Pressure Sore

Geizar arsika ramadhana

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Pressure Sore?
 Definisi: Cedera lokal pada kulit atau
jaringan di bawahnya akibat tekanan,
gesekan , tergeser atau kombinasi dari
semuanya. Biasanya lebih dari satu tonjolan
tulang.
 95% akibat tekanan pada tubuh bagian

bawah (sekitar 65% di daerah panggul dan

30% pada ekstremitas bawah)

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4 Stages of Pressure Ulcers
I) Reddened area of skin
II) Blister/Open Sore
III) Crater (bowl shaped depression on
surface)
IV) Damage to muscle or bone

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4 Stages of Pressure Ulcers

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Stage 1

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Stage 2

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Stage 3

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Stage 4

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Patophysciology
 Compression >> → ischemic → nekrotic &
ulceration

 Nekrotic >> infection, inflamation, edema &

unknown risk factor.

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Guidelines for Pressure Sore
 Recognition
 Diagnosis
 Prevention and Treatment
 Monitoring

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Recognition Steps
 Examine the patient’s skin thoroughly to
identify existing pressure ulcers
 Identify risk factors for developing pressure

ulcers
 Review records/resident interview to identify

previous history of pressure ulcers

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Distinguishing Features of Common Types of Pressure
Sore
Ulcer Type Pathophysiology Location
Diabetic Peripheral neuropathy secondary Usually lower extremities
to small or large vessel
disease in chronic,
uncontrolled diabetes
Ischemic Reduction in blood flow to tissues Usually distal lower extremities
caused by coronary artery Tips of toes
disease, diabetes mellitus,
hypertension, hyperlipidemia,
peripheral arterial disease, or
smoking
Pressure Unrelieved pressure resulting in Usually over bony prominences
damage to skin or underlying (e.g., buttocks, elbows, heels,
tissue ischium, medial and lateral
malleolus, sacrum,
trochanters)
Venous Venous hypertension resulting Usually lower leg region
from
incompetence of venous valves,
post-phlebitic syndrome, or
venous insufficiency. Tend to
be irregularly shaped

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Factors for Developing Pressure Ulcers
 Comorbid conditions (e.g., diabetes mellitus,
end-stage renal disease, thyroid disease)
 Drugs that may affect ulcer healing (e.g.,

steroids)
 Exposure of skin to urinary or fecal

incontinence
 History of a healed Stage III or IV pressure ulcer
 Impaired diffuse or localized blood flow (e.g.,

generalized atherosclerosis, lower-extremity

arterial insufficiency)

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 Impaired or decreased mobility and
functional ability
 Increase in friction or shear
 Moderate to severe cognitive impairment
 Resident refusal of some aspects of care and
treatment
 Undernutrition, malnutrition, and hydration
deficits
(Adapted from CMS, 2007)

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Assessment
 Assess the patient’s overall physical and psychosocial
health and characterize the pressure ulcer
 Identify factors that can affect ulcer treatment and

healing
 Identify priorities in managing the ulcer and the

patient
 Assess the patient’s nutritional status, including

dietary and fluid intake

 Assess for the presence of medical conditions that

may interfere with independent feeding or decrease

overall oral intake

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 In patients with lower-extremity ulcers, assess
for the presence of coolness, delayed capillary
refill, dusky discoloration, or pedal pulses. The
ankle-brachial index, determined by Doppler
arterial studies, may be helpful in determining
whether a lower-extremity ulcer is caused by
vascular insufficiency or by pressure.
 Assess the patient’s bed and chair mobility

and ability to sense and react to pain and

discomfort.

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Factors that can affect ulcer treatment and healing

 Physiologic factors
 Functional factors
 Psychosocial factors
 Ethical considerations

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Prevention and Treatment
 Create a turning and positioning schedule that is
based on the patient’s individual risk factors
 Do not massage reddened areas over bony
prominences
 Evaluate and manage urinary and fecal
incontinence
 Initiate a plan to prevent or manage a
contracture
 Inspect skin during bathing or daily personal
care
 Maintain adequate nutrition and hydration if
possible
 Maintain the lowest possible head elevation to
reduce the impact of shear
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Prevention and Treatment
 Position the patient to minimize pressure
over bony prominences and shearing forces
over the heels and elbows, base of head,
and ears
 Use appropriate offloading or pressure-
redistribution devices
 Use lifting devices such as draw sheets or a
trapeze
 Use proper transferring techniques

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Nutrition
 Increased protein intake is often emphasized
in patients with nonhealing wounds;
adequate intake of any single nutrient,
however, does not prevent pressure ulcer
formation or facilitate healing.
 Many clinicians recommend caloric intake of

30 kcal/kg to 35 kcal/kg33 and daily protein

intake of 1.2 to 1.5 g/kg of body weight34
for nutritionally compromised patients who
have or are at risk of pressure ulcers

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Pain Management
 After assessing pain and defining its
characteristics (e.g., frequency, intensity,
possible aggravating factors) and causes,
treat it aggressively by using appropriate pain
management protocols.
 (See AMDA’s 2003 clinical practice guideline,

Pain Management in the Long-Term Care

Setting)

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Manage Pressure
 Patients at risk of skin breakdown should be
placed on a static support surface (e.g.,
foam overlay, foam mattress, static flotation
device) rather than on a standard mattress

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Ulcer Dressings
The goals of dressing an ulcer are to:
 Keep the ulcer bed moist and the

surrounding skin dry

 Protect the ulcer from contamination
 Promote healing.

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Surgical treatment
Debridement
- Removal of the necrotic tissue  specimens of viable tissue
- Wound is packed and dressings changed every 6 to 8 hours.

Ostectomy
Skin grafting
has only a 30% success rate as grafting tends to provide
unstable coverage

Skin Flap

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Debridement of an ulcer
When choosing a debridement method, consider
 Ulcer size,
 Amount of slough and exudate,
 Presence and severity of pain associated either
with the ulcer or with the method of
debridement,
 Feasibility of performing sharp or surgical
debridement, and
 Risks of transporting the patient outside of the
facility vs. the benefits of surgical
debridement.

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Monitoring Considerations
Daily Monitoring
 Evaluate ulcer if no dressing is present
 Evaluate status of dressing if present: Is dressing
intact? Is drainage present? If so, is it leaking?
 Status of area surrounding ulcer that can be
observed without removing the dressing
 Presence of possible complications (e.g., signs
of increasing area of ulceration, soft tissue
infection)
 Evaluate whether pain, if present, is adequately
controlled
 Document when a change or complication is
identified

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Use of Photography in Pressure Ulcer
Monitoring
 Photography may be used in monitoring as part
of the facility’s compliance efforts, if the facility
has developed a protocol consistent with
accepted standards, which include the following:
 Photos taken at a consistent distance from the
wound
 Type of photographic equipment used
 Means to ensure that digital images are accurate
and not modified
 Inclusion of resident identification, ulcer
location, dates, etc., within the photographic
image
 Parameters for comparison over time

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Conclussion
 Area of skin breaks down when no movement
occurs
Constant pressure reduces blood supply to specific
area death of tissue
4 Stages of Pressure Ulcers : Reddened area of skin,
blister/open Sore, crater (bowl shaped depression
on surface), and damage to muscle or bone.
 Sign and simptoms : Foul odor from ulcer,

Redness/tenderness around ulcer, warm/swollen

skin and fever, weakness, and confusion if infection
spread to blood or other areas of body.

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 Treatment : Relieve pressure in area (pillows,
cushions), physician can treat depending on
stage, avoid further trauma, prevent infection
by properly cleaning open ulcers and
medication to promote skin healing.

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Refferences
 Bauer, J.D; Mancoll, J.S; & Phillips, L.G. 2007
 EPUAP. European Pressure Ulcer.2003
 Governor's Executive Order 2007-01:

“Ensuring Quality in Long Term Care”

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Thank You

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