Dr. Ehsanur reza
Pressure Ulcers
Definition
• Pressure Ulcers are localized areas of tissue
necrosis that tend to occur when soft tissue is
compressed between a bony prominence and
an external surface for a prolonged period.
• These lesions are also called bedsores,
decubitus ulcers and pressure sores
Pressure Ulcers
Epidemiology
• 1-3 million Americans are affected
• Health care expenditures: $ 5 billion/year
• More than 17,000 lawsuits related to pressure
Ulcers are filed annually
• 1 in 4 persons in the USA who died in 1987
had a dermal ulcer
• Pressure Ulcers develop primarily in elderly
patients
Pressure Ulcers
Epidemiology
• Setting
– Hospital 60%
– Nursing homes 18%
– Home 18%
• 1/3 of patients undergoing surgery for hip fracture
develop a pressure ulcer
• The longer the patient stays in a nursing home, the
greater the likelihood of developing a pressure ulcer
THERMODYNAMICS, METABOLISM
AND PRESSURE
• Thermodynamic factors - skin/surface
interface
• As temperature increases, skin becomes more
metabolically active and 02 demands increase
• With increased pressure, metabolic demands
not able to be met and skin becomes hypoxic
• Hypoxic skin more susceptible to breakdown
• Adding friction and shear to already fragile
skin is “perfect storm”
THE 4 FORCES
1. Pressure: Force applied to soft tissue between
hard surface and bony prominence. When skin
and the underlying tissues are trapped between
bone and a surface such as a wheelchair or bed,
blood flow is restricted. This deprives tissue of
oxygen and other nutrients -> tissue death.
2. Friction: Resistance of one body sliding or rolling
over another. Making skin more susceptible to
pressure sores.
PRESSURE AND FRICTION
3. Shear: This occurs when skin moves in one
direction, and the underlying bone moves in
another. Sliding down in a bed or chair or
raising the head of bed more than 30 degrees
is especially likely to cause shearing, which
stretches and tears cell walls and tiny blood
vessels. Especially affected are areas such as
tailbone where skin is already thin and fragile.
4. Strain: Tissue deformation in response to
pressure
Pathophysiology
• Prolong weight bearing and mechanical shear
forces act on areas of soft tissue overlying
bony prominence ―> when this pressure
exceeds normal capillary perfusion pressure
(32 mm Hg) ―> occlusion & tearing of small
blood vessels ―> reduced tissue perfusion ―>
ischaemic necrosis ―> Pressure sore.
Risk factors
• Age. Older adults tend to have thinner skin,
making them more susceptible to damage
from minor pressure. They have less natural
cushioning over their bones. And poor
nutrition, delays wound healing.
• Lack of pain perception. Spinal cord
injuries and some diseases cause a loss of
sensation ―> bedsore is forming.
• Natural thinness or weight loss. Muscle atrophy and
wasting are common in people living with paralysis. If
you lose fat and muscle there is no cushion over your
bones.
• Malnutrition. Pressure sores develops if you have a
poor diet, especially one deficient in protein, zinc and
vitamin C.
• Urinary or fecal incontinence. Problems with bladder
control can greatly increase risk of pressure sores
because skin stays moist, making it more likely to
break down. And bacteria from fecal matter not only
can cause serious local infections but also can lead to
life-threatening systemic complications such as sepsis,
gangrene and, rarely, necrotizing fasciitis, a severe
and rapidly spreading infection.
• Other medical conditions. diabetes and
vascular disease affect circulation ―> tissue
damage.
• Smoking. Smokers tend to develop more
severe wounds and heal more slowly, mainly
because nicotine impairs circulation and
reduces the amount of oxygen in blood.
• Decreased mental awareness. People whose
mental awareness is lessened by disease,
trauma or medications are often less able to
take the actions needed to prevent or care for
pressure sores.
Risk Factors
•
•
•
•
•
•
Spinal cord injuries
Traumatic brain injury
Neuromuscular disorders
Immobility
Malnutrition
Fecal and urinary
incontinence
• Altered level of
consciousness
• Chronic systemic illness
• Fractures
• Aging skin
– decreased epidermal
turnover
– dermoepidermal
junction flattens
– fewer blood vessels
• Decreased pain
perception
Site
• Pressure ulcers
commonly occur
over the :
– Sacrum
– Greater
trochanter
– Ischial tuberosity
– Malleolus
– Heel
– Fibular head
– Scapula
While on a wheelchair a pressure sore develop
on:
tailbone or buttocks
shoulder blades and spine
The backs of arms and legs where they
rest
against the chair
Stages/ classification
 Stage I
Classification
1. 1. most superficial,




2. non blanchable redness, does not subside
after pressure is relieved.
3. The skin may be hotter or cooler than normal
4. have an odd texture, or
5. perhaps be painful to the patient.
STAGE I
• Stage II is damage to the epidermis extending
into, but no deeper than, the dermis. In this
stage, the ulcer may be referred to as a blister
or abrasion.
• The ulcer is superficial and manifest clinically
as an abrasion, blister or shallow crater
STAGE II
STAGE II
• Stage III involves the full thickness of the skin
and may extend into the subcutaneous tissue
layer. This layer has a relatively poor blood
supply and can be difficult to heal.
The ulcer manifests clinically as a deep crater
with or without undermining of adjacent
tissue
STAGE III
STAGE III
• Stage IV is the deepest, extending into the
muscle, tendon or even bone.
• “Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed.
Often include undermining and/or tunneling”
• Depth varies according to anatomic location
• Exposed bone/tendon usually directly visible
and/or palpable
STAGE IV
Stage 4
A
B
STAGE IV
Complications
• Cellulitis. This causes pain, redness and swelling, all of
which can be severe. Cellulitis can also lead to lifethreatening complications, including sepsis and
meningitis.
• Bone and joint infections. These develop when the
infection from a bedsore burrows deep into joints and
bones. Joint infections (septic or infectious arthritis) can
damage cartilage and tissue, whereas bone infections
(osteomyelitis) may reduce the function of joints and
limbs.
• Sepsis. It occurs when bacteria enters
bloodstream through the broken skin and
spreads throughout the body — a rapidly
progressing, life-threatening condition that
can cause shock and organ failure.
• Cancer. This is usually an aggressive carcinoma
affecting the skin's squamous cells.
Tests and diagnosis
• Bedsores are usually unmistakable, even in
the initial stages, but doctor is likely to order
blood tests to check nutritional status and
overall health. Depending on the
circumstances, there may have other tests.
• Wound swab – C/S
• Incision biopsy – if malignancy is suspected.
Treatments and drugs
• Treating bedsores is challenging. Open
wounds are slow to heal, and because skin
and other tissues have already been
damaged or destroyed, healing is never
perfect.
• Requires a multidisciplinary approach –
nurses, physician, social worker, physical
therapist, urologist or gastroenterologist, a
neurosurgeon, orthopedic surgeon and
plastic surgeon.
TREATMENT OBJECTIVES
•
•
•
•
•
•
Identification of problem
Debridement of necrotic tissue
Moist wound care without maceration
Control of infection/bioburden
Management of pain
Pressure redistribution/Offloading
• Choice of wound care products is individual
preference as long as above objectives met.
• A) Conservative treatment
Although it may take some time, most stage I
and stage II sores will heal within weeks with
conservative measures. But stage III and stage
IV wounds, which are less likely to resolve on
their own, may require surgery.
• 1. Changing positions often. Carefully follow the
schedule for turning and repositioning — approximately
every 15 minutes if in a wheelchair and at least once
every two hours when in bed. If unable to change
position on own, a family member or other caregiver
must be able to help.
• 2. Using support surfaces. These are special cushions,
pads, mattresses and beds that relieve pressure on an
existing sore and help protect vulnerable areas from
further breakdown.
PRESSURE REDISTRIBUTION
• 3. Cleaning. It's essential to keep wounds
clean to prevent infection. A stage I wound
can be gently washed with water and mild
soap, but open sores should be cleaned with a
saltwater (saline) solution each time the
dressing is changed. Avoid antiseptics such as
hydrogen peroxide and iodine, which can
damage sensitive tissue and delay healing.
• 4. Controlling incontinence as far as possible
is crucial to helping sores
• 5. Removal of damaged tissue (debridement). To
•
•
•
•
•
•
•
heal properly, wounds need to be free of damaged,
dead or infected tissue. This can be accomplished in
several ways a. Autolytic debridement is autolysis with the body's
own enzymes.
b. Biological debridement, or maggot debridement
therapy,
c. Chemical debridement, or enzymatic debridement
d. Mechanical debridement
e. Sharp debridement is the removal of necrotic tissue
with a scalpel or similar instrument.
f. Surgical debridement
g. Ultrasound-assisted wound therapy
•
•
•
•
•
6. Dressings.
7. Oral antibiotics.
8. Healthy diet.
9. Muscle spasm relief
10. Educating the caregiver
• B) Surgical repair by - tissue flap, free flap,
Negative Pressure Wound Therapy
• C) Other treatment options
Researchers are searching for more effective
bedsore treatments. Under investigation are
hyperbaric oxygen, electrotherapy and the
topical use of human growth factors.
Prevention
• Bedsores are easier to prevent than to treat,
but that doesn't mean the process is easy or
uncomplicated. Although wounds can develop
in spite of the most scrupulous care, it's
possible to prevent them in many cases.
• Position changes
Changing position frequently and consistently
is crucial to preventing bedsores. Experts
advise shifting position about every 15
minutes that you're in a wheelchair and at
least once every two hours, even during the
night, if you spend most of your time in bed.
• Skin inspection
Daily skin inspections for pressure sores are an
integral part of prevention.
• Nutrition
A healthy diet is important in preventing skin
breakdown and in aiding wound healing
• Lifestyle changes –
-Quitting smoking,
- Exercise - Daily exercise improves
circulation