This document defines pressure ulcers, also known as bedsores or decubitus ulcers, as localized skin injuries that occur over bony prominences due to pressure or pressure combined with shear and friction forces. Pressure ulcers develop when external pressure compresses blood vessels, obstructing blood flow and depriving tissues of oxygen and nutrients. Risk factors include limited mobility, incontinence, poor nutrition, and comorbidities like diabetes. Treatment involves repositioning, special mattresses and dressings, wound cleaning and debridement, nutritional support, and sometimes surgery.

1. pressure ulcers
DONE BY :
ASER MOHAMED KAMAL

2. • definition decubitus ulcers or bedsores, are
localized injuries to the skin and/or underlying
tissue that usually occur over a bony prominence
as a result of pressure, or pressure in combination
with shear and/or friction. The most common sites
are the skin overlying the sacrum, coccyx, heels or
the hips, but other sites such as
the elbows, knees, ankles or the back of
the cranium can be affected.
• Pressure ulcers occur due to pressure applied
to soft tissue resulting in completely or partially
obstructed blood flow to the soft tissue.
PRESSURE ULCER

3. Causes :
There are two mechanisms that contribute to pressure ulcer development
(1) external pressure that compresses blood vessels and (2) friction and shearing
forces that tear and injure blood vessels.
External pressure :
applied over an area of the body, especially over the bony prominences can result in
obstruction of the blood capillaries, which deprives tissues of oxygen and nutrients,
causing ischemia(deficiency of blood in a particular area), hypoxia(inadequate amount
of oxygen available to the cells), edema, inflammation, and, finally, necrosis and ulcer
formation. Ulcers due to external pressure occur over the sacrum and coccyx,
followed by the trochanter and the calcaneus(heel)

4. Friction :
is damaging to the superficial blood vessels directly under the skin. It occurs when
two surfaces rub against each other. The skin over the elbows and can be injured
due to friction. The back can also be injured when patients are pulled or slid over
bed sheets while being moved up in bed or transferred onto a stretcher .
shear :
is a separation of the skin from underlying tissues. When a patient is partially sitting
up in bed, their skin may stick to the sheet, making them susceptible to shearing in
case underlying tissues move downward with the body toward the foot of the bed.
This may also be possible on a patient who slides down while sitting in a chair. In
addition to pressure, friction, and shear, there are more risk factors of pressure
ulcers.

5. Risk factor :
Intrinsic :
Limited mobility
Spinal cord injury
Cerebrovascular accident
Progressive neurologic disorders (Parkinson
disease, Alzheimer disease, multiple sclerosis)
Pain
Fractures

6. Postsurgical procedures
Coma or sedation
Arthropathies
Poor nutrition
Anorexia
Dehydration
Poor dentition
Dietary restriction
Weak sense of smell or taste
Poverty or lack of access to food
Comorbidities
Diabetes mellitus
Depression or psychosis
Vasculitis or other collagen vascular disorders
Peripheral vascular disease

7. Decreased pain sensation
Immunodeficiency or use of corticosteroid therapy
Congestive heart failure
Malignancies
Decreased pain sensation
Immunodeficiency or use of corticosteroid therapy
Congestive heart failure
Malignancies
End-stage renal disease
Chronic obstructive pulmonary disease

8. Extrinsic :
Pressure from any hard surface (e.g., bed, wheelchair, stretcher)
Friction from patient's inability to move well in bed
Shear from involuntary muscle movements
Moisture
Bowel or bladder incontinence
Excessive perspiration
Wound drainage

10. Pathophysiology :
is indicative of impeded blood flow to affected areas. Within 2 hours, this
shortage of blood supply, called ischemia, may lead to tissue damage and cell
death. The sore will initially start as a red, painful area. The other process of
pressure ulcer development is seen when pressure is high enough to damage
the cell membrane of muscle cells. The muscle cells die as a result and skin fed
through blood vessels coming through the muscle die. This is the deep tissue
injury form of pressure ulcers and begins as purple inta
Pressure ulcers may be caused by inadequate blood supply and
resulting reperfusion injury when blood re-enters tissue. A simple example of a
mild pressure sore may be experienced by healthy individuals while sitting in the
same position for extended periods of time: the dull ache experienced

11. Sites :
Common pressure sore sites include the skin over the ischial tuberosity, the sacrum, the
heels of the feet, over the heads of the long bones of the foot, buttocks, over the
shoulder, and over the back of the head.[5]

12. Classification :
The definitions of the four pressure ulcer stages they are as follows:
Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the
surrounding area. The area differs in characteristics such as thickness and temperature as
compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones.
May indicate "at risk" persons (a heralding sign of risk).
Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound
bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as
a shiny or dry shallow ulcer without slough or bruising. This stage should not be used to describe
skin tears, tape burns, perineal dermatitis, maceration or excoriation.
Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle
are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include
undermining and tunneling. The depth of a stage III pressure ulcer varies by anatomical location.
The bridge of the nose, ear, occiput and malleolus do not have (adipose)subcutaneous tissue

13. subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant
adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or
directly palpable.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough
or eschar may be present on some parts of the wound bed. Often include undermining and
tunneling. The depth of a stage IV pressure ulcer varies by anatomical location. Thebridge of
the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these
ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures
(e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/tendon
is visible or directly palpable. In 2012, the NPUAP stated that pressure ulcers with
exposed cartilageare also classified as a stage IV.

14. Healing time is prolonged for higher stage ulcers. While about
75% of Stage II ulcers heal within eight weeks, only 62% of
Stage IV pressure ulcers ever heal, and only 52% heal within
one year. It is important to note that pressure ulcers do not
regress in stage as they heal. A pressure ulcer that is
becoming shallower with healing is described in terms of its
original deepest depth (e.g., healing Stage II pressure ulcer).

15. Pressure Ulcer Measurement
First, reposition the patient to expose the area to be measured, placing the
wound as far from the sleep surface as possible. Avoid exposing the patient
unnecessarily.
Place the patient in the same anatomical position each time you measure.
Different positions may cause the contours of the surface of the wound to
stretch or sag and distort the measurement. Do not stretch or pull wound edges
for measurement.
Using a centimeter ruler, measure the length of the wound from open wound
edge to open wound edge at the longest point. Direction of length is from head
to toe, using the "clock method" : 12:00 (head) and 6:00 (toe).
Measure the width of the wound from open wound edge to open wound edge
at the longest point. Width is from side to side or, with the clock method, from
3:00 to 9:00.
To measure depth, moisten a sterile cotton-tipped applicator with saline. Place
the applicator into the deepest area of the wound, keeping the applicator
vertical to the wound bed. Grasp the applicator with the thumb and index finger,
at the point where the applicator exits the wound at skin level. While still
grasping the applicator, remove from the wound and place next to a centimeter
ruler to determine measurement.

16. Complications :
Pressure ulcers can trigger other ailments, cause considerable suffering, and can be expensive to treat.
Some complications include
autonomic dysreflexia
bladder distension
,bone infection
, sepsis
, amyloidosis
, anemia
, urethral fistula,
gangrene and very rarely
malignant transformation
(Marjolin's ulcer - secondary carcinomas in chronic wounds).
Sores may recur if those with pressure ulcers do not follow recommended treatment or may instead
develop seromas, hematomas, infections, or wound dehiscence.
Paralyzed individuals are the most likely to have pressure sores recur. In some cases, complications from
pressure sores can be life-threatening. The most common causes of fatality stem from kidney
failure and amyloidosis. Pressure ulcers are also painful, with individuals of all ages and all stages of
pressure ulcers reporting pain.

17. Prevention :
If you are on bed rest or cannot move because of a medical condition, someone should check you
for pressure sores every day.
You or your caregiver should examine your body from head to toe. Pay special attention to the
areas where pressure ulcers often form. Look for reddened areas that, when pressed, do not turn
white. Also look for blisters, sores, or craters.
Take the following steps to prevent pressure ulcers:
Change position at least every 2 hours to relieve pressure.
Use items that can help reduce pressure -- pillows, sheepskin, foam padding, and powders from
medical supply stores.
Eat well-balanced meals that contain enough calories to keep you healthy.
Drink plenty of water (8 to 10 cups) every day.
Exercise daily, including range-of-motion exercises.
Keep the skin clean and dry.
After urinating or having a bowel movement, clean the area and dry it well. A doctor can
recommend creams to help protect the skin.

18. Treating pressure ulcers
Treatment for pressure ulcers can vary, depending on the grade of the ulcer. Treatment options may include regularly
changing your position, or using special mattresses and dressings to relieve pressure or protect the skin. In some
cases, surgery may be needed.
Changing position
It's important to avoid putting pressure on areas that are vulnerable to pressure ulcers or where pressure
ulcers have already formed. Moving and regularly changing your position helps to prevent pressure ulcers
developing and relieves the pressure on the ulcers that have developed.
After your risk assessment is completed, your care team will draw up a "repositioning timetable", which states
how often you need to be moved. For some people, this may be as often as once every 15 minutes. Others
may need to be moved only once every two hours.
The risk assessment will also consider the most effective way of avoiding putting any vulnerable areas of skin
under pressure whenever possible.
You may also be given training and advice about:
correct sitting and lying positions
how you can adjust your sitting and lying position
how often you need to move or be moved
how best to support your feet
how to maintain good posture
the special equipment you should use and how to use it

19. • Mattresses and cushions
• There are a range of special mattresses and cushions that can relieve pressure on vulnerable parts of the
body. Your care team will discuss the types of mattresses and cushions most suitable for you.
• Those thought to be at risk of developing pressure ulcers, or who have pre-existing grade one or two
pressure ulcers, usually benefit from a specially designed foam mattress, which relieves the pressure on
their body.
• People with a grade three or four pressure ulcer will require a more sophisticated mattress or bed system.
For example, there are mattresses that can be connected to a constant flow of air, which is automatically
regulated to reduce pressure as and when required.
• Dressings
• Specially designed dressings and bandages can be used to protect pressure ulcers and speed up the
healing process. Examples of these types of dressings include:
• hydrocolloid dressings – these contain a special gel that encourages the growth of new skin cells in the
ulcer, while keeping the surrounding healthy area of skin dry
• alginate dressings – these are made from seaweed and contain sodium and calcium, which are known
to speed up the healing process
• Creams and ointments
• Topical preparations, such as creams and ointments, can be used to help speed up the healing process
and prevent further tissue damage.

20. • Antibiotics
• If you have a pressure ulcer, you will not routinely be prescribed antibiotics. These are usually only
prescribed to treat an infected pressure ulcer and prevent the infection from spreading.
Antiseptic cream may also be applied directly to pressure ulcers to clear out any bacteria that may be
present.
• Debridement
• In some cases, it may be necessary to remove dead tissue from the ulcer to help stimulate the healing
process. This procedure is known as debridement.
• If there is a small amount of dead tissue, it may be possible to remove it using specially designed
dressings and paste. Larger amounts of dead tissue may be removed using mechanical means. Some
mechanical debridement techniques include:
• cleansing and pressure irrigation – where dead tissue is removed using high-pressure water jets
• ultrasound – dead tissue is removed using low-frequency energy waves
• laser – dead tissue is removed using focused beams of light
• surgical debridement – dead tissue is removed using surgical instruments, such as scalpels and
forceps
• A local anaesthetic will be used to numb the area of skin and tissue around the ulcer so that
debridement does not cause any pain or discomfort.

21. • Nutrition
• Certain dietary supplements, such as protein, zinc and vitamin C, have been shown to
accelerate wound healing.
• If your diet lacks these vitamins and minerals, your skin may be more vulnerable to
developing pressure ulcers. As a result of this, you may be referred to a dietitian so that
a
suitable dietary plan can be drawn up for you.

22. • Surgery
• It's not always possible for a grade three or four pressure ulcer to heal. In such cases, surgery will be
required to seal the wound and prevent any further tissue damage occurring.
• Surgical treatment involves cleaning the wound and closing it by bringing together the edges of the
wound (direct closure), or by using tissue moved from a nearby part of the body (flap reconstruction).
• Pressure ulcer surgery can be challenging, especially because most people who have the procedure
are already in a poor state of health. There is a risk of a large number of possible complications
occurring after surgery, including:
• infection
• tissue death of the implanted flap
• muscle weakness
• blisters (small pockets of fluid that develop inside the skin)
• recurrence of the pressure ulcers
• blood poisoning
• infection of the bone (osteomyelitis)
• internal bleeding
• abscesses (painful collections of pus that develop inside the body)
• deep vein thrombosis (a blood clot that develops inside the veins of the leg)
• Despite the risks, surgery is often a necessity to prevent life-threatening complications, such as blood
poisoning and gangrene (the decay or death of living tissue).

23. • - Hydrotherapy may be used to remove bacteria and debris from the surface of pressure ulcers.
Whirlpool can help to soften and loosen adherent necrotic tissue while removing wound exudate.
Prolonged periods of wetness to the tissue may be associated with bacterial contamination
• Whirlpool therapy leads to vasodilatation and increased circulation, but these may be undesired outcomes
in some clinical situations; use cautiously in the care of the patients with diabetes and with vascular ulcers
.Avoid using whirlpool with granulating wounds or pressure ulcers in the presence of venous insufficiency,
as the limb will be further congested with this intervention.

24. • Electrical stimulation for wound healing is defined as the use of a capacitive coupled
electrical current to transfer energy to a wound. The type of electricity that is transferred to the target
tissue is controlled by the electrical source. A physical therapist will have the knowledge required to set
the polarity, amplitude and voltage, amperage, wave forms, frequency and duty cycle appropriate for the
state of each wound and patient. Electrical stimulation to the wound bed uses galvanotaxis to attract
cells of repair to the site. There is a significant body of research that demonstrates that polarity
influences healing in different ways at different phases .Electrical stimulation also improves local blood
flow and oxygen delivery, has antibacterial effects, helps with debridement and thrombolysis, and
decreases pain. Contraindications are malignancy, an electronic implant or metal implant
• These technologies are pulsed radio frequency stimulation, pulsed electromagnetic fields, and pulsed
short-wave diathermy

25. • Hyperbaric oxygen therapy is the application of oxygen to the host's tissues above
atmospheric pressure. Hyperbaric oxygen therapy can increase oxygen diffusion to a wound and the
hemoglobin's ability to carry oxygen, therefore meeting the increased demand of oxygen for cellular
metabolism. It may also eliminate oxygen-free radicals; reduce bacterial growth; increase the ability for
white blood cells to kill bacteria; and increase angiogenesis, collagen synthesis, granulation tissue
formation, epithelialization, and wound contraction

26. • Non-contact, non-thermal ultrasound
• . Ultrasound can be modulated for thermal effects, non-thermal effects, diagnostic reading, and excision as
in debridement. It is not in the scope of this protocol to discuss the diagnostic or debriding ultrasound
devices. If set for thermal effects, using MHz ultrasound, a chronic wound can be returned to acute
wound healing. Non-thermal ultrasound, most commonly administered as kHz ultrasound, can stimulate
the cells of repair to do more of what they are already programmed to do: be bacteriocidal, and stimulate
capillary growth in the wound bed, depending on the kind of kHz device selected.

27. • Phototherapy: Photobiologists are studying the effects of different wavelengths of light on human
tissues. When focused and intensified, as in laser form, doses of light can quickly and painlessly be
administered to patients. The two most studied phototherapies are infrared and ultraviolet. Ultraviolet
aides in wound healing because it is bacteriocidal
• Infared has two main effects: the release of nitric oxide, a known vasodilator and angiogenic stimulator;
and increasing cellular activity of all cells

28. Reference :
https://en.wikipedia.org/wiki/Pressure_ulcer#Treatment
http://img.webmd.com/dtmcms/live/webmd/consumer_assets/site_image
s/media/medical/hw/h9991533_002.jpg
https://www.nlm.nih.gov/medlineplus/ency/article/007071.htm