1. Pressure ulcers Presented by: dr. menna shawkat
Prepared by: Dr. Mohamed fahmy
Lecturer of Geriatrics and Gerontology
Ain Shams University

2. Objectives: The pressure ulcer staging .
The common risk factors for pressure ulcer development
Techniques for preventing pressure ulcers and treatment strategies for each stage

3. Definition
A localized area of soft-tissue injury resulting from compression between a bony prominence and an external surface.
It a type of avascular necrosis

4. RISK FACTORS
Intrinsic: physiologic factors or disease states that increase the risk for pressure ulcer development
Age
Nutritional status
Decreased arteriolar blood pressure
Local skin disorder
Extrinsic: external factors that damage skin
Pressure, friction, shear
Moisture, urinary, or fecal incontinence

5. FACTORS PREDICTIVE OF PRESSURE ULCER DEVELOPMENT
Age 70+
Impaired mobility
Current smoking
Low BMI
Confusion
Urinary and fecal incontinence
Malnutrition
Restraints
Many other disorders: malignancy, diabetes, stroke, pneumonia, CHF, fever, sepsis, hypotension, renal failure, dry skin, history of pressure ulcers, anemia, lymphopenia, hypoalbuminemia

6. RISK ASSESSMENT: Patients at risk can be identified clinically by:
Norton Scale
It detect the physical and mental condition, the activity, mobility
and incontinent
A score High risk of ulcer development.

8. Clinical picture and Stages

9. Stage I: Persistent non-blanchable erythema of intact skin.

10. Pressure ulcer over the left ischial tuberosity is shallow with loss of dermis.
Stage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an abrasion, blister, or shallow crater.

11. The right sacral ulcer extends into subcutaneous tissue.
No muscle, bone, or tendon is visible.
Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.

12. Stage 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 may also be present.

14. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body's natural (biological) cover” and should not be removed.
Unstageable: Full thickness tissue loss in which slough (yellow, tan, gray, green or brown), eschar (tan, brown or black), or both in the wound bed cover the base of the ulcer.

15. Usual pressure ulcer locations Any skin exposed to continuous pressure
Over Bony Prominences
Occiput
Ears
Scapula
Spinous Processes
Shoulder
Elbow
Iliac Crest
Sacrum/Coccyx
Ischial Tuberosity
Trochanter
Knee
Malleolus
Heel
Toes

16. Other locations… Any skin surface subject to excess pressure
Examples include skin surfaces under:
Oxygen tubing
Urinary catheter drainage tubing
Casts
Cervical collars

17. COMPLICATIONS Sepsis Localized infection: cellulitis, osteomyelitis
Pain
Depression

18. PREVENTION Mechanical loading Support surfaces Skin care
ACOVE guidelines say to start prevention techniques within 12 hours of admission to the hospital.

19. (1)SKIN CARE Daily systematic skin inspection and cleansing
 factors that promote dryness
Avoid massaging over bony prominences
 moisture (incontinence, perspiration, drainage)
(It requires gentle washing and drying)
Minimize friction and shear
Daily systematic skin inspection and cleansing Especially bony prominences, Use warm water and mild cleanser
 factors that promote dryness
Avoid low humidity and exposure to cold
Moisturize dry skin
Minimize friction and shear
Friction/Shear - is usually thought as occurring horizontally. Friction is the resistance created when one surface moves across another (e.g. dragging a patient across bed linen). Shear occurs when one layer of tissue slides over another and disrupts blood flow (e.g. when the head of the bed is raised > 30 degrees). Both require pressure exerted by body against bed/chair surface to create the tissue injury. Friction ulcers tend to be more superficial starting in the epidermal and dermal layers. Ulcers caused by shear tend to develop deep in the fascia.
Use proper repositioning, turning, transferring techniques
Use lubricants, protective films, dressings, padding
4. Avoid massage as post-mortem evaluations found degenerated tissue in areas exposed to massage

20. (2) MECHANICAL LOADING
Reposition at least every 2 hours (may use pillows), chairs every 15 min
Keep head of bed < 30 degrees.
Use lifting devices to decrease friction and shear
Pay special attention to heels (heel ulcers account for 20% of all pressure ulcers)
PREVENTING HEEL ULCERS Avoid massage as post-mortem evaluations found degenerated tissue in areas exposed to massage
Assess heels of high-risk patients every day
Use moisturizer on heels (no massage) twice a day
Apply dressings to heels:
Transparent film for patients prone to friction problems
Single or extra-thick hydrocolloid dressing for those with pre-stage 1 reactive hyperemia
Have patients wear:
Socks to prevent friction (remove at bedtime)
Properly fitting sneakers or shoes when in wheelchair
Place pillow under legs to support heels off bed
Place heel cushions to prevent pressure
Turn patients every 2 hours, repositioning heels

21. (3)PRESSURE-REDUCING SUPPORT SURFACES
**Use for all older persons at risk for ulcers**
Static
Foam, static air, gel, water, combination (less expensive)
Dynamic
Alternating air, low-air-loss, or air-fluidized
Dynamic
Alternating air, low-air-loss, or air-fluidized
Use if the status surface is compressed to <1 inch or high-risk patient has reactive hyperemia on a bony prominence despite use of static support
Potential adverse effects: dehydration, sensory deprivation, loss of muscle strength, difficulty with mobilization

22. Air mattress; Alternate pressure / low air loss / air fluidized
Heal protector
Air mattress; Alternate pressure / low air loss / air fluidized
Other media; gel / water/ foam

23. Pressure Ulcer Prevention Bundle
Risk assessment (tool)
Skin assessment every 8 hours
Head of bed ≤30° unless contraindicated
Incontinence skin care
Position change
Bed – 2 hourly
Chair – hourly
Heel elevation
Nutritional assessment
Pressure relief mattresses (not a replacement for positional change)

24. Ulcer assessment, monitoring healing
Management
General assessment
Ulcer assessment, monitoring healing
Cleaning
Debridement
Dressings
Surgical repair

25. (1) General assessment Medical diseases
Health problems (e. g, urinary incontinence)
Nutritional status
Pain level

26. (2) Ulcer assessment and healing monitoring (3) Cleaning
Location, Stage, Depth, Pain, Drainage, Necrosis, Cellulitis
(3) Cleaning
Avoid topical antiseptics because of their tissue toxicity
(4) Debridement
Is necessary to remove dead tissue it include
Autolytic debridement using foam dressings
Enzymatic debridement (e.g. cream)
Surgical, sharp Scalpel, scissor to remove dead tissue;
MONITORING HEALING
Use validated tools (eg, PUSH)

27. (8) Infection management
(5) Dressings
By wet to dry saline or hydrocolloid (duo-derm)
(6) SURGICAL REPAIR
May be used for stage III and IV ulcers
skin grafting, skin flaps, musculocutaneous flaps
(7) Pain management
(8) Infection management

28. (9) ADJUNCTIVE THERAPIES
Promising research continues:
Recombinant platelet-derived growth factors
Electrical stimulation
Vacuum-assisted closures
Warm-up therapy (  basal ulcer temperature promotes healing)
Hyperbaric oxygen

29. Nonhealing ulcers may be due to: Inadequate treatment
Suspicion of osteomyelitis or, rarely, squamous cell carcinoma within the ulcer (Marjolin's ulcer).
sinus tracts, which can be superficial or connect the ulcer to deep adjacent structures (eg, to the bowel in sacral ulcers)
PUs are a reservoir for hospital-acquired antibiotic-resistant organisms, which can slow healing and cause bacteremia and sepsis.

30. The mainstay in pressure ulcer treatment prevention of risk factors.

31. Summary
Older adults are at high risk for development of pressure ulcers
Pressure ulcers may result in serious morbidity and mortality
Techniques that reduce pressure, moisture, friction, and shear can prevent pressure ulcers
Pressure ulcers should be treated with proper cleansing, dressings, debridement, or surgery as indicated

32. Thank you