DECUBITUS ULCERS PRESSURE ULCERS Any lesion caused by unrelieved pressure that causes local interference with circulation

n and subsequent tissue damage. Pressure ulcers commonly called bedsore or pressure sores PATHOPHYSIOLOGY: Pressure ulcer is caused by an injury to the skin and its underlying tissue Pressure exerted (area) = hypoxemia and ischemia to affected tissues ( blood flow to the site As the capillaries collapse, thrombosis occurs which leads to tissue edema and progression to tissue necrosis Ischemia adds to an accumulation of waste products at the site production of toxins Toxins further breaks down the tissue and eventually lead to cell death Deep lesions commonly go undetected until they penetrate the skin subcutaneous damage STAGE 1 Area of eryhtema - RED Erythema does not blanch with pressure Skin temperature elevated Tissue swollen and congested Patient complains of discomfort Erythema progresses to dusky blue gray STAGE II Skin breaks Abrasion, blister or shallow crater Edema persist Ulcer drains Infection may develop Partial thickness wound STAGE III Ulcer extends into subcutaneous tissue Necrosis and drainage continue Infection develops Full thickness wound STAGE IV Ulcer extends to underlying muscle and bone Deep pockets of infection develop Necrosis and drainage continue Full thickness wound The Braden Scale for Predicting Pressure Ulcer Risk, is a scale to help health

professionals, especially nurses, assess a patient's risk of developing a pressure ulcer The BRADEN SCALE assesses a patient's risk of developing a pressure ulcer by examining six criteria: 1.Sensory Perception measures ability to detect and respond to discomfort or pain that is related to pressure on parts of the body. The ability to sense pain and level of consciousness of a patient and therefore their ability to cognitively react to pressure-related discomfort. 2. Moisture assesses the degree of moisture the skin is exposed to. Excessive and continuous skin moisture can pose a risk to compromise the integrity of the skin by causing the skin tissue to become macerated and therefore be at risk for epidermal erosion 3. Activity clients level of physical activity since very little or no activity can encourage atrophy of muscles and breakdown of tissue. 4. Mobility capability of a client to adjust their body position independently. This assess the physical competency to move and can involve the clients willingness to move 5. Nutrition Nutritional status is assessed - normal patterns of daily nutrition. Eating only portions of meals or having imbalanced nutrition can indicate a high risk in this category. 6. Friction and Shear Friction and shear looks at the amount of assistance a client needs to move and the degree of sliding on beds of chairs that they experience. Assess sliding motion can cause shear Scoring with the Braden Scale Each category is rated on a scale of 1 to 4, excluding the 'friction and shear' category which is rated on a 1-3 scale. Total = 23 points, with a higher score meaning a lower risk of developing a pressure ulcer and vice-versa.

Score 23 - no risk for developing a pressure ulcer while Score 6 - severest risk for developing a pressure ulcer.

Prolonged pressure impedes blood flow, reducing nourishment of the skin and underlying tissues pressure ulcer develops 3. Decrease Tissue Perfusion DM patients compromised microcirculation Edema patients impaired circulation & poor nourishment Obese patients large amounts of poorly vascularize adipose tissue- susceptible to break down 4. Decreased Nutritional status - Nutritional deficiencies - protein tissue wasting and inhibited tissue repair Vit C and trace minerals tissue maintenance and repair - Anemia - hemoglobin - Metabolic disorders 5. Friction and Shear Shear occurs tissue layers slide over one another, blood vessels stretch and twist and microcirculation disrupted. Sacrum and heels most susceptible to the effects of shear 6. Increase moisture Prolong contact with moisture from perspiration, urine, feces, or drainage produces maceration (softening) ,irritation, breakdown of the skin Microorganisms invade broken skin Foul smelling infectious drainage is present Lesion continue to enlarge and extend deep into the fascia, muscle, and bone SEPSIS Management: 1.Relieving pressure - teach patient to change position or by turning and repositioning the patient - shifting weight allows the blood to flow into the ischemic area Push ups pushes down on arm rests and raises buttocks off the seat of the chair. One half push-up repeats the push on the right side & then the left, pushing up on one side by pushing down on the armrest

An adult with a score below 18 is considered to have a high risk for developing a pressure ulcer. Risk Factors for Development of Pressure Ulcers 1. Immobility pressure is exerted on the skin and subcutaneous tissue by objects on which the person rests (mattress, chair or cast) - weight bearing bony prominences (most susceptible) because they are covered only by skin and small amounts of subcutaneous tissue. Immobility (bed and chair bound clients) Impaired sensory perception or cognition Decreased tissue perfusion Decreased nutritional status Friction, shear Increased moisture Areas Susceptible to Pressure Ulcers

2. Impaired Sensory Perception or cognition - may not be aware of the discomfort associated with prolong pressure May not change their position to relieve pressure

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Moving side to side - Moves from one side to the other while sitting on the chair. Shifting - Bends forward with the head down between the knees(if able) and constantly shift in the chair. Positioning the patient Patients able to shift their weight every 15-20 min and move independently may change total position every 2-4 hours. Change position at least every 2 hours to relieve pressure (loss of sensation,paralysis,coma,edema) Bridging technique support client with pillows 30 degree on a side lying position avoids pressure on the trochanter. Small rolled towel under the shoulder or hip Using pressure relieving devices Use items that can help reduce pressure -pillows, sheepskin, foam padding, and powders. Gel type flotation pads and air fluidized beds Oscillating or kinetic beds change pressure by rocking movements multiple trauma patients Improving Mobility Encourage to remain active and is ambulated whenever possible Active and passive exercises increase muscular, skin and vascular tone Improving Sensory perception Stimulate increase awareness of self in the environment. Encourage to participate in self care Support the clients efforts towards active compensation for loss of sensation (paraplegia- lifting from the sitting position every 15 minutes) Decreased sensation inspect potential pressure areas visually (AM/PM) using a mirror Improving tissue perfusion Activity, exercise and repositioning Massage of erythematous areas AVOIDED because damage to the capillaries and deep tissues may occur. Do NOT massage the area of the ulcer. Massage can damage tissue under the skin.

7. Improving Nutritional Status Eat well-balanced meals that contain enough calories to keep you healthy. Drink plenty of water (8 to 10 cups) every day. High protein diet Iron preparations to raise the hemoglobin concentration Ascorbic acid for tissue healing, promotes collagen synthesis Vit A, B, zinc 8. Reducing friction and shear Shear occurs when the patient is pulled, allowed to slump or move by digging heals or elbows into the mattress. SEMIRECLINING POSITION - AVOIDED 9. Minimize irritating moisture - Meticulous hygiene measures especially in skin folds, areas under the breasts,arms, groin, and between the toes. - Perspiration, urine, stool, and drainage must be removed from the skin promptly - Soiled skin washed immediately with mild soap and water and blotted dry with a soft towel. Lubricate skin with a bland lotion to keep it soft and pliable. Drying agents and powders are avoided. Absorbent pads to absorb drainage 10.Promote pressure ulcer healing Debridement- wet to damp dressing changes, mechanical flushing Culture and sensitivity After pressure ulcer is clean topical treatment to promote granulation Negative-pressure wound therapy (NPWT) is a therapeutic technique using a vacuum dressing to promote healing in acute or chronic wounds and enhance healing of first and second degree burns. It involves the controlled application of subatmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump. Negative-pressure wound therapy (NPWT Promotes wound healing by applying a vacuum through a special sealed dressing.

The continued vacuum draws out fluid from the wound and increases blood flow to the area. The vacuum may be applied continuously or intermittently Dressing is changed 2 3 times per week.

Bone resection Skin grafting 11. Prevent recurrence Teach patient to increase mobility Follow a regimen of turning, weight shifting and repositioning

Hyperbaric medicine, also known as hyperbaric oxygen therapy (HBOT), is the medical use of oxygen at a level higher than atmospheric pressure. The equipment - pressure chamberdelivers 100% oxygen Promotes healing by stimulating new vascular growths Signs of an infected ulcer include: A foul odor from the ulcer Redness and tenderness around the ulcer Skin close to the ulcer is warm and swollen

When complicatons exist and does not respond to treatment Surgical debridement Incission and drainage Bone resection Skin grafting Care and Treatment of Pressure Ulcers Deep tissue injury Immediate pressure relief to affected area Stage I: Remove pressure Prevent moisture, shear, friction Promote proper nutrition, hydration Stage II: Clean with sterile saline Semipermeable occlusive dressings, hydrocolloid dressings, or wet saline dressings provide moist healing environment Stage III and Stage IV: Debridement to remove infected, necrotic tissues Wet-to-damp dressing Enzyme preparations Surgical debridement Topical treatment to promote granulation of tissue Surgical interventions may be required