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How to Prevent & Cure Pressure Ulcers
Home Mobility & Park House Solutions
Overview
• Pressure Ulcer– Definition– Causes– Predisposing Risk Factors– Grades– Effects on Patient
• Solutions– Risk Assessment– Skin Wound Protocol
Pressure UlcerCauses of Pressure Ulcer Development
Pressure
Pressure UlcerWhat is Pressure Ulcer?
• A localized area of cellular damage resulting from:– Direct pressure: skin and other tissues are directly
compressed between bone and another surface (bed, chair). Tissue damage will depend on intensity and duration of exposure to pressure.
– Shearing: tissues are wrenched in opposite directions, resulting in disruption or angulations of capillary blood vessels.
– Friction: skin rubs against another surface (sheet) causing epidermis to be stripped away.
• Also called Pressure Sores, Decubitus Ulcers or Bed Sores
Pressure UlcerBony Prominences at Risk
Pressure UlcerPredisposing Risk Factors
• Level of Mobility
• Nutrition
• Continence
• Medication
• Concurrent disease
• Age
Pressure Ulcer Grades of Ulcers
Two Hours …
… That’s what it takes to develop a pressure ulcer.
Pressure UlcerGrades of Ulcers
Grade 1
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
Redness that does not disappear when pressure is applied
Pressure UlcerGrades of Ulcers
Grade 2
Pressure UlcerGrades of Ulcers
Grade 3
Pressure UlcerGrades of Ulcers
Grade 4
Pressure UlcerGrades of Ulcers
Very Fast Process
Very Slow Process
Grade I: 14 Days
Grade II: 45 days
Grade III: 90 days
Grade IV: 120 Days
Pressure UlcerEffects on Patient
• Pain
• Systemic illness
• Reduced self-esteem
• Altered body image
• Delayed rehabilitation measures
• Amputation
• Death
Pressure Ulcer
Solution
Pressure UlcerRisk Assessment
• Why?– Because we can prevent Pressure Ulcers– Because we can cure Pressure Ulcers
• To Whom?– All person with reduced mobility / activity or sedated
• When?– Admission– Regular Intervals– Change in patient conditions– During day and night
Pressure UlcerRisk Assessment
• Benefits?– Act as aid-memory– Target preventive care– Effective use of scarce resources– Provide quantifiable data of audit– Provides objective criteria to base care
pathways
• How?– Use Risk Assessment Tools
Pressure UlcerRisk Assessment Tools
• Braden
• Gosnell
• PSPS (Lowthian)
• Norton
• Walsall
• Douglas
• Knoll
• Medley
• N.P.R.U
• Waterlow
Pressure UlcerSkin Wound Protocol
• Pressure Reduction
• Pressure Relief
• Incontinence Care
• Nutrition Consult
• Moisturize Skin
• Positioning
• Wound Care
Pressure UlcerSkin Wound Protocol
Pressure Reduction
Pressure Ulcer Pressure Reduction
• Reduce the intensity of pressure and shear : Blood irrigation occlusion diminish O2 flows in tissue– Intensity is determined by contact surface (mattress
or cushion). When the surface is increased, pressure is more evenly redistributed decreasing pressure.
– Avoid several tissue layers because they increase the pressure
– Avoid anything that reduces the size of the pressure surface (ring cushions)
• Should be combined with scheduled alternated repositioning of the patient.
Pressure Ulcer Pressure Reduction
• Pressure Reduction can be done through specialized mattresses / Cushions
• Static Mattresses are non electric system that reduces intensity of the pressure and shear by increasing contact surface
• Overlay is placed over standard mattress and has the same effect as static mattress
• The nature and composition of the material modify the form and the consistency of the mattress that is subject to patient body pressure.
Pressure Ulcer Pressure Reduction
Different Materials:– Water– Static Air– Gel– Fiber– Foam
• CMHR: Combustion Modified High Resilient
• Visco-elastic
Pressure Ulcer Pressure Reduction
Water Mattress Advantages:
• Cheap
• Distributes weight evenly
Water Mattress Disadvantages:
• A spontaneous or assisted change in the positioning is more difficult favours longer period in the same position higher risk of pressure ulcer development.
Pressure Ulcer Pressure Reduction
Water Mattress Disadvantages:• Very difficult to position the patient in Lateral
Decubitus @ 30° (this position is recommended for long stay periods) Low comfort and increased pressure higher risk of pressure ulcer development.
• Cannot be used on profiling beds (electrical) because of the weight of the mattress and the bed inclination
• Cold sensation from the water patient discomfort
Pressure Ulcer Pressure Reduction
Water Mattress Disadvantages:• Extremely heavy weight can causes back
injury to carer• The mattress can break inundation
unpleasant situation for both patient and carer.• Rocking effect may cause dizziness to
predisposed patients• Not durable• Requires a second mattress below
Pressure Ulcer Pressure Reduction
Static Air Mattress Advantages:• Easy use: once filled with air, it does not require an
electric pump.• Heat build up and moisture are greatly reduced, due to
the air holes throughout the mattress. • Light weight.• Best in its class for seating (cushions); however should
be thick enough to prevent bottoming effect Static Air Mattress Disadvantages:• Contact surface is not increased enough to reduce
pressure.• Not durable• Requires a second mattress below
Pressure Ulcer Pressure Reduction
Gel Mattress Advantages:• Comfortable• Viscous gel migrates through sectioned bladders
to relieve pressure around bony prominences.
Gel Mattress Disadvantages:• Contact surface is not increased enough to
reduce pressure.• Gel can dissociate and loose all its properties.• Not durable
Pressure Ulcer Pressure Reduction
Fiber Mattress advantages:• High quality patient comfort• Lasting durability• Easy Maintenance• Body is enveloped by the fiber• Used for very frail bony patients• Light weightFiber Mattress Disadvantages:• Pressure reducing properties are not enough• Rocking effect may cause dizziness to predisposed
patients• Requires a second mattress below
Pressure Ulcer Pressure Reduction
Foam Mattress CMHR advantages:• Longer useful life than non-HR foam• High tear strength• Ability of material to revert to its original shape after pressure
optimal lying comfort • Easy Maintenance• More Supple • Moulds body shape Maximize weight distribution Reduce
pressure• Extremely fire retardant, complies to institutional regulatory
standards Foam Mattress HR Disadvantages:• Used for Low to Medium risk patients only
Pressure Ulcer Pressure Reduction
Foam Mattress Visco-Elastic advantages:• Best in its class for static mattresses. • High quality patient comfort• Lasting durability• Easy Maintenance• Moulds the body allowing patient immersion thus
increasing the contact surface and decreasing the pressure.
• High Memory Foam
Pressure Ulcer Pressure Reduction
Foam Mattress Visco-Elastic advantages:• Heat sensitive property allows the top of the
mattress to be more supple whereas the deeper parts remains firm for a proper support. This maintains the physiological position of the patient maximizing the weight distribution.
• Used for Medium to High Risk Patient
Pressure Ulcer Pressure Reduction
Cover of the mattress is very important and should provide the following:
• Two way stretch Reduce friction and sheer effects.
• Elastic, otherwise it will limit the capacity of the mattress to reduce pressure
• Vapor Permeable evacuate heat patient comfort
• Fire Retardant Fire safety patient safety
Pressure Ulcer Pressure Reduction
• Water Resistant Prevent fluid contamination patient hygiene & safety
• Concealed Zip Fastening Prevent fluid contamination patient hygiene & safety
• Fully Fitted moulds to the shape of the bed Reduce friction and sheer effects
• Detachable cover machine washable easy to clean patient hygiene
Pressure Ulcer Skin Wound Protocol
Pressure Relief
Pressure UlcerPressure Relief
• Purpose is to reduce the duration of pressure and shear by changing the points of pressure.
• Pressure Relief can be done in two ways:– Scheduled alternated positioning– Specialized mattresses
Pressure UlcerPressure Relief
• Scheduled alternated positioning– Change the position of the patient in a way that body
prominences at risk (points of pressure) are different.– Frequency per 24 hours/day, 7 days/week:
Laying Position• Every two hours if no pressure reduction mattress is used
Almost impossible to manage.• Every four hours when a good and appropriate pressure
reduction mattress is usedSeating Position• Every one hour if no pressure reduction cushion is used • Every two hours when a good and appropriate pressure
reduction cushion is used
Pressure UlcerPressure Relief
• Specialized Mattresses are electric system that reduces the duration of the pressure and shear.
• Consist of an inflatable mattress and an electric pump.
• Overlay is placed over standard mattress and has the same effect as an active mattress.
• The cells / compartments of the mattress inflates and deflates in alternation.
• The form of the mattress, that is subject to patient body pressure, changes due to external factors (air pump).
Pressure UlcerPressure Relief
• Differentiation points:– Pump characteristics– Availability of an “intelligent” feed-back
system– Diameter of the cells – Distinct compartments– Additional facilities– Cell structure– Cover
Pressure UlcerPressure Relief
• Pump characteristics:– Quiet– Lightweight and Compact– Clear user instructions – Snap fit connectors, color coded – Adjustable pressure control (better if it is automatic)– Audio – visual alarms– Different settings: Pulsate, Therapy & Static– Comfort control
Pressure UlcerPressure Relief
• Pump characteristics:– Equalized cell pressure when mattress is
disconnected from power unit (transport / power failure)
– Duration of the pressure: 9 to 10 minutes cycle.
– External fusibles to protect the pump from current fluctuations.
Pressure UlcerPressure Relief
• Availability of an “intelligent” feed-back system :– Senses movement of patient– Automatic adjustment to individual patient
weight and position– Optimum pressure is delivered at all times
regardless of body mass.– Back-Raise sensor for semi-recumbent
position push more air in torso section for better support prevents bottoming-out
Pressure UlcerPressure Relief
• Diameter of the cells :– Small cells (less then 10 cm) even when
inflated to the maximum, do not allow the body to elevates enough above the deflated cells.
– Cells larger then 10 cm are recommended.
Pressure UlcerPressure Relief
• Distinct compartments:– Individual cells easy replacement– Tri zonal: comfort for head, torso & heel– Sloping heel section
• Additional Facilities:– Timed static facility– Static facility for fast transfer– CPR facility near head section for faster deflation– Intubation's facility
Pressure UlcerPressure Relief
• The cell structure - number and form:– Double layer cell structure is more efficient then single
layer.
– Cells are linked between each others by series of 3 and same cycle is applied for both layers simultaneously:
1st max. inflation, 2nd half inflation, 3rd total deflation
1st half inflation, 2nd max. inflation, 3rd half inflation
1st total deflation, 2nd half inflation, 3rd max. inflation
Pressure UlcerPressure Relief
• Cover :– Two way stretch Reduce friction and sheer effects.– Elastic maintain reduction property of mattress. – Vapor Permeable evacuate heat patient comfort– Fire Retardant Fire safety patient safety– Water Resistant Prevent fluid contamination patient
hygiene & safety– Concealed Zip Fastening Prevent fluid contamination
patient hygiene & safety – Fully Fitted moulds to the shape of the bed Reduce friction
and sheer effects– Detachable cover easy cleaning– Hoses covered as per disinfections properties
Pressure UlcerPressure Relief
• Special mattresses:– Fluidized Air: Mattress is composed of silicom
particles inside a synthetic cover. When hot air is injected the silicon particles liquefies.
– Low air-loss: Reduce humidity build-up to to the air-loss.
Pressure UlcerPressure Relief
Fluidized Air Advantages: • The body is totally immersed in the mattress which
maximizes the contact surface between the body and the mattress
• Excellent system for treating burns or wounds with high exudates.
Fluidized Air Disadvantages: • Very expensive• Extremely difficult to clean• Cannot be moved from 1 patient to another before a
special cleaning process has taken place.
Pressure UlcerPressure Relief
Low Air loss Advantages: • Designed to provide very high degree of comfort • Constant air flow will help dry up wounds• Separate mattress system can be easily moved
from patient to patient and from bed to bed.• Easy to clean and decontaminate
Pressure UlcerSkin Wound Protocol
Incontinence Care
Pressure Ulcer Incontinence Care
• Clean skin at time of soiling
• Provide quick drying surface (under pads) to the skin.
• Avoid hot water and too much soap while bathing.
Pressure Ulcer Skin Wound Protocol
Nutrition Consult
Pressure Ulcer Nutrition Consult
• Diet should have adequate calories and protein, vitamins and mineral supplements.
• Consult your dietician and doctor.• There is no direct link between bad
nutrition and pressure ulcer prevention however nutrition optimization ameliorates the general condition of the patient and helps the cicatrisation process.
Pressure Ulcer Skin Wound Protocol
Moisturize Skin
Pressure Ulcer Moisturize Skin
• Maintain good hygiene
• Wash with mild soap and warm water, rinse well and pat dry carefully and gently.
• Use moisturizers for dry skin
• Minimize environmental factors leading to dry skin (Low humidity, cold air)
• Do not massage skin over bony parts of the body (can damage tissue)
Pressure Ulcer Skin Wound Protocol
Positioning
Pressure Ulcer Positioning
• The intensity of the pressure is determined by the weight of the patient, his positioning and the hardness of the material he is seated in.
• The contact surface depends on the positioning: Surface redistribution of pressure Pressure
Pressure Ulcer Positioning
• Some facts:– In laying position: Avoid bottoming effect where the
patient is not sustained by the mattress but lies directly on the sub-adjacent surface, specially for obese patients.
– With a simple manual verification, we should not feel patient body.
Pressure Ulcer Positioning
• Some facts:– In laying position: when the bed head is
elevated, the pressure and shear effects increase.
– In seating position, the weight is redistributed in a small surface: more pressure then laying position.
– In seating position, a lateral or vertical inclination increases the pressure.
Pressure UlcerPositioning
• Dorsal Decubitus– Head and legs of the bed are elevated 30°:
maximum reduction of pressure and shear.– Preferred positioning for long periods.
Pressure UlcerPositioning
• Lateral Decubitus– Body forms a 30° angle with the mattress aided by a 30° cushion– The sacrum should not be under pressure.– Above leg is positioned behind the other one, tilted 30° at the
level of the hip and 35° at the level of knee.– Positioning can be made more comfortable with cushions– Use of inflatable cushions is not
recommended due to the effect of shear.
Pressure UlcerPositioning
• Alternated positioning– Use as often as possible
Dorsal Decubitus positioning
– Alternate with lateral Decubitus positioning
• When using appropriate pressure reducing mattress, the schedule can be every 4 hours instead of 2 hours.
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2
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Semi-Fowler 30° - 30°30° 30°
L R
30°
Lat. 30°
Nom :
Mobilisation alternée
Pressure UlcerPositioning
• Seating position in bed– Limit seating positions in bed because it is the cause
of shearing.– Preferred position is 60° but should be limited in
duration.– Use this position only for eating time.
Pressure UlcerPositioning
• Ventral Decubitus– Should be used with soft mattress for comfort– To prevent pressure on feet, either place a cushion or remove
end of bed and slide down patient so that feet are outside mattress.
– Should observe pressure points: shoulder, thorax, basin, knees,
feet, ears.
Décubitus ventral
Pressure UlcerPositioning
– Heel
Pressure UlcerPositioning
• Seating– Slight dorsal inclination, legs resting on
support and heels free of pressure– In case dorsal inclination is not possible,
straight seating with both feet on floor
Pressure UlcerPositioning
• Seating– Limit the duration of seating position: time spent on
chair should be less then time spent in fauteuil which is less then the bed.
– Armchair help stabilize the positioning of the person.– Avoid lateral and vertical sliding from chair.– Make sure that the person is well seated to provide
optimum contact surface. – Cushion and backs help to keep a right positioning.
The type should be studied case by case.
Pressure Ulcer Skin Wound Protocol
Wound Care
Pressure Ulcer Wound Care
- Debride – Ask your doctor- Surgical: most rapid, recommended for large necrotic areas.
- Mechanical: hydrotherapy, wound irrigation
- Enzymatic: collagenase to slow infection if present.
- Autolytic: via enzymes in wound fluid (very slow)
- Pick a dressing (must provide a-moist wound healing)- Transparent semi permeable films (eg Opsite, Tegaderm) for
Grade I & II
- Hydrocolloids (e.g. DuoDerm, Comfeel, Restore) for non infected Grade II & III
- Saline soaked gauze (covered by occlusive wrap) gently pack dead space for Grade II to IV
- Alignates: (eg. CalciCare, Kaltostat) for +++ exudates
Pressure Ulcer Wound Care
- Watch for infection and treat - Ask your doctor for proper treatment.
- Use dry lubricants (cornstarch) or protective coverings to reduce friction injury.
Pressure UlcerHealing signs
- The pressure ulcer will get smaller
- Pinkish tissue usually starts forming along the edges of the sore.
- Smooth or bumpy surfaces of new tissue
- Some bleeding may be present which shows good blood circulation.
Pressure Ulcer
Any Questions
Thank You for Your Time