Presentation on theme: "PRESSURE ULCERS AND WOUNDS"— Presentation transcript:
1PRESSURE ULCERS AND WOUNDS By Monica Warhaftig, D.O.Assistant Professor of GeriatricsN.S.U.
2Chronic Wounds Greater than 12 hours Debridement Cleansing Dressing Pressure redistributionMultidisciplinary care
3GOALS Types of wounds Risk factors and Risk Scales Local/Systemic FactorsWound Care HealingWound care products
4Types of Wounds Location, Location, Location Pressure: sacrum, heels, trochanterVenous: Inside the leg -MedialArterial- LateralDiabetic: neuropathic areasTraumatic: anywhere
5RISK ASSESSMENT: Low score=high risk (16 or 12) The Norton Scale*The Braden Scale
6*Extrinsic FactorsPressure Relief : proper patient positioning; pressure devices: pressure greater that 32 mm hg (ischial tubes 300) (sacrum up to 300)Special Beds: static and dynamicFriction : rubbing of a body part against another or a surface..damage to stratum corneum..ex patient pulled across a bedShear Stress: head of bed elevated greater that 30 degrees..patient slides down(opp directions)Moisture: weakens the skin
7*Stages of Wound Healing Inflammation- (approx. 2-3 days)consists of a vascular and a cellular responseacute and chronic inflammation (neutrophils, cytokines, oxygen, platelets rush to the site)Proliferation – (approx. 2-3 weeks)Begins at the time of injuryRebuilding begins with scaffolding of the skinRevascularization of the wound beginsMaturation Stage- (Approx 2-3 years)Depositing of scar tissueThe body attempts to contract or close the wound(Wounds are only ever 80% healed)
9The Local Factors Necrotic tissue and foreign bodies Drying of a wound MicroorganismsTrauma (pressure, shearing, friction)FibrinOxygenEdema
10Intrinsic (Patient Status) DiabetesAnemia: decreases O2 to the woundNutritional State (Serum chemistries, Albumin, Prealbumin)Weight Loss (oxandrelone)Coagulopathic stateMultiple comorbiditiesIncontinence;foleyImmobility:turning q2 hours
11What is a Pressure Ulcer ? Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue
13Stage 1 Intact Skin with nonblanchable erythema (extravasation of blood from ischemic leaky blood vessels) (up to 30 minutes)Blanchable – means congested vessels…vanishes shortly after pressure reliefCone Shaped…apex to the skin (no indic of below)Muscle & Ischemia– high metabolic rate less blood supply ..More susceptible
14Pressure Ulcer Staging Stage IStage I - An observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
16Pressure Ulcer Staging Stage IIStage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
17Pressure Ulcer Staging Stage IIPartial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
21Pressure Ulcer Staging Stage IIIFull thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
22Pressure Ulcer Staging Stage IIIStage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
24Pressure Ulcer Staging Stage IVFull thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcersStage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers
27Pressure Ulcer Staging Stage IVStage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers
34Arterial WoundsComplete or partial arterial blockage may lead to tissue necrosis and / or ulceration.Signs on the extremity:Pulselessness of the extremityPainful ulcerationSmall, punctate ulcers that are usually well circumscribedCool or Cold skinDelayed capillary return time (briefly push on the end of the toe and release, normal color should return to the toe in 3 seconds or less)
35Arterial Disease Atrophic appearing skin (shiny, thin, dry) Loss of digital and pedal hairCan occur anywhere, but is frequently seen on the dorsum (top) of the foot.Utilize noninvasive vascular tests:Doppler, waveform, Ankle Brachial Indices (ABI) and Transcutaneous Oxygen Pressure measurements (TCPO2) to aid in your diagnosis. Duplex scanning and arteriograms may also be performed if indicated.
36Arterial DiseaseAnkle brachial index (ABI) : arterial blood flow in the lower extremities determines level of ischemia:Normal >1.0; LEAD = 0.9;Borderline is < ;Severe is <0.5. (The ABI can be falsely elevated in people with diabetes.(calcified noncompressible vessels)Recheck the ABI periodicallyToe pressure (TP) in patients with diabetes in whom LEAD is suspected. Toe pressure <30 indicates LEAD.Tissue perfusion with transcutaneous oxygen measurement (TcPO2) if ulcer is not healing and ABI is <0.9 or toe pressure <30 mmHg, or if unable to perform ABI
40*Signs of Infection Delayed Healing Change in Exudate Change in Pain Change in Granulation TissueChange in SmellChange in SizeFeverLeukocytosis
41Types of debridementAutolytic – (Occlusive Dressings) the body heals itselfMechanical – using gauzesEnzymatic – chemical enzymes (Collagenase, Papain, )Sharps – scalpel, laser, surgeryBiosurgical – maggots, leeches
42Topical Dressings Occlusive Dressings Divided into polymer films, polymer foams, hydrogels, hydrocolloids, alginates, and biomembranes.Dressings left in place until fluid leaks from the sides (3 days to 3 weeks)
43Products Primary/secondary type of dressing Hydrophyllic Hydrogel AlginateFoamAccuzymepanafil
44Transparent Film Autolytic debridement Primary or secondary dressing Partial thickness wounds*Stage I or II pressure ulcersSuperficial burns
45Hydrocolloids (Autolytic) Primary or secondary dressing*Partial and full thickness woundsPressure ulcers*Necrotic woundsGranular wounds preventative dressingUsed as a secondary dressing or under compression
46Hydrogels Stage 2 to stage 4 pressure ulcers Partial and full thickness*Painful woundsSkin tearsMinor burns*Necrotic wounds
47Collagens *Infected Wounds Tunneling Wounds Surgical Wounds Can be used with other topical agents*Not for necrotic wounds
48Negative Pressure Therapy VAC DeviceFor Nonhealing wounds and fecal incontinenceRemoves Interstitial Fluid from the wound
49Antimicrobial Dressings Infected WoundsControls bacteria bioburdenEffective against a broadspectrum of microorganismsIODOSORBAQUACELIODOFLEX
50Saline –soaked Gauze Dressings Saline soaked and not allowed to drySimilar to occlusive dressingsHowever, Time intensive for nursing*Used for Partial and full thickness woundsDraining woundsWounds requiring debridement packing,Or management of tunnels, tracts or dead spaceSurgical incisions/Burns/pressure ulcers
51Calcium Alginate Highly absorptive- brown seaweed *exudative wounds. Alginates do not adhere to a woundCan damage epithelial tissue if the wound dries
52FOAM Nonocclusive absorptive wound dressing Partial and full thickness wounds…minimal to heavy drainageStage II to IV press. Ulcers*Infected and non-infected
53*Compression Therapy Venous Ulcers Used to manage edema and promote the return of venous blood to the heartUse cautiously with arterial ulcers
54Advanced Wound Care Products Platelet Derived Growth FactorsOTHERS
55*Healing Factors – The Push Scale Wounds heal by contraction and scar formation (Can’t reverse stage)Push ScaleMeasures:Size: greatest length (head to toe) and the greatest width (side to side) using a centimeterExudate: none, light, moderate, heavyTissue Type: 4-any necrotic tissue; 3-any amount of slough…no necrotic tissue; 2-clean wound with granulation tissue; 1-wound closed
56Tissue Types Slough-yellow or white..strings or thick clumps Granulation tissue-pink or beefy red tissue ,shiny, moist, granular appearanceEpithelial tissue: new pink or shiny tissuegrows in from the edgesNecrotic Tissue (eschar) : Black, brown, or tan firmly adheres to the wound bedClosed/resurfaced-wound completely covered