Pressure Sores


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Pressure Sores

  1. 1. Jorge G. Ruiz, MD, FACP Division of Gerontology and Geriatric Medicine University of Miami School of Medicine Pressure Ulcers
  2. 2. Pressure Ulcers <ul><li>Epidemiology </li></ul><ul><li>Definition and Location </li></ul><ul><li>Classification </li></ul><ul><li>Pathogenesis and Risk Factors </li></ul><ul><li>Prevention </li></ul><ul><li>Treatment </li></ul><ul><li>Pressure Ulcers treatment for each stage </li></ul><ul><li>Complications </li></ul>
  3. 3. Epidemiology
  4. 4. Pressure Ulcers Epidemiology <ul><li>1-3 million Americans are affected </li></ul><ul><li>Health care expenditures: $ 5 billion/year </li></ul><ul><li>More than 17,000 lawsuits related to pressure Ulcers are filed annually </li></ul><ul><li>1 in 4 persons in the USA who died in 1987 had a dermal ulcer </li></ul><ul><li>Pressure Ulcers develop primarily in elderly patients </li></ul>
  5. 5. Pressure Ulcers Epidemiology <ul><li>Setting </li></ul><ul><ul><li>Hospital 60% </li></ul></ul><ul><ul><li>Nursing homes 18% </li></ul></ul><ul><ul><li>Home 18% </li></ul></ul><ul><li>1/3 of patients undergoing surgery for hip fracture develop a pressure ulcer </li></ul><ul><li>The longer the patient stays in a nursing home, the greater the likelihood of developing a pressure ulcer </li></ul>
  6. 6. Definition and Location
  7. 7. Pressure Ulcers Definition <ul><li>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. </li></ul><ul><li>These lesions are also called bedsores, decubitus ulcers and pressure sores </li></ul>
  8. 8. Pressure Ulcers Location <ul><li>Pressure ulcers commonly occur over the : </li></ul><ul><ul><li>Sacrum </li></ul></ul><ul><ul><li>Greater trochanter </li></ul></ul><ul><ul><li>Ischial tuberosity </li></ul></ul><ul><ul><li>Malleolus </li></ul></ul><ul><ul><li>Heel </li></ul></ul><ul><ul><li>Fibular head </li></ul></ul><ul><ul><li>Scapula </li></ul></ul>
  9. 10. Areas of pressure
  10. 11. Classification
  11. 12. Pressure Ulcers / Classification National Pressure Ulcer Advisory Panel <ul><li>Stage 1: non blanchable erythema of intact skin </li></ul><ul><li>Stage 2: partial thickness skin loss that involves the epidermis or dermis (or both) </li></ul><ul><li>Stage 3: full thickness skin loss and damage or necrosis of subcutaneous tissue that may extend to, but not through, underlying fascia </li></ul><ul><li>Stage 4: full thickness skin loss associated with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures, such as tendons or joint capsules </li></ul>
  12. 14. Stage 1 The heralding lesion of skin ulceration
  13. 16. Stage 2 The ulcer is superficial and manifest clinically as an abrasion, blister or shallow crater
  14. 18. Stage I-II Pressure sore
  15. 19. Stage 3 The ulcer manifests clinically as a deep crater with or without undermining of adjacent tissue
  16. 21. Stage 4 A B
  17. 23. Stage IV Pressure sore
  18. 24. Pressure Ulcers Staging. Limitations <ul><li>Staging definitions recognize these assessment limitations: </li></ul><ul><li>Identification of Stage I pressure ulcers may be difficult in patients with darkly pigmented skin. </li></ul><ul><li>When eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided. </li></ul>
  19. 25. Pathogenesis and Risk Factors
  20. 26. Pressure Ulcers Pathogenesis <ul><li>Four key factors: </li></ul><ul><ul><li>Pressure </li></ul></ul><ul><ul><li>Shearing forces </li></ul></ul><ul><ul><li>Friction </li></ul></ul><ul><ul><li>Moisture </li></ul></ul>
  21. 27. Pathogenesis
  22. 28. Pressure Ulcers Risk Factors <ul><li>Spinal cord injuries </li></ul><ul><li>Traumatic brain injury </li></ul><ul><li>Neuromuscular disorders </li></ul><ul><li>Immobility </li></ul><ul><li>Malnutrition </li></ul><ul><li>Fecal and urinary incontinence </li></ul><ul><li>Altered level of consciousness </li></ul><ul><li>Chronic systemic illness </li></ul><ul><li>Fractures </li></ul><ul><li>Aging skin </li></ul><ul><ul><li>decreased epidermal turnover </li></ul></ul><ul><ul><li>dermoepidermal junction flattens </li></ul></ul><ul><ul><li>fewer blood vessels </li></ul></ul><ul><li>Decreased pain perception </li></ul>
  23. 29. Prevention
  24. 30. Pressure Ulcers Risk Assessment <ul><li>Select and use a method of risk assessment that ensures systematic evaluation of individual risk factors. </li></ul><ul><li>Many risk assessment tools exist, but only the Norton Scale and Braden Scale have been tested extensively. </li></ul><ul><li>Tools include the following risk factors: mobility/activity impairment, moisture, incontinence, and impaired nutrition. </li></ul>
  25. 31. Pressure Ulcers Activity or Mobility Deficit <ul><li>Bed- or chair-bound individuals or those whose ability to reposition is impaired should be considered at risk for pressure ulcers. </li></ul><ul><li>Identification of additional risk factors (immobility, moisture/incontinence, and nutritional deficit) should be undertaken to direct specific preventive treatment regimes. </li></ul>
  26. 32. Pressure Ulcers Educational Program <ul><li>Educational programs for the prevention of pressure ulcers should be: </li></ul><ul><ul><li>Structured </li></ul></ul><ul><ul><li>Organized </li></ul></ul><ul><ul><li>Comprehensive </li></ul></ul><ul><ul><li>Directed at all levels of health care providers, patients, and family or caregivers. . </li></ul></ul>
  27. 33. Pressure Ulcers Reassessment <ul><li>Active, mobile individuals should be periodically reassessed for changes in activity and mobility status. </li></ul><ul><li>The frequency of reassessment depends on patient status and institutional policy. </li></ul>
  28. 34. Pressure Ulcers/Mechanical Loading and Support Surfaces <ul><li>For bed-bound individuals: </li></ul><ul><li>Reposition at least every 2 hours. </li></ul><ul><li>Use pillows or foam wedges to keep bony prominences from direct contact. </li></ul><ul><li>Use devices that totally relieve pressure on the heels. </li></ul><ul><li>Avoid positioning directly on the trochanter. </li></ul>
  29. 35. Pressure Relieving Devices
  30. 36. Pressure Relieving Boot
  31. 37. Pressure Ulcers/ Mechanical Loading and Support Surfaces <ul><li>Elevate the head of the bed as little and for as short a time as possible. </li></ul><ul><li>Use lifting devices to move rather than drag individuals during transfers and position changes. </li></ul><ul><li>Place at-risk individuals on a pressure-reducing mattress. </li></ul><ul><li>Do not use donut-type devices. </li></ul>
  32. 38. Pressure Ulcers/ Mechanical Loading and Support Surfaces <ul><li>For chair-bound individuals: </li></ul><ul><li>Reposition at least every hour. </li></ul><ul><li>Have patient shift weight every 15 minutes </li></ul><ul><li>Pressure-reducing devices for seating surfaces. Do not use doughnut-type devices. </li></ul><ul><li>Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning individuals in chairs or wheelchairs. </li></ul>
  33. 39. Pressure Ulcers Skin Care and Early Treatment <ul><li>Inspect skin at least once a day. </li></ul><ul><li>Individualize bathing schedule (Avoid hot water and mild cleansing agent) </li></ul><ul><li>Minimize environmental factors such as low humidity and cold air. </li></ul><ul><li>Use moisturizers for dry skin </li></ul><ul><li>Avoid massage over bony prominences. </li></ul><ul><li>Use proper positioning, transferring, and turning techniques. </li></ul><ul><li>Use lubricants to reduce friction injuries. </li></ul><ul><li>Rehabilitation program. </li></ul><ul><li>Monitor and document interventions/outcomes. </li></ul>
  34. 40. Pressure Ulcers Nutritional Deficit <ul><li>Investigate factors that compromise an apparently well-nourished individual's dietary intake. </li></ul><ul><li>Plan and implement a nutritional support and/or supplementation program for nutritionally compromised individuals. </li></ul>
  35. 41. Treatment
  36. 42. Assessment <ul><li>History and Physical Examination </li></ul><ul><li>Assessing Complications </li></ul><ul><li>Nutritional Assessment and Management </li></ul><ul><li>Pain Assessment and Management </li></ul><ul><li>Psychosocial Assessment and Management </li></ul>
  37. 43. Pressure Ulcers Ulcer care <ul><li>The four basic components </li></ul><ul><li>debridement of necrotic tissue as needed on initial and subsequent assessments </li></ul><ul><li>cleansing the wound initially and with each dressing change </li></ul><ul><li>prevention, diagnosis, and treatment of infection </li></ul><ul><li>using a dressing that keeps the ulcer bed moist and the surrounding intact tissue dry </li></ul>
  38. 44. Debridement <ul><li>Moist, devitalized tissue supports the growth of pathological organisms. </li></ul><ul><li>Therefore, the removal of such tissue favorably alters the healing environment of a wound. </li></ul><ul><li>Removal of devitalized tissue is considered necessary for wound healing </li></ul><ul><li>It has not been studied in a randomized trial. </li></ul>
  39. 45. Eschar tissue
  40. 46. Eschar tissue
  41. 47. Granulating tissue & necrotic tissue
  42. 48. Wound Cleansing <ul><li>Remove necrotic tissue, exudate, and metabolic wastes from the wound. </li></ul><ul><li>Minimum of chemical and mechanical trauma. . </li></ul><ul><li>Cleanse wounds initially and at each dressing change </li></ul><ul><li>Do not clean ulcer wounds with skin cleansers or antiseptics </li></ul><ul><li>Use normal saline for cleansing </li></ul><ul><li>Consider whirlpool treatment for ulcers that contain thick exudate, slough, or necrotic tissue. </li></ul>
  43. 49. Dressings <ul><li>Keep the ulcer bed continuously moist. </li></ul><ul><li>Wet-to-dry dressings should be used only for debridement </li></ul><ul><li>No differences in pressure ulcer healing outcomes with diverse dressings </li></ul><ul><li>Keep the surrounding intact (periulcer) skin dry while keeping the ulcer bed moist. </li></ul>
  44. 50. Dressings <ul><li>Control exudate but do not desiccate the ulcer bed. </li></ul><ul><li>Consider caregiver time </li></ul><ul><li>Eliminate wound dead space by loosely filling all cavities with dressing material. </li></ul><ul><li>Avoid overpacking the wound. </li></ul><ul><li>Monitor dressings applied near the anus </li></ul>
  45. 51. Adjunctive Therapies <ul><li>The therapies included : </li></ul><ul><ul><li>electrical stimulation </li></ul></ul><ul><ul><li>hyperbaric oxygen </li></ul></ul><ul><ul><li>infrared and ultraviolet light </li></ul></ul><ul><ul><li>low-energy laser irradiation </li></ul></ul><ul><ul><li>ultrasound </li></ul></ul><ul><ul><li>miscellaneous topical agents (including cytokine growth factors) </li></ul></ul><ul><ul><li>systemic drugs other than antibiotics </li></ul></ul>
  46. 52. Pressure Ulcers Treatment for each stage
  47. 53. Stage 1 <ul><li>Intensive implementation of preventive measures as usual </li></ul><ul><li>Polyurethane dressings (transparent) applied every 1 to 10 days (Tegaderm  ) </li></ul><ul><li>They are semipermeable films, permeable to water vapor, oxygen and other gases and impermeable to water and bacteria </li></ul><ul><li>Most lesions can be expected to heal by 2 weeks </li></ul>
  48. 54. Stage 2 <ul><li>The same as for stage I but… </li></ul><ul><li>Wound should be inspected for signs of infection </li></ul><ul><li>Polyurethane dressings are more effective and less costly than wet-to-dry dressings (Tegaderm  or thin Duoderm  ) </li></ul><ul><li>Wet-to-dry dressings are rarely indicated at this stage </li></ul>
  49. 55. Stage 3 <ul><li>Remove necrotic material </li></ul><ul><li>Small eschar: </li></ul><ul><ul><li>Debridement by experienced PCP </li></ul></ul><ul><ul><li>Topical application of enzymatic debriding agents </li></ul></ul><ul><ul><ul><li>Eschar should be scored </li></ul></ul></ul><ul><ul><ul><li>Enzymes must not touch surrounding areas </li></ul></ul></ul><ul><li>Large eschar: Surgical consultation </li></ul>
  50. 56. Stage 3 <ul><li>Loose material can be debrided with wet-to-dry dressings every 8 hours </li></ul><ul><li>Polyurethane and hydrocolloid dressings (Duoderm  ) are more effective </li></ul><ul><li>Hydrocolloids are impermeable to gas and moisture and are changed every 1-4 days </li></ul><ul><li>Deeper stage 3 or 4: Wounds need to be packed with material depending on exudate </li></ul>
  51. 57. Stage 3 <ul><li>Hydrocolloid dressings are not appropriate </li></ul><ul><ul><li>Dry wounds: less absorptive Hydrogels or moist soaks with normal saline </li></ul></ul><ul><ul><li>Exudative wounds: Absorptive dressings such as Hydrophilic foam alginates (Kaltostat  ) or saline impregnated gauze </li></ul></ul><ul><li>Packings are changed daily </li></ul>
  52. 58. Stage 3 <ul><li>Consider specialized beds: </li></ul><ul><ul><li>air fluidized beds </li></ul></ul><ul><ul><li>low-air-loss beds </li></ul></ul><ul><li>They should be used for at least 60 days </li></ul><ul><li>Patients with large defects: surgery consult </li></ul><ul><li>Patients with large defects in the sacral area and urinary incontinence may require catheterization </li></ul>
  53. 59. Low Air Loss Mattress
  54. 60. Stage 4 <ul><li>They require surgical consultation for initial debridement </li></ul><ul><li>Wet-to-dry dressings may help </li></ul><ul><li>Whirlpool baths may facilitate debridement </li></ul><ul><li>Clean deep ulcers require packing </li></ul><ul><li>Consider grafting procedures </li></ul><ul><li>Always keep in mind the goals of the patient </li></ul>
  55. 61. Managing Bacterial Colonization and Infection <ul><li>Stage 2, 3 and 4 pressure ulcers are invariably colonized with bacteria. </li></ul><ul><li>In most cases, adequate cleansing and debridement prevent bacterial colonization from proceeding to the point of clinical infection </li></ul><ul><li>If purulence or foul odor is present, more frequent cleansing and possibly debridement are required. </li></ul>
  56. 62. Infected Pressure Sore
  57. 63. Managing Bacterial Colonization and Infection <ul><li>Do not use swab cultures to diagnose wound infection (colonization) </li></ul><ul><li>Consider 2-week trial of topical antibiotics for clean pressure ulcers that are not healing or producing exudate </li></ul><ul><li>Effective against gram negative, positive, and anaerobes </li></ul><ul><li>Perform quantitative bacterial cultures of soft tissue and evaluate for osteomyelitis when ulcer does not respond to topical antibiotic therapy. </li></ul>
  58. 64. Managing Bacterial Colonization and Infection <ul><li>Systemic antibiotic therapy for patients with bacteremia, sepsis, advancing cellulitis, or osteomyelitis. </li></ul><ul><li>Do not use topical antiseptics (povidone iodine, iodophor, Dakins® solution, hydrogen peroxide, acetic acid) to reduce bacteria in wound tissue. </li></ul><ul><li>Systemic antibiotics are not required for pressure ulcers with signs of local infection. </li></ul><ul><li>Protect pressure ulcers from exogenous sources of contamination </li></ul>
  59. 65. Infection Control <ul><li>Follow body substance isolation precautions or an equivalent system. </li></ul><ul><li>Use clean gloves for each patient. </li></ul><ul><li>When treating multiple ulcers on the same patient, attend to the most contaminated ulcer last </li></ul><ul><li>Use sterile instruments to debride ulcers </li></ul><ul><li>Use clean dressings, rather than sterile ones, to treat pressure ulcers. </li></ul>
  60. 66. Operative Repair of Pressure Ulcers <ul><li>Operative procedures to repair pressure ulcers include one or more of the following: </li></ul><ul><ul><li>Direct closure </li></ul></ul><ul><ul><li>Skin grafting </li></ul></ul><ul><ul><li>Skin flaps </li></ul></ul><ul><ul><li>Musculocutaneous flaps </li></ul></ul><ul><ul><li>Free flaps. </li></ul></ul>
  61. 67. Operative Repair of Pressure Ulcers <ul><li>Consider for operative repair when clean Stage III-IV do not respond to optimal patient care </li></ul><ul><li>Candidates are medically stable, well nourished and can tolerate operative blood loss and postop immobility. </li></ul><ul><li>Correct factors that may be associated with impaired healing (smoking, spasticity, levels of bacterial colonization, incontinence, and UTI) </li></ul><ul><li>Minimize pressure to the operative site by use of special beds </li></ul>
  62. 68. Assessment of Ulcer Healing <ul><li>Evaluate at least weekly </li></ul><ul><li>If general condition deteriorates, the ulcer should be reassessed promptly </li></ul><ul><li>Evaluate using size, depth, presence of exudate, epithelialization, granulation tissue, necrotic tissue, sinus tracts, undermining, tunneling, purulent drainage or signs of infection. </li></ul><ul><li>A clean pressure ulcer with adequate innervation and blood supply should show progress toward healing in 2 to 4 weeks </li></ul>
  63. 69. Monitoring <ul><li>Healing ulcers should be assessed regularly </li></ul><ul><li>Monitor the individual's general health, nutritional status, psychosocial support, pain level and be alert to signs of complications </li></ul><ul><li>The frequency of monitoring should be determined by the clinician based on the condition of the patient, ulcer, rate of healing, and the health care setting. </li></ul>
  64. 70. Complications
  65. 71. Pressure Ulcers Complications <ul><li>Amyloidosis </li></ul><ul><li>Endocarditis </li></ul><ul><li>Heterotopic bone formation </li></ul><ul><li>Maggot infestation </li></ul><ul><li>Meningitis </li></ul><ul><li>Perineal-urethral fistula </li></ul><ul><li>Pseudoaneurysm </li></ul><ul><li>Septic arthritis </li></ul><ul><li>Sinus tract or abscess </li></ul><ul><li>Squamous cell carcinoma in the ulcer </li></ul><ul><li>Systemic complications of topical treatment </li></ul><ul><li>Osteomyelitis </li></ul><ul><li>Bacteremia </li></ul><ul><li>Advancing cellulitis </li></ul>
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