Assessment and management

of pressure sores
By
Ansingunza.
@ COU BWINDI COMMUNITY HOSPITAL
AIP DEPARTMENT
Objectives
• By the end of this participant should be able to understand;
• Definition
• Facts
• Pathophysiology
• Assessment
• Risk factors
• Prevention
• Management
• Complications
Definition and facts
• A pressure ulcer also referred to as decubitus ulcers, bedsores, or pressure
sores is a localized injury to the skin or underlying tissue, usually over a bony
prominence, as a result of unrelieved pressure.
• Facts
• Pressure ulcer incidence ranges from 0.4 percent to 38 percent in hospitals,
from 2.2 percent to 23.9 percent in skilled nursing facilities, and from 0
percent to 17 percent for home health agencies(NPUP).
• There is ample evidence that the majority of pressure ulcers occur relatively
in the first 2 weeks of admission
• new data suggest that 15% of elderly patients will develop pressure ulcers
within the first week of hospitalization
Facts
• Various studies noted mortality rates as high as 60 percent for older
persons with pressure ulcers within 1 year of hospital discharge due
sequential decline in the health stastus .
• cost of treating pressure ulcers is 2.5 times the cost of preventing
them.
• the HCUP study reported an average cost of $37,800=132.3MUGX
PATHOPHYSIOLOGY
• Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues
are compressed enough to impede perfusion, leading ultimately to tissue necrosis.
• Normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm Hg as
average.
• keeping the external pressure less than 32 mm Hg should be sufficient to prevent the
development of pressure ulcers.
• Capillary blood pressure may be less than 32 mm Hg in critically ill patients due to
hemodynamic instability and comorbid conditions;
• Thus, even lower applied pressures may be sufficient to induce ulceration in this
group of patients.
• Pressure ulcers can develop within 1to 2hours of persistent pressure.
ASOCIATED RISK FACTORS
Direct causes • Indirect causes
• Urinary incontinence (bedsore
Pressure
contamination risk)
Shear • Fecal incontinence (bedsore
Friction contamination risk)
• Diminished cognitive/mental ability
Immobility (inability to self-report problems)
Loss of sensation • Malnutrition
Combine pathology • Obesity
Bony prominences • Auto-immune deficiencies
• age greater than 70yrs
Forces
• Pressure: As the living tissues are not static. Persistent pressure
distort there arrangement say occlude vessel initiating ischemia
• Shear: Shearing occludes flow more easily than compression consider
bending tubes and pinching them. Shear prone ischial tuberosities,
heels, shoulder blades and elbows.
• Frictional forces
Risk Assessment
Most health care institutions that use the Braden Scale or Norton Scale,
with the Braden scale being the most widely used in the United States
Assesse
1 sensory perception
2 Moisture
3 Activity
4 Mobility
5 Nutrition
6 Friction and shear forces
Assessment.

• Most experts agree that when a pressure ulcer develops its location,
size (length, width, and depth), and color of the wound; amount and
type of exudate (serous, sangous, pustular); odor; nature and
frequency of pain if present (episodic or continuous); color and type
of tissue/character of the wound bed, including evidence of healing
(e.g., granulation tissue) or necrosis (slough or eschar); and
description of wound edges and surrounding tissue (e.g., rolled edges,
redness, hardness/induration, maceration) should be assessed and
documented.
STAGING for Europeans
• For Grade 1, nonblanchable erythema of intact skin, discoloration of the skin,
warmth, edema, and induration or hardness may be used as indicators,
particularly on individuals with darker skin.
• For Grade 2, indicators include partial thickness skin loss involving epidermis,
dermis, or both. The ulcer is superficial and presents clinically as an abrasion or
blister.
• Grade 3 includes full thickness skin loss involving damage to or necrosis of
subcutaneous tissue that may extend down to, but not through, underlying fascia.
• Grade 4 includes extensive destruction; tissue necrosis; or damage to muscle,
bone, or supporting structures, with or without full thickness skin loss. Staging
should be done on dressing and evaluates weekly.
Prevention
1 Mattresses and cushions
Protection is the best way to prevent ulcers
Bd careful examination of the skin for inflammatory features
The skin should be kept clean, dry & rubricated.
Pressure relieving mattresses by use of foam filled mattresses, air-filled
mattresses, fluid-filled mattresses. Or electrical alternating air pressure
mattresses or pneumatic ripple beds.
For small areas like hand, ankle and foot, use water filled tied surgical
hand gloves
Prevention
• Change positions regularly
• avoid laying directly on the hip bones
• lay at a 30 degree angle to reduce pressure on the hips
• Raise the head more than 30 degrees to reduce friction
• Regular treating pressure areas.
Management
• Cleaning and debridemen
• Sharp debridement
• Mechanical debridement-use of wet to dry guaze
• Enzymatic
• Bio surgery
• Dressing
• classified as non-absorbent, absorbent, debriding, self-adhering and
many others
Dressings
• Honey-impregnated alginate dressings are known to accomplish total
wound healing to pressure ulcers.
• Nano silver dressings: These use the antibacterial property of silver to
clean the ulcer
• Hydrocolloid dressings a special gel that encourages the growth of
new skin cells in the ulcer and keeps the nearby healthy area of skin
dry
• NEGATIVE PRESSURE WOUND THERAPY
Bacterial burden
• Antibiotics are usually only prescribed to treat an infected pressure
ulcer and prevent the infection from spreading. Signs of infections:
• serous exudate, delayed healing, discoloration of granulation tissue,
friable granulation tissue, pocketing at the base of the wound, foul
odor, and wound breakdown) were better predictors of wound
infection than the classic signs of infection (i.e., increasing pain,
erythema, edema, heat, and purulence
• Treatment using silver-impregnated dressings has been shown to be
somewhat effective in decreasing bacterial bioburden load
(ecoli,stapp,clymadia and candida)
Exudate Management

• The use of dressings is a major component in maintaining a moist

environment.
• dressings can be broken down into seven classifications: transparent
films, foam islands, hydrocolloids, petroleum-based nonadherents,
alginates, hydrogels, and gauze
• Nongauze protocols of care should be used to accelerate pressure
ulcer healing.
Nutrition

• The use of high-protein diets for patients with protein deficiency is

essential to wound healing.
• Vitamins and electrolytes are of great value.
• Pain Management
• Pressure ulcers can be painful. In particular, patients with Stage IV
ulcers can experience significant pain.
• Goal of pain management eliminate the cause of pain, to provide
analgesia, or both
Monitoring Healing

Score after every week

• The Pressure Ulcer Scale for Healing (PUSH) was developed by the
NPUAP in 1997.
• Reconstructive surgery
References
• Gefen A. Reswick and Rogers pressure-time curve for pressure ulcer
risk. Part 2. Nurs Stand. 2009;23:40–4. [PubMed] [Google Scholar]
• Krouskop TA, Reddy NP, Spencer WA, Secor JW. Mechanisms of
decubitus ulcer formation — An hypothesis. Med Hypotheses.
1978;4:37–9. [PubMed] [Google Scholar
• Leblebici B, Turhan N, Adam M, Akman MN. Clinical and
epidemiologic evaluation of pressure ulcers in patients at a university
hospital in Turkey. J Wound Ostomy Continence Nurs. 2007;34:407–
11. [PubMed] [Google Scholar], myos clinic. Medicape and WHO
website.