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1. 13.pressure ulcers Dr.Hurriya sehar (consultant pt)

2. introduction Pressure ulcers are a global healthcare concern and require an interdisciplinary approach to care and management. Over the centuries, pressure ulcers have been referred to as decubitus ulcers, bedsores, and pressure sores. The term pressure ulcer has become the preferred name because it most closely describes the etiology and resultant ulcer.  In 2009, the National Pressure Ulcer Advisory Panel (NPUAP), in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP), released this common definition: “A 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.

3. Pressure ulcers are usually located over bony prominences (such as the sacrum, coccyx, hips, heels) and are classified according to the extent of the type of observable tissue damage. Relying just on depth of tissue damage rather than tissue type may be misleading because pressure ulcers in locations where there is little adipose tissue, such as the ear, may be shallow but still extend through the subcutaneous tissue. More recent research, using techniques such as magnetic resonance imaging (MRI), has documented cellular distortion and damage from pressure. There is also a renewed appreciation for the effects of shear in damaging deeper tissue and microclimate (moisture and temperature) in rendering tissue less tolerant of the effects of pressure. Body tissues differ in their ability to tolerate pressure. The blood supply to the skin originates in the underlying muscle. Muscle is more sensitive to pressure damage than is skin tissue.Tissue tolerance is further compromised by extrinsic and intrinsic factors. Extrinsic factors include moisture, friction, and irritants. Numerous intrinsic factors affect the ability of the skin and supporting structures to respond to pressure and shear forces, including age, spinal cord injury, nutrition, and steroid administration; these factors are believed to affect collagen synthesis and degradation. Other intrinsic factors affect tissue perfusion, including systemic blood pressure, extracorporeal circulation, serum protein, smoking, hemoglobin and hematocrit, vascular disease, diabetes mellitus, vasoactive drugs, and increases in body temperature.

4. Etiology of pressure ulcers Once the conditions for increased pressure intensity and duration are established, intrinsic and extrinsic factors affecting tissue tolerance contribute to pressure ulcer development.  According to epidemiological evidence, these factors fall under several categories: (1) poor nutritional status (e.g., decreased intake of nutrients—especially protein, weight loss, lower albumin); (2) skin moisture (e.g., urinary or fecal incontinence, excessive sweating or wound drainage); (3) advanced age; (4) factors affecting perfusion and oxygenation (e.g., hypotension, hemodynamic instability, peripheral vascular disease, diabetes, vasopressor drugs, need for supplemental oxygen); (5) friction and shear; (6) poor general health status; and (7) increased body temperature. Friction and shear are also mechanical forces contributing to pressure ulcer formation. The tissue injury resulting from friction may look like a superficial skin insult. Shear has the potential to damage deeper tissue. Shear and friction are two separate phenomena, yet they often work together to create tissue ischemia and ulcer development.

5. International NPUAP/EPUAP pressure ulcer classification system Category/Stage I: Non-blanchable Erythema • Intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Category/Stage II: Partial Thickness Skin Loss • Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.* Category/Stage III : Full Thickness Skin Loss • Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. Category/Stage IV: Full Thickness Tissue Loss • Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.

6. Unstageable: Depth Unknown • Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Suspected Deep Tissue Injury : Depth Unknown • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, fi rm, mushy, boggy, or warmer or cooler as compared to adjacent tissue.

7. prevention Preventing pressure ulcers is of vital importance. Elements of pressure ulcer prevention include identifying individuals at risk for developing pressure ulcers, preserving skin integrity, treating the underlying causes of the ulcer, relieving pressure, paying attention to the total state of the patient to correct any deficiencies, and educating the patient and his or her family about pressure ulcers. BRADEN SCALE The Braden Scale is the most commonly used pressure ulcer assessment tool in the United States. The Braden Scale has six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/ shear.

8. Braden Scale: Maintains good position in bed or chair at all times. TOTAL.  SCORE . Total  score  of 12 or less represents HIGH RISK

9. Acute Care The NPUAP/EPUAP clinical practice guideline1 recommends that reassessment be conducted regularly and based on the acuity of the patient. Although the guideline recommends frequent skin assessment for shear injury in critically ill individuals,1 no guidance is given as to what “frequently” means. The Institute for Healthcare Improvement (IHI) recommends that pressure ulcer risk assessment be done every 24 hours.45 The World Union of Wound Healing Societies46 recommends that assessments be performed daily in the intensive care unit and every second day on general medical/ surgical floors.

10. Long term care and home health care Assess initially upon admission, then reassess weekly for the fi rst 4 weeks, monthly to quarterly after that, and whenever the resident’s condition changes. The plan of care needs to address the areas of risk for home care patients. Any good prevention program begins with assessing the patient’s skin. The skin should be assessed and its condition documented daily in acute and long-term care settings and at each home care visit. Careful attention to preventing skin injury during performance of activities of daily living is paramount. The bathing schedule should be individualized based on the patient’s age, skin texture, and dryness or excessive oiliness of the skin. Use of nondrying products to clean the skin is recommended. One study found that the incidence of stage I and II pressure ulcers could be reduced by educating the staff about using body wash and skin protectant products.

11. Avoid excessive friction and hot water when cleaning. Use nonalcoholic moisturizers after bathing. A daily bath may not be needed for all patients; elderly patients, for example, may benefi t from “lotion” baths. For the incontinent patient, moisture barriers and ointments should be considered as treatment options. Soiled skin should be cleaned immediately and products to protect the skin applied. If containment products are used, follow the correct methods of application. The skin should be protected from injury. Pad bony prominences using dressings, such as films, hydrocolloids, foams, stockinettes , or roller gauze. In a study of 93 high-risk patients in a surgical trauma intensive care unit, the use of intervention bundles that included a prophylactic soft silicone dressing product resulted in 0 pressure ulcers. Physical and occupational therapists are important members of the pressure ulcer team, a valuable resource for maximizing patient mobility. Their expertise in selecting appropriate-size wheelchairs and evaluating seating angles and postural alignment can’t be over-emphasized. Patients who are confined to a chair should be repositioned every hour, with small shifts in weight made every 15 minutes. Although most clinicians consider turning and repositioning bedridden patients every 2 hours to be a standard of care, the appropriate turning interval for all patients has yet to be determined by research.

12. PRESSURE ULCER STAGING The NPUAP(NATIONAL PRESSURE ULCER ADVISORY PANEL) staging system was designed specifically for pressure ulcers. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.

13. PRESSURE ULCER TREATMENT PREVENTION STRATGIES : 1.Treat the cause 2. Patient-centered concerns TREATMENT STRATEGIES : LOCAL WOUND CARE (cleansing with saline solution, Pressure redistribution, Dressings can be broken down into several classifi cations: gauze, non-adherent gauze, transparent films, hydrocolloids, foams, alginates, hydrogels, collagens, antimicrobials, composites, and combinations. Matching the dressing to the wound bed characteristics is essential.,Nutrition )1.Debridement 2.Infection Control 3.Moisture Balance EVALUATION : Re-Evaluate TREATMENT : Biological Agents and adjunctive therapies( Adjunctive therapies include electrical stimulation, hyperbaric oxygen, radiant heat, growth factors, and skin equivalents

14. summary Pressure ulcers are a common healthcare problem throughout the world. Intensity and duration of pressure as well as tissue tolerance are the etiologic factors that lead to pressure ulcer development. Incorporation of clinical practice guidelines provides a basis for evidence-based pressure ulcer prevention and treatment practice. A multidisciplinary approach to patient care that includes patient and family education as well as staff education is essential. A comprehensive plan to treat the pressure ulcer that uses a combination of local wound care, debridement, moist wound healing, cleaning, and pressure relief needs to be implemented.