Prevention and Rehabilitation of Pressure Ulcers

1
Prevention and Rehabilitation of Pressure Ulcers

• Michael Kosiak , MD
• MAY,1991. Decubitus. VOL. NO.2

2

• Every care provider is well aware of the
  complications manifested by the occurrence of
  ulceration in the chair- or bed-ridden patient.
• The healthcare professional is being required,
  with increasing frequency to maintain and
  rehabilitate the elderly and severely disabled.

3
DEFINITION

• Pressure ulcers are localized areas of cellular
  necrosis which usually occur over bony
  prominences which are subjected for prolonged
  periods of time to pressures in excess of
  capillary pressure.

4
INCIDENCE

• The incidence of ulcerations is considerably
  greater in the spinal cord-injured hospital
  population and many deaths in this group of
  patients can be attributed to complications
  arising from the presence of pressure ulcers.

5
DISTRIBUTION

• While pressure ulcers can develop over any area
  of the body subjected to supra-capillary pressure
  for a sufficient period of time.

6
PRIMARY FACTORS

• Pressure
• Working with normal and paraplegic rats, we
  reported that microscopic examination of rat
  muscle 24 hours after being subjected to pressure
  of 70 mm Hg for two hours showed a decrease or
  loss of cross-striations and myofibrils,
  hyalinization of fibers and neutrophilic
  infiltrations.

7
PRIMARY FACTORS

• Pressure
• When complete relief of pressure was provided
  at regular five-minute intervals, as with an
  alternating pressure support system, the tissue
  showed consistently less change or no change at
  all when compared with tissues subjected to an
  equivalent amount of constant pressure.

8
PRIMARY FACTORS

• Pressure
• This was true even at pressures as high as 240
  mm Hg for three hours (Kosiak, 1959).
• Pressure as high as 190 mm Hg when applied
  either constantly or intermittently for up to one
  hour showed no microscopic changes.

9
PRIMARY FACTORS

• Friction and Shearing
• Dmsdale (1973), working with swine,
  demonstrated significant skin breakdown when the
  tissue was subjected to both pressure and
  friction, at a pressure significantly less than
  that when necrosis was caused by pressure alone
  (45 mm Hg versus 290 mm Hg).

10
PRIMARY FACTORS

• Temperature
• Raising tissue temperature increases cellular
  metabolism and, therefore, increases the risk of
  ischemic necrosis.
• Aging
• After the third decade, a progressive decrease
  in skin pliability and elasticity has been
  reported .
• whereas after the fifth decade, a rapid
  decrease in blood flow through the skin occurs.

11
CONTRIBUTING FACTORS

• Nutrition
• Increased emphasis has recently been placed on
  the role of nutrition during the acute and
  convalescent phases of illness, especially on the
  negative nitrogen and calcium balances that
  inevitably appear after an acute insult.

12
CONTRIBUTING FACTORS

• Nutrition
• Protein insufficiency inhibits or prevents the
  healing of ulcers.
• For a good metabolic response, the patient
  with a pressure ulcer should be eating 80-100 gm
  of protein each day.

13
CONTRIBUTING FACTORS

• Edema
• Anemia
• Endocrine Disorders
• Diabetes mellitus is the most frequent
  hormonal problem.

14
PREVENTION

• Pressure ulcers are entirely preventable.
• They need not and should not occur.

15
GENERAL PREVENTIVE MEASURES

• Education
• Identification of the high-risk patient
• Those persons with impaired mobility,
  especially in combination with decreased
  sensation or alteration in the level of mental
  awareness, are obvious candidates for skin
  breakdown if they are neglected.
• A single episode of neglect of a comatose
  or anesthetized patient for even an hour may
  result in pressure necrosis.
• Special consideration must be given to
  patients who require sedation or mood-altering
  drugs.

16
GENERAL PREVENTIVE MEASURES

• Recognition of Impending Skin Breakdown
• Specific Preventive Measures for Elimination or
  Reduction of Pressure
• Position changes must be made around the
  clock but not less frequently than every two
  hours.

17
MANAGEMENT

• General Measures
• maintenance of the patient in a good state of
  nutrition and hygiene should be of high priority
  both to sustain healing and to avoid infection.

18
SPECIFIC MEASURES

• Pressure Relief
• The ulcerated area should never be subjected
  to any pressure unless absolutely necessary for
  resting support.
• Elimination of Shearing or Friction.
• Reduction of Heat and Moisture Build-up.

19
SPECIFIC MEASURES

• Debridement
• Mechanical Debridement
• Chemical Debridement
• Control of Infections
• If infection is prevented or controlled,
  healing begins to occur promptly and rapidly.

20
SUMMARY

• The importance of providing pressure relief to
  the areas supporting the weight of the body must
  continue to be stressed and materials and methods
  must never be substituted for sound nursing care.