Pressure Sores.pptx

A Topic Presentation on Hepatoma

1. Pressure Sores By: Dr. Noshirwan P. Gazder

2. Pressure-induced skin and soft tissue injuries are areas of localized damage to the skin and/or underlying tissue, usually over a bony prominence as a result of pressure or pressure in combination with shear (eg, sacrum, calcaneus, ischium)

3. Three primary contributing factors for bedsores Pressure :  Constant pressure on any part of your body can lessen the blood flow to tissues. Blood flow is essential for delivering oxygen and other nutrients to tissues. Without these essential nutrients, skin and nearby tissues are damaged and might eventually die. This kind of pressure tends to happen in areas that aren't well padded with muscle or fat and that lie over a bone, such as the spine, tailbone, shoulder blades, hips, heels and elbows. Friction: Friction occurs when the skin rubs against clothing or bedding. It can make fragile skin more vulnerable to injury, especially if the skin is also moist. Shear:  Shear occurs when two surfaces move in the opposite direction. For example, when a bed is elevated at the head, you can slide down in bed. As the tailbone moves down, the skin over the bone might stay in place — essentially pulling in the opposite direction.

4. Common sites for Pressure Ulcers

5. Risk Factors Immobility:  This might be due to poor health, spinal cord injury and other causes. Incontinence:  Skin becomes more vulnerable with extended exposure to urine and stool. Lack of sensory perception:  Spinal cord injuries, neurological disorders and other conditions can result in a loss of sensation. An inability to feel pain or discomfort can result in not being aware of warning signs and the need to change position. Poor nutrition and hydration:  People need enough fluids, calories, protein, vitamins and minerals in their daily diets to maintain healthy skin and prevent the breakdown of tissues .

6. Pathophysiology

7. Stage 1 I ntact skin with a localized area of nonblanchable erythema , which may appear differently in darkly pigmented skin. The presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

8. Stage 2 Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister . Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel .

9. Stage 3 Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia , muscle, tendon, ligament, cartilage, and/or bone are not exposed.

10. Stage 4 F ull-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible . Epibole (rolled edges), undermining, and/or tunneling often occur. Depth varies by anatomical location.

11. Unstageable Pressure Injury Unstageable pressure injury   is characterized by full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar . If slough or eschar is removed, a stage 3 or stage 4 pressure injury will be revealed.

12. Deep Tissue Pressure Injury Deep tissue pressure injury is characterized as intact or non-intact skin with a localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister . Pain and temperature change often precede skin color changes . This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.

13. General Care The general approach to management of a patient with a pressure-induced skin injury should include the following: Reduce or eliminate underlying contributing factors by providing pressure redistribution with proper positioning and support surfaces. Provide appropriate local wound care, which may include debridement for patients with necrotic tissue, based on the ulcer's characteristics. Monitor and document the patient's progress .

14. Control Pain Adequate pain relief should be provided, as pressure-induced injuries can be quite painful. Local factors that may be contributing to pain such as ischemia, infection, or breakdown of the surrounding skin should be addressed. Pain may be classified as intermittent, which occurs at the time of wound debridement, or cyclic, which occurs at the time of a dressing change, or as persistent pain occurring all the time. Oral non-opioid pain medications can be used for mild pain. Opioid analgesics may be needed for moderate-to-severe pain. Topical local anesthetics (eg, lidocaine) have been used and can provide pain relief for a short period of time, but there is little evidence of effectiveness from clinical trials. Topical opioids, such as a morphine gel, have shown some benefit in small trials. However , many patients with deep ulcers will require systemic therapy for pain .

15. Treat Infection   All open ulcers are colonized with bacteria, but only clinically evident infections should be addressed with culture and antibiotic treatment. Clinical signs of wound infection that might warrant antibiotic therapy include local (cellulitis , purulence, malodor, wet gangrene, osteomyelitis) and systemic (fever, chills, nausea, hypotension , leukocytosis, change in mental status) symptoms.   Systemic antibiotics are not recommended unless there is evidence of advancing cellulitis, osteomyelitis, and bacteremia.

16. Optimize Nutrition   Patients with pressure-induced skin often are in a chronic catabolic state. Optimizing both protein and total caloric intake is important, particularly for patients with stage 3 and 4 pressure injuries. Nutritional intake should be assessed by a nutritionist. Elements of this comprehensive assessment may include protein and caloric intake, hydration status, serum albumin, and total lymphocyte count. Lab markers by themselves are not a sufficient marker of nutritional status. Nutritional deficiencies should be corrected.

17. If oral intake is not adequate to ensure sufficient calories, protein, vitamins, and minerals, nutritional supplementation with enteral or parenteral nutrition.   A retrospective cohort study of 882 patients with pressure injuries at long-term care facilities demonstrated that total caloric intake of at least 30 kcal/kg promoted healing and decreased the size of stage 3 and 4 wounds. Increased dietary protein intake also promotes healing. The protein target is usually 1.25 to 1.5 g/kg/day.

18. Redistribute Pressure Proper positioning and support to minimize tissue pressure should be provided for all patients, particularly those with open wounds . The development of any new areas of skin damage should prompt review of the method and intensity of preventive measures. Patients should be positioned and repositioned at least every two hours to relieve tissue pressure . Use of nonpowered support surfaces (eg, foam mattresses or overlays) for most patients with pressure-induced skin and soft tissue injuries. When cost is not a limiting factor, powered surfaces (eg air-fluidized beds) may be appropriate for selected patients with large or multiple ulcers that preclude appropriate positioning.

19. Prevent Contamination Contamination of wounds from urinary or fecal soiling may impair wound healing. Urinary catheters or rectal tubes are often used to help promote healing, but there is little evidence for benefit.

20. GENERAL WOUND MANAGEMENT Stage 1 skin injuries should be covered for protection. Stage 2 pressure injuries generally need little debridement and require a dressing that maintains a moist wound environment. Stage 3 and 4 pressure or deeper injuries generally require debridement of necrotic tissue and possibly treatment of infection. Following appropriate wound bed preparation, coverage may involve skin grafting or other tissue transfer procedures. 

21. Poly-Urethane Film

22. S emi Permeable Foam Dressing

23. Hydro-Colloid Dressing/ Duoderm

24. WOUND DRESSINGS When a suitable dressing is applied to a wound and changed appropriately, the dressing can have a significant impact on the speed of wound healing, wound strength and function of the repaired skin, and cosmetic appearance of the resulting scar. No single dressing is perfect for all wounds; rather, a clinician should evaluate individual wounds and choose the best dressing on a case-by-case basis.

25. An ideal dressing is one that has the following characteristics  : Absorbs excessive wound fluid while maintaining a moist environment Protects the wound from further mechanical or caustic damage Prevents bacterial invasion or proliferation Conforms to the wound shape and eliminates dead space Debrides necrotic tissue Does not damage the surrounding viable tissue Achieves hemostasis and minimizes edema through compression Eliminates pain during and between dressing changes Is inexpensive, readily available, and has a long shelf life Is transparent in order to monitor wound appearance without disrupting dressing

26. MONITORING The following parameters of care should be monitored daily and documented Evaluation of the ulcer (Healing scales) Status of the dressing, if present Status of the area surrounding the ulcer Presence of pain and adequacy of pain control Presence of possible complications, such as infection

27. EUSOL: Used for wound disinfection, ulcers cleaning and wet dressing. It is used as an antiseptic agent and prevents the growth of bacteria, fungi and viruses as well. Eusol Solution protects against infection, prevents bacterial growth and can also be used as a normal disinfectant. Eusol Solution is only meant for external use and users who suffer from skin disease such as eczema should avoid using it.

28. Magnesium Sulfate Paste: Increases collagen synthesis and angiogenesis, providing faster and higher quality wound healing. In addition it provides an analgesic effect, it will also eliminate the pain sensation caused by the wound and increase the quality of life of the patient whose skin integrity is impaired.

29. Zinc oxide: Medicated cream, ointment or paste that treats or prevents skin irritation like cuts, burns or diaper rash. Sudocre m: M edicated cream aimed primarily at the treatment of nappy rash. It contains a water-repellent base; protective and emollient agents; antibacterial and antifungal agents; and a weak anesthetic .

30. Sources National Pressure Injury Advisory Panel (NPIAP). UptoDate. CMDT.

31. Thank You