MANAGEMENT OF PRESSURE ULCERS DR EDITH H TERNAYAWE
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MANAGEMENT OF PRESSURE ULCERS DR. EDITH H. TERNA-YAWE MBBS, FWACS, FACS CONSULTANT PLASTIC AND RECONSTRUCTIVE SURGEON NATIONAL HOSPITAL ABUJA © NITMED TUTORIALS
OUTLINE • • • INTRODUCTION DEFINITION PATHOPHYSIOLOGY RISK FACTORS CLASSIFICATION/STAGING MANAGEMENT • • HISTORY & EXAMINATION DIAGNOSIS INVESTIGATIONS TREATMENT • PREVENTION • CONCLUSION
INTRODUCTION • Increase burden of healthcare • Increases morbidity and mortality • Sepsis, anaemia • Becoming a medico-legal issue • Viewed as quality indicator of care • Development may be viewed as a failure of healthcare system • Prevention is key
DEFINITIONS • Pressure ulcers are skin lesions caused by unrelieved pressure or other forces resulting in damage to the underlying tissue. • Usually pressure ulcers are located over bony prominences. • Soft tissue injury resulting from unrelieved pressure over a bony prominence
PATHOPHYSIOLOGY • Capillary pressure in a single capillary ranges from 12 mm. Hg on the venous end to 32 mm. Hg on the arterial end. • If the external compressive force exceeds capillary bed pressure, capillary perfusion is impaired and ischaemia will ensue. However, this depends on duration/length of unrelieved pressure. • Application of constant pressure >/= 70 mm. Hg for more than 2 h produces irreversible damage • Minimal tissue damage was observed when the pressure exceeded 240 mm. Hg provided there was intermittent pressure relief
PATHOPHYSIOLOGY • HISTOPATHOLOGICAL CHANGES • Secondary changes to pressure on the tissues include: • Occlusion of blood flow to the tissues • Occlusion for short periods of time results in anoxia of the cells • Longer periods of pressure leads to complete occlusion of blood flow resulting in ischaemia of the cells and then necrosis and consequently irreversible tissue damage • Muscle fibres are more sensitive to the ischaemia effect of prolonged pressure than skin
PATHOPHYSIOLOGY • Shear forces are an aetiological factor in development of pressure and ulcers caused by movement of bony prominence against the subcutaneous tissues. • This occurs when the position of the patient is shifted in a way that the skin remains stationary in relation to the support of the body. As a result, the subepidermal vessels are bent at a right angle • Friction forces relate to rubbing of the skin against linen or clothing • Most abrasion injuries caused by friction • Can damage the epidermis making skin susceptible to pressure ulcers
PATHOPHYSIOLOGY • SIGNIFICANT FACORS IN DEVELOPMENT OF PRESSURE ULCERS • Skin moisture • Poor nutrition • Ageing skin • Thin patient • Insensate patient • Spinal cord injury • Spina bifida • Other generalized systemic neurological diseases eg multiple sclerosis,
PATHOPHYSIOLOGY Predisposing factors in developing pressure ulcers • SYSTEMIC FACTORS • Congestive heart failure • Dehydration in old age • Immune deficiency syndrome • Neurological diseases • All decrease skin blood flow, vascularity and skin nutrition
PATHOPHYSIOLOGY Predisposing factors in developing pressure ulcers • BODY MECHANICAL FACTORS • Skeletal deformities of spine • Scoliosis, kyphosis • Pelvic deformities • Dislocated hips, heterotopic ossification, fracture of the hip • Pelvic obliquity – patient cannot lay down straight or sit in a proper way – abnormal position exerts high pressure on some areas of the body – skin breakdown • Skeletal deformity factor should be considered and corrected to the extent possible • Muscle spasm • Contractures
PATHOPHYSIOLOGY Other factors contributing to the development of pressure ulcers • Medical conditions • Allergic diseases of skin • HIV and other immunosuppressive illnesses • Systemic medications eg steroids • External materials applied on the skin • Dressing tapes • Casts • Tight elastic pressure bandages • Smoking/drug abuse • Nicotine – impairs blood circulation
RISKS ASSOCIATED WITH PRESSURE SORES • Limited mobility and prolonged bed rest • Decreased skin sensation • Moisture from bladder or bowel accidents can cause skin breakdown more quickly • Spasticity or improper transfer of patients can result in skin shearing and injury
SITES OF PRESSURE ULCER DEVELOPMENT • Ischial area • Sacrococcgeal area • Trochanteric area • Occipital area • Spinous process • Scapular ridge • Calcaneal bone • Malleolar region
STAGING OF PRESSURE ULCERS Shea pressure sore grading system(1975) Grade II The ulcer is confined to the epidermis and superficial dermis The ulcer extends through the skin and into the subcutaneous fat Grade III The ulcer extends into the underlying muscle Grade IV The ulcer has invaded bone or joint structures
MANAGEMENT • HISTORY • Risk of predisposing factors • Risk of worsening factors/other comorbid factors • Hx relevant to plans for surgery
MANAGEMENT • INVESTIGATIONS • Baseline • Specific
MANAGEMENT Treatment • CONSERVATIVE • • • Relieve pressure Correct anaemia Treat infection Correct malnutrition Treat spasticity Adequate social support
MANAGEMENT • • TREATMENT OF SPASTICITY Diazepam 10 -40 mg Baclofen 15 -100 mg Dantrolene Sodium 50 -800 mg • • • SURGICAL Peripheral nerve block Epidural stimulators Baclofen pumps Rhizotomy Phenol rhizotomy
MANAGEMENT Treatment • SURGICAL • Debridement • Flap cover
MANAGEMENT • POST-OP CARE • Suction drains – until 20 -30 ml in 24 hrs. Usually up to 7 -10 days postop but may extend to 4 weeks • Antibiotics – 7 -10 days or more • Avoid pressure to flap for 3 -4 weeks
MANAGEMENT • COMPLICATIONS • Slight wound separation • Haematoma • Seroma • Wound infection • Partial flap necrosis
MANAGEMENT • REHABILITATION • Education/instruction of patients because of high risk of recurrence • Need assistance to acquire special equipments eg wheel chair with appropriate padding
COMPLICATIONS OF CHRONIC PRESSURE ULCERS • Acute sepsis • Amyloidosis • Heterotopic ossification • Septic joint • Perineal/urethral fistula • Squamous cell carcinoma • Acute or chronic osteomyelitis
PREVENTION • Continuous education of healthcare staff • Measures for prevention in hospitals and nursing homes etc include: • Patient positioning and turning schedule • Preventing and treating excessive body moisture, faecal and urinary incontinence • Using advanced equipment eg special beds, mattresses and wheelchair cushions • Attention to patient’s nutrition • Patient and family education
REFERENCES • Salah Rubayi, Pressure ulcers: An important condition in Medicine and Surgery. Reconstructive Plastic Surgery of Pressure Ulcers • Charles Thorne. Grabb and Smith’s Plastic Surgery. 6 th Ed. Lippincott Williams and Wilkins. 2007. • Shea JD: Pressure Sores: Classification and Management. Clinical Orthopaedics 1975: 112: 89 • Matthes Plastic Surgery. Vol 6
- Pressure mapping for pressure ulcers
- Peptic ulcer definition
- Intestine
- Duodenal ulcer vs gastric ulcer
- Anorexia and stomach ulcers
- Phlebography
- What causes ulcers
- Sloping ulcer edge
- Dehydration gastritis
- Elmslie trillat
- Pressure support vs pressure control
- Intrapulmonary pressure vs intrapleural pressure
- Starling
- Hypergraph containers
- Hypoxaemia vs hypoxia
- Regional metamorphism
- Pressure support vs pressure control
- Bernoulli's equation
- Oncotic pressure vs hydrostatic pressure
- Colloid osmotic pressure vs hydrostatic pressure
- Osmolarity vs osmolality
- Hydrostatic oncotic pressure
- Dynamothermal
- Baroreceptors
- How to find partical pressure
- What is ppeak in ventilator