Pressure Ulcer

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  • 1. PRESSURE ULCER PREVENTION & TREATMENT Prepared by Linda Kennedy-Mull
  • 2. All SCI individuals are atrisk for developingpressure ulcers (PU).
  • 3. Pressure Ulcers occur more frequently in people with: More extensive  Irresponsible paralysis & behavior – completeness of SCI smoking/ETOH/drug Longer duration of abuse SCI  Poor nutrition Less functional  Those who won’t independence assume (para’s vs. quad’s) responsibility for skin care
  • 4. Incidence: 32-40% of individuals admitted to SCI units in the USA develop pressure ulcers during initial hospitalization:  37% of ulcers were sacral ulcers & of those, 50% were Stage III or IV.
  • 5. Recurrence ’97 study – 176 veterans with SCI had 35% recurrence rate; smoking, diabetes & coronary / vascular disease all associated with highest risk of recurrence.
  • 6. Costs: ’94 study – total cost of treatment was ~ $1,335 Billion / year.  69% of this provided in hospitals ’92 study – cost was:  ~ $70,000 to treat full thickness ulcer  ~ $20-30,000 to treat less serious ulcers
  • 7. RISK FACTORS Standard Risk Factors: Malnutrition  Friction  Incontinence Moisture  Shearing Loss of Sensation  Immobility
  • 8. RISK FACTORS Assess Degree of Risk Use Braden Scale:  Admission  Every time patient’s condition changes  Monthly in NHCU * Use clinical judgment as well
  • 9. RISK FACTORS Assess Demographic & Psych/social Risk Factors Age  Ethnicity, Cultural Values Sex  Cognition Marital Status  Substance Abuse Education  Psychological Health
  • 10. RISK FACTORS Normal Skin Largest single organ of the body Main function is to isolate & protect the body from environment Skin insulates the body & helps maintain core body temp Skin consists of 2 layers: Epidermis, Dermis
  • 11. RISK FACTORS Neurologically Impaired Skin SCIs have altered autonomic nervous system Degree of alteration varies with level of injury SCI above T6 changes functional properties of the skin-sweating reflex is lost SCIs are unable to maintain constant body temp in early stages following injury
  • 12. RISK FACTORS Neurologically Impaired Skin Changes that occur in skin:  Increase in collagen catabolism  Decrease in amino-acid metabolites in skin  Decrease in Type I & II collagen, which robs the skin of elasticity & strength  Skin is more fragile below injury  Decrease blood flow & supply below injury, which affects delivery of nutrients, etc. * Takes 3-5 years for changes to stabilize
  • 13. RISK FACTORSMuscle Atrophy Caused by Paralysis Produces loss of muscle bulk:  Less cushioning  Less protection  Less absorption of mechanical forces
  • 14. PHYSIOLOGY of WOUND HEALING Two Mechanisms of Repair  Regeneration: replacement of lost tissue with more of the same tissue  Connective Tissue Repair: lost tissue is replaced by scar formation  Type of Repair: determined by the tissue layer involved
  • 15. PHYSIOLOGY of WOUND HEALING Partial Thickness Wounds:  Dermal Repair: Epidermal Repair: Concurrent with Inflammatory response epithelialization  Epithelial  Angiogenesis proliferation  Fibroblasts  Migration become (resurfacing) plentiful– 7 days  Re-establishment  Collagen fibers of epidermal are visible – 10 layers days
  • 16. PHYSIOLOGY of WOUND HEALING Full Thickness Wounds: (3 Phases)  Inflammatory Phase (1-4 days)  Hemostasis  Characterized by: – Edema – Erythema – Heat – Pain  Macrophages arrive: destroy bacteria & clean wound  Produces chemo attractants & growth factors
  • 17. PHYSIOLOGY of WOUND HEALING Full Thickness Wounds (continued)  Proliferative Phase (3-20 days)  Granulation tissue develops  Wound contracts  Collagen is produced to give strength & elasticity  Maturation Phase (up to 2 years)  Begins when the wound has closed  Tensile strength of scar tissue =/<80%
  • 18. PRESSURE ULCERS Most pressure ulcers can be prevented, but sometimes even VIGILANT nursing care will not prevent the development or worsening of ulcers in some high-risk individuals.  Improving Nutrition  Managing Incontinence  Activating Prevention Measures  Frequent turning  Use of overlays, low air loss, etc.
  • 19. PRESSURE ULCERS (CONTINUED) Four Goals for Protection  Identify at risk individuals & factors placing them at risk  Maintaining & improving tissue tolerance to pressure  Protecting against adverse effects of external mechanical forces  Reducing incidence through education
  • 20. Severe Pressure Ulcer withBone Loss
  • 21. PRESSURE ULCERS Staging of Pressure Ulcers: WOCN Staging Stage I: non-blanching  Stage III: full thickness skin loss erythema of intact skin involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, Stage II: partial thickness skin the fascia. Presents as a deep loss involving epidermis &/or crater with or without dermis. Ulcer is superficial & undermining. presents as an abrasion, blister, or shallow crater  Stage IV: full thickness skin loss with extensive damage, * Staging Limitations: destruction,or necrosis of muscle,  Echar/slough prevents staging bone or supporting structures.  Identifying Stage I is difficult in Undermining & sinus tracts may be dark skin present  No reverse staging as wound heals
  • 22. Stage I Pressure Ulcer
  • 23. Stage II Pressure Ulcer
  • 24. Stage III Pressure Ulcer
  • 25. Stage IV Pressure Ulcer
  • 26. PRESSURE ULCERS Ulcer Assessment Stage the Ulcer  Drainage: exudate, transudate Location (serosanguinous), amount Size – measure weekly or more  Undermining, often,if dramatic Tunneling, Sinus change Tract
  • 27. PRESSURE ULCERS Ulcer Assessment (continued) Tissue Type: viable/non-viable, describe as red, yellow, tan, black, etc. Surrounding Skin:  Pain/sensation or lack of in SCI  Edema  Induration  Color  Maceration  Fungus  Hair present
  • 28. ULCER TREATMENT Goals  Treatment / Intervention  Evolve as the patient’s wound progresses  Pressure Relief  Dressings change from absorbent, to debriding,  REPOSTIONING to maintaining moist  Overlays, mattress wound environment replacement, static or  Patient & family dynamic, low air loss, air education fluidized
  • 29. SCI Pressure Relief
  • 30. Assisted Repositioning
  • 31. Types of Overlay Mattresses
  • 32. ULCER TREATMENT Debridement Enzymatic  Sharp  Autolytic Mechanical = whirlpool, wet-to-  Biosurgery = maggots dry, irrigation <30psi
  • 33. Maggot Treatments
  • 34. ULCER TREATMENT Electrical Stimulation  Appropriate Dressing  Increases oxygen & nutrient  Choice is based on 3 aspects: transport  Color of wound  Decreases edema  Depth of wound  Increases fibroblastosis  Exudates  Increases collagen development  Other considerations: • Indication: chronic wounds not  Infection responding to conservative tx  Tissue surrounding wound • Contraindicated: in osteo, malignancy, pacemakers, over  Fragility of skin pregnant uteruses, over heart or  Medical conditions impacting carotid sinuses, or over laryngeal healing musculature  Change Tx if wound has not Surgical improved after 2-4 wks or Immediately, if negative  Flap Repair outcome  Skin Graft
  • 35. Flap Repair
  • 36. Skin Grafting
  • 37. FACTORS IMPACTING WOUND HEALING Tissue Perfusion &  Extrinsic Factors Oxygenation –  Pressure impaired in SCI  Sheering  Friction Intrinsic Factors  Moisture  Steroid dependence  Medications  Immuno-suppression (antineoplastics,etc.)  Age  Disease  Malnutrition: albumin <3.5
  • 38. FACTORS IMPACTING WOUND HEALING Infection  Infection vs. Contamination  All chronic wounds are contaminated, but can still heal  Infection prolongs the Inflammation Phase & delays healing  Obtain appropriate cultures: superficial swab, needle aspiration, tissue biopsy.  Culture Technique: 10 point method
  • 39. FACTORS IMPACTING WOUND HEALING Treatment  Systemic antibiotics  Topical antiseptics, antimicrobial, antibiotic agents  NPUAP – do not use topical antiseptics to reduce Bacterial load. If used, limit to 2-3 days  Cytotoxic topical agents:  Betadine  Dakins (bleach)  Acetic Acid (vinegar)  Hydrogen Peroxide
  • 40. PREVENTION MEASURES Reposition at lease q2 hrs. using  Prevent moisture accumulation pillows or foam wedges  Use lifting devices to move Keep bony prominences from patient; friction injuries can be direct contact from one another prevented by using linen to move Provide total heel pressure relief patient, using lotion & films for patients who are immobile  At risk patient should be Side-to-side turning of no more automatically placed on a than 30 degrees rotation pressure reducing device: Keep head of bed at lowest  Zone-Aire Beds degree of elevation consistent  RIK Gel Flotation Mattresses with condition  Alternating Pressure Mattress  Water Mattress Limit amount of time HOB is elevated to prevent shearing
  • 41. PREVENTION MEASURES Chair bound patients need pressure relieving cushions – consult O.T. Chair bound patients need repositioning q 1 hr or taught to shift weight q 15 minutes Positioning of chair bound patients should include consideration of postural alignment, distribution of weight, balance, stability, & pressure relief Conduct DAILY comprehensive skin inspections Education of patient, family / significant other
  • 42. Roho Wheelchair Cushion