1/20 Prevention and Rehabilitation of Pressure Ulcers Michael Kosiak, MD MAY,1991. Decubitus. VOL. NO.2

2/20  Every care provider is well aware of the complications manifested by the occurrence of ulceration in the chair- or bed-ridden patient.  The healthcare professional is being required, with increasing frequency to maintain and rehabilitate the elderly and severely disabled.

3/20 DEFINITION  Pressure ulcers are localized areas of cellular necrosis which usually occur over bony prominences which are subjected for prolonged periods of time to pressures in excess of capillary pressure.

4/20 INCIDENCE  The incidence of ulcerations is considerably greater in the spinal cord-injured hospital population and many deaths in this group of patients can be attributed to complications arising from the presence of pressure ulcers.

5/20 DISTRIBUTION  While pressure ulcers can develop over any area of the body subjected to supra-capillary pressure for a sufficient period of time.

6/20 PRIMARY FACTORS  Pressure Working with normal and paraplegic rats, we reported that microscopic examination of rat muscle 24 hours after being subjected to pressure of 70 mm Hg for two hours showed a decrease or loss of cross-striations and myofibrils, hyalinization of fibers and neutrophilic infiltrations.

7/20 PRIMARY FACTORS  Pressure When complete relief of pressure was provided at regular five-minute intervals, as with an alternating pressure support system, the tissue showed consistently less change or no change at all when compared with tissues subjected to an equivalent amount of constant pressure.

8/20 PRIMARY FACTORS  Pressure This was true even at pressures as high as 240 mm Hg for three hours (Kosiak, 1959). Pressure as high as 190 mm Hg when applied either constantly or intermittently for up to one hour showed no microscopic changes.

9/20 PRIMARY FACTORS  Friction and Shearing Dmsdale (1973), working with swine, demonstrated significant skin breakdown when the tissue was subjected to both pressure and friction, at a pressure significantly less than that when necrosis was caused by pressure alone (45 mm Hg versus 290 mm Hg).

10/20 PRIMARY FACTORS  Temperature Raising tissue temperature increases cellular metabolism and, therefore, increases the risk of ischemic necrosis.  Aging After the third decade, a progressive decrease in skin pliability and elasticity has been reported. whereas after the fifth decade, a rapid decrease in blood flow through the skin occurs.

11/20 CONTRIBUTING FACTORS  Nutrition Increased emphasis has recently been placed on the role of nutrition during the acute and convalescent phases of illness, especially on the negative nitrogen and calcium balances that inevitably appear after an acute insult.

12/20 CONTRIBUTING FACTORS  Nutrition Protein insufficiency inhibits or prevents the healing of ulcers. For a good metabolic response, the patient with a pressure ulcer should be eating gm of protein each day.

13/20 CONTRIBUTING FACTORS  Edema  Anemia  Endocrine Disorders Diabetes mellitus is the most frequent hormonal problem.

14/20 PREVENTION  Pressure ulcers are entirely preventable.  They need not and should not occur.

15/20 GENERAL PREVENTIVE MEASURES  Education  Identification of the high-risk patient Those persons with impaired mobility, especially in combination with decreased sensation or alteration in the level of mental awareness, are obvious candidates for skin breakdown if they are neglected. A single episode of neglect of a comatose or anesthetized patient for even an hour may result in pressure necrosis. Special consideration must be given to patients who require sedation or mood-altering drugs.

16/20 GENERAL PREVENTIVE MEASURES  Recognition of Impending Skin Breakdown  Specific Preventive Measures for Elimination or Reduction of Pressure Position changes must be made around the clock but not less frequently than every two hours.

17/20 MANAGEMENT  General Measures maintenance of the patient in a good state of nutrition and hygiene should be of high priority both to sustain healing and to avoid infection.

18/20 SPECIFIC MEASURES  Pressure Relief The ulcerated area should never be subjected to any pressure unless absolutely necessary for resting support. Elimination of Shearing or Friction. Reduction of Heat and Moisture Build- up.

19/20 SPECIFIC MEASURES  Debridement Mechanical Debridement Chemical Debridement  Control of Infections If infection is prevented or controlled, healing begins to occur promptly and rapidly.

20/20 SUMMARY The importance of providing pressure relief to the areas supporting the weight of the body must continue to be stressed and materials and methods must never be substituted for sound nursing care.