PRESSURE ULCERS AND WOUNDS

1. PRESSURE ULCERS AND WOUNDS By Monica Warhaftig, D.O. Assistant Professor of Geriatrics N.S.U.

2. Chronic Wounds • Greater than 12 hours • Debridement • Cleansing • Dressing • Pressure redistribution • Multidisciplinary care

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

4. Types of WoundsLocation, Location, Location • Pressure: sacrum, heels, trochanter • Venous: Inside the leg -Medial • Arterial- Lateral • Diabetic: neuropathic areas • Traumatic: anywhere

5. RISK ASSESSMENT:Low score=high risk (16 or 12) • The Norton Scale *The Braden Scale

6. *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

7. *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)

8. Systemic Factors that affect Wound Healing • Nutritional Status • Vascular Status • Metabolic Factors • Immunological Factors • Age • Medications (Steroids, etc) • Genetic

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

10. Intrinsic (Patient Status) • Diabetes • Anemia: decreases O2 to the wound • Nutritional State (Serum chemistries, Albumin, Prealbumin) • Weight Loss (oxandrelone) • Coagulopathic state • Multiple comorbidities • Incontinence;foley • Immobility:turning q2 hours

11. What is a Pressure Ulcer ? • Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

12. Pressure ulcer stages • Stage 1: epidermis; nonblanching erythema • Stage 2: epidermis/dermis; shallow opening;blisters • Stage 3: Subcutaneous tissue/fascia • Stage 4: fascia + bone, tendon, muscle, cartilage

13. Stage 1 • Intact Skin with nonblanchable erythema (extravasation of blood from ischemic leaky blood vessels) (up to 30 minutes) Blanchable – means congested vessels…vanishes shortly after pressure relief Cone Shaped…apex to the skin (no indic of below) Muscle & Ischemia– high metabolic rate less blood supply ..More susceptible

14. Pressure Ulcer Staging Stage I

15. Pressure Ulcer Staging Stage I Dark Skin

16. 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.

17. Pressure Ulcer Staging Stage II

18. Pressure Ulcer Staging Stage II

19. Pressure Ulcer Staging Stage II

20. Pressure Ulcer Staging Stage II

21. 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.

22. Pressure Ulcer Staging Stage III

23. Pressure Ulcer Staging Stage III

24. 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

25. Stage IV

26. Stage IV

27. Pressure Ulcer Staging Stage IV

28. Pressure Ulcer Staging Stage IV

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

30. Venous Ulcer

32. Diabetic Ulcer

33. Venous Ulcers

34. 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)

35. 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.

36. Arterial Disease Ankle brachial index (ABI) : arterial blood flow in the lower extremities determines level of ischemia: Normal >1.0; LEAD = 0.9; Borderline is <0.60-0.8; Severe is <0.5. (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 whomLEAD is suspected. Toe pressure <30 indicates LEAD. • Tissue perfusion with transcutaneous oxygen measurement (TcPO2) if ulcer is not healing and ABI is <0.9 or toe pressure <30 mmHg, or if unable to perform ABI

37. Arterial Ulcers

38. Slowing factors • Temperature ; cold or open • Necrotic tissue • Exudate (too much vs dry wound)

39. Infection • Contamination • Colonization • Critical Colonization • Infection

40. *Signs of Infection • Delayed Healing • Change in Exudate • Change in Pain • Change in Granulation Tissue • Change in Smell • Change in Size • Fever • Leukocytosis

41. 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

42. 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)

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

44. Transparent Film • Autolytic debridement • Primary or secondary dressing • Partial thickness wounds • *Stage I or II pressure ulcers • Superficial burns

45. 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

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

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

48. Negative Pressure Therapy • VAC Device • For Nonhealing wounds and fecal incontinence • Removes Interstitial Fluid from the wound

49. Antimicrobial Dressings • Infected Wounds • Controls bacteria bioburden • Effective against a broadspectrum of microorganisms • IODOSORB • AQUACEL • IODOFLEX

50. 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