subject: INTEGUMENTARY PT

WOUNDS AND WOUND HEALING

● WOUND
○ An injury involving cutting or breaking
of bodily tissue (as by violence,
accident or surgery).

WOUND TYPES
● Acute Wounds
○ Abrasion: caused by a combination of
friction and shear forces, typically over
a rough surface.
○ Avulsion: a serious wound resulting
from tension that causes skin to become
detached from underlying structures.
● Ulcers
○ Incisional wound: most often
○ Arterial Insufficiency Ulcers: occur
associated with surgery; created
secondary to inadequate circulation of
intentionally by means of sharp objects
oxygenated blood.
such as a scalpel or scissors.
○ Venous Insufficiency Ulcers: occur
○ Laceration: a wound or irregular tears
secondary to impaired functioning of
of tissues often associated with trauma.
the venous system resulting in
○ Penetrating Wound: a wound that enters
inadequate circulation and eventual
the interior of an organ or cavity.
tissue damage and ulceration.
○ Puncture: made by sharp pointed object
○ Neuropathic Ulcers: are secondary
as it penetrates the skin and underlying
complications usually associated with a
tissues.
combination of ischemia and
○ Skin Tear: results from trauma to
neuropathy.
fragile skin such as bumping into an
○ Pressure Ulcers: result from sustained
object, adhesive removal, shear or
or prolonged pressure on tissues at
friction forces.
levels greater that of capillary
pressures.

ARTERIAL VENOUS NEUROPATHI

C

LOCATION Lower Proximal Areas of the

one-third of to the foot susceptible
leg, toes, medial to pressure or
web spaces malleolus shear forces
(distal toes, during weight
dorsal foot, bearing
lateral
malleolus)
 APPEARA Smooth Irregular Well-defined
NCE edges, well shape, oval or circle; Wound Classification by Depth of Injury
defined; shallow callused firm; ● Superficial Wound: causes trauma to the skin
lack cracked with the epidermis remaining intact
granulation periwound ● Partial Thickness wound: extends through the
tissue; tend tissue: Hittle to epidermis and possibly into but not through the
to be deep no wound bed dermis
necrosis with
● Full thickness wound: extends through the dermis
good
granulation into deeper structures such as subcutaneous fat.
● Subcutaneous Wound: extend through
EXUDATE Minimal Moderate/ Low/ Moderate integumentary tissues and involve deeper
heavy structures such as subcutaneous fat, muscles,
tendon or bone.
PAIN Severe Mild to None, however
moderate dysesthesia may Wagner Ulcer Grade Classification System
be reported

PEDAL Diminished Normal Diminished or

PULSES or Absent Absent

EDEMA Normal Increased Normal

SKIN Decreased Normal Decreased

TEMP.

TISSUE Thin and Flaking, Dry, inelastic,

CHANGES shiny; hair dry skin; shiny skin;
loss; yellow brownish decreased or
nails discolorati absent sweat Exudate Classification
on and ● Serous: presents with a clear, light color and thin
oil production watery consistency; considered normal and
observed during wound healing
MISCELLA Leg Leg Loss of ● Sanguineous: presents with red color and thin
NEOUS Elevation Elevation protective watery consistency; may be indicative of new
increases lessens sensation
pain pain blood vessel growth or the disruption of blood
vessels.
● Serosanguineous: presents with light red or pink
WOUND ASSESSMENT color and a thin watery consistency; considered
Components of Wound Examination and Documentation normal in a healthy healing wound
◦ Etiology ● Seropurulent: Presents as cloudy or opaque with
◦ Location a yellow or tan color and a thin watery
◦ Wound type and Classification consistency; may be an early warning sign of an
◦ Clinical signs of infection impending infection
◦ Area, depth, and shape of wound ● Purulent: presents with a yellow or green color
◦ condition of wound margin/ edges and a thick, viscous consistency; generally an
◦ Undermining or tunneling indication of wound infection
◦ Involvement of underlying structures
◦ Stage of healing Necrotic Tissue types
◦ Odor ● Eschar: described as hard or leathery,
◦ Exudate type and volume black/brown, dehydrated tissue that tends to be
◦ Chronicity firmly adhered to the wound bed.
◦ Response to previous treatment ● Gangrene: refers to the death and decay of tissue
◦ Surrounding skin/scar assessment resulting from an interruption in blood flow to an
◦ Presence of necrosis area of the body; MC affect the extremities
● Hyperkeratosis: aka callus; typically white/gray
in color and can vary in texture from firm to
 soggy depending on the moisture level in patient with an acute condition will not tolerate
surrounding tissue. an inflation pressure higher than 40 mm Hg; once
● Slough: described as moist, stringy or mucinous, the pain threshold has been reached, do not
white/yellow tissue that tends to be loosely continue to inflate the cuff; test the non involved
attached in clumps to the wound bed. lower extremity first if only one extremity is
suspected of having a deep vein thrombosis.
General Assessment for Peripheral Vascular Disease
● OBJECTIVE INFORMATION
◦ Skin examination
◦ Measure skin temperature 3) Cuff Test
◦ Palpate pulse - Wrap a blood pressure cuff around the calf and
◦ Auscultation test if the patient can tolerate a pressure of 40 mm
◦ Doppler Ultrasound Hg
◦ Blood Pressure
◦ Edema 1) Rubor of Dependency Test
- Used to evaluate the arterial circulation by
● SUBJECTIVE INFORMATION observing skin color changes that occur with the
◦ Patient history and lifestyle lower extremity elevated and level
- When the patient is supine, observe and record
PERIPHERAL VENOUS AND ARTERIAL the color of the plantar surface of the foot
CIRCULATION TEST (normal = pinkish); elevate the lower extremity
● VENOUS INSUFFICIENCY TESTS approximately 45 to 60 degrees for 1 minute
○ PERCUSSION TEST (abnormal = rapid loss of color)
○ DVT TEST - Return the extremity to a level position; observe
○ CUFF TEST and record the color of the plantar surface
● ARTERIAL INSUFFICIENCY TEST (normal = rapid pink flush; abnormal = 30
○ RUBOR OF DEPENDENCY seconds or longer for color to appear; color will
○ ANKLE BRACHIAL TEST be bright red)
○ VENOUS FILLING TIME
○ CLAUDICATION TEST 2) Ankle Brachial Test
1) Percussion Test - Used to determine if a person has peripheral
- Used to assess the function of the valves of the artery disease; the blood pressure is measured at
saphenous vein the ankle and in the arm while a person is at rest;
- With the patient standing, the caregiver palpates a the test is often repeated after 5 min of walking
proximal segment of the saphenous vein with the on a treadmill; if the blood pressure at the ankle
fingers of one hand, then uses the fingers of the is the same or greater than in the arm, this is an
other hand to tap (percuss) a distal segment of the indication of normal blood flow; if the blood
vein. pressure at the ankle is lower initially or after
- A fluid movement will be sensed by the fingers exercise, this is an indication of peripheral artery
on the proximal segment during percussion if the disease.
valves are not functioning properly.
- Test both lower extremities and compare the 3) Venous Filling Time
results. - Used to determine the length of time required for
superficial veins to refill, after they have been
2) Deep Vein Thrombophlebitis Test emptied, as a result of arterial flow through the
- Used to assess the possible presence of a capillaries into the veins (Note: The patient must
thrombus have a normal venous system)
- The caregiver grasps and lightly presses the - The patient is supine, and the lower extremities
patient’s calf while passively forcing the foot into are elevated 45-60 degrees for 1 min; then the
dorsiflexion; if the patient complains of pain in legs are dangled over the edge of the bed or table;
the calf, a positive response is reported; this is refilling of the veins is observed and timed
known as a positive Homans’ sign (normal = 10 to 15 s for refilling)
- Another method is to apply a blood pressure cuff
around the patient’s calf and inflate it gradually; a
 4) Claudication HEALING BY INTENTION
- Used to measure the length of time a patient can ● PRIMARY INTENTION
walk before claudication is experienced - MC in acute wounds with minimal tissue loss
- The patient walks on a level-grade treadmill at 1 - Typically have minimal scarring and heal
mile/h until claudication occurs; the time elapsed uncomplicated and orderly progression (e.g.,
is recorded when calf pain prevents continuation surgical incision, laceration, puncture, and
of walking superficial and partial thickness wounds).
- The test can be repeated at specified intervals,
and the time elapsed values can be compared. ● SECONDARY INTENTION
- Permits wounds to close on their own without
WOUND HEALING superficial closure.
1) INFLAMMATORY PHASE - Require on going wound care and have
○ function is to limit tissue damage, significantly larger scars. (e.g., neuropathic,
remove injured or damaged cells, and arterial, venous or pressure ulcers, most full
repair the injured tissue. thickness wounds, and chronically inflamed
○ Debris and necrotic tissue are removed wounds).
and bacteria are killed by mast cells,
neutrophils and leukocytes. Factors Influencing Wound Healing
○ Processes occurring in the ◦Age
inflammatory phase establish a clean ◦Co-morbidities
wound bed which signals tissue ◦Edema
restoration and permanent repair ◦Harsh or Inappropriate Wound care
processes to begin. ◦Infection
◦Lifestyle
2) PROLIFERATIVE PHASE ◦Medication
○ The proliferative phase overlaps the ◦Obesity
inflammatory phase with granulation,
angiogenesis to reestablish capillary WOUND HEALING INTERVENTIONS
buds, contraction, and epithelialization ● Debridement
of the wound site. ○ SELECTIVE
○ The fibroblastic cells proliferate and ■ SHARP
collagen tissue develops to initiate scar ■ ENZYMATIC
formation. ■ AUTOLYTIC
○ A bed of granulation tissue forms ○ NON-SELECTIVE
gradually over the surface of the ■ WET TO DRY DRESSINGS
wound, and the epithelial margins ■ WOUND IRRIGATION
begin to migrate toward the center of ■ HYDROTHERAPY
the wound on top of this granulation
bed. MODALITIES AND PHYSICAL AGENTS
1) Negative Pressure Wound Therapy (NPWT)
3) REMODELLING PHASE - Also referred to as Vacuum-Assisted Closure
○ characterized by the organization of the (VAC)
collagen tissue into a more definitive - A non-invasive wound care modality used to
and finite pattern. facilitate healing and manage dressing.
○ Scar tissue is remodeled and strengthen - A sterile foam dressing is placed in the wound
through the process of collagen lysis and sealed with air tight secondary dressing
and synthesis. which attach via tubing to a vacuum pump with a
○ Newly repaired tissues have reservoir container.
approximately 15% of preinjury tensile
integrity and should be protected to
prevent re-injury. Over time, tensile
integrity may increase to as much as
80% of the preinjury strength.

2) Hyperbaric Oxygen
- Refers to the inhalation of 100% oxygen
delivered at pressures greater than one
atmosphere.
- Delivered in a closed chamber typically at
pressures two or three times that of the
atmosphere, effectively reducing edema and
hyperoxygenating tissues.
3) Growth Factors
- Derived from naturally occurring protein factors
- These substances facilitate healing by stimulating
the activity of specific cell types (e.g.,
neutrophils, endothelial cells, fibroblast).
- Currently, only a limited number of growth
factors have been approved by the FDA for
topical wound healing applications.
TYPES OF DRESSINGS
Table 11-5 Product Selection Based on Wound Severity
DRESSING VALUE/EFFECTS
Transparent file Dressing of choice for stages 1 and
(6.0. Bioclusive, ll wounds with blister formation
Tegaderm, over bony prominences; resists
and OpSite) shear; may be applied to heels
prophylactically, sell-adherent and
allows wound to be observed; may
be used for autolytic debridement:
do not use on draining or infected
wounds
Hydrocolloid Dressing of choice for stages ll and
(e-9 ll wounds with minimal drainage;
DuoDem, provides moist wound bed; absorbs
Restore [paste small amount of drainage;
or granules], self-adherent and provides
Tegasorb. cushioning over bony prominence;
Hydrocol, and do not use on infected wounds;
DermaFilm) medications cannot be used under
the dressing
Hydrogel (e.g. Recommended for stages ll and ll
Vigilon. wounds with dressing covering the
ClearSite, and gel; moist wound bed is
NU-GEL) maintained; recommended for use
on skin tear, cover with rolled
absorbent material (Kling) may
cause maceration of surrounding
healthy tissue: does not protect
wound from external soling; helps
clean and debride necrotic tissue
Wet to wet Safe choice for unstaged wounds:
use on stage ll partial-thickness
wounds and stages I and I wounds;
dressing will need to be changed
every 8 h to maintain moist wound
base; moisten dressing with saline
solution before removal if dressing
is dry to prevent bleeding and
disruption of granulation bed;
moisture barrier must be used on
surrounding tissue to prevent
maceration
Wet to dry Use on stages ll and IV wounds for
debridement; slough and necrotic
tissue adhere to dressing and are
removed with dressing; this
dressing is the most widely used
and probably the most
controversial, because research
shows disruption of angiogenesis
by
dressing removal and increased risk
of infection because of the need for
frequent dressing changes
Calcium Use to absorb heavy drainage, but
alginates will require a secondary dressing to
cover the wound (Kaltostat
ALgosteril); calcium alginates may
be used on infected wounds or tor
fling in the cavity of deep wounds
Foam dressings Used for heavily exudative wounds
(e.g., (especially during the inflammatory
Polyderm, phase after debridement and
Lyofoam, desloughing when exudate is at its
Mepilex, and peak), deep cavity wounds, and
Allevyn) weeping ulcers such as venous
stasis ulcers, is very absorbent and
can be left on for 3-4 days
 Collagen (e.g., When added to a wound , t acts as a
Collagen/Ag. hemostatic agent; continued
BIOSTEP, and application seems to hasten healing;
Medifil it absorbs 40- 60 times its weight in
fluid

Enzymatic Particularly effective for tunneling

2) Skin Trauma
debriding agents ulcers that may be hard to see or
(e.g., Accuzyme, reach; some of these ● Skin injury results in desquamation and
Kovia ointment. " debriders are selective for necrotic hemorrhage. If not properly treated, subsequent
Gladase, tissue, while others are not; by bacterial infection and interstitial edema cause
Ethezyme, and loosening necrotic debris, surgical dermo epidermal necrosis, which leads to the
papain urea debridement may be avoided development of decubitus ulcer
debriding
ointment

Hydrofiber (e.g., Indicated for wounds with moderate

Aquacel and to high exudate that are infected or
Aquacel Ag at risk for infection; provides a
Hydrofiber) moist wound environment and
provides sustained antimicrobial
activity for up to 7 days 3) Friction
● The friction of skin sliding against the contact
surface, especially the skin friction by external
DECUBITUS ULCER
forces or sharp objects, can be a cause of
- A decubitus ulcer is a condition where soft tissue
decubitus ulcer with abrasion
or underlying tissue over a bony prominence is
injured by peripheral circulatory disturbance or
unrelieved pressure over a localized area,
resulting in ischemic necrosis by hypoxia and
nutritional deficiency
- a typical skin damage of long-term bed-rest
patients and patients with vascular disease,
sensory neuron lesion, diabetes, dementia, and
spinal cord injury, frequently occurring in soft 4) Sense Deprivation
tissues ● When cutaneous sensation is lost or decreased,
the skin tissues are subject to damage.
Causes ● patients in such conditions cannot sense that their
1. pressure skin is damaged, the secondary decubitus ulcer
2. skin trauma could develop.
3. friction
4. sense deprivation
5. body temperature and humidity
6. malnutrition & impaired vasomotor response

1) Pressure
● A decubitus ulcer occurs frequently to long term
bed-rest patients or wheelchair user
● Prolonged pressure over a bony prominence is
the major cause of developing decubitus ulcer
● Pressure greater than 32 mmHg decreases tissue
resistance and damages soft tissue by impeding
capillary blood flow.
5) Body Temperature and Humidity
● moisture on the skin’s surface acts as a medium
for bacterial growth, the moist skin is subject to
developing decubitus ulcer
● Higher body temperature results in higher
metabolic needs, and when the raised needs are
not sufficiently provided, decubitus ulcer
develops.
 Classification
● Pressure Ulcer
A pressure ulcer is clinically called as a bed sore. It is
caused by prolonged and unrelieved pressure over a
bony prominence and eventually results in ischemic
necrosis
6) Malnutrition and Impaired Vasomotor
Response
● Impaired regulation of vasomotion hinders blood
flow, leading to the formation of decubitus ulcer
● Not only is poor nutrition associated with the
failure of healing, but it leads to insufficient
● Diabetic Ulcer
supply of oxygen and nutrition to epidermal
Diabetic ulcer is caused due to the peripheral
tissues, making them vulnerable to decubitus
circulatory disturbance rather than pressure, and it
ulcer
leads to the formation of gangrene on the feet or toes
 ● The Assessment Tools for Decubitus Ulcer
STAGE SKIN CHANGES TREATMENT
S
ASSESSMENT OF DECUBITUS ULCER
Stage • Skin is in not • Pressure ● Ocular inspection and Palpation
one damaged, but when relaxation ● Observe the shape and the color
pressure is removed, methods ● kinds and the amount of the exudate
erythema does not Turn over ● smell, inflammation or infection
disappear. frequently ● edema, figure out the location and the degree of
•Usually half of the Use tools to
it.
reactive hyperemia relieve pressure
appears when Change ● location of the decubitus ulcer, measure the size
circulatory positions and the depth of it
disturbances occur by
pressure. Reactive ● BRADEN SCALE
hyperemia must be Braden scale is a risk assessment tool made up of six
distinguished from the
indicators: sensory perception, moisture, activity,
stage one of a
decubitus ulcer mobility, nutrition, and friction. Each indicator is scored
1–4 (1–3 for friction) with total score ranging 6–23.
The lower the total score, the higher the risk for decubitus
ulcer. As for inpatients, a score of 15–18, a score
of 13–14, and a score of 13 or lower indicate low risk,
Stage • Loss of fragmentary • Keep in a middle risk, and high risk, respectively. In the case of
two thick skin invaded into moist non-patient elderly, a score of 17 or lower indicates high
the epidermis and environment
dermis. for treatment risk of pressure ulcer
• The Ulcer is • Use normal
superficial, and has saline ● PUSH SCALE
abrasion, herpes, and • Gauze PUSH scale (Pressure Ulcer Scale for Healing scale),
shallow holes. dressings developed by the NPUAP,sorts out the pressure ulcer with
(Improve respect to surface area, exudate, and type of wound tissue,
natural therapy
and each category is scored accordingly
and
interrupt scab
formation) ● PRESSURE ULCER HEALING CHART
Pressure ulcer healing chart, also developed by the NPUAP,
Stage • Loss of the • Debridement allows to monitor and record trends in PUSH scores over
three fragmentary thick skin (necrectomy) time
with necrotic tissues execution
invaded into the • Wet dressing
INTERVENTION
subcutaneous tissue •Surgical
(not into the fascia). intervention ● MEDICAL
• Ulcers are holes in •Proteolytic ● SURGICAL
skin but it doesn’t enzyme ● PHYSICAL THERAPY
affect the
central tissues. ● MEDICAL
• Debridement - Protect the decubitus ulcer and tissue surrounding
(necrectomy) execution
it to prevent an additional injury.
Stage • The complete loss of • Noncontact - Relieve tissue tension surrounding the decubitus
four the skin including dressing ulcer.
necrosis and damages (change every - Protect the area around the decubitus ulcer from
muscles, bones, 8–12 hours) epidemiology stress from the patient’s activities.
tendons, and joints. • Skin graft if - Decrease the virus microbes around the decubitus
• Sinus tract (pupil necessary ulcer.
tract) is a stage four
- Improve the process of decubitus ulcer
decubitus ulcer
management.
- Prevent new decubitus ulcer formation
Tests and Assessment
● Assessment of Decubitus Ulcer ★ DRESSING
➔ Gauze dressing
- By placing dry gauze after sterilizing the ulcer
area, the gauze dressing absorbs the exudates and
protects the decubitus ulcer by keeping the ulcer
area sterilized.
➔ Wet Dressing
- Keeping moisture of the decubitus ulcer area
shortens the ulcer’s and soft tissue’s treatment
times and it also helps to prevent scars. Choose a
hydrocolloid, hydrogel, or polyurethane dressing
depending on the decubitus ulcer’s condition
★ MEDICINE
● Injecting antibiotics (bacitracin, polysporin,
neomycin, etc.) is effective to prevent local
infection of the decubitus ulcer.
● To use neomycin, it has to be checked if the
decubitus ulcer patient has an allergic reaction to
it
● Antiseptic drugs are not recommended for a
decubitus ulcer patient because the drugs remain
in the body.
★ SURGICAL
- If the decubitus ulcer’s necrotic tissue is big or
treatment is impossible through dressing, then
surgery is needed (skin graft, fl ap). Surgery for
decubitus ulcer involves in removing ulcers and
infected bone, trimming the protrusion bone, and
suturing the skin with healthy tissues.
★ PHYSICAL THERAPY
● POSTURES PREVENTING DECUBITUS
ULCER
● EXERCISE
● MANUAL
● PHYSICAL AGENTS
★ Posturing
- The posturing of decubitus ulcer patients can
prevent deformities and complications of
decubitus ulcer
➢ Supine
➢ prone
➢ Side-lying
➢ Sitting
★ POSTURES PREVENTING DECUBITUS
ULCER
- Supine position is lying down with shoulders
parallel to the hips and straight backbones.
- Placing a small pillow or a cervical roll under the
patient’s head is necessary. The height of the
pillow should not make the neck and body bend
too much or round shoulders.
- Placing a small cushion under the knees helps to
make the patient comfortable and prevent lumbar
lordosis. If a cushion is too big, it may cause
contracture on the iliopsoas and hamstring so the
long time used should be avoided.
- To disperse the pressure on the heel, a small
towel can be used, but it should be used carefully
to avoid hyperextension.
- Don’t let the patient’s arms fall outside of the
bed; put them next to the body or on the chest
★ Prone
★ Side-lying
★ Sitting
● Prone position
- The prone position makes a patient’s shoulder
and backbone parallel to each other. Patients,
who have feelings in their arms or don’t have any
problem communicating, put their arms next to
the body or head. But physical therapists should
ask the patents if their arms feel numbness or
become insensitive when they are in the prone
position for a long period of time. Decubitus
ulcer can occur or become worse because of the
nerve compression and poor circulation.
- When a patient is in prone position, put a small
pillow under their head and turn the patient’s
head to one side or put on table with a hole (table
with a head hole; Fig. 3.11 ). Armrests and face
control tables help patients to have a comfortable
position because patients can have enough spaces
and supports for their heads. This table is used to
keep a patient’s neck balanced (Fig. 3.12 ).
- Putting a pillow under a patient’s stomach can
reduce lumbar lordosis. Putting towels under the
shoulder increases scapular adduction and protect
the humerus head by reducing tension on the
adductor canal between the scapulas. Relax the
pelvis and lumbar and reduce the hamstring
muscle tension by putting a small pillow or a roll
under the patient’s ankle. But a big pillow may
 cause the hamstring muscles to contract by
bending the knees.
● Side-lying position
- The side-lying position is a position when the
patient is located at the middle of the bed and
arranges the head, body, and pelvis. Make the
patient’s hip and knee joints semifl exed (Fig.
3.13 ).
- Support the upper legs with a couple of pillows
and locate lower legs a little bit to the back. Let
the lower part of the legs support the patient’s
pelvis and lower half of the body.
- Prevent a patient’s upper body from inclining
through supporting the brachial with a pillow in
front of the patient's chest.
- Use a safety belt and a thick pillow when the
patient can’t lie on his side by himself.
- Increase the body’s comfort and safety with the
patient's arm. If protection is needed under the
bony spur concerned with the decubitus ulcer
development due to the compression, put a pillow
at the distal end of the limb and put a second
pillow under the bony spur. Avoiding the direct
compression to the bony spur is the most
important in a long term side-lying position.
Therefore, a side lying position against
something should be considered.
- Use more than one pillow when a patient sits
against the treatment table and let the patient
support the upper part of the body (Fig. 3.14 ).
When the patient has been leaned against the
back of the chair for a long time, put a cushion on
the patient’s back.
- Move the patient’s arms to their knees or onto the
armrests. When patients are sitting for a long
period of time, make them do push-ups holding
the armrests and lifting their hips, move their
upper body to the left and right, or bend their
upper body every 15 min to relieve hip
compression.
- Using a special wheelchair with a tilt-in-space or
a reclining back will be more comfortable (Fig.
3.15 ).
● Changing Position
Because the continuous compression is the reason of
decubitus ulcers, change position at least every 2 h when a
patient is lying down and every 15 min when a patient is
sitting. When a patient is lying down on their side (e.g.,
watching TV), lay down making the body 30° to the floor
in any direction following the 30° angle law . Keep a
30° angle of the patient’s arms, legs, and even head by
using pillows

● Sitting position
- A stable chair needs to be used for patients in the
sitting position. A patient’s foot should rest on
the floor or a prop of a wheelchair. The femoral
buttocks tissue and deep tissue shouldn’t be
compressed from the edge of chairs or the ★ EXERCISE
wheelchairs.
 - Exercise therapy for decubitus ulcer focuses on
aerobic exercise and enhancing peripheral
circulation. When a compression decubitus ulcer
has occurred, promote the circulation of ulcer
through increasing a patient’s deep breathing and
enhancing the pump functions of the calf muscle
- exercising by walking on the treadmill or the
ground or riding a stationary bicycle for 15 to 40
min.
- intensity at 60–80 % of their HRmax. ,
- conduct ankle-pumping exercises 20 times a set,
and do two or three sets per day.
- heel raise exercises ten times a set, three sets a
day

★ PHYSICAL AGENTS
★ MANUAL
● Whirlpool Bath Treatment
A decubitus ulcer surgery such as a skin graft or flap leaves
● Ultraviolet Therapy
a scar. A scar will limit the epidermis and subcutaneous
● Iontophoresis
tissue’s mobility through its adherence to the surrounding
● Laser Therapy
tissues. It can cause pain inside the scar. Skin rolling and
scar tissue release are effective ways to relieve pain and
● Whirlpool Bath Treatment
increase skin mobility
- whirlpool bath removes dirty ulcer fragments,
bacteria, exudates, and blood residue, reduces
● Skin Rolling
pain, and stimulates the decubitus ulcer healing
- Physical therapists hold the wounded skin softly
through hydrating the ulcer areas with water
with their thumb and index finger and roll it up,
down, and diagonally When a sutured wound is
● Ultraviolet Therapy
too thick for rolling, hold the skin farthest away
- Ultraviolet radiation is effective to improve
from the wound and roll the skin by moving
immunity by creating Vitamin D while sterilizing
toward the center. Conduct skin rolling in a
the area around the ecubitus ulcer.
variety of ways. However, before conducting the
- destroys decrepit cells, improve regrowth of cells,
skin rolling, remove the skin’s oil from the skin
and boost treatment for the decubitus ulcer by
of therapist and patient, and keep the area clean
causing a crust to form on the necrotic tissue
● Scar Tissue Release
● Iontophoresis
- Ask the patient which sutured wound is the most
- is a drug electrotherapy that passes local
sensitive, and press it with the tip of an index
activating ions to scar tissues of the decubitus
finger. The therapists’ fingers should turn
ulcer by using continuous anode and cathode
clockwise and the therapists should continue to
penetrating into the skin. Iontophoresis has an
ask a patient which sutured wound is the most
anesthetic effect that can reduce pain and
sensitive. At this point, repeat the scar tissue
inflammation on the area of the decubitus ulcer
release to induce a loosening of the tissue through
light compression and retrogression of the tissue
● LASER Therapy
- reduce inflammation, increase prostaglandins’
concentration, boost ATP creation, increase
collagen, and increase fibroblast cells. It also
increases the phagocytosis of macrophages,
activates the immune system, and promotes cell
proliferations by stimulating the absorption of
exudates and a diffusion reaction.
 2) Educate the patient to change positions every 2 h
le-g. position change, lift their bottom on a
wheelchair, lift their pelvis in a supine posi-tion,
or lift their body from a sitting position (Fig,
323)],
3) Disperse the pressure through the use of an air
mattress or a water mattress.
4) Protect the area of bone protrusions by using joint
guards and bandages.
5) Take care to not make abrasions on a patient's
skins when changing the mattress sheets or a
patient's position.
6) Establish the early mobilization programs and
practices.

3.2.3 Prevention and Management

3.2.3.1 Diabetic Ulcer
1) Prevent a decubitus ulcer through clean foot care.
2) Wear customized shoes to prevent toe pressurc
and deformity.
3) Wear layered socks to reduce frictional force.
4) Educate the patients so they can prevent
peripheral neuropathy through controlling their
blood glucose.
5) Increase muscular strength and bloodstream flow
through regular exercise (aerobic exer-cise,
endurance training, and progressive resistance
exercise) to improve their balance and ability to
walk,
6) Lose weight by dietary treatment to remove
weight from the patient's legs.

3.2.3.2 Pressure Ulcer

1) Remove the pressure of the protruding bones
through the use of a pillow or a cushion.