1. How to Prevent & Cure Pressure Ulcers
Home Mobility & Park House Solutions

2. Overview Pressure Ulcer Solutions Definition Causes
Predisposing Risk Factors
Grades
Effects on Patient
Solutions
Risk Assessment
Skin Wound Protocol

3. Pressure Ulcer
Causes of Pressure Ulcer Development
Pressure

4. Pressure Ulcer What is Pressure Ulcer?
A localized area of cellular damage resulting from:
Direct pressure: skin and other tissues are directly compressed between bone and another surface (bed, chair). Tissue damage will depend on intensity and duration of exposure to pressure.
Shearing: tissues are wrenched in opposite directions, resulting in disruption or angulations of capillary blood vessels.
Friction: skin rubs against another surface (sheet) causing epidermis to be stripped away.
Also called Pressure Sores, Decubitus Ulcers or Bed Sores

5. Pressure Ulcer Bony Prominences at Risk

6. Pressure Ulcer Predisposing Risk Factors
Level of Mobility
Nutrition
Continence
Medication
Concurrent disease
Age

7. Pressure Ulcer Grades of Ulcers
Two Hours …
… That’s what it takes to develop a pressure ulcer.

8. Pressure Ulcer Grades of Ulcers
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
Redness that does not disappear when pressure is applied

9. Pressure Ulcer Grades of Ulcers

10. Pressure Ulcer Grades of Ulcers

11. Pressure Ulcer Grades of Ulcers

12. Pressure Ulcer Grades of Ulcers
Very Fast Process
Grade I: 14 Days
Grade II: 45 days
Grade III: 90 days
Grade IV: 120 Days
Very Slow Process

13. Pressure Ulcer Effects on Patient
Pain
Systemic illness
Reduced self-esteem
Altered body image
Delayed rehabilitation measures
Amputation
Death

14. Pressure Ulcer
Solution

15. Pressure Ulcer Risk Assessment
Why?
Because we can prevent Pressure Ulcers
Because we can cure Pressure Ulcers
To Whom?
All person with reduced mobility / activity or sedated
When?
Admission
Regular Intervals
Change in patient conditions
During day and night

16. Pressure Ulcer Risk Assessment
Benefits?
Act as aid-memory
Target preventive care
Effective use of scarce resources
Provide quantifiable data of audit
Provides objective criteria to base care pathways
How?
Use Risk Assessment Tools

17. Pressure Ulcer Risk Assessment Tools
Braden
Gosnell
PSPS (Lowthian)
Norton
Walsall
Douglas
Knoll
Medley
N.P.R.U
Waterlow

19. Pressure Ulcer Skin Wound Protocol
Pressure Reduction
Pressure Relief
Incontinence Care
Nutrition Consult
Moisturize Skin
Positioning
Wound Care

20. Pressure Ulcer Skin Wound Protocol
Pressure Reduction

21. Pressure Ulcer Pressure Reduction
Reduce the intensity of pressure and shear : Blood irrigation occlusion diminish  O2 flows in tissue
Intensity is determined by contact surface (mattress or cushion). When the surface is increased, pressure is more evenly redistributed decreasing pressure.
Avoid several tissue layers because they increase the pressure
Avoid anything that reduces the size of the pressure surface (ring cushions)
Should be combined with scheduled alternated repositioning of the patient.

22. Pressure Ulcer Pressure Reduction
Pressure Reduction can be done through specialized mattresses / Cushions
Static Mattresses are non electric system that reduces intensity of the pressure and shear by increasing contact surface
Overlay is placed over standard mattress and has the same effect as static mattress
The nature and composition of the material modify the form and the consistency of the mattress that is subject to patient body pressure.

23. Pressure Ulcer Pressure Reduction
Different Materials:
Water
Static Air
Gel
Fiber
Foam
CMHR: Combustion Modified High Resilient
Visco-elastic

24. Pressure Ulcer Pressure Reduction
Water Mattress Advantages:
Cheap
Distributes weight evenly
Water Mattress Disadvantages:
A spontaneous or assisted change in the positioning is more difficult  favours longer period in the same position  higher risk of pressure ulcer development.

25. Pressure Ulcer Pressure Reduction
Water Mattress Disadvantages:
Very difficult to position the patient in Lateral 30° (this position is recommended for long stay periods)  Low comfort and increased pressure  higher risk of pressure ulcer development.
Cannot be used on profiling beds (electrical) because of the weight of the mattress and the bed inclination
Cold sensation from the water  patient discomfort

26. Pressure Ulcer Pressure Reduction
Water Mattress Disadvantages:
Extremely heavy weight  can causes back injury to carer
The mattress can break  inundation  unpleasant situation for both patient and carer.
Rocking effect  may cause dizziness to predisposed patients
Not durable
Requires a second mattress below

27. Pressure Ulcer Pressure Reduction
Static Air Mattress Advantages:
Easy use: once filled with air, it does not require an electric pump.
Heat build up and moisture are greatly reduced, due to the air holes throughout the mattress.
Light weight.
Best in its class for seating (cushions); however should be thick enough to prevent bottoming effect
Static Air Mattress Disadvantages:
Contact surface is not increased enough to reduce pressure.
Not durable
Requires a second mattress below

28. Pressure Ulcer Pressure Reduction
Gel Mattress Advantages:
Comfortable
Viscous gel migrates through sectioned bladders to relieve pressure around bony prominences.
Gel Mattress Disadvantages:
Contact surface is not increased enough to reduce pressure.
Gel can dissociate and loose all its properties.
Not durable

29. Pressure Ulcer Pressure Reduction
Fiber Mattress advantages:
High quality patient comfort
Lasting durability
Easy Maintenance
Body is enveloped by the fiber
Used for very frail bony patients
Light weight
Fiber Mattress Disadvantages:
Pressure reducing properties are not enough
Rocking effect  may cause dizziness to predisposed patients
Requires a second mattress below

30. Pressure Ulcer Pressure Reduction
Foam Mattress CMHR advantages:
Longer useful life than non-HR foam
High tear strength
Ability of material to revert to its original shape after pressure  optimal lying comfort
Easy Maintenance
More Supple
Moulds body shape  Maximize weight distribution  Reduce pressure
Extremely fire retardant, complies to institutional regulatory standards
Foam Mattress HR Disadvantages:
Used for Low to Medium risk patients only

31. Pressure Ulcer Pressure Reduction
Foam Mattress Visco-Elastic advantages:
Best in its class for static mattresses.
High quality patient comfort
Lasting durability
Easy Maintenance
Moulds the body allowing patient immersion thus increasing the contact surface and decreasing the pressure.
High Memory Foam

32. Pressure Ulcer Pressure Reduction
Foam Mattress Visco-Elastic advantages:
Heat sensitive property allows the top of the mattress to be more supple whereas the deeper parts remains firm for a proper support. This maintains the physiological position of the patient maximizing the weight distribution.
Used for Medium to High Risk Patient

33. Pressure Ulcer Pressure Reduction
Cover of the mattress is very important and should provide the following:
Two way stretch  Reduce friction and sheer effects.
Elastic, otherwise it will limit the capacity of the mattress to reduce pressure
Vapor Permeable  evacuate heat  patient comfort
Fire Retardant  Fire safety  patient safety

34. Pressure Ulcer Pressure Reduction
Water Resistant  Prevent fluid contamination  patient hygiene & safety
Concealed Zip Fastening  Prevent fluid contamination  patient hygiene & safety
Fully Fitted  moulds to the shape of the bed  Reduce friction and sheer effects
Detachable cover  machine washable  easy to clean  patient hygiene

35. Pressure Ulcer Skin Wound Protocol
Pressure Relief

36. Pressure Ulcer Pressure Relief
Purpose is to reduce the duration of pressure and shear by changing the points of pressure.
Pressure Relief can be done in two ways:
Scheduled alternated positioning
Specialized mattresses

37. Pressure Ulcer Pressure Relief
Scheduled alternated positioning
Change the position of the patient in a way that body prominences at risk (points of pressure) are different.
Frequency per 24 hours/day, 7 days/week:
Laying Position
Every two hours if no pressure reduction mattress is used  Almost impossible to manage.
Every four hours when a good and appropriate pressure reduction mattress is used
Seating Position
Every one hour if no pressure reduction cushion is used
Every two hours when a good and appropriate pressure reduction cushion is used

38. Pressure Ulcer Pressure Relief
Specialized Mattresses are electric system that reduces the duration of the pressure and shear.
Consist of an inflatable mattress and an electric pump.
Overlay is placed over standard mattress and has the same effect as an active mattress.
The cells / compartments of the mattress inflates and deflates in alternation.
The form of the mattress, that is subject to patient body pressure, changes due to external factors (air pump).

39. Pressure Ulcer Pressure Relief
Differentiation points:
Pump characteristics
Availability of an “intelligent” feed-back system
Diameter of the cells
Distinct compartments
Additional facilities
Cell structure
Cover

40. Pressure Ulcer Pressure Relief
Pump characteristics:
Quiet
Lightweight and Compact
Clear user instructions
Snap fit connectors, color coded
Adjustable pressure control (better if it is automatic)
Audio – visual alarms
Different settings: Pulsate, Therapy & Static
Comfort control

41. Pressure Ulcer Pressure Relief
Pump characteristics:
Equalized cell pressure when mattress is disconnected from power unit (transport / power failure)
Duration of the pressure: 9 to 10 minutes cycle.
External fusibles to protect the pump from current fluctuations.

42. Pressure Ulcer Pressure Relief
Availability of an “intelligent” feed-back system :
Senses movement of patient
Automatic adjustment to individual patient weight and position
Optimum pressure is delivered at all times regardless of body mass.
Back-Raise sensor for semi-recumbent position  push more air in torso section for better support  prevents bottoming-out

43. Pressure Ulcer Pressure Relief
Diameter of the cells :
Small cells (less then 10 cm) even when inflated to the maximum, do not allow the body to elevates enough above the deflated cells.
Cells larger then 10 cm are recommended.

44. Pressure Ulcer Pressure Relief
Distinct compartments:
Individual cells  easy replacement
Tri zonal: comfort for head, torso & heel
Sloping heel section
Additional Facilities:
Timed static facility
Static facility for fast transfer
CPR facility near head section for faster deflation
Intubation's facility

45. Pressure Ulcer Pressure Relief
The cell structure - number and form:
Double layer cell structure is more efficient then single layer.
Cells are linked between each others by series of 3 and same cycle is applied for both layers simultaneously:
1st max. inflation, 2nd half inflation, 3rd total deflation
1st half inflation, 2nd max. inflation, 3rd half inflation
1st total deflation, 2nd half inflation, 3rd max. inflation

46. Pressure Ulcer Pressure Relief
Cover :
Two way stretch  Reduce friction and sheer effects.
Elastic  maintain reduction property of mattress.
Vapor Permeable  evacuate heat  patient comfort
Fire Retardant  Fire safety  patient safety
Water Resistant  Prevent fluid contamination  patient hygiene & safety
Concealed Zip Fastening  Prevent fluid contamination  patient hygiene & safety
Fully Fitted  moulds to the shape of the bed  Reduce friction and sheer effects
Detachable cover  easy cleaning
Hoses covered  as per disinfections properties

47. Pressure Ulcer Pressure Relief
Special mattresses:
Fluidized Air: Mattress is composed of silicom particles inside a synthetic cover. When hot air is injected the silicon particles liquefies.
Low air-loss: Reduce humidity build-up to to the air-loss.

48. Pressure Ulcer Pressure Relief
Fluidized Air Advantages:
The body is totally immersed in the mattress which maximizes the contact surface between the body and the mattress
Excellent system for treating burns or wounds with high exudates.
Fluidized Air Disadvantages:
Very expensive
Extremely difficult to clean
Cannot be moved from 1 patient to another before a special cleaning process has taken place.

49. Pressure Ulcer Pressure Relief
Low Air loss Advantages:
Designed to provide very high degree of comfort
Constant air flow will help dry up wounds
Separate mattress system can be easily moved from patient to patient and from bed to bed.
Easy to clean and decontaminate

50. Pressure Ulcer Skin Wound Protocol
Incontinence Care

51. Pressure Ulcer Incontinence Care
Clean skin at time of soiling
Provide quick drying surface (under pads) to the skin.
Avoid hot water and too much soap while bathing.

52. Pressure Ulcer Skin Wound Protocol
Nutrition Consult

53. Pressure Ulcer Nutrition Consult
Diet should have adequate calories and protein, vitamins and mineral supplements.
Consult your dietician and doctor.
There is no direct link between bad nutrition and pressure ulcer prevention however nutrition optimization ameliorates the general condition of the patient and helps the cicatrisation process.

54. Pressure Ulcer Skin Wound Protocol
Moisturize Skin

55. Pressure Ulcer Moisturize Skin
Maintain good hygiene
Wash with mild soap and warm water, rinse well and pat dry carefully and gently.
Use moisturizers for dry skin
Minimize environmental factors leading to dry skin (Low humidity, cold air)
Do not massage skin over bony parts of the body (can damage tissue)

56. Pressure Ulcer Skin Wound Protocol
Positioning

57. Pressure Ulcer Positioning
The intensity of the pressure is determined by the weight of the patient, his positioning and the hardness of the material he is seated in.
The contact surface depends on the positioning: Surface  redistribution of pressure Pressure

58. Pressure Ulcer Positioning
Some facts:
In laying position: Avoid bottoming effect where the patient is not sustained by the mattress but lies directly on the sub-adjacent surface, specially for obese patients.
With a simple manual verification, we should not feel patient body.

59. Pressure Ulcer Positioning
Some facts:
In laying position: when the bed head is elevated, the pressure and shear effects increase.
In seating position, the weight is redistributed in a small surface: more pressure then laying position.
In seating position, a lateral or vertical inclination increases the pressure.

60. Pressure Ulcer Positioning
Dorsal Decubitus
Head and legs of the bed are elevated 30°: maximum reduction of pressure and shear.
Preferred positioning for long periods.

61. Pressure Ulcer Positioning
Lateral Decubitus
Body forms a 30° angle with the mattress aided by a 30° cushion
The sacrum should not be under pressure.
Above leg is positioned behind the other one, tilted 30° at the level of the hip and 35° at the level of knee.
Positioning can be made more comfortable with cushions
Use of inflatable cushions is not
recommended due to the effect of shear.

62. Pressure Ulcer Positioning
Alternated positioning
Use as often as possible Dorsal Decubitus positioning
Alternate with lateral Decubitus positioning
When using appropriate pressure reducing mattress, the schedule can be every 4 hours instead of 2 hours.

63. Pressure Ulcer Positioning
Seating position in bed
Limit seating positions in bed because it is the cause of shearing.
Preferred position is 60° but should be limited in duration.
Use this position only for eating time.

64. Pressure Ulcer Positioning
Ventral Decubitus
Should be used with soft mattress for comfort
To prevent pressure on feet, either place a cushion or remove end of bed and slide down patient so that feet are outside mattress.
Should observe pressure points: shoulder, thorax, basin, knees, feet, ears.

65. Pressure Ulcer Positioning
Heel

66. Pressure Ulcer Positioning
Seating
Slight dorsal inclination, legs resting on support and heels free of pressure
In case dorsal inclination is not possible, straight seating with both feet on floor

67. Pressure Ulcer Positioning
Seating
Limit the duration of seating position: time spent on chair should be less then time spent in fauteuil which is less then the bed.
Armchair help stabilize the positioning of the person.
Avoid lateral and vertical sliding from chair.
Make sure that the person is well seated to provide optimum contact surface.
Cushion and backs help to keep a right positioning. The type should be studied case by case.

68. Pressure Ulcer Skin Wound Protocol
Wound Care

69. Pressure Ulcer Wound Care
Debride – Ask your doctor
Surgical: most rapid, recommended for large necrotic areas.
Mechanical: hydrotherapy, wound irrigation
Enzymatic: collagenase to slow infection if present.
Autolytic: via enzymes in wound fluid (very slow)
Pick a dressing (must provide a-moist wound healing)
Transparent semi permeable films (eg Opsite, Tegaderm) for Grade I & II
Hydrocolloids (e.g. DuoDerm, Comfeel, Restore) for non infected Grade II & III
Saline soaked gauze (covered by occlusive wrap) gently pack dead space for Grade II to IV
Alignates: (eg. CalciCare, Kaltostat) for +++ exudates

70. Pressure Ulcer Wound Care
Watch for infection and treat - Ask your doctor for proper treatment.
Use dry lubricants (cornstarch) or protective coverings to reduce friction injury.

71. Pressure Ulcer Healing signs
The pressure ulcer will get smaller
Pinkish tissue usually starts forming along the edges of the sore.
Smooth or bumpy surfaces of new tissue
Some bleeding may be present which shows good blood circulation.

72. Pressure Ulcer
Any Questions
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