pressure points: shoulder, thorax, basin, knees,

feet, ears.

Décubitus ventral

http://www.health.fgov.be/vesalius/factory/publication/decubitus/fr/ventral%20.htm


– Heel


• Seating– Slight dorsal inclination, legs resting on

support and heels free of pressure– In case dorsal inclination is not possible,

straight seating with both feet on floor


• Seating– Limit the duration of seating position: time spent on

chair should be less then time spent in fauteuil which is less then the bed.

– Armchair help stabilize the positioning of the person.– Avoid lateral and vertical sliding from chair.– Make sure that the person is well seated to provide

optimum contact surface. – Cushion and backs help to keep a right positioning.

The type should be studied case by case.


Wound Care

Pressure Ulcer Wound Care

- Debride – Ask your doctor- Surgical: most rapid, recommended for large necrotic areas.

- Mechanical: hydrotherapy, wound irrigation

- Enzymatic: collagenase to slow infection if present.

- Autolytic: via enzymes in wound fluid (very slow)

- Pick a dressing (must provide a-moist wound healing)- Transparent semi permeable films (eg Opsite, Tegaderm) for

Grade I & II

- Hydrocolloids (e.g. DuoDerm, Comfeel, Restore) for non infected Grade II & III

- Saline soaked gauze (covered by occlusive wrap) gently pack dead space for Grade II to IV

- Alignates: (eg. CalciCare, Kaltostat) for +++ exudates

Pressure Ulcer Wound Care

- Watch for infection and treat - Ask your doctor for proper treatment.

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

Pressure UlcerHealing signs

- The pressure ulcer will get smaller

- Pinkish tissue usually starts forming along the edges of the sore.

- Smooth or bumpy surfaces of new tissue

- Some bleeding may be present which shows good blood circulation.

Pressure Ulcer

Any Questions

Thank You for Your Time

how to prevent & cure pressure ulcers home mobility & park house solutions

Documents

intensity of pressure

pressure ulcer effects

pressure ulcer solution

pressure sores

direct pressure

risk slide

days slide

pressure surface ring