How to Prevent

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How to Prevent Cure Pressure Ulcers

• Home Mobility Park House Solutions

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Overview

• Pressure Ulcer
• Definition
• Causes
• Predisposing Risk Factors
• Grades
• Effects on Patient
• Solutions
• Risk Assessment
• Skin Wound Protocol

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Pressure Ulcer
Causes of Pressure Ulcer Development

Pressure
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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

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Pressure UlcerBony Prominences at Risk
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Pressure UlcerPredisposing Risk Factors

• Level of Mobility
• Nutrition
• Continence
• Medication
• Concurrent disease
• Age

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Pressure Ulcer Grades of Ulcers

• Two Hours
• Thats what it takes to develop a pressure
  ulcer.

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Pressure UlcerGrades of Ulcers
Grade 1
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
Redness that does not disappear when pressure is
applied
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Pressure UlcerGrades of Ulcers
Grade 2
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Pressure UlcerGrades of Ulcers
Grade 3
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Pressure UlcerGrades of Ulcers
Grade 4
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Pressure UlcerGrades of Ulcers
Very Fast Process
Grade I 14 Days Grade II 45 days Grade III 90
days Grade IV 120 Days
Very Slow Process
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Pressure UlcerEffects on Patient

• Pain
• Systemic illness
• Reduced self-esteem
• Altered body image
• Delayed rehabilitation measures
• Amputation
• Death

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Pressure Ulcer

• Solution

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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

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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

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Pressure UlcerRisk Assessment Tools

• Braden
• Gosnell
• PSPS (Lowthian)
• Norton
• Walsall

• Douglas
• Knoll
• Medley
• N.P.R.U
• Waterlow

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Pressure UlcerSkin Wound Protocol

• Pressure Reduction
• Pressure Relief
• Incontinence Care
• Nutrition Consult
• Moisturize Skin
• Positioning
• Wound Care

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Pressure UlcerSkin Wound Protocol

• Pressure Reduction

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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.

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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.

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Pressure Ulcer Pressure Reduction

• Different Materials
• Water
• Static Air
• Gel
• Fiber
• Foam
• CMHR Combustion Modified High Resilient
• Visco-elastic

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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.

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Pressure Ulcer Pressure Reduction

• Water Mattress Disadvantages
• Very difficult to position the patient in Lateral
  Decubitus _at_ 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

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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

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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

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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

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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 weight
• Fiber Mattress Disadvantages
• Pressure reducing properties are not enough
• Rocking effect ? may cause dizziness to
  predisposed patients
• Requires a second mattress below

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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

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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

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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

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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

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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

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Pressure Ulcer Skin Wound Protocol

• Pressure Relief

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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

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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 used
• Seating Position
• Every one hour if no pressure reduction cushion
  is used
• Every two hours when a good and appropriate
  pressure reduction cushion is used

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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).

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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

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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

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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.

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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

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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.

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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

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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

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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

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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.

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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.

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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

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Pressure UlcerSkin Wound Protocol

• Incontinence Care

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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.

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Pressure Ulcer Skin Wound Protocol

• Nutrition Consult

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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.

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Pressure Ulcer Skin Wound Protocol

• Moisturize Skin

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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)

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Pressure Ulcer Skin Wound Protocol

• Positioning

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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
  

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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.

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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.

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Pressure UlcerPositioning

• Dorsal Decubitus
• Head and legs of the bed are elevated 30
  maximum reduction of pressure and shear.
• Preferred positioning for long periods.

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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.

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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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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.

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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.

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Pressure UlcerPositioning

• Heel

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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

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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.

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Pressure Ulcer Skin Wound Protocol

• Wound Care

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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

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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.

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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.

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Pressure Ulcer

• Any Questions
• Thank You for Your Time