Lecture notes for students

1. Alice Pomidor, MD, MPH
Department of Geriatrics
Florida State University College of Medicine
Copyright 2010, Florida State University College of Medicine. This work was supported by a
grant from the Donald W. Reynolds Foundation. All rights reserved.
Pressure Ulcers, Skin
and Wound Care

2. Objectives
 Identify normal changes in aging skin and their
clinical impact
 Recognize risk factors for skin damage and
pressure ulcers
 Use the staging system for wounds
 Choose pressure relief devices and strategies
 Apply the 7 basic principles of wound care
 Recognize different wound care products and
their appropriate applications

3. Case: Mrs. G
 78 year old female type II diabetic
hypertensive with hyperlipidemia, probable
peripheral vascular disease
 Meds: felodipine, lisinopril, glyburide, aspirin
 Spot on foot, another on sacrum, recent
purulent drainage from foot
 Lived alone b/f hospitalized for hip Fx,
smokes ½ ppd x 40 years, was indep ADLs
 Pulses present 2+ carotids and radials, 2+
femorals, trace popliteals, DP & PT not
palpable bilaterally

4. Right foot

5. Increasing Age
Dermis:
Less blood supply
Less elastin, collagen
20% less thickness
10 – 20% fewer
melanocytes/decade
Clinical Effects:
Delayed wound healing
High prevalence of xerosis
Skin tears and blisters easily
Prone to sun damage, malignancy
Epidermis:
Less moisture
50% slower turnover
Flattened dermal-
epidermal junction
Skin Changes with
Aging

6. Risk Factors
 Decreased mobility
 Poor nutrition/hydration
 Vascular compromise
 Sensory impairment
 Multiple medical comorbidities
 Pressure: unrelieved on any firm surface
 Moisture: incontinence, in skin folds
 Friction: dragging across sheets, agitation
 Shear: sliding down in bed. pushing up w/heels

7. Describe & measure
accurately
 Look!
 Must see base of wound
 The presence of necrotic material
means the wound cannot be staged: “at
least” a stage III
 Record all 3 dimensions of length, width
and depth

8. Stage I: Erythema not resolved w/in 30 min pressure relief.
Epidermis remains intact. Reversible with intervention.
Stage II: Abrasion, blister, or shallow crater w/ partial-
thickness skin loss of epidermis and/or dermis. No
subcutaneous necrosis.
Stage III: Crater unless covered by eschar. Full-thickness
skin loss through the dermis into subcutaneous tissue.
Stage IV: Deep crater, tissue destruction extending to
fascia, possibly including muscles, tendons, joint capsule,
and/or bone.
Wound Staging

9. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

10. Put the patient in the right
place at the right time
 Choose appropriate support surfaces
 Change positions q2h when supine &
q1h when up
 Reevaluate the wound q1-2 weeks

11. Extremity padding
Heelbo/Elbo
Ankle ring
Heel pillow
Multipodus splint

12. Pressure Relief
Seating
Gel
Foam
Roho
Eggcrate
Sheepskin

13. Pressure Relief Beds
Low Air Loss
Air-fluidized
Alternating
mattress overlay

14. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

15.  Macrodebridement
– Sharp vs. blunt
– Maggots
 Microdebridement
– Wet-to-dry dressings
 Enzymatic debridement
– Collegenase
– Papain
 Autolytic debridement
– Occlusive dressings
“ Clean” Wound

16. Dressings-Gauze

17.  All wounds are colonized
 No surface cultures; deep cultures OK
 Anaerobic organisms plus skin flora
 Cellulitis—reactive vs. infective
hyperemia
 Consider osteomyelitis if less than 1 cm
from a bony surface and/or no healing
in 3 months
 Local agents only reduce overgrowth
(silver, metronidazole, mesalt)
Uninfected Wound

18. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

19. Moist environment
 If it’s wet, dry it (alginate, hydrofiber,
foam)—excess drainage apparent
 If it’s dry, wet it (hydrogel)—secondary
film of dried material will become visible
 If it’s just right, keep it that way
(hydrocolloid or hydrogel)

20. Minimize disruption
 Dressing changes traumatize the healing
wound surface
 Goal: once per day
 Better: even less often!
 Also more cost effective when accounting
for nursing time

21. Barrier Creams
Ointments
Dessicators,
Antiseptics
Enzymes
Protease Inhibitors
Platelet
Growth Factor
Creams & Ointments

22. •Zinc, A&D, petroleum
•Dakin’s solution, iodoform, peroxide
•Silvadene, metronidazole, antibiotic
Creams & Ointments

23. Antiseptic
Dressings
Impregnated
Gauzes
Thin Films:
Opsite, Tegaderm
Foam
Wafers
Dressings/Films

24. Dressings/Films

25. Dressings/Films

27. Hydrocolloids
Hydrogels
Alginates,
hydrofibers
Biologicals
& Grafts
Gels, Colloids plus

28. Gels, Colloids, Alginates,
Biologicals

31. Describe/measure wound accurately
Put the patient in the right place at the right time
Achieve a clean, uninfected wound
Provide a moist environment suitable for healing
Minimize disruption of wound surface
Prevent damage to viable tissue: SALINE!
Feed, water, oxygenate the patient to
compensate for fluid and calorie loss
Wound Care Principles

32. Preserve viable tissue
 Everything except saline is cytotoxic in
wet-to-dry dressings
 Always use saline for cleansing
 Beware of commercial cleansers or
antibiotic topicals
 Protect the surrounding skin (tape
anchors, petroleum)
 Shield wound/skin from incontinence

33. Feed, water and
oxygenate
 Stress-level protein/calorie replacement
– 1.5 gm/kg/d of protein
– 30 kcal/kg/d
 Minimum 125% daily fluid requirements
for insensible loss & drainage
 Consider transfusion for Hgb <9.0
 Keep blood sugars below 200
 Assess nutrition by Hgb & prealbumin
q2 wks

34. Compression: Ted hose, Jobst stockings, etc.
Support surfaces: Foam, gel, air and fluid-filled, etc.
Negative pressure therapy: lg, high-exudate wounds
Hydrotherapy: whirlpool debridement
Hyperbaric oxygen: anaerobic, radiation, salvage sites
Electrotherapy: low-intensity DC, AC. Limited data and
reimbursement
Ultrasound: results equivocal at best
Supplements: pentoxifylline, zinc, vit. C, oxandrolone
Adjuvant Therapies

36. Mrs. G’s studies
 Labs:
– Glucose 200-280’s
– Basic metabolic panel otherwise normal
– Hgb/Hct 10/ 30
– WBC 14.9, no shift
– Albumin 3.0
 X-ray: Negative for osteomyelitis
 Dopplers: Significantly impaired arterial blood flow,
right greater than left
 Arteriogram: Significant disease of the trifurcation,
reconstituted below with collaterals

37. Mrs. G’s treatment
plan
 Use silver alginate/hydrofiber daily to the foot to
keep it moist
 Debride sacral wound until the base can be seen;
consider enzyme to assist break up of slough
 Refer to vascular surgeon for evaluation of possible
femoropopliteal bypass later
 If bone visible on sacrum, IV antibiotics for possible
osteomyelitis followed by oral therapy for total 8
week course
 Start protein supplement and check prealbumin,
Hgb 2 weeks later
 Reduce blood sugars by increase in oral therapy
and use of sliding scale insulin to target range
150’s

38. Mrs. G’s treatment
plan
 Use extremity padding of some type; order mattress
overlay
 Consider physiatry consult for weight-bearing
reduction orthotic for right foot as well as usual hip
rehab therapy
 Encourage to walk to increase blood flow
 Check fasting lipid profile
 Reduce blood pressure with ACE inhibitor
 Encourage to stop smoking
 Consider subacute/nursing home placement for wound
care and physical therapy

39. Objectives
 Identify normal changes in aging skin and their
clinical impact
 Recognize risk factors for skin damage and
pressure ulcers
 Use the staging system for wounds
 Choose pressure relief devices and strategies
 Apply the 7 basic principles of wound care
 Recognize different wound care products and
their appropriate applications