PRESSURE ULCER

PRESSURE ULCER

Pressure ulcer, also known as pressure sore, pressure injuries, bedsores, and decubitus ulcers, are localized damage to the skin and/or underlying tissue that usually occur over a bony prominent area as a result of pressure or pressure in combination with shear and/or friction.

COMMON SITE FOR PRESSURE ULCER

The most common sites prone to pressure ulcer are the bony prominent areas. These include

Ø Sacrum

Ø Greater trochanters

Ø Heels

Ø Ischial tuberosities

Ø Knees

Ø Ankles

Ø Scapula

Ø Occiput

Ø Elbow

ETIOLOGY OF PRESSURE ULCER

There are four mechanisms that contribute to pressure ulcer development

 

RISK FACTOR

Risk factors for developing  Pressure Ulcers includes;

Ø  Immobility or limited mobility

Ø Bowel & Bladder Incontinence

Ø Shearing and friction injuries

Ø Advanced age

Ø Malnutrition

Ø Obesity

Ø Dehydration

Ø Contractures

Ø Use of orthotic devises or restrains

Ø Use of diapers / excess skin moisture.

SIGNS AND SYMPTOMS OF PRESSURE ULCER

Warning signs of pressure ulcers are:

Ø Unusual changes in skin colour or texture

Ø Swelling

Ø Pus-like draining

Ø An area of skin that feels cooler or warmer to the touch than other areas

Tendered areas.

PATHPHYSIOLOGY

CLASSIFICATION OF PRESSURE ULCER

The staging of pressure ulcers, as defined by national pressure ulcer advisory panel (NPUAP) initiated a guideline that allows common understanding for healthcare professionals. The stages reflect the amount of tissue damage. These stages are as follows:

Ø STAGE I

Ø STAGE II

Ø STAGE III

Ø STAGE IV

Ø UNSTAGEABLE

Ø SUSPECTED DEEP TISSUE INJURY (SDTI)

STAGE 1

This is the mildest stage. These pressure sores only affect the upper layer of your skin.

Characteristics

Intact skin with non-blanchable redness of a localized area, usually over a bony prominent area. The area may be painful, firm, soft, warmer or cooler than adjacent tissue.

 

MANAGEMENT OF STAGE- I PRESSURE ULCER

Ø Off-load areas of pressure ulcer with pressure reducing devise like foam pads, pillows or mattress.

Ø Change patient’s position at least every 2hrs while lying and 15 min while seating.

Ø Wash the sore with mild soap and water and dry gently

Ø Maintain diet high in protein, Vitamin A&C, mineral, iron & zinc

STAGE 2

This happens when the sore digs deeper below the surface of the skin.

Characteristics

Partial thickness skin loss, presenting as a shallow open ulcer with a red-pink wound bed without slough. May also present as an intact or open serum-filled blister.

Management of Stage- II Pressure Ulcer

Dry Wound Bed

Ø  Dress with normal saline, apply small amount of hydrogel and cover with non-adherent dressing, change every day.

Ø Off load area of pressure ulcer with pressure reducing / distribution surface, turning and repositioning.

Minimal Drainage

Dress with normal saline, apply hydrocolloid dressing. Change dressing when soiled or dislodged.

STAGE 3

This stage, the sore have gone through the second layer of skin into the fat tissue.

Characteristics    

Full thickness skin loss: Fat may be visible but bone, tendon or muscle tissue are not. Slough may be present but does not obscure the depth of tissue lost. The

MANAGEMENT OF STAGE- III PRESSURE ULCER

Minimal Drainage and Clean Wound Bed

Ø Clean with normal saline, apply small amount of hydrogel and cover with non adherent dressing change every day.

Ø Off load area of pressure ulcer with pressure relieving / distribution surface, turning and repositioning schedule.

Presence of Slough with drainage

Ø Debridement

Ø Constant dressing

Ø Prescribe antibiotics to fight infection.

Ø There may be need for special bed or mattress

STAGE 4

These sores are the most serious. Some may even affect the muscles and ligaments. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis likely to occur. Exposed bone/tendon is visible or directly palpable.

Characteristics

Full-thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.

MANAGEMENT OF STAGE- IV PRESSURE ULCER

Minimal Drainage and Clean Wound Bed

Ø Clean with normal saline, apply hydrogel and cover with non adherent dressing  and change every day.

Ø Off load area of pressure ulcer with pressure relieving surface, turning and repositioning schedule.

Presence of Slough with drainage

Ø Debridement

Ø Use Foam or Calcium Alginate dressing for moderate to copious drainage ulcer management.

Tunneling and undermining should be filled appropriately.

UNSTAGEABLE

This is when the depth of the sore cannot be determined.

Characteristics

Full thickness tissue loss in which the base of the ulcer is covered by slough or eschar. Until enough of the base is exposed, the true depth and stage cannot be determined.

MANAGEMENT OF UN-STAGEABLE PRESSURE ULCERS

Ø Clean with normal saline, apply hydrogel and cover with non-adherent dressing and change every day.

Ø Off load area of pressure ulcer with pressure relieving / distribution surface, turning and repositioning schedule.

Ø Use Foam dressing for drainage management.

Ø Debridement for the management of slough.

Ø Constant dressing.

Ø Use of antibiotics.

SUSPECTED DEEP TISSUE INJURY

This is when the surface of the skin looks like a Stage 1 or 2 sore, but underneath the surface it’s at Stage 3 or 4.

Characteristics    

This appeared as purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

MANAGEMENT OF SUSPECTED DEEP TISSUE INJURY

Ø Clean with normal saline and change every day.

Ø Off load area of pressure ulcer with pressure relieving devices.

Ø Change patient’s position.

Ø Use Foam dressing for drainage management

MANAGEMENT OF PRESSURE ULCER: SUMMARY

Ø Debridement: Necrotic tissue should be removed in most pressure ulcers. Necrotic tissue is an ideal area for bacterial growth, which has the ability to greatly compromise wound healing. The most common form of debridement is the Surgical debridement, or sharp debridement. It is the fastest method as it allows quick removal of dead tissue.

Dressing:

Ø None to moderate exudates: Dress with Gauze, secure with plaster

Ø Moderate to heavy exudates: Foam dressing, apply moist gauze and apply plaster

Ø Frequent soiling: Foam  dressing, hydrocolloid dressing    apply plaster

Ø Fragile skin: Stretch gauze or stretch net

Medication:

Ø Antibiotics

Ø Analgesics

Ø Vitamins

PRESSURE ULCER PREVENTION / NURSING INTERVENTIONS

Ø Turn every 2 hours Schedule: e.g. alternating positions Right/Back/Left. May place pillow under the hip if patient cannot tolerate full turning.

Ø  Maximal Remobilization: Passive range of motion. Spinal Cord Injury and Disorder (SCI&D) patients (or any patient with customize chairs) are to sit in their own wheelchairs and cushions only.

Ø Protect Heels: Support entire leg with pillows to allow heels to suspend above the mattress or use heel protectors. Assess heels everyday for signs of pressure. Consider pressure relieving / distribution bed surface.

Ø Manage Moisture: Correct  the cause, (e.g., diarrhea), reduce or eliminate incontinent episodes (e.g., bladder training); Use mild soap, rinse, and dry skin well and apply moisture barrier cream.

Ø Manage Nutrition: Increase protein intake, calories and vitamins.

Ø Reduce Friction and Shear: Use bed trapeze or pull sheet for lifting and moving patient up in bed. Apply transparent film or hydrocolloid dressing (Duoderm) over friction areas (e.g., elbows).

COMPLICATIONS OF PRESSURE ULCER

Pressure ulcers can trigger other ailments, cause considerable suffering, and can be expensive to treat. Some complications include:

Ø Autonomic dysreflexia

Ø Bladder distension

Ø Bone infection

Ø Pyarthrosis

Ø Sepsis

Ø Amyloidosis

Ø Anemia

Ø Urethral fistula

Ø Gangrene

CASE STUDY OF A PATIENT WITH PRESSURE ULCER

Ø An 73 year old female presents to the hospital with her family. The patient looks very thin and malnourished. Pt’s weight is 45kg and height is 5′ 6ft. Pt has advance stage of Alzheimer’s and is aphasic. Pt is also a type 2 Diabetic. Contractures are noted in both upper extremities. The family states the patient has been unable to walk for the past year which has lead to her being bed ridden with bowel and bladder incontinence and has not be able to eat for the past weeks.

Ø On assessment, it was noted that the patient has a stage 3 pressure ulcer on her right heel and sacral area. The wound on the heel is draining purulent yellow drainage and is 2 inches wide and 1.5 inches deep. The sacral wound is 5 inches wide and 2 inches deep with no drainage noted. Pt VS: HR 80b/m, BP 120/80, So2 Sat 75%, and RR 9c/m.

Ø Wound approximation, wound edge approximation, surrounding skin erythema, wound oedema and wound odour is all extensive and severe. While the immune status is severely compromised, excessive weight loss due to gastrointestinal dysfunction. Genitourinary, respiratory, mucosa integrity are all severely compromised with the score of 1.

Ø Patient’s Vital Signs: HR 80b/m, BP 120/80, So2 Sat 75% , and RR 9c/m.

ANALYSIS BASED ON THE PRESENTATION

Ø The patient has the following

Ø Stage 3 pressure ulcer at the sacrum

Ø Type 2 diabetic patient

Ø Bedridden patient

Ø Contracture

Ø Loss of appetite

Ø Compromised immunity

Ø Bowel/bladder incontinence

POSSIBLE NURSING DIAGNOSIS COULD BE

Ø  Impaired skin integrity

Ø  Risk for infection

Ø  Acute Pain

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