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Pressure sore diagnosis and management for medical student
- 3. INTRODUCTION • Pressure ulcers = damage of soft tissue that get compressed between bony prominence and external surface for prolonged period of time • Risk groups: people who cannot avoid long-term uninterrupted pressure over bony prominences • Elderly • Neurologic impairment • Acute hospitalization
- 4. COMMON LOCATIONS • Hip and buttock 70% • Ischial tuberosity,trochanteric and sacral locations • Lower extremities 15-25% • Malleolar, heel, patellar and pretibial locations • Others • Nose, chin,forehead,occiput,chest,back, elbow ทุกที่สามารถเกิด pressure sore ได/
- 5. ETIOLOGY OF PRESSURE SORE • Impaired mobility • prolonged uninterrupted pressure • Muscle and soft tissue atrophy à bony prominences got less protection • Inability to perceive pain: most important stimuli for repositioning • Friction and shear forces: eg. Spasticity,moving of patient • Skin tear à bacterial contamination, water loss, maceration and adherence to clothing • Quality of skin • Atrophy, decrease rate of turnover, loss of vascularity,flattening of dermal-epidermal junction
- 6. ETIOLOGY OF PRESSURE SORE • Incontinence or fistula • moist à maceration (ผิวเป34อย) + bacterial reservoirs • Bacteria: contamination à delay or prevent wound healing • Poor nutrition • Malnutrition, hypoproteinemia, anemia à contribute to tissue vulnerability and delayed wound healing
- 8. n • Complex process • External forces to the skin (Host-specific factor) PATHOGENESIS
- 9. n Pressure PATHOGENESIS Excess of arteriolar pressure > 32 mmHg Venous capillary closing pressure > 8-12 mmHg Oxygen and Nutrient to tissue Tissue hypoxia Wasted product and free radical
- 10. n • Most susceptible tissue to pressure – induced injury Muscle >> Subcutaneous fat >> Dermis • Greatest pressure at bony prominence area cone - shaped distribution PATHOGENESIS
- 13. n • Sitting position : ischial tuberosity (100mmHg) • Supine position : sacrum (150mmHg) and heel (40mmHg) • Prone position : knee and chest (40mmHg) • Lateral decubitus position : greater trochanter PRESSURE DISTRIBUTION INTERIOR
- 14. n INTERIOR
- 15. n • Body Level One • Body LevelTwo • Body LevelThree • Body Level Four • Body Level Five Eros et accumsan et iustoodiodignissimquiblandit praesent luptatum INTERIOR
- 18. GRADING แผลกดทับแบ;งเป=น 1. stage 1 2. stage 2 3. stage 3 4. stage 4 5.Suspected DeepTissue Injury (DTI) 6.Unstageable
- 22. GRADE 4 1.สูญเสียผิวหนังทุกชั้นจนถึงMuscleหรือ Bone 2.มักมีเนื้อตายสีดําแข็ง(eschar) หรือ โพรงใต/ผิวหนัง 3.ComplicationOsteiomyelitis และOsteitis
- 23. SUSPECTED DEEP TISSUE INJURY (DTI) • บริเวณที่ผิวหนังยังคงปกคลุมอยู;ไม;มีการฉีกขาดแต;มีการเปลี่ยนสีเป=นสีม;วงคล้ําหรือสีแดง หรือมี ตุ;มเลือดที่เกิดจากกล/ามเนื้อใต/บริเวณนั้นได/รับแรงกดทับ หรือแรงไถล
- 24. SUSPECTED DEEP TISSUE INJURY (DTI) • แข็งแฉะ หรือหยุ;นเหมือนมีน้ําใต/ผิวหนังร/อนขึ้น หรือเย็นลงกว;าผิวหนังบริเวณ ใกล/เคียง นอกจากนี้ยังตรวจพบได/ยากในคนที่มีผิวดํา • การเปลี่ยนแปลงที่พบหลังจากพบผิวหนังที่เกิด DTI คือพบตุ;มน้ําบนผิวหนัง ที่เกิดDTI พบการเปลี่ยนแปลงเป=น eschar บางๆ ได/เร็วและพบการ ทําลายชั้นเนื้อเยื่อเพิ่มเติมได/แม/จะได/พยายามรักษาอย;างเต็มที่แล/ว
- 25. SUSPECTED DEEP TISSUE INJURY (DTI)
- 26. UNSTAGEABLE • มีการสูญเสียผิวหนังทั้งหมดโดยที่พื้นแผลทั้งหมดถูก คลุมไว/ด/วยเนื้อตายสีเหลืองหรือ เนื้อตายสีดําแข็งแม/ จะตัดเอา เนื้อตายสีเหลืองหรือ เนื้อตายสีดําแข็งออก แล/ว ยังคงไม;สามารถระบุระดับของแผลกดทับได/ว;าเป=น ระดับ ที่ 3หรือระดับ 4
- 27. UNSTAGEABLE • แผลบริเวณก/นกบ • มีการสูญเสียผิวหนังทั้งหมด • มีเนื้อตายคลุมทั่วแผล • ไม;สามารถประเมินความลึกของแผลได/
- 28. WOUND CARE & WOUND CLOSURE
- 29. GENERAL PRINCIPLES ◦multidisciplinary of wound care teams ◦debridement of necrotic tissue ◦maintain moist wound environment (healing, relief pressure) ◦Address host issues (nutrition, metabolic, circulatory status) ◦Promote healing of the wound bed ◦appropriate dressings or wound packing ◦Prevent recurrence
- 31. NON-SURGICAL TREATMENT • Remove necrotic tissue • Manage patient factors • Infection,vascular disease,DM, smoking,nutrition • Management of contracture & spasm • Reduce pressure : • change position every 2 hrs • mattress system e.g.เตียงลม
- 33. PREOPERATIVE CARE • Appropriate nutrition • Treat infection • Relieve pressure • Management of spasm • Medication e.g. diazepam • Sx: perioperative nerve blocks,rhizotomy • Contracture therapy (of hip, knee/ reduce recurrence)
- 34. OPERATION • Excisionaldebridement • m/c surgically (or enzymatic proteolytic, hydrotherapy etc.) • Partial/ complete Osteotomy • remove bony prominence (i.e. กระดูกที.ตายแล้ว) • ไม ่ควรทํา radical ostectomy (bleeding problems) • wound closure e.g. skin flap • once sufficiently minimize bacterial load optimize social & nutritional status (Alb>3.5g/mL) • Poor candidates: • poor Sx candidates • lack supportive network at home (e.g. pressure-release bed) • Poor compliance to prior secondary intention healing
- 35. POST OPERATIVE CARE • Continuous care similar to pre-operative care • Relief pressure • Psychosocial • Rehabilitative care • Drain • Prevent contamination (feces, urine) • Prevent recurrence
- 37. SPECIFIC TREATMENT - GUIDED BY STAGE • Stage 1 : • covered with transparent film • protection & prevent from more serious ulcer
- 38. • Stage 2 ulcers • Require moist wound environment & little debridement • avoid wet-to-dry dressings. • Semi-occlusive (transparent film) or occlusive dressings (hydrocolloids or hydrogels) •Enzymes normally present in the wound base—>digest necrotic tissue •Contraindication:infection
- 39. • Stage 3 and 4 ulcers •Debridement of necrotic tissue •cover with appropriate dressings •treat infection.
- 40. DEBRIDEMENT • Debride necrotic tissue (mechanical, enzymatic, biological) • necrotic tissue promotes bacterial growth and impairs wound healing • Contraindication: • Absence of necrotic tissue • Granulation tissue is present
- 41. • Indications: } treat an infected pressure ulcer } ATB (adjunctive) + Debridement } prevent the infection from spreading • Avoid topical antibiotics } BUT may applyAntiseptic cream (eg. Nanosilver cream) topically Antibiotics
- 42. OTHER MANAGEMENT OPTIONS • Negative pressure wound therapy • Reconstructive surgery } skin grafting } Local flaps
- 43. COMPLICATION
- 44. COMPLICATION: INFECTION • Superficial wound infection • Deep:cellulitis, osteomyelitis(stage4) • Systemic: bacteremia,endocarditis • septic arthritis
- 45. COMPLICATION • Marjolin’s ulcer • Urethro-cutaneous fistula • vesico-cutaneous fistula • Wound dehiscence
- 46. COMPLICATION • Autonomic dysreflexia (spinal cord injury when debridement) • Hematoma & Seroma (after reconstructive surgery) • Recurrence
- 47. PREVENTION
- 48. IDENTIFICATION OF PATIENTS AT RISK • Elderly persons • Chronically ill (eg cancer,stroke, or diabetes) • Immobile (eg fracture,arthritis, or pain) • Weak or debilitated • Altered mental status (eg narcotics,anesthesia,or coma) • Decreased sensation or paralysis
- 49. Braden scale
- 51. SECONDARY FACTORS • Illness or debilitation • Fever àincreases metabolic demands • Predisposing ischemia • Diaphoresis àskin maceration • Incontinence àskin irritation and contamination • Other factors:edema,jaundice, pruritus, and xerosis (dry skin)
- 52. INTERVENTIONS • Scheduled turning and body repositioning • Appropriate bed positioning • Protection of vulnerable bony • Skin care • Alertness for skin changes • Use of support surfaces and specialty beds • Nutritional support - enteral or parenteral nutrition or vitamin therapy • Maintenance of current levels of activity,mobility,and range of motion
- 53. SCHEDULED TURNING AND BODY REPOSITIONING
- 55. PROTECTION OF VULNERABLE BONY PROMINENCES
- 56. SKIN CARE
- 57. USE OF SUPPORT SURFACES AND SPECIALTY BEDS
- 58. NUTRITIONAL SUPPORT - ENTERAL OR PARENTERAL NUTRITION OR VITAMIN THERAPY
- 59. MAINTENANCE OF CURRENT LEVELS OF ACTIVITY, MOBILITY, AND RANGE OF MOTION
- 61. THANK YOU FOR YOUR ATTENTION