pressure ulcer
TRANSCRIPT
PRESSURE ULCER PREVENTION &
TREATMENT
Prepared byLinda Kennedy-Mull
All SCI individuals are at risk for developing pressure ulcers (PU).
Pressure Ulcers occur more frequently in people
with:
More extensive paralysis & completeness of SCI
Longer duration of SCI Less functional independence (para’s vs. quad’s)
Irresponsible behavior – smoking/ETOH/drug abuse
Poor nutrition Those who won’t assume
responsibility for skin care
Incidence:
32-40% of individuals admitted to SCI units in the USA develop pressure ulcers during initial hospitalization:
37% of ulcers were sacral ulcers & of those, 50% were Stage III or IV.
Recurrence
’97 study – 176 veterans with SCI had 35% recurrence rate; smoking, diabetes & coronary / vascular disease all associated with highest risk of recurrence.
Costs:
’94 study – total cost of treatment was ~ $1,335 Billion / year. 69% of this provided in hospitals
’92 study – cost was: ~ $70,000 to treat full thickness
ulcer ~ $20-30,000 to treat less serious
ulcers
RISK FACTORSStandard Risk Factors:
Malnutrition
Moisture
Loss of Sensation
Friction
Incontinence
Shearing
Immobility
RISK FACTORSAssess Degree of Risk
Use Braden Scale:
Admission Every time patient’s condition
changes Monthly in NHCU
* Use clinical judgment as well
RISK FACTORSAssess Demographic &
Psych/social Risk Factors Age
Sex
Marital Status
Education
Ethnicity, Cultural Values Cognition
Substance Abuse
Psychological Health
RISK FACTORSNormal Skin
Largest single organ of the body Main function is to isolate &
protect the body from environment Skin insulates the body & helps
maintain core body temp Skin consists of 2 layers:
Epidermis, Dermis
RISK FACTORSNeurologically Impaired Skin
SCIs have altered autonomic nervous system
Degree of alteration varies with level of injury
SCI above T6 changes functional properties of the skin-sweating reflex is lost
SCIs are unable to maintain constant body temp in early stages following injury
RISK FACTORSNeurologically Impaired Skin
Changes that occur in skin: Increase in collagen catabolism Decrease in amino-acid metabolites in
skin Decrease in Type I & II collagen, which
robs the skin of elasticity & strength Skin is more fragile below injury Decrease blood flow & supply below
injury, which affects delivery of nutrients, etc.
* Takes 3-5 years for changes to
stabilize
RISK FACTORSMuscle Atrophy Caused by
Paralysis
Produces loss of muscle bulk: Less cushioning
Less protection
Less absorption of mechanical forces
PHYSIOLOGY of WOUND HEALING
Two Mechanisms of Repair
Regeneration: replacement of lost tissue with more of the same tissue
Connective Tissue Repair: lost tissue is replaced by scar formation
Type of Repair: determined by the tissue layer involved
PHYSIOLOGY of WOUND HEALING
Partial Thickness Wounds:
Epidermal Repair: Inflammatory response
Epithelial proliferation
Migration (resurfacing)
Re-establishment of epidermal layers
Dermal Repair: Concurrent with epithelialization
Angiogenesis Fibroblasts
become plentiful– 7 days
Collagen fibers are visible – 10 days
PHYSIOLOGY of WOUND HEALING
Full Thickness Wounds:(3 Phases)
Inflammatory Phase (1-4 days) Hemostasis Characterized by:
– Edema– Erythema– Heat– Pain
Macrophages arrive: destroy bacteria & clean wound
Produces chemo attractants & growth factors
PHYSIOLOGY of WOUND HEALING
Full Thickness Wounds (continued)
Proliferative Phase (3-20 days) Granulation tissue develops Wound contracts Collagen is produced to give strength
& elasticity
Maturation Phase (up to 2 years) Begins when the wound has closed Tensile strength of scar tissue =/<80%
PRESSURE ULCERS
Most pressure ulcers can be prevented, but sometimes even VIGILANT nursing care will not prevent the development or worsening of ulcers in some high-risk individuals.
Improving Nutrition Managing Incontinence Activating Prevention Measures
Frequent turning Use of overlays, low air loss, etc.
PRESSURE ULCERS(CONTINUED)
Four Goals for Protection Identify at risk individuals & factors
placing them at risk Maintaining & improving tissue
tolerance to pressure Protecting against adverse effects of
external mechanical forces Reducing incidence through
education
Severe Pressure Ulcer with Bone Loss
PRESSURE ULCERSStaging of Pressure Ulcers: WOCN
Staging Stage I: non-blanching
erythema of intact skin
Stage II: partial thickness skin loss involving epidermis &/or dermis. Ulcer is superficial & presents as an abrasion, blister, or shallow crater
* Staging Limitations: Echar/slough prevents
staging Identifying Stage I is difficult
in dark skin No reverse staging as
wound heals
Stage III: full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, the fascia. Presents as a deep crater with or without undermining.
Stage IV: full thickness skin loss with extensive damage, destruction,or necrosis of muscle, bone or supporting structures. Undermining & sinus tracts may be present
Stage I Pressure Ulcer
Stage II Pressure Ulcer
Stage III Pressure Ulcer
Stage IV Pressure Ulcer
PRESSURE ULCERSUlcer Assessment
Stage the Ulcer
Location
Size – measure weekly or more often,if dramatic change
Drainage: exudate, transudate (serosanguinous), amount
Undermining, Tunneling, Sinus Tract
PRESSURE ULCERSUlcer Assessment (continued)
Tissue Type: viable/non-viable, describe as red, yellow, tan, black, etc.
Surrounding Skin: Pain/sensation or lack of in SCI Edema Induration Color Maceration Fungus Hair present
ULCER TREATMENT
Goals Evolve as the
patient’s wound progresses
Dressings change from absorbent, to debriding, to maintaining moist wound environment
Patient & family education
Treatment / Intervention
Pressure Relief REPOSTIONING Overlays, mattress
replacement, static or dynamic, low air loss, air fluidized
SCI Pressure Relief
Assisted Repositioning
Types of Overlay Mattresses
ULCER TREATMENTDebridement
Enzymatic
Mechanical = whirlpool, wet-to-dry, irrigation <30psi
Sharp
Autolytic
Biosurgery = maggots
Maggot Treatments
ULCER TREATMENT Electrical
Stimulation Increases oxygen & nutrient
transport Decreases edema Increases fibroblastosis Increases collagen
development• Indication: chronic wounds
not responding to conservative tx
• Contraindicated: in osteo, malignancy, pacemakers, over pregnant uteruses, over heart or carotid sinuses, or over laryngeal musculature
Surgical Flap Repair Skin Graft
Appropriate Dressing Choice is based on 3
aspects: Color of wound Depth of wound Exudates
Other considerations: Infection Tissue surrounding wound Fragility of skin Medical conditions
impacting healing Change Tx if wound has
not improved after 2-4 wks or Immediately, if negative outcome
Flap Repair
Skin Grafting
FACTORS IMPACTING WOUND HEALING
Tissue Perfusion & Oxygenation – impaired in SCI
Intrinsic Factors Steroid
dependence Immuno-
suppression Age Disease Malnutrition:
albumin <3.5
Extrinsic Factors Pressure Sheering Friction Moisture Medications
(antineoplastics,etc.)
FACTORS IMPACTING WOUND HEALING
Infection Infection vs. Contamination
All chronic wounds are contaminated, but can still heal
Infection prolongs the Inflammation Phase & delays healing
Obtain appropriate cultures: superficial swab, needle aspiration, tissue biopsy.
Culture Technique: 10 point method
FACTORS IMPACTING WOUND HEALING
Treatment Systemic antibiotics Topical antiseptics, antimicrobial,
antibiotic agents NPUAP – do not use topical antiseptics to
reduce Bacterial load. If used, limit to 2-3 days
Cytotoxic topical agents: Betadine Dakins (bleach) Acetic Acid (vinegar) Hydrogen Peroxide
PREVENTION MEASURES Reposition at lease q2 hrs.
using pillows or foam wedges
Keep bony prominences from direct contact from one another
Provide total heel pressure relief for patients who are immobile
Side-to-side turning of no more than 30 degrees rotation
Keep head of bed at lowest degree of elevation consistent with condition
Limit amount of time HOB is elevated to prevent shearing
Prevent moisture accumulation
Use lifting devices to move patient; friction injuries can be prevented by using linen to move patient, using lotion & films
At risk patient should be automatically placed on a pressure reducing device: Zone-Aire Beds RIK Gel Flotation Mattresses Alternating Pressure Mattress Water Mattress
PREVENTION MEASURES
Chair bound patients need pressure relieving cushions – consult O.T.
Chair bound patients need repositioning q 1 hr or taught to shift weight q 15 minutes
Positioning of chair bound patients should include consideration of postural alignment, distribution of weight, balance, stability, & pressure relief
Conduct DAILY comprehensive skin inspections
Education of patient, family / significant other
Roho Wheelchair Cushion