Pressure Ulcer Dr Hourvash Ebrahimi

Bedsores , also called pressure ulcers and decubitus ulcers.

PRESSURE ULCER: DEFINITION Skin lesion caused by unrelieved pressure resulting in damage to soft tissue compressed between a bony prominence and external surface over a prolonged period of time The time for pressure ulcer development is variable due to severity of illness and number of comorbid conditions Normal wound healing: Homeostasis, inflammatory, proliferative and maturation Aging can affect the wound healing process/phases

Pressure Pressure is an external force where soft tissue is compressed between a bony prominence and a hard surface . The capillaries become occluded and the tissues starved of vital nutrients and oxygen, and become ischaemic If pressure is unrelieved, tissue necrosis will take place A service delivered on behalf of the NHS by Serco, South Essex Partnership University NHS Foundation Trust and Community Dental Services CIC.

Epidemiology: Pressure Ulcers Affect 1 million adults annually Higher risk in older people because: Local blood supply to skin decreases Epithelial layers flatten and thin Subcutaneous fat decreases Collagen fibers lose elasticity Tolerance to hypoxia decreases

Causes Bedsores are caused by pressure against the skin that limits blood flow to the skin. Other factors related to limited mobility can make the skin vulnerable to damage and contribute to the development of pressure sores. Three primary contributing factors for bedsores are: 1-Pressure. Constant pressure on any part of your body can lessen the blood flow to tissues. Blood flow is essential to delivering oxygen and other nutrients to tissues. Without these essential nutrients, skin and nearby tissues are damaged and might eventually die. For people with limited mobility, this kind of pressure tends to happen in areas that aren't well-padded with muscle or fat and that lie over a bone, such as the spine, tailbone, shoulder blades, hips, heels and elbows.

2-Friction. Friction occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury, especially if the skin is also moist. 3-Shear. Shear occurs when two surfaces move in the opposite direction. For example, when a bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place — essentially pulling in the opposite direction.

You are more likely to get a pressure sore if you: -Use a wheelchair or stay in bed for a long time -Are an older adult -Cannot move certain parts of your body without help -Have a disease that affects blood flow, including diabetes or vascular disease -Have Alzheimer disease or another condition that affects your mental state -Have fragile skin -Cannot control your bladder or bowels -Do not get enough nutrition

Staging Bed Sore

Stage 1 sores are not open wounds Stage 1 sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.

At stage 2, the skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.

During stage 3, the sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone. At stage 4, the pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur. In stages 3 and 4 there may be little or no pain due to significant tissue damage. Serious complications, such as infection of the bone (osteomyelitis) or blood (sepsis), can occur if pressure sores progress.

The following important information should be obtained from the history: Overall physical and mental health, including life expectancy ,Previous hospitalizations, operations, or ulcerations Diet and recent weight changes Bowel habits and continence status Presence of spasticity or flexion contractures Medications and allergies to medications Tobacco, alcohol, and recreational drug use Place of residence and the support surface used in bed or while sitting level of independence, mobility, and ability to comprehend and cooperate with care Underlying social and financial support structure

RISK FACTORS Intrinsic: physiologic factors or disease states that increase the risk for pressure ulcer development Age Nutritional status Decreased arteriolar blood pressure Extrinsic: external factors that damage skin Pressure, friction, shear Moisture, urinary, or fecal incontinence

FACTORS PREDICTIVE OF PRESSURE ULCER DEVELOPMENT Age 70+ Impaired mobility Current smoking Low BMI Confusion Urinary and fecal incontinence Malnutrition Restraints Many other disorders: malignancy, diabetes, stroke, pneumonia, CHF, fever, sepsis, hypotension, renal failure, dry skin, history of pressure ulcers, anemia, lymphopenia, hypoalbuminemia

Factors that increase the risk include: Older age as skin gets thinner and more vulnerable with age Reduced pain perception, due, for example, to a spinal cord or other injury, as they may not notice the sore Poor blood circulation, due to diabetes, vascular diseases, smoking, and compression Poor diet, especially with a lack of protein, vitamin C, and zinc Reduced mental awareness, due to a disease, injury, or medication, can reduce the patient's ability to take preventive action

Incontinence of urine or feces can cause areas of permanently moist skin, increasing the risk of skin breakdown and damage A low or high body mass index (BMI) increases the risk. A person with a low body weight will have less padding around their bones, while those with obesity can develop sores in unusual places. Studies show that people with a BMI of 30 to 39.9 have a 1.5 times higher rate of developing pressure ulcers.

Pressure sores tend to form where skin covers bone, such as your: Buttocks Elbow Hips Heels Ankles Shoulders Back Back of head

95% OF ALL PRESSURE ULCERS ARE PREVENTABLE!

Ways to Prevent Pressure Ulcers 1. Skin Inspections: a patient’s skin should be examined regularly for signs of pressure damage. The first sign of tissue damage is often non-blanching erythema. Other signs of skin damage include heat, induration and swelling. 2. Skin care: keeping a patient’s skin clean, dry, and hydrated can help prevent damage. Skin should be dried carefully and any rubbing or friction should be avoided. .

3. Moisture: excessive perspiration, oedema and incontinence can cause skin damage from excess moisture. Incontinence can be particularly harmful to a patient’s skin and appropriate measures should be taken to prevent any associated damage 4. Incontinence: incontinence and pressure ulcers often co-exist. The use of incontinence pads with the appropriate application of a barrier cream can be helpful, while the use of indwelling urethral catheters should only be considered as a last resort due to the risk of infection.

5. Nutrition: good nutrition is essential for pressure ulcer prevention and healing. A Patient’s diet should be assessed regularly and any nutritional needs should be addressed. Keeping patients hydrated is also a vital part of preventing pressure ulcers. 6. Position: the position of a patient’s body should be considered when trying to prevent pressure ulcers. 7. Ergonomics: ergonomics refers to making sure a patient’s environment is suited to aiding in the performance of everyday tasks. It is important to consider ergonomics when choosing the size and placement of furniture such as beds, chairs and mattresses.

8. Repositioning: all patients should be encouraged to reposition themselves regularly. For patients who require assistance, repositioning should be done with consideration for the patient’s comfort, dignity and functional ability. 9. Pressure-redistributing equipment: pressure ulcer equipment has two main functions — to redistribute pressure and to provide comfort. Mattresses and seating must provide pressure-reducing cushioning for patients at high risk for developing pressure ulcers.

PREVENTION An evidence-based approach to preventing pressure ulcers focuses on: Skin care Nutrition Mechanical loading Mobility Support surfaces

PREVENTION: MECHANICAL LOADING Reposition at least every 2 h (may use pillows, foam wedges) Use lubricants and protective dressings/pads Keep head of bed at lowest elevation possible Use lifting devices to decrease friction and shear Remind patients in chairs to shift weight every 15 min “Doughnut” seat cushions are contraindicated, as they may cause pressure ulcers Pay special attention to heels (account for 20% of all pressure ulcers)

Five simple steps to prevent and treat pressure ulcers

POSSIBLE COMPLICATIONS Sepsis (aerobic or anaerobic bacteremia) Localized infection, cellulitis, osteomyelitis Pain Depression Mortality rate = 60% in older people who develop a pressure ulcer within 1 year of hospital discharge

Costs - individual reduced quality of life difficulties for patients, their carers and families even a grade one pressure ulcer is very painful estimated that up to 30% patients in nursing and residential homes may be affected increased risk of secondary infection ~ 4 x increase of risk of death in older people in ICU increased morbidity

Caring for a Pressure Sore Stage I or II sores will heal if cared for carefully. Stage III and IV sores are harder to treat and may take a long time to heal. Here's how to care for a pressure sore at home. Relieve the pressure on the area. Use special pillows, foam cushions, booties, or mattress pads to reduce the pressure. Some pads are water- or air-filled to help support and cushion the area. What type of cushion you use depends on your wound and whether you are in bed or in a wheelchair. Talk with your doctor about what choices would be best for you, including what shapes and types of material.

Change positions often Change positions often. If you are in a wheelchair, try to change your position every 15 minutes. If you are in bed, you should be moved about every 2 hours. Care for the sore as directed by your health care provider. Keep the wound clean to prevent infection. Clean the sore every time you change a dressing. For a stage I sore, you can wash the area gently with mild soap and water. If needed, use a moisture barrier to protect the area from bodily fluids. Ask your provider what type of moisturizer to use.

Stage II pressure sores should be cleaned with a salt water (saline) rinse to remove loose, dead tissue. Or, your provider may recommend a specific cleanser. DO NOT use hydrogen peroxide or iodine cleansers. They can damage skin. Keep the sore covered with a special dressing. This protects against infection and helps keep the sore moist so it can heal. Depending on the size and stage of the sore, you may use a film, gauze, gel, foam, or other type of dressing. Avoid slipping or sliding as you move positions. Try to avoid positions that put pressure on your sore. Care for healthy skin by keeping it clean and moisturized.

Check your skin for pressure sores every day. If the pressure sore changes or a new one forms, tell your doctor. Take care of your health. Eat healthy foods. Getting the right nutrition will help you heal. Lose excess weight. Get plenty of sleep.   DO NOT massage the skin near or on the ulcer. This can cause more damage. DO NOT use donut-shaped or ring-shaped cushions. They reduce blood flow to the area, which may cause sores.