3Pressure UlcerCauses of Pressure Ulcer DevelopmentPressure
4Pressure Ulcer What is Pressure Ulcer? A localized area of cellular damage resulting from:Direct pressure: skin and other tissues are directly compressed between bone and another surface (bed, chair). Tissue damage will depend on intensity and duration of exposure to pressure.Shearing: tissues are wrenched in opposite directions, resulting in disruption or angulations of capillary blood vessels.Friction: skin rubs against another surface (sheet) causing epidermis to be stripped away.Also called Pressure Sores, Decubitus Ulcers or Bed Sores
15Pressure Ulcer Risk Assessment Why?Because we can prevent Pressure UlcersBecause we can cure Pressure UlcersTo Whom?All person with reduced mobility / activity or sedatedWhen?AdmissionRegular IntervalsChange in patient conditionsDuring day and night
16Pressure Ulcer Risk Assessment Benefits?Act as aid-memoryTarget preventive careEffective use of scarce resourcesProvide quantifiable data of auditProvides objective criteria to base care pathwaysHow?Use Risk Assessment Tools
21Pressure Ulcer Pressure Reduction Reduce the intensity of pressure and shear : Blood irrigation occlusion diminish O2 flows in tissueIntensity is determined by contact surface (mattress or cushion). When the surface is increased, pressure is more evenly redistributed decreasing pressure.Avoid several tissue layers because they increase the pressureAvoid anything that reduces the size of the pressure surface (ring cushions)Should be combined with scheduled alternated repositioning of the patient.
22Pressure Ulcer Pressure Reduction Pressure Reduction can be done through specialized mattresses / CushionsStatic Mattresses are non electric system that reduces intensity of the pressure and shear by increasing contact surfaceOverlay is placed over standard mattress and has the same effect as static mattressThe nature and composition of the material modify the form and the consistency of the mattress that is subject to patient body pressure.
23Pressure Ulcer Pressure Reduction Different Materials:WaterStatic AirGelFiberFoamCMHR: Combustion Modified High ResilientVisco-elastic
24Pressure Ulcer Pressure Reduction Water Mattress Advantages:CheapDistributes weight evenlyWater Mattress Disadvantages:A spontaneous or assisted change in the positioning is more difficult favours longer period in the same position higher risk of pressure ulcer development.
25Pressure Ulcer Pressure Reduction Water Mattress Disadvantages:Very difficult to position the patient in Lateral 30° (this position is recommended for long stay periods) Low comfort and increased pressure higher risk of pressure ulcer development.Cannot be used on profiling beds (electrical) because of the weight of the mattress and the bed inclinationCold sensation from the water patient discomfort
26Pressure Ulcer Pressure Reduction Water Mattress Disadvantages:Extremely heavy weight can causes back injury to carerThe mattress can break inundation unpleasant situation for both patient and carer.Rocking effect may cause dizziness to predisposed patientsNot durableRequires a second mattress below
27Pressure Ulcer Pressure Reduction Static Air Mattress Advantages:Easy use: once filled with air, it does not require an electric pump.Heat build up and moisture are greatly reduced, due to the air holes throughout the mattress.Light weight.Best in its class for seating (cushions); however should be thick enough to prevent bottoming effectStatic Air Mattress Disadvantages:Contact surface is not increased enough to reduce pressure.Not durableRequires a second mattress below
28Pressure Ulcer Pressure Reduction Gel Mattress Advantages:ComfortableViscous gel migrates through sectioned bladders to relieve pressure around bony prominences.Gel Mattress Disadvantages:Contact surface is not increased enough to reduce pressure.Gel can dissociate and loose all its properties.Not durable
29Pressure Ulcer Pressure Reduction Fiber Mattress advantages:High quality patient comfortLasting durabilityEasy MaintenanceBody is enveloped by the fiberUsed for very frail bony patientsLight weightFiber Mattress Disadvantages:Pressure reducing properties are not enoughRocking effect may cause dizziness to predisposed patientsRequires a second mattress below
30Pressure Ulcer Pressure Reduction Foam Mattress CMHR advantages:Longer useful life than non-HR foamHigh tear strengthAbility of material to revert to its original shape after pressure optimal lying comfortEasy MaintenanceMore SuppleMoulds body shape Maximize weight distribution Reduce pressureExtremely fire retardant, complies to institutional regulatory standardsFoam Mattress HR Disadvantages:Used for Low to Medium risk patients only
31Pressure Ulcer Pressure Reduction Foam Mattress Visco-Elastic advantages:Best in its class for static mattresses.High quality patient comfortLasting durabilityEasy MaintenanceMoulds the body allowing patient immersion thus increasing the contact surface and decreasing the pressure.High Memory Foam
32Pressure Ulcer Pressure Reduction Foam Mattress Visco-Elastic advantages:Heat sensitive property allows the top of the mattress to be more supple whereas the deeper parts remains firm for a proper support. This maintains the physiological position of the patient maximizing the weight distribution.Used for Medium to High Risk Patient
33Pressure Ulcer Pressure Reduction Cover of the mattress is very important and should provide the following:Two way stretch Reduce friction and sheer effects.Elastic, otherwise it will limit the capacity of the mattress to reduce pressureVapor Permeable evacuate heat patient comfortFire Retardant Fire safety patient safety
34Pressure Ulcer Pressure Reduction Water Resistant Prevent fluid contamination patient hygiene & safetyConcealed Zip Fastening Prevent fluid contamination patient hygiene & safetyFully Fitted moulds to the shape of the bed Reduce friction and sheer effectsDetachable cover machine washable easy to clean patient hygiene
36Pressure Ulcer Pressure Relief Purpose is to reduce the duration of pressure and shear by changing the points of pressure.Pressure Relief can be done in two ways:Scheduled alternated positioningSpecialized mattresses
37Pressure Ulcer Pressure Relief Scheduled alternated positioningChange the position of the patient in a way that body prominences at risk (points of pressure) are different.Frequency per 24 hours/day, 7 days/week:Laying PositionEvery two hours if no pressure reduction mattress is used Almost impossible to manage.Every four hours when a good and appropriate pressure reduction mattress is usedSeating PositionEvery one hour if no pressure reduction cushion is usedEvery two hours when a good and appropriate pressure reduction cushion is used
38Pressure Ulcer Pressure Relief Specialized Mattresses are electric system that reduces the duration of the pressure and shear.Consist of an inflatable mattress and an electric pump.Overlay is placed over standard mattress and has the same effect as an active mattress.The cells / compartments of the mattress inflates and deflates in alternation.The form of the mattress, that is subject to patient body pressure, changes due to external factors (air pump).
39Pressure Ulcer Pressure Relief Differentiation points:Pump characteristicsAvailability of an “intelligent” feed-back systemDiameter of the cellsDistinct compartmentsAdditional facilitiesCell structureCover
40Pressure Ulcer Pressure Relief Pump characteristics:QuietLightweight and CompactClear user instructionsSnap fit connectors, color codedAdjustable pressure control (better if it is automatic)Audio – visual alarmsDifferent settings: Pulsate, Therapy & StaticComfort control
41Pressure Ulcer Pressure Relief Pump characteristics:Equalized cell pressure when mattress is disconnected from power unit (transport / power failure)Duration of the pressure: 9 to 10 minutes cycle.External fusibles to protect the pump from current fluctuations.
42Pressure Ulcer Pressure Relief Availability of an “intelligent” feed-back system :Senses movement of patientAutomatic adjustment to individual patient weight and positionOptimum pressure is delivered at all times regardless of body mass.Back-Raise sensor for semi-recumbent position push more air in torso section for better support prevents bottoming-out
43Pressure Ulcer Pressure Relief Diameter of the cells :Small cells (less then 10 cm) even when inflated to the maximum, do not allow the body to elevates enough above the deflated cells.Cells larger then 10 cm are recommended.
44Pressure Ulcer Pressure Relief Distinct compartments:Individual cells easy replacementTri zonal: comfort for head, torso & heelSloping heel sectionAdditional Facilities:Timed static facilityStatic facility for fast transferCPR facility near head section for faster deflationIntubation's facility
45Pressure Ulcer Pressure Relief The cell structure - number and form:Double layer cell structure is more efficient then single layer.Cells are linked between each others by series of 3 and same cycle is applied for both layers simultaneously:1st max. inflation, 2nd half inflation, 3rd total deflation1st half inflation, 2nd max. inflation, 3rd half inflation1st total deflation, 2nd half inflation, 3rd max. inflation
46Pressure Ulcer Pressure Relief Cover :Two way stretch Reduce friction and sheer effects.Elastic maintain reduction property of mattress.Vapor Permeable evacuate heat patient comfortFire Retardant Fire safety patient safetyWater Resistant Prevent fluid contamination patient hygiene & safetyConcealed Zip Fastening Prevent fluid contamination patient hygiene & safetyFully Fitted moulds to the shape of the bed Reduce friction and sheer effectsDetachable cover easy cleaningHoses covered as per disinfections properties
47Pressure Ulcer Pressure Relief Special mattresses:Fluidized Air: Mattress is composed of silicom particles inside a synthetic cover. When hot air is injected the silicon particles liquefies.Low air-loss: Reduce humidity build-up to to the air-loss.
48Pressure Ulcer Pressure Relief Fluidized Air Advantages:The body is totally immersed in the mattress which maximizes the contact surface between the body and the mattressExcellent system for treating burns or wounds with high exudates.Fluidized Air Disadvantages:Very expensiveExtremely difficult to cleanCannot be moved from 1 patient to another before a special cleaning process has taken place.
49Pressure Ulcer Pressure Relief Low Air loss Advantages:Designed to provide very high degree of comfortConstant air flow will help dry up woundsSeparate mattress system can be easily moved from patient to patient and from bed to bed.Easy to clean and decontaminate
50Pressure Ulcer Skin Wound Protocol Incontinence Care
51Pressure Ulcer Incontinence Care Clean skin at time of soilingProvide quick drying surface (under pads) to the skin.Avoid hot water and too much soap while bathing.
53Pressure Ulcer Nutrition Consult Diet should have adequate calories and protein, vitamins and mineral supplements.Consult your dietician and doctor.There is no direct link between bad nutrition and pressure ulcer prevention however nutrition optimization ameliorates the general condition of the patient and helps the cicatrisation process.
55Pressure Ulcer Moisturize Skin Maintain good hygieneWash with mild soap and warm water, rinse well and pat dry carefully and gently.Use moisturizers for dry skinMinimize environmental factors leading to dry skin (Low humidity, cold air)Do not massage skin over bony parts of the body (can damage tissue)
57Pressure Ulcer Positioning The intensity of the pressure is determined by the weight of the patient, his positioning and the hardness of the material he is seated in.The contact surface depends on the positioning: Surface redistribution of pressure Pressure
58Pressure Ulcer Positioning Some facts:In laying position: Avoid bottoming effect where the patient is not sustained by the mattress but lies directly on the sub-adjacent surface, specially for obese patients.With a simple manual verification, we should not feel patient body.
59Pressure Ulcer Positioning Some facts:In laying position: when the bed head is elevated, the pressure and shear effects increase.In seating position, the weight is redistributed in a small surface: more pressure then laying position.In seating position, a lateral or vertical inclination increases the pressure.
60Pressure Ulcer Positioning Dorsal DecubitusHead and legs of the bed are elevated 30°: maximum reduction of pressure and shear.Preferred positioning for long periods.
61Pressure Ulcer Positioning Lateral DecubitusBody forms a 30° angle with the mattress aided by a 30° cushionThe sacrum should not be under pressure.Above leg is positioned behind the other one, tilted 30° at the level of the hip and 35° at the level of knee.Positioning can be made more comfortable with cushionsUse of inflatable cushions is notrecommended due to the effect of shear.
62Pressure Ulcer Positioning Alternated positioningUse as often as possible Dorsal Decubitus positioningAlternate with lateral Decubitus positioningWhen using appropriate pressure reducing mattress, the schedule can be every 4 hours instead of 2 hours.
63Pressure Ulcer Positioning Seating position in bedLimit seating positions in bed because it is the cause of shearing.Preferred position is 60° but should be limited in duration.Use this position only for eating time.
64Pressure Ulcer Positioning Ventral DecubitusShould be used with soft mattress for comfortTo prevent pressure on feet, either place a cushion or remove end of bed and slide down patient so that feet are outside mattress.Should observe pressure points: shoulder, thorax, basin, knees, feet, ears.
66Pressure Ulcer Positioning SeatingSlight dorsal inclination, legs resting on support and heels free of pressureIn case dorsal inclination is not possible, straight seating with both feet on floor
67Pressure Ulcer Positioning SeatingLimit the duration of seating position: time spent on chair should be less then time spent in fauteuil which is less then the bed.Armchair help stabilize the positioning of the person.Avoid lateral and vertical sliding from chair.Make sure that the person is well seated to provide optimum contact surface.Cushion and backs help to keep a right positioning. The type should be studied case by case.
69Pressure Ulcer Wound Care Debride – Ask your doctorSurgical: most rapid, recommended for large necrotic areas.Mechanical: hydrotherapy, wound irrigationEnzymatic: collagenase to slow infection if present.Autolytic: via enzymes in wound fluid (very slow)Pick a dressing (must provide a-moist wound healing)Transparent semi permeable films (eg Opsite, Tegaderm) for Grade I & IIHydrocolloids (e.g. DuoDerm, Comfeel, Restore) for non infected Grade II & IIISaline soaked gauze (covered by occlusive wrap) gently pack dead space for Grade II to IVAlignates: (eg. CalciCare, Kaltostat) for +++ exudates
70Pressure Ulcer Wound Care Watch for infection and treat - Ask your doctor for proper treatment.Use dry lubricants (cornstarch) or protective coverings to reduce friction injury.
71Pressure Ulcer Healing signs The pressure ulcer will get smallerPinkish tissue usually starts forming along the edges of the sore.Smooth or bumpy surfaces of new tissueSome bleeding may be present which shows good blood circulation.
72Pressure UlcerAny QuestionsThank You for Your Time