pressure ulcer

S.K.MOHANASUNDARI M.SC(N)

AIIMS RISHIKESH

COLLEGE OF NURSING

PRESSURE ULCERS

Introduction

Skin is the Human body’s largest organ it is Body’s first line of defense. it function as Protector, Regulator, Sensor, Metabolism and Communicator. Pressure ulcer is the commonest problem which arises when tissue injury, ischemia and tissue necrosis has been occurred. It is prevalent in bedridden patient. Meticulous skin care is needed to prevent this condition. Earlier days Pressure ulcer also called as decubitus ulcers or bed sores.

Definition:

According to The National Pressure Ulcer Advisory Panel (NPUAP) pressure ulcer is  a 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 that leads to tissue injury, ischemia, and tissue necrosis.

Statistics:

Around  70% occur in people over 65 yrs, 2-6 times greater risk of mortality, 95%  it occur lower body,   in sacrum(65%) and heal (30%) and Shoulder, heel, and ear were the favorite sites of newly developed Pressure ulcer.

Where do they form?

They from in the bony prominences like occiput, ear, scapula elbow, sacrum ischial tuberosities, grater trochander, medial condyle of tibia, fibular head, medial malleolus, lateral mallelous and heal.

Factors causing pressure ulcer?

Intrinsic factors:	Extrinsic factors:
Malnutrition and dehydration Critical illness Bedridden/wheel chair. Incontinence Age/Fragile skin Chronic diseases Infection, 0besity Smoking	Friction Shear Dryness Moisture Pressure

Pathology: Unrelieved pressure on the skin squeezes tiny blood vessels, which supply the skin with nutrients and oxygen.  When the skin is starved for too long, the tissue dies, and a pressure ulcer develops

How it look clinically?

1. Rounded, crater like shapes with regular edges
2. Usually dark regular base that do not bleed easily
3. Over bony prominences, but can take on the shape of the bone
4. Foul odor from ulcer
5. Warm/swollen skin
6. 6. Fever, weakness, and confusion

Are all ulcers pressure ulcers?        

• NO!
• Trauma, skin tears, moisture, arterial, venous, diabetic ulcer are often confused with Pressure ulcers. Pressure Ulcers are over bony prominences as a result of pressure.
• Do not stage any other ulcer besides pressure ulcers

What does it mean to “stage” a pressure ulcer?

Pressure ulcers are graded or “staged” to indicate the amount of tissue damage

§  Stage-1:Reddened area of skin

§  Stage-II. Blister/Open Sore

§  Stage –III: Crater (bowl shaped depression on surface)

§  Stage-IV: Damage to muscle or bone

How to Assess Pressure Ulcer?

1.      Systematic skin assessment (SSA): Every time you change, help to the toilet, dress, bathe, transfer, and/or turn a resident... you have a chance to check and care for a resident’s skin. What to look for on the skin: An area of skin that is noticeably different than the surrounding area. It may look red, and the redness does not “fade” when the skin is touched, and released (blanched). For residents with darker skin, the skin may look darker or lighter than the surrounding skin. Skin may look a little red, blue, or purple in color. When you check a resident’s skin, be sure to have good lighting. Another thing to try: Gently feel for a change in skin temperature, it may feel warmer or cooler than the surrounding area. A “suspicious area” may feel "spongy“ or "raised".

2.      Risk assessment scale
Braden scale

Criteria	Score
	1	2	3	4
1. sensory perception	Unresponsive	Responsive to pain stimuli	Response to verbal  commends	No impairment
2. Moisture	Constantly moist	Often moist but not always	Occasionally moist	Rarely moist
3. Activity	Bed fast	chair fast	Walk  occasionally	Walks frequently
4. Mobility	Completely immobile	Very limited	Slightly limited	No limitations
5. Nutrition	Very poor	Probably adequate	Adequate	Excellent
6. friction and shear	Problem	Potential problem	No apparent problem

Score and interpretation :

Criteria	Score
Very high risk	9 or less
High risk	10-12
Moderate risk	13-14
Mild risk	15-18
No risk	19-23

Norton scale:

Criteria	Score
	4	3	2	1
Physical condition	Good	Fair	Poor	Very bad
Mental condition	Alert	Apathy	Confused	Stupors
Activity	Ambulant	Walks  with help	Chair bound	Bed fast
Mobility	Full	Slightly impaired	Very limited	Immobilized
Incontinence	None	Occasionally	Usually urinary	Urinary and fecal

Score and interpretation:

Score	Criteria
>18	low risk
14-18	medium risk
10-14	high risk
<10	very high risk

Reduction of risk factor:

§  Inspect daily and Keep skin clean and dry

§  Reposition residents at least every two hours

§  Keep linen dry and free of wrinkles and objects that cause pressure to the skin

§  Clean urine and feces from skin as soon as possible

§  Make sure clothing and shoes do not bind or constrict

§  Pat skin dry when bathing; never scrub

§  Encourage adequate nutrition and fluids

§  Massage pressure points when the resident is repositioned

§  Report any changes in skin condition immediately

SSKIN a 5 step model for Reduction of risk factor IS:

S- Surface

S- Skin inspection

K- Keep moving

I- Incontinence/moisture

N- Nutrition and Hydration

Five pillow rule for risk reduction:

1.      Pillow 1 under legs to elevate heel

2.      Pillow 2 between ankles if on side

3.      Pillow 3 between knees if on side

4.      Pillow behind the back (unless you are using the Turn and position unit)

5.      Pillow 5 under the head

How to treat pressure ulcer?

1.      Pressure management

2.      Cleaning and dressing wound

3.      Wound debridement

4.      Other interventions

5.      Surgery

1.      Pressure management:

§  Patients who are capable of shifting their weight every 10 minutes should be encouraged to do so.

§  Reposition every 2 hours in case of bed ridden. After repositioning use a pillow to support the new position in the bed or chair.

§  Heels elevated off mattress supported by pillows under the legs

§  Use a pillow to keep the knees and heels from rubbing together

§  Patients who are bedbound should be positioned at a 30° angle

§  Use draw sheet and trapeze if possible to decrease friction

§  Do not position, if possible, over area of break  down

§  NEVER massage reddened areas (this is friction and will increase break down)

§  Keep in mind heel pads and elbow pads prevent FRICTION not PRESSURE,

§  Use Lift sheets, Trapeze, Heel and elbow pads, Moisturizers, Hydration, Transparent dressings and Skin sealants to prevent friction.

§  Anti-shear mattress, lift sheets, elevating bed for 30 degrees, using pillows or wedges, using, turning and Positioning system can prevent shear.

2. Cleaning and dressing wound

§  Stage I (not broken): gently wash it with water and mild soap and pat dry

§  Stage II (open sore): gently wash it with saline solution each time the dressing is changed

§  Dressing choice includes: films, gauzes, gels, and hydro cellular foams dressing

§  A combination of dressing may be used

3. Wound debridement

§  Surgical debridement

§  Mechanical debridement                          

§  Autolytic debridement

§  Enzymatic debridement

4. Other interventions

§  Pain management

§  Antibiotics

§  Topical application of Insulin drops

§  Granulated sugar

§  Electrotherapy 

§  A healthy diet

§  Management of incontinence

§  Muscle spasm relief

§  Negative pressure therapy (vacuum assisted closure)

5. Surgery

§  STAGE III & IV with exudates :  flap reconstruction

Complications:

§  Sepsis. .

§  Cellulitis. 

§  osteomylitis

§   Arthritis . 

§  Cancer. 

Reference: EE

1. Nightingale Florence. Notes on nursing: what it is, and what it is not. New York: D Appleton and Company; 1860.
2. Braden B, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehabil Nurs. 1987 Jan–Feb;12(1):8–12. 
3. European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide [monograph on the Internet]. Washington DC: National Pressure Ulcer Advisory Panel; 2009. [cited 2010 Apr 5]. Available from:
4. Black JM, Black SB. Unusual wounds: deep tissue injury. Wounds. 2003 Nov 10;15(11):38.
5. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden Scale for Predicting Pressure Sore Risk.Nurs Res. 1987 Jul–Aug;36(4):205–10.