PRESSURE ULCERS AND WOUNDS

By Monica Warhaftig, D.O. Assistant Professor of Geriatrics N.S.U.

Chronic Wounds
Greater than 12 hours Debridement Cleansing Dressing Pressure redistribution Multidisciplinary care

GOALS
Types of wounds Risk factors and Risk Scales Local/Systemic Factors Wound Care Healing Wound care products

Types of Wounds Location, Location, Location

Pressure: sacrum, heels, trochanter Venous: Inside the leg -Medial Arterial- Lateral
Diabetic: neuropathic areas Traumatic: anywhere

RISK ASSESSMENT: Low score=high risk (16 or 12)

*The Braden Scale The Norton Scale

*Extrinsic Factors
Pressure Relief : proper patient positioning; pressure devices: pressure greater that 32 mm hg (ischial tubes 300) (sacrum up to 300) Special Beds: static and dynamic Friction : rubbing of a body part against another or a surface..damage to stratum corneum..ex patient pulled across a bed Shear Stress: head of bed elevated greater that 30 degrees..patient slides down(opp directions) Moisture: weakens the skin

*Stages of Wound Healing

Inflammation- (approx. 2-3 days)
consists of a vascular and a cellular response acute and chronic inflammation (neutrophils, cytokines, oxygen, platelets rush to the site) Proliferation (approx. 2-3 weeks) Begins at the time of injury Rebuilding begins with scaffolding of the skin Revascularization of the wound begins Maturation Stage- (Approx 2-3 years) Depositing of scar tissue The body attempts to contract or close the wound (Wounds are only ever 80% healed)

Systemic Factors that affect Wound Healing

Nutritional Status Vascular Status Metabolic Factors Immunological Factors Age Medications (Steroids, etc) Genetic

The Local Factors

Necrotic tissue and foreign bodies Drying of a wound Microorganisms Trauma (pressure, shearing, friction) Fibrin Oxygen Edema

Intrinsic (Patient Status)

Diabetes Anemia: decreases O2 to the wound Nutritional State (Serum chemistries, Albumin, Prealbumin) Weight Loss (oxandrelone) Coagulopathic state Multiple comorbidities Incontinence;foley Immobility:turning q2 hours

What is a Pressure Ulcer ?

Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

Pressure ulcer stages

Stage 1: epidermis; nonblanching erythema Stage 2: epidermis/dermis; shallow opening;blisters Stage 3: Subcutaneous tissue/fascia Stage 4: fascia + bone, tendon, muscle, cartilage

Stage 1
Intact Skin with nonblanchable erythema (extravasation of blood from ischemic leaky blood vessels) (up to 30 minutes) Blanchable means congested vesselsvanishes shortly after pressure relief Cone Shapedapex to the skin (no indic of below) Muscle & Ischemia high metabolic rate less blood supply ..More susceptible

Pressure Ulcer Staging

Stage I

Pressure Ulcer Staging

Stage I
Dark Skin

Pressure Ulcer Staging

Stage II

Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Pressure Ulcer Staging

Stage II

Pressure Ulcer Staging

Stage II

Pressure Ulcer Staging

Stage II

Pressure Ulcer Staging

Stage II

Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Pressure Ulcer Staging

Stage III

Pressure Ulcer Staging

Stage III

Pressure Ulcer Staging

Stage III

Pressure Ulcer Staging

Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers

Stage IV

Stage IV

Stage IV

Pressure Ulcer Staging

Stage IV

Pressure Ulcer Staging

Stage IV

Venous Ulcers
Due to venous insufficiency Medial Aspect of the leg Beefy Red Jagged Painless Treat with compression

Venous Ulcer

Diabetic Ulcer

Venous Ulcers

Arterial Wounds
Complete or partial arterial blockage may lead to tissue necrosis and / or ulceration. Signs on the extremity: Pulselessness of the extremity Painful ulceration Small, punctate ulcers that are usually well circumscribed Cool or Cold skin Delayed capillary return time (briefly push on the end of the toe and release, normal color should return to the toe in 3 seconds or less)

Arterial Disease
Atrophic appearing skin (shiny, thin, dry) Loss of digital and pedal hair Can occur anywhere, but is frequently seen on the dorsum (top) of the foot. Utilize noninvasive vascular tests: Doppler, waveform, Ankle Brachial Indices (ABI) and Transcutaneous Oxygen Pressure measurements (TCPO2) to aid in your diagnosis. Duplex scanning and arteriograms may also be performed if indicated.

Arterial Disease
Ankle brachial index (ABI) : arterial blood flow in the lower extremities determines level of ischemia: Normal >1.0; LEAD = 0.9; Borderline is <0.60-0.8; Severe is <0.5. (The ABI can be falsely elevated in people with diabetes.(calcified noncompressible vessels) Recheck the ABI periodically Toe pressure (TP) in patients with diabetes in whom LEAD is suspected. Toe pressure <30 indicates LEAD.

Arterial Ulcers

Slowing factors
Temperature ; cold or open Necrotic tissue Exudate (too much vs dry wound)

Infection
Contamination Colonization Critical Colonization Infection

*Signs of Infection
Delayed Healing Change in Exudate Change in Pain Change in Granulation Tissue Change in Smell Change in Size Fever Leukocytosis

Types of debridement
Autolytic (Occlusive Dressings) the body heals itself Mechanical using gauzes Enzymatic chemical enzymes (Collagenase, Papain, ) Sharps scalpel, laser, surgery Biosurgical maggots, leeches

Topical Dressings
Occlusive Dressings Divided into polymer films, polymer foams, hydrogels, hydrocolloids, alginates, and biomembranes. Dressings left in place until fluid leaks from the sides (3 days to 3 weeks)

Products
Primary/secondary type of dressing Hydrophyllic Hydrogel Alginate Foam Accuzyme panafil

Transparent Film
Autolytic debridement Primary or secondary dressing Partial thickness wounds *Stage I or II pressure ulcers Superficial burns

Hydrocolloids (Autolytic)
Primary or secondary dressing *Partial and full thickness wounds Pressure ulcers *Necrotic wounds Granular wounds preventative dressing Used as a secondary dressing or under compression

Hydrogels
Stage 2 to stage 4 pressure ulcers Partial and full thickness *Painful wounds Skin tears Minor burns *Necrotic wounds

Collagens
*Infected Wounds Tunneling Wounds Surgical Wounds Can be used with other topical agents *Not for necrotic wounds

Negative Pressure Therapy

VAC Device For Nonhealing wounds and fecal incontinence Removes Interstitial Fluid from the wound

Antimicrobial Dressings
Infected Wounds Controls bacteria bioburden Effective against a broadspectrum of microorganisms IODOSORB AQUACEL IODOFLEX

Saline soaked Gauze Dressings

Saline soaked and not allowed to dry Similar to occlusive dressings However, Time intensive for nursing *Used for Partial and full thickness wounds Draining wounds Wounds requiring debridement packing, Or management of tunnels, tracts or dead space Surgical incisions/Burns/pressure ulcers

Calcium Alginate
Highly absorptive- brown seaweed *exudative wounds. Alginates do not adhere to a wound Can damage epithelial tissue if the wound dries

FOAM
Nonocclusive absorptive wound dressing Partial and full thickness woundsminimal to heavy drainage Stage II to IV press. Ulcers *Infected and non-infected

*Compression Therapy
Venous Ulcers Used to manage edema and promote the return of venous blood to the heart Use cautiously with arterial ulcers

Advanced Wound Care Products

Platelet Derived Growth Factors OTHERS

*Healing Factors The Push Scale

Wounds heal by contraction and scar formation (Cant reverse stage) Push Scale Measures: Size: greatest length (head to toe) and the greatest width (side to side) using a centimeter
Exudate: none, light, moderate, heavy Tissue Type: 4-any necrotic tissue; 3-any amount of sloughno necrotic tissue; 2-clean wound with granulation tissue; 1-wound closed

Tissue Types
Slough-yellow or white..strings or thick clumps
Granulation tissue-pink or beefy red tissue ,shiny, moist, granular appearance Epithelial tissue: new pink or shiny tissue grows in from the edges

Necrotic Tissue (eschar) : Black, brown, or tan firmly adheres to the wound bed
Closed/resurfaced-wound completely covered

What stage is it?

What Stage ?

What type of wound ?

What type of wound ?

Review
Picture Stage of pressure ulcer/type of wound Intrinsic/Extrinsic factors Scoring for assessment Factors in healing scales Factors in Infection

SKIN TEARS