تقرحات الفراش

1. PRESSURE SORES
by Dr/ Khaled ALsayani

2. Pressure Ulcers
• 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.
• These lesions are also called bedsores,
decubitus ulcers and pressure sores

3. Epidemiology
• 1-3 million Americans are affected
• Health care expenditures: $ 5 billion/year
• More than 17,000 lawsuits related to pressure
Ulcers are filed annually
• 1 in 4 persons in the USA who died in 1987
had a dermal ulcer
• Pressure Ulcers develop primarily in elderly
patients

4. • Setting
–Hospital 60%
–Nursing homes 18%
–Home 18%
• 1/3 of patients undergoing surgery for hip
fracture develop a pressure ulcer
• The longer the patient stays in a nursing
home, the greater the likelihood of developing
a pressure ulcer

5. THERMODYNAMICS, METABOLISM AND
PRESSURE
• Thermodynamic factors - skin/surface
interface
• As temperature increases, skin becomes more
metabolically active and 02 demands increase
• With increased pressure, metabolic demands
not able to be met and skin becomes hypoxic
• Hypoxic skin more susceptible to breakdown
• Adding friction and shear to already fragile
skin is “perfect storm”

6. THE 4 FORCES
1. Pressure
2. Friction
3. Shear
4. Strain

7. PRESSURE AND FRICTION
FRICTION PRESSURE

9. Risk Factors
• Spinal cord injuries
• Traumatic brain injury
• Neuromuscular
disorders
• Immobility
• Malnutrition
• Fecal and urinary
incontinence
• Altered level of
consciousness
• Chronic systemic
illness
• Fractures
• Aging skin
– decreased epidermal
turnover
– dermoepidermal
junction flattens
– fewer blood vessels
• Decreased pain
perception
• Smoking

10. • Pressure ulcers
commonly occur
over the :
– Sacrum
– Greater
trochanter
– Ischial tuberosity
– Malleolus
– Heel
– Fibular head
– Scapula
Site

12. While on a wheelchair a
pressure sore develop
on:
- Tailbone or buttocks
- Shoulder blades and
spine
- The backs of arms
and legs where they
rest against the chair
- Feet

13. Classification/ Stages/
Grades

14.  Stage I
1. most superficial,
2. redness, does not subside after
pressure is relieved.
3. The skin may be hotter or cooler than
normal
4. have an odd texture, or
5. perhaps be painful to the patient.

15. STAGE
I

17. • Stage II is damage to the epidermis extending
into, but no deeper than, the dermis. In this
stage, the ulcer may be referred to as a blister
or abrasion.
• The ulcer is superficial and manifest clinically
as an abrasion, blister or shallow crater

18. STAGE II

19. STAGE II

20. Stage III
 and may extend into the subcutaneous tissue layer. This
layer has a relatively poor blood supply and can be
difficult to heal.
involves the full thickness of the skin
The ulcer manifests clinically as a deep crater
with or without undermining of adjacent
tissue

21. STAGE III

22. STAGE III

23. Stage IV
• is the deepest, extending into the muscle,
tendon or even bone.
• “Full thickness tissue loss with exposed
bone, tendon or muscle. Slough or eschar
may be present on some parts of the
wound bed.
• Depth varies according to anatomic location
• Exposed bone/tendon usually directly visible
and/or palpable

24. STAGE IV

25. B
A
Stage
4

26. STAGE IV

27. Complications
• Cellulitis.
• Bone and joint infections.
• Sepsis.
• Cancer

28. Tests and diagnosis
•
•
•
•
•
Determine the size and depth of the ulcer
Check for bleeding, fluids or debris in the wound that
can indicate severe infection
Try to detect odours indicating an infection or dead
tissue
Check the area around the wound for signs of
spreading tissue damage or infection
Check for other pressure sores on the body
•
•
•
Blood test
Wound swab – C/S
Incision biopsy/ Tissue cultures– if malignancy is
suspected.

29. Treatments and drugs
• Treating bedsores is challenging. Open
wounds are slow to heal, and because skin
and other tissues have already been
damaged or destroyed, healing is never
perfect.
• Requires a multidisciplinary approach –
nurses, physician, social worker, physical
therapist, urologist or gastroenterologist, a
neurosurgeon, orthopedic surgeon and
plastic surgeon.

30. TREATMENT OBJECTIVES
1. Identification of problem
2. Debridement of necrotic tissue
3. Moist wound care without maceration
4. Control of infection/bioburden
5. Management of pain
6. Pressure redistribution/Offloading
7. Choice of wound care products.

31. A) Conservative treatment
Although it may take some time, most stage I
and stage II sores will heal within weeks with
conservative measures. But stage III and stage
IV wounds, which are less likely to resolve on
their own, may require surgery.

32. 1- Changing positions often.
2- Using support surfaces

33. 3. Cleaning.
4. Dressings
5. Removal of damaged tissue (debridement)
6. Oral antibiotics
7. Controlling incontinence
8. Healthy diet
9. Muscle spasm relief
10. Educating the caregiver

34. B) Surgical repair by
a. Negative Pressure Wound Therapy : also
called vacuum-assisted closure.
b. Tissue Flap, Free Flap

35. C) Other treatment options
Researchers are searching for more effective
bedsore treatments. Under investigation are
hyperbaric oxygen, electrotherapy and the
topical use of human growth factors.

36. Prevention
• Bedsores are easier to prevent than to treat,
but that doesn't mean the process is easy or
uncomplicated. Although wounds can develop
in spite of the most scrupulous care, it's
possible to prevent them in many cases.
• Position changes
– It is advisable to change position frequently with
proper cushioning.

37. Repositioning in a Wheelchair
• Shift weight frequently, every 15 minutes.
• If patient has enough upper body strength, do
wheelchair pushups.
• Special wheelchair, some wheelchairs allow
tilting to them, which can relieve pressure.
• Use cushions to relieve pressure and help
ensure your body is well-positioned in the
chair, such as foam, gel, water filled and air
filled.

38. Repositioning in a bed
•
•
•
•
Change body position every two hours.
If you have enough upper body strength, try
repositioning yourself using a device such as a
trapeze bar. Caregivers can use bed linens to help lift
and reposition you. This can reduce friction and
shearing.
Use special cushions and mattresses such as, a foam,
pneumatic mattress, Ripple, Alpha or a water
mattress, Roho Cushions to help with positioning.
Bed can be elevated at the head, raise it no more
•
than 30 degrees. This helps prevent shearing.
Protect bony areas with proper positioning and
cushioning.

39. • Skin care
– Daily skin inspections for pressure sores are an
integral part of prevention.
– Clean the skin with mild soap and warm water or
a no-rinse cleanser. Gently pat dry.
– Use talcum powder to protect skin vulnerable to
excess moisture. Apply lotion to dry skin.
– Change bedding and clothing frequently
– Watch for buttons on the clothing and wrinkles in
the bedding that irritate the skin.
– Manage incontinence to keep the skin dry, take
steps to prevent exposing the skin to moisture
and bacteria.

40. • Nutrition
– A healthy diet is important in preventing skin
breakdown and in aiding wound healing.
– Good hydration is important for maintaining
healthy skin.
• Lifestyle changes –
- Quitting smoking,
- Exercise - Daily exercise improves
circulation.

41. PHYSIOTHERAPY TREATMENT

42. PT Aims
• Physiotherapy treatment usually aimed to
consider the local wound area and prevention
and improving the general condition of the
patient.
• Local Aims :
– Increase circulation to ulcer area to promote
healing.
– Clear any infection.
– Reduce edema.
– Prevent adherence of wound to underlying
tissues.

43. • General aims :
– To relieve pain.
– To relieve venous congestion and edema.
– To decrease risk of wound infection.
– To improve general circulation of lower limb.
– To mobilize joints surrounding the pressure sores.
– To strengthen the muscles of surrounding the
pressure sores.
– Teach home care and management.

44. PT Treatment
• Positioning:
– every 2 hourly on bed
– every 15 minutes on siiting.
• Soft tissue techniques:
– slow deep effleurage and deep kneading.
– region of wound is treated with finger and thumb
kneading to prevent induration
– scar also moved from side-to-side to prevent adherence.
– Deep manipulation is given to whole limb to reduce
edema and venous congestion;
– Begin from thigh and continuing down the limb towards
knee and ankle; in case of lower limb pressure sores.

45. • UVR :
– destroy microorganism and to improve
circulation.
– In open infected wound, E-4 dose of UVB or UVC
using ultraviolet opaque material for 2-3 times a
wk.
– In Uninfected wound, Floor : E-4 dose of UVB or
UVC / 2 – 3 times a week.Edges : E-1 or E-0 dose
of UVB or UVC / Daily.
– InShallow healing wound : Floor : E-1 dose/daily
,edges are being screened.
– Deep healing pressure sores : Floor :€“ E-2 dose
twice a wk.
Edges and surrounding skin : E-0 /E-1 dose daily.

46. • Ultrasound :
– Promoting healing.
– Soften the indurations.
– Increase vascularity in surrounding tissues.
– Dosage of 0.25 – 0.5 W / cm square for 5 -10
minutes to the surrounding skin and with use of
hydro gel sheet to the ulcer area itself.
NOTE : US is contraindicated in presence of
associated superficial or deep
vein thrombosis.
• LASER :
– to increase vasodilatation and to decrease
pain at wound site.

47. – Usually visible and infra-red part of the spectrum
(600 – 950 nm) is used.
– Treatment on alternate days.
• Pulsed Electro Magnetic Energy (PEME) :
– Continuous high frequency current at sufficient
intensity produce heat in tissues.
– If PEME is applied to tissues, there is a relatively
long rest period, during which the heat is
dispersed by circulation, thus producing non-
thermal effect.
– With PEME application, there will be increase
reepithelialisation and promote healing.

48. • Exercises :
– Passive ROM exercises to the paralyzed limb to
improve circulation and prevent contractures are
performed several times a day.
– Re education of walking with more emphasis on
push-off must be given.
– Active assisted SLR
– Ankle pump exercises
– Strengthening of muscles and joints, without
impeding the healing of ulcer.
– Teaching corrective measures like shifting from
bed, turning positions, using assistive devices.

49. • IRR and Hot packs :
– have been used in chronic wounds
– apply over the proximal areas, increases local
wound and skin temperature, facilitating higher
metabolic rate and improving circulating activity
to wound.