SKIN MANAGEMENT

DECUBITIS ULCER
Presented By: Maj(R) Nazma Noreen
N/Lecturer ION/WMC
Wah Cantt
OBJECTIVES
At the end of this session, we all will be able to:
 Define decubitis ulcer.

 Enlist the causes and risk factors.

 Stage the ulcer

 Describe the treatment of ulcer

 Enumerate the preventive measures of ulcer

 Identify the complications related to ulcer.

PRESSURE ULCER
 The National Pressure Ulcer Advisory Panel
(NPUAP) defines a pressure ulcer as an area of
unrelieved pressure over a defined area, usually
over a bony prominence, resulting in ischemia,
cell death, and tissue necrosis.
DECUBITIS ULCER
 Pressure ulcers, also known as pressure
sores, bedsores and decubitus ulcers, are
localized injuries to the skin and/or underlying
tissue that usually occur over a bony prominence
as a result of pressure, or pressure in
combination with shear and/or friction.
PRESSURE ULCERS CONTD..
 Pressure ulcers occur due to pressure applied
to soft tissue resulting in completely or partially
obstructed blood flow to the soft tissue.
 Shear is also a cause, as it can pull on blood
vessels that feed the skin.
 Pressure ulcers most commonly develop in
individuals who are not moving about, such as
those being bedridden or confined to a
wheelchair.
PRESSURE ULCERS CONTD..
 It is widely believed that other factors can
influence the tolerance of skin for pressure and
shear, thereby increasing the risk of pressure
ulcer development.
 The rate of pressure ulcers in hospital settings is
high, but improvements are being made. They
resulted in 29,000 documented deaths globally in
2013, up from 14,000 deaths in 1990.
COMMON SITES FOR PRESSURE ULCER
The most common sites are the skin overlying
the:
 Sacrum

 Coccyx

 Heels

 Hips

 but other sites such as the elbows,

knees, ankles or the back of the cranium can be
affected as well.
AREAS OF PRESSURE
PRESSURE ULCERS / CLASSIFICATION
NATIONAL PRESSURE ULCER ADVISORY PANEL
 Stage 1: non blanchable erythema of
intact skin
 Stage 2: partial thickness skin loss that
involves the epidermis or dermis (or both)
 Stage 3: full thickness skin loss and
damage or necrosis of subcutaneous tissue
that may extend to, but not through,
underlying fascia
 Stage 4: full thickness skin loss associated
with extensive destruction, tissue
necrosis, or damage to muscle, bone, or
supporting structures, such as tendons or
joint capsules
STAGE 1

The heralding lesion of skin ulceration

 STAGE 2

The ulcer is superficial and manifest clinically

as an abrasion, blister or shallow crater
STAGE I-II PRESSURE SORE
STAGE 3

The ulcer manifests clinically as a deep crater

with or without undermining of adjacent
tissue
 STAGE 4

B
STAGE IV PRESSURE SORE
PRESSURE ULCERS
PATHOGENESIS
 Four key factors:
 Pressure
 Shearing forces (Shearing forces are
unaligned forces pushing one part of a body in one
direction, and another part of the body in the opposite
direction. When the forces are aligned into each other,
they are called compression forces, A shear is a separation
of the skin from underlying tissues.)

 Friction
 Moisture
PATHOGENESIS
PRESSURE ULCERS
RISK FACTORS
 Spinal cord injuries  Chronic systemic
 Traumatic brain illness
injury  Fractures

 Neuromuscular  Aging skin

disorders  decreased epidermal
 Immobility
turnover
 dermoepidermal
 Malnutrition junction flattens
 Fecal and urinary  fewer blood vessels
incontinence  Decreased pain
 Altered level of perception
consciousness
PATHOPHYSIOLOGY

 Pressure ulcers may be caused by inadequate

blood supply and resulting reperfusion
injury when blood re-enters tissue.
 A simple example of a mild pressure sore may be
experienced by healthy individuals while sitting
in the same position for extended periods of time:
the dull ache experienced is indicative of impeded
blood flow to affected areas.
 Within 2 hours, this shortage of blood supply,
called ischemia, may lead to tissue damage and
cell death.
PATHOPHYSIOLOGY CONTD..
 The sore will initially start as a red, painful area.
 The other process of pressure ulcer development
is seen when pressure is high enough to damage
the cell membrane of muscle cells
 The muscle cells die as a result and skin fed
through blood vessels coming through the muscle
die
 This is the deep tissue injury form of pressure
ulcers and begins as purple intact skin
PREVENTION OF PRESSURE ULCERS
 Knowing patient’s condition, risk factors for
pressure ulcers, prevention measures are very
important.
 For example, older adults have a higher risk of
developing pressure ulcers because chronic
diseases, more common in this age group, may
compromise circulation and oxygenation of
dermal structures.
 The nutrition and hydration status of elderly
may as well predispose them to pressure ulcer
formation.
PRESSURE ULCERS
RISK ASSESSMENT
 Select and use a method of risk
assessment that ensures systematic
evaluation of individual risk factors.
 Many risk assessment tools exist, but only
the Norton Scale and Braden Scale
have been tested extensively.
 Tools include the following risk factors:
mobility/activity impairment, moisture,
incontinence, and impaired nutrition.
PRESSURE ULCERS
ACTIVITY OR MOBILITY DEFICIT
 Bed- or chair-bound individuals or those
whose ability to reposition is impaired
should be considered at risk for pressure
ulcers.
 Identification of additional risk factors
(immobility, moisture/incontinence, and
nutritional deficit) should be undertaken
to direct specific preventive treatment
regimes.
PRESSURE ULCERS
EDUCATIONAL PROGRAM
 Educational programs for the prevention of
pressure ulcers should be:
 Structured
 Organized
 Comprehensive
 Directed at all levels of health care providers,
patients, and family or caregivers. .
PRESSURE ULCERS
REASSESSMENT
 Active, mobile individuals should be periodically
reassessed for changes in activity and mobility
status.
 The frequency of reassessment depends on
patient status and institutional policy.
PRESSURE ULCERS/MECHANICAL
LOADING AND SUPPORT SURFACES
For bed-bound individuals:
 Reposition at least every 2 hours.
 Use pillows or foam wedges to keep bony
prominences from direct contact.
 Use devices that totally relieve pressure on the
heels.
 Avoid positioning directly on the trochanter.
PRESSURE RELIEVING DEVICES
PRESSURE ULCERS/MECHANICAL LOADING
AND SUPPORT SURFACES
 Elevate the head of the bed as little and for as
short a time as possible.
 Use lifting devices to move rather than drag
individuals during transfers and position
changes.
 Place at-risk individuals on a pressure-reducing
mattress.
 Do not use donut-type devices, or air cushions.
PRESSURE ULCERS/MECHANICAL LOADING
AND SUPPORT SURFACES
For chair-bound individuals:
 Reposition at least every hour.
 Have patient shift weight every 15
minutes
 Pressure-reducing devices for seating
surfaces. Do not use donut-type devices.
 Consider postural alignment, distribution
of weight, balance and stability, and
pressure relief when positioning
individuals in chairs or wheelchairs.
PRESSURE ULCERS
SKIN CARE AND EARLY TREATMENT
 Inspect skin at least  Avoid massage over
once a day. bony prominences.
 Individualize bathing  Use proper positioning,
schedule (Avoid hot transferring, and
water and mild turning techniques.
cleansing agent)  Use lubricants to reduce
 Minimize friction injuries.
environmental factors  Rehabilitation program.
such as low humidity
and cold air.  Monitor and document
interventions/outcomes.
 Use moisturizers for
dry skin
PRESSURE ULCERS
NUTRITIONAL DEFICIT
 Investigate factors that compromise an
apparently well-nourished individual's dietary
intake.
 Plan and implement a nutritional support and/or
supplementation program for nutritionally
compromised individuals.
TREATMENT
ASSESSMENT
 History and Physical Examination
 Assessing Complications

 Nutritional Assessment and Management

 Pain Assessment and Management

 Psychosocial Assessment and Management

PRESSURE ULCERS
ULCER CARE
The four basic components
1. Debridement of necrotic tissue as needed on
initial and subsequent assessments
2. Cleansing the wound initially and with each
dressing change
3. Prevention, diagnosis, and treatment of
infection
4. Using a dressing that keeps the ulcer bed
moist and the surrounding intact tissue dry
DEBRIDEMENT
 Moist, devitalized tissue supports the
growth of pathological organisms.
 Therefore, the removal of such tissue
favorably alters the healing environment
of a wound.
 Removal of devitalized tissue is
considered necessary for wound healing.
ESCHAR TISSUE
ESCHAR TISSUE
GRANULATING TISSUE & NECROTIC TISSUE
WOUND CLEANSING
 Remove necrotic tissue, exudate, and
metabolic wastes from the wound.
 Minimum of chemical and mechanical
trauma. .
 Cleanse wounds initially and at each
dressing change
 Do not clean ulcer wounds with skin
cleansers or antiseptics
 Use normal saline for cleansing .
DRESSINGS
 Keep the ulcer bed continuously moist.
 Wet-to-dry dressings should be used only for
debridement
 No differences in pressure ulcer healing outcomes
with diverse dressings
 Keep the surrounding intact (periulcer) skin dry
while keeping the ulcer bed moist.
DRESSINGS
 Control exudate but do not desiccate the ulcer
bed.
 Consider caregiver time

 Eliminate wound dead space by loosely filling all

cavities with dressing material.
 Avoid overpacking the wound.

 Monitor dressings applied near the anus

ADJUNCTIVE THERAPIES
 The therapies included :
 electrical stimulation
 hyperbaric oxygen
 infrared and ultraviolet light
 low-energy laser irradiation
 ultrasound
 miscellaneous topical agents (including
cytokine growth factors)
 systemic drugs other than antibiotics
PRESSURE ULCERS
TREATMENT FOR EACH STAGE
STAGE 1
 Intensive implementation of preventive
measures as usual
 Polyurethane dressings (transparent)
applied every 1 to 10 days (Tegaderm)
 They are semipermeable films, permeable
to water vapor, oxygen and other gases
and impermeable to water and bacteria
 Most lesions can be expected to heal by 2
weeks
STAGE 2
 The same as for stage I but…
 Wound should be inspected for signs of infection
 Polyurethane dressings are more effective and
less costly than wet-to-dry dressings (Tegaderm
 or thin Duoderm )
 Wet-to-dry dressings are rarely indicated at this
stage
STAGE 3
 Remove necrotic material
 Small eschar:
 Debridement by experienced personnel
 Topical application of enzymatic debriding
agents
Eschar should be scored


Enzymes must not touch surrounding

areas
 Large eschar: Surgical consultation
STAGE 3
 Loose material can be debrided with wet-
to-dry dressings every 8 hours
 Polyurethane and hydrocolloid dressings
(Duoderm) are more effective
 Hydrocolloids are impermeable to gas and
moisture and are changed every 1-4 days
 Deeper stage 3 or 4: Wounds need to be
packed with material depending on
exudate
STAGE 3
 Consider specialized beds:
 air fluidized beds
 low-air-loss beds
 They should be used for at least 60 days
 Patients with large defects: surgery
consult
 Patients with large defects in the sacral
area and urinary incontinence may
require catheterization
STAGE 4
 They require surgical consultation for initial
debridement
 Wet-to-dry dressings may help
 Clean deep ulcers require packing
 Consider grafting procedures
 Always keep in mind the goals of the patient
MANAGING BACTERIAL COLONIZATION AND
INFECTION
 Stage 2, 3 and 4 pressure ulcers are
invariably colonized with bacteria.
 In most cases, adequate cleansing and
debridement prevent bacterial
colonization from proceeding to the point
of clinical infection
 If purulence or foul odor is present, more
frequent cleansing and possibly
debridement are required.
INFECTED PRESSURE SORE
MANAGING BACTERIAL COLONIZATION AND
INFECTION
 Do not use swab cultures to diagnose
wound infection (colonization)
 Consider 2-week trial of topical
antibiotics for clean pressure ulcers that
are not healing or producing exudate
 Effective against gram negative, positive,
and anaerobes
 Perform quantitative bacterial cultures of
soft tissue and evaluate for osteomyelitis
when ulcer does not respond to topical
antibiotic therapy.
MANAGING BACTERIAL COLONIZATION AND
INFECTION
 Systemic antibiotic therapy for patients
with bacteremia, sepsis, advancing
cellulitis, or osteomyelitis.
 Do not use topical antiseptics (povidone
iodine, iodophor, Dakins® solution,
hydrogen peroxide, acetic acid) to reduce
bacteria in wound tissue.
 Systemic antibiotics are not required for
pressure ulcers with signs of local
infection.
 Protect pressure ulcers from exogenous
sources of contamination
INFECTION CONTROL
 Follow body substance isolation
precautions or an equivalent system.
 Use clean gloves for each patient.
 When treating multiple ulcers on the
same patient, attend to the most
contaminated ulcer last
 Use sterile instruments to debride ulcers
 Use clean dressings, rather than sterile
ones, to treat pressure ulcers.
OPERATIVE REPAIR OF PRESSURE ULCERS
 Operative procedures to repair pressure ulcers
include one or more of the following:
 Direct closure
 Skin grafting
 Skin flaps
 Musculocutaneous flaps
 Free flaps.
OPERATIVE REPAIR OF PRESSURE ULCERS
 Consider for operative repair when clean
Stage III-IV do not respond to optimal
patient care
 Candidates are medically stable, well
nourished and can tolerate operative
blood loss and postop immobility.
 Correct factors that may be associated
with impaired healing (smoking,
spasticity, levels of bacterial colonization,
incontinence, and UTI)
 Minimize pressure to the operative site by
use of special beds
ASSESSMENT OF ULCER HEALING
 Evaluate at least weekly
 If general condition deteriorates, the ulcer
should be reassessed promptly
 Evaluate using size, depth, presence of
exudate, epithelialization, granulation
tissue, necrotic tissue, sinus tracts,
undermining, tunneling, purulent
drainage or signs of infection.
 A clean pressure ulcer with adequate
innervation and blood supply should show
progress toward healing in 2 to 4 weeks
MONITORING
 Healing ulcers should be assessed
regularly
 Monitor the individual's general health,
nutritional status, psychosocial support,
pain level and be alert to signs of
complications
 The frequency of monitoring should be
determined by the clinician based on the
condition of the patient, ulcer, rate of
healing, and the health care setting.
COMPLICATIONS
PRESSURE ULCERS
COMPLICATIONS
 Endocarditis  Septic arthritis
 Maggot infestation  Sinus tract or abscess

 Meningitis  Squamous cell

 Perineal-urethral carcinoma in the ulcer

fistula  Systemic

 Pseudoaneurysm complications of
topical treatment
 Osteomyelitis

 Bacteremia

 Advancing cellulitis