PRESSURE ULCERS AND WOUNDS By Monica Warhaftig D

PRESSURE ULCERS AND WOUNDS By Monica Warhaftig, D. O. Assistant Professor of Geriatrics N. S. U.

Chronic Wounds • • • Greater than 12 hours Debridement Cleansing Dressing Pressure redistribution Multidisciplinary care

GOALS • • • Types of wounds Risk factors and Risk Scales Local/Systemic Factors Wound Care Healing Wound care products

Types of Wounds Location, Location • Pressure: sacrum, heels, trochanter • Venous: Inside the leg -Medial • Arterial- Lateral • Diabetic: neuropathic areas • Traumatic: anywhere

RISK ASSESSMENT: Low score=high risk (16 or 12) • The Norton Scale *The Braden Scale •

*Extrinsic Factors • Pressure Relief : proper patient positioning; pressure devices: pressure greater that 32 mm hg (ischial tubes 300) (sacrum up to 300) • Special Beds: static and dynamic • Friction : rubbing of a body part against another or a surface. . damage to stratum corneum. . ex patient pulled across a bed • Shear Stress: head of bed elevated greater that 30 degrees. . patient slides down(opp directions) • Moisture: weakens the skin

*Stages of Wound Healing • Inflammation- (approx. 2 -3 days) consists of a vascular and a cellular response acute and chronic inflammation (neutrophils, cytokines, oxygen, platelets rush to the site) • Proliferation – (approx. 2 -3 weeks) Begins at the time of injury Rebuilding begins with scaffolding of the skin Revascularization of the wound begins • Maturation Stage- (Approx 2 -3 years) Depositing of scar tissue The body attempts to contract or close the wound (Wounds are only ever 80% healed)

Systemic Factors that affect Wound Healing • • Nutritional Status Vascular Status Metabolic Factors Immunological Factors Age Medications (Steroids, etc) Genetic

The Local Factors • • Necrotic tissue and foreign bodies Drying of a wound Microorganisms Trauma (pressure, shearing, friction) Fibrin Oxygen Edema

Intrinsic (Patient Status) • Diabetes • Anemia: decreases O 2 to the wound • Nutritional State (Serum chemistries, Albumin, Prealbumin) • Weight Loss (oxandrelone) • Coagulopathic state • Multiple comorbidities • Incontinence; foley • Immobility: turning q 2 hours

What is a Pressure Ulcer ? • Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

Pressure ulcer stages • Stage 1: epidermis; nonblanching erythema • Stage 2: epidermis/dermis; shallow opening; blisters • Stage 3: Subcutaneous tissue/fascia • Stage 4: fascia + bone, tendon, muscle, cartilage

Stage 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 relief Cone Shaped…apex to the skin (no indic of below) Muscle & Ischemia– high metabolic rate less blood supply. . More susceptible

Pressure Ulcer Staging Stage I

Pressure Ulcer Staging Stage I Dark Skin

Pressure Ulcer Staging Stage II • Stage 2: Partial thickness skin loss involving epidermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

Pressure Ulcer Staging Stage II

Pressure Ulcer Staging 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.

Pressure Ulcer Staging Stage III

Pressure Ulcer Staging 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 Stage IV

Stage IV

Pressure Ulcer Staging Stage IV

Venous Ulcers • • • Due to venous insufficiency Medial Aspect of the leg Beefy Red Jagged Painless Treat with compression

Venous Ulcer

Diabetic Ulcer

Venous Ulcers

Arterial Wounds Complete or partial arterial blockage may lead to tissue necrosis and / or ulceration. Signs on the extremity: • Pulselessness of the extremity • Painful ulceration • Small, punctate ulcers that are usually well circumscribed • Cool or Cold skin • Delayed 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)

Arterial Disease • Atrophic appearing skin (shiny, thin, dry) • Loss of digital and pedal hair • Can 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 (TCPO 2) to aid in your diagnosis. Duplex scanning and arteriograms may also be performed if indicated.

Arterial Disease Ankle brachial index (ABI) : arterial blood flow in the lower extremities determines level of ischemia: Normal >1. 0; LEAD = 0. 9; Borderline is <0. 60 -0. 8; Severe is <0. 5. (The ABI can be falsely elevated in people with diabetes. (calcified noncompressible vessels) • Recheck the ABI periodically • Toe pressure (TP) in patients with diabetes in whom LEAD is suspected. Toe pressure <30 indicates LEAD.

Arterial Ulcers

Slowing factors • Temperature ; cold or open • Necrotic tissue • Exudate (too much vs dry wound)

Infection • • Contamination Colonization Critical Colonization Infection

*Signs of Infection • • Delayed Healing Change in Exudate Change in Pain Change in Granulation Tissue Change in Smell Change in Size Fever Leukocytosis

Types of debridement • Autolytic – (Occlusive Dressings) the body heals itself • Mechanical – using gauzes • Enzymatic – chemical enzymes (Collagenase, Papain, ) • Sharps – scalpel, laser, surgery • Biosurgical – maggots, leeches

Topical 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)

Products • • Primary/secondary type of dressing Hydrophyllic Hydrogel Alginate Foam Accuzyme panafil

Transparent Film • • • Autolytic debridement Primary or secondary dressing Partial thickness wounds *Stage I or II pressure ulcers Superficial burns

Hydrocolloids (Autolytic) • • • Primary or secondary dressing *Partial and full thickness wounds Pressure ulcers *Necrotic wounds Granular wounds preventative dressing Used as a secondary dressing or under compression

Hydrogels • • • Stage 2 to stage 4 pressure ulcers Partial and full thickness *Painful wounds Skin tears Minor burns *Necrotic wounds

Collagens • • • *Infected Wounds Tunneling Wounds Surgical Wounds Can be used with other topical agents *Not for necrotic wounds

Negative Pressure Therapy • VAC Device • For Nonhealing wounds and fecal incontinence • Removes Interstitial Fluid from the wound

Antimicrobial Dressings • Infected Wounds • Controls bacteria bioburden • Effective against a broadspectrum of microorganisms • IODOSORB • AQUACEL • IODOFLEX

Saline –soaked Gauze Dressings • Saline soaked and not allowed to dry • Similar to occlusive dressings • However, Time intensive for nursing • *Used for Partial and full thickness wounds • Draining wounds • Wounds requiring debridement packing, Or management of tunnels, tracts or dead space • Surgical incisions/Burns/pressure ulcers

Calcium Alginate • • Highly absorptive- brown seaweed *exudative wounds. Alginates do not adhere to a wound Can damage epithelial tissue if the wound dries

FOAM • Nonocclusive absorptive wound dressing • Partial and full thickness wounds…minimal to heavy drainage • Stage II to IV press. Ulcers • *Infected and non-infected

*Compression Therapy • Venous Ulcers • Used to manage edema and promote the return of venous blood to the heart • Use cautiously with arterial ulcers

Advanced Wound Care Products • Platelet Derived Growth Factors • OTHERS

*Healing Factors – The Push Scale • Wounds heal by contraction and scar formation (Can’t reverse stage) • Push Scale • Measures: Size: greatest length (head to toe) and the greatest width (side to side) using a centimeter Exudate: none, light, moderate, heavy Tissue Type: 4 -any necrotic tissue; 3 -any amount of slough…no necrotic tissue; 2 -clean wound with granulation tissue; 1 -wound closed

Tissue Types • Slough-yellow or white. . strings or thick clumps • Granulation tissue-pink or beefy red tissue , shiny, moist, granular appearance • Epithelial tissue: new pink or shiny tissue grows in from the edges • Necrotic Tissue (eschar) : Black, brown, or tan firmly adheres to the wound bed • Closed/resurfaced-wound completely covered

What stage is it?

What Stage ?

What type of wound ?

Review • • • Picture Stage of pressure ulcer/type of wound Intrinsic/Extrinsic factors Scoring for assessment Factors in healing scales Factors in Infection

SKIN TEARS