PRESSURE ULCERS AND WOUNDS

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PRESSURE ULCERS AND WOUNDS

• By Monica Warhaftig, D.O.
• Assistant Professor of Geriatrics
• N.S.U.

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Chronic Wounds

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

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GOALS

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

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Types of WoundsLocation, Location, Location

• Pressure sacrum, heels, trochanter
• Venous Inside the leg -Medial
• Arterial- Lateral
• Diabetic neuropathic areas
• Traumatic anywhere

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RISK ASSESSMENTLow scorehigh risk (16 or 12)

• The Norton Scale

The Braden Scale

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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

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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)

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Systemic Factors that affect Wound Healing

• Nutritional Status
• Vascular Status
• Metabolic Factors
• Immunological Factors
• Age
• Medications (Steroids, etc)
• Genetic

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The Local Factors

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

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Intrinsic (Patient Status)

• Diabetes
• Anemia decreases O2 to the wound
• Nutritional State (Serum chemistries, Albumin,
  Prealbumin)
• Weight Loss (oxandrelone)
• Coagulopathic state
• Multiple comorbidities
• Incontinencefoley
• Immobilityturning q2 hours

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What is a Pressure Ulcer ?

• Any lesion caused by unrelieved pressure usually
  over a bony prominence that results in damage to
  underlying tissue

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Pressure ulcer stages

• Stage 1 epidermis nonblanching erythema
• Stage 2 epidermis/dermis shallow
  openingblisters
• Stage 3 Subcutaneous tissue/fascia
• Stage 4 fascia bone, tendon, muscle, cartilage

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Stage 1

• Intact Skin with nonblanchable erythema
• (extravasation of blood from ischemic
  leaky blood vessels) (up to 30 minutes)
• Blanchable means congested vesselsvanishes
  shortly after pressure relief
• Cone Shapedapex to the skin (no indic of below)
• Muscle Ischemia high metabolic rate less blood
  supply ..More susceptible

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Pressure Ulcer Staging
Stage I
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Pressure Ulcer Staging
Stage I Dark Skin
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Pressure Ulcer Staging
Stage II

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

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Pressure Ulcer Staging
Stage II
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Pressure Ulcer Staging
Stage II
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Pressure Ulcer Staging
Stage II
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Pressure Ulcer Staging
Stage II
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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.
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Pressure Ulcer Staging
Stage III
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Pressure Ulcer Staging
Stage III
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Pressure Ulcer Staging
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 also may be associated with Stage IV
pressure ulcers
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Stage IV
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Stage IV
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Pressure Ulcer Staging
Stage IV
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Pressure Ulcer Staging
Stage IV
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Venous Ulcers

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

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Venous Ulcer
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Diabetic Ulcer
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Venous Ulcers
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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)

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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
  (TCPO2) to aid in your diagnosis. Duplex scanning
  and arteriograms may also be performed if
  indicated.

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Arterial Disease

• Ankle brachial index (ABI) arterial blood flow
  in the lower extremities determines level of
  ischemia
• Normal gt1.0 LEAD 0.9
• Borderline is lt0.60-0.8
• Severe is lt0.5. (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 lt30
  indicates LEAD.
• Tissue perfusion with transcutaneous oxygen
  measurement (TcPO2) if ulcer is not healing and
  ABI is lt0.9 or toe pressure lt30 mmHg, or if
  unable to perform ABI

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Arterial Ulcers
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Slowing factors

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

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Infection

• Contamination
• Colonization
• Critical Colonization
• Infection

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Signs of Infection

• Delayed Healing
• Change in Exudate
• Change in Pain
• Change in Granulation Tissue
• Change in Smell
• Change in Size
• Fever
• Leukocytosis

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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

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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)

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Products

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

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Transparent Film

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

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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

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Hydrogels

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

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Collagens

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

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Negative Pressure Therapy

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

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Antimicrobial Dressings

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

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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

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Calcium Alginate

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

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FOAM

• Nonocclusive absorptive wound dressing
• Partial and full thickness woundsminimal to
  heavy drainage
• Stage II to IV press. Ulcers
• Infected and non-infected

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Compression Therapy

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

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Advanced Wound Care Products

• Platelet Derived Growth Factors
• OTHERS

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Healing Factors The Push Scale

• Wounds heal by contraction and scar formation
  (Cant 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 sloughno necrotic tissue 2-clean wound with
  granulation tissue 1-wound closed

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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

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What stage is it?
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What Stage ?
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What type of wound ?
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What type of wound ?
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Review

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

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SKIN TEARS