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MANAGEMENT OF PRESSURE ULCER

Wound Care Training Module

Wound Care Training Module - National Wound Care Committee

Wound Care Training Module

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Content

  1. Definition
  2. Pathophysiology
  3. Management

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DEFINITION

A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. 

(NPUAP 2007)

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PATHOPHYSIOLOGY

  1. Primary Factor
    1. Pressure
    2. Shear
    3. Friction

  • Secondary Factor

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1. Primary Factor

    • Pressure

    • There is an inverse relationship of pressure and time whereby,
    • Intense pressure, short duration, can be as damaging as lower intensity pressure for longer periods.
    • Furthermore Tissues can tolerates much higher cyclic pressure than constant pressure

Kosiak 1961 Arch Phys Meds & Rehab (Animal Study)

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    • Shear

  • Occurs when skin remain static and underlying tissue shifts.
  • Accounts for the high incident of sacral ulcer and when head of the bed is elevated more than 30 degree and less than 80 degree.

    • Friction
  • Occurs when skin moves against a support surface.
  • Produces skin tear and abrasion.

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FRICTION + SHEAR + PRESSURE

=

EXTENSIVE INJURY

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2. Secondary Factor

  • Elderly
  • Limited mobility and prolonged bed rest
  • Decreased skin sensation
  • Moisture from bladder or bowel accidents
  • Spasticity or improper transfer of patients in and out of chairs or beds can result in skin shearing and or friction
  • Associated co-morbidities such as Diabetes Mellitus, end-stage renal failures, anemia, small vessel occlusion disease, hypoproteinemia
  • Poor nutritional status
  • Poor psychosocial support

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COMMON SITES OF �PRESSURE ULCERS

Knees

Toes

Male Genitalia

Breasts

Shoulder

Cheek and Ear

Heel

Sacrum

Elbow

Scapula

Occiput

Malleolus

Fibula head

Trochanter

Elbow

Ear

Skull

Shoulder

Heels

Ischium

Sacrum

Shoulder

Occiput

Elbow

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HOW TO ASSESS PRESSURE ULCER

  • Risk factor evaluation
    • To aid in the planning of appropriate preventive interventions, Barbara Braden and Nancy Bergstrom introduced a risk assessment scale (Braden scale) which is widely used in clinical setting.

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  • Staging of pressure ulcer:
    • Data from National Pressure Ulcer Advisory Panel (NPUAP)
      • Stage I to IV
      • Unstageble
      • Suspected Deep tissue Imjury
  • T.I.M.E. principle can be used as a guide to assess pressure ulcer and planning for its treatment .

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Staging of Pressure Ulcer:

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.

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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.

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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.

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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.

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Unstageable

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

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Suspected Deep Tissue Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

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MANAGEMENT

What is the best management of pressure ulcer?

  1. Prevention is paramount
  2. General Treatment
  3. Local Treatment

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1. Prevention is paramount

  • Prevention is the main modality in the management of pressure ulcer.
  • Proper bed positioning and turns every 2 hours.
  • Bony prominence should be checked once or twice a day by the care giver.
  • To provide the appropriate type of mattress-overlay or chair cushion to reduce pressure during sitting or lying.
  • Best managed by a dedicated, multi-disciplinary team who has special interest in wound management.

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2. General treatment

  • Restoration of tissue perfusion by relief of pressure.
  • Treatment of underlying systemic problem e.g Anemia, Hypoprotenemia, Diabetes Mellitus.
  • Treatment of reflex spasms- e.g. Baclofen, Diazepam and Tizanidine.
  • Preventing or treating infection (refer national antibiotic guidelines).
  • Improvement in general health and nutrition.

 

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3. Local treatment

    • Conservative:

Management of wounds - please refer algorithm on wound care.

    • Surgical:

Please refer chapter on principle of wound closure and wound debridement.

 

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TAKE HOME MESSAGE

  • Prevention is the most important in pressure ulcer management.
  • Small skin lesion may hide a large underlying wounds.
  • Management requires multidiscipline approach and family support.
  • Not all pressure ulcer patients are suitable for surgical intervention.

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REFERENCES

  • Plastic Surgery Second Edition (Mathes), 2006, Volume VI, Pg 1317-1353
  •  Salcido R.,Goldman R., Prevention and Management of Pressure Ulcers and Other Chronic Wounds,:645-661 Phys. Med. &Rehab.,2nd ed. Braddom RL.
  •  http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/
  •  BergstromN,BradenBJ,LaguzzaA,HolmanV.The Braden Scale for predicting pressure sore risk. Nurs Res. 1987;36(4):205-210.
  •  KatrinBalzer, Claudia Pohl, Theo Dassen, Rudd Halfens: The Norton, Waterlow, Braden, and Care Dependency Scales Comparing Their Validity When Identifying Patients’ Pressure Sore Risk. Journal of Wound, Ostomy and Continence Nursing:2007;34(4):389-398.

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REFERENCES

  •  Linden, O., Greenway, R. M., and Piazza, J. M. Pressure distribution on the surface of the human body. I. Evaluation in lying and sitting positions using a “bed of springs and nails”. Arch. Phys. Med. Rehabil. 46: 378, 1965.
  •  Enis J, Sarmiento A: The pathophysiology and management of pressure sores. Othop Rev 2:26, 1973
  •  Maklebust J: Pressure ulcers: etiology and prevention. NursClin North Am 22:359, 1987
  •  Special thanks to Mohd. Asrul b. Mohd Noh. Illustrator

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THANK YOU

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