Pressure

ulcers

Dr. Doha Rasheedy

Pressure
ulcers

Intended Learning
Outcomes
Definition
Risk factors
Diagnosis, staging
prevention
Treatment

Case
A 75yrs elderly male pt, with PH of DM,
recurrent CVS, bed ridden of 2 yrs duration
and has urinary incontince. On exam. There
was an ulcer about 232 cm with necrotic
non viable base , painless, on the sacrum.
What is the most likely diagnosis ?

Definition
A localized

area of soft-tissue injury

resulting from compression between
a bony prominence and an external
surface.

RISK
FACTORS
Intrinsic

Extrinsic

Normal ageing

Epidermal turnover rates decrease

delayed wound healing.
The dermal-epidermal junction fattens
resulting in decreased contact between
the two layers
Basal and peak levels of cutaneous blood
flow are reduced.
Collagen synthesis decreases
Elastic fibers decrease in number and
size, resulting in decreased skin elasticity.
Subcutaneous fat decreases with age,
decreasing its ability to protect deeper

Clinical picture
and Stages

Screening:
risk assessment of ulcer development.
Frequent inspection of pressure points for
early non-blanchable erytheama (stage 1).

Pressure Ulcer Staging

Stage I: Persistent non-blanchable erythema

of intact skin
Stage II: Partial-thickness skin loss involving
epidermis, dermis, or both. Ulcer is superficial
and presents as an abrasion, blister, or
shallow crater
Stage III: Full-thickness skin loss involving
damage or necrosis of subcutaneous tissue that
may extend down to, but not through,
underlying fascia.
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 may also be

 Unstageable:

Full thickness tissue

loss in which slough (yellow, tan,
gray, green or brown), eschar (tan,
brown or black), or both in the
wound bed cover the base of the
ulcer.

Pictures - Royal College of Surgeons of Edinburgh

Sites

SITES

Any skin exposed to continuous

pressure.

Internal viscera exposed to

unusual pressure, as trachea
pressed by balloon of endotracheal
tube

Usual pressure ulcer

locations

Over Bony Prominences

1. Occiput
2. Ears
3. Scapula
4. Spinous Processes
5. Shoulder
6. Elbow
7. Iliac Crest
8. Sacrum/Coccyx
9. Ischial Tuberosity
10.Trochanter
11.Knee
12.Malleolus
13.Heel
14.Toes

Internal
organs

Other locations
Any skin surface
subject to excess
pressure
Examples include
skin surfaces under:

Oxygen tubing
Urinary catheter
drainage tubing
Casts
Cervical collars

Differential diagnosis

Should

be differentiated from other lacerations,

ulcers and eczymas; by site, sensation, surrounding
inflammation, underlying pressure points, viability of
the floor.

Prevention
and
treatment

PREVENTION
focuses on:
Local Pressure reduction
Skin care
Improve general condition

PREVENTION: MECHANICAL LOADING

Reposition every 2 hours

Use pillows to keep bony prominence away
from direct contact
Use devices that relieve pressure on heels
Elevate the head of the bed as little as possible
Use lifting devices to move rather than drag the
patient during transfer
Pressure reducing mattresses

Pressure relief

Heal protector

Air mattress;
Alternate pressure /
low air loss / air
fluidized
http://www.diamond-medical.com/images/database/medlinesupracxc.jpg

PREVENTION: SKIN CARE

Daily systematic skin inspection and cleansing

factors that promote dryness

Avoid massaging over bony prominences

moisture (incontinence, perspiration,

drainage)

Improve general health by:

adequate

nutrition

adequate

hydration

control

of medical illnesses

GENERAL
ASSESSMENT

Risk factor elimination

ULCER ASSESSMENT,
MONITORING HEALING

MANAGEMENT

Cleaning
Debridement
Dressings
SURGICAL

GENERAL ASSESSMENT

Health problems (e. g, urinary

incontinence)
Nutritional status
Pain level

ULCER
ASSESSMENT:
Location
Stage
Area
Depth
Drainage
Necrosis
Granulation
Cellulitis

MONITORING
HEALING
Document all
observations over
time

Describe each
ulcer to track
progress of healing

Cleaning Avoid topical antiseptics because of their tissue toxicity

Debridement
Is necessary to remove dead tissue it include
1. Autolytic debridement using hydrocolloid or foam dressings
2. Enzymatic debridement using exogenous collagenase
(IRUXOL)
3. Mechanical debridement
4. Surgical, sharp Scalpel, scissor to remove dead tissue; laser
debridement
5. Bio surgery: Larvae to digest dead tissue

Dressings
hydrocolloid (duo-derm), or polyurethane, in exudative
wounds fill the wound by aligniates or hydro gel.
SURGICAL REPAIR
May be used for stage III and IV ulcers
Direct closure, skin grafting, skin flaps,
musculocutaneous flaps, free flaps

Complications

POSSIBLE COMPLICATIONS

Sepsis (aerobic or anaerobic bacteremia)

Localized infection, cellulitis, osteomyelitis

Pain

Depression

The mainstay in
pressure ulcer
treatment is
prevention of risk
factors.

Summary

Older adults are at high risk for development of

pressure ulcers

Pressure ulcers may result in serious morbidity

and mortality

Techniques that reduce pressure, moisture,

friction, and shear can prevent pressure ulcers

Pressure ulcers should be treated with proper

cleansing, dressings, debridement, or surgery as
indicated

First line treatment for pressure ulcer

1. Surgical closure
2. Debridement
3. Pressure relief
4. Dressing
.Stage 3 pressure ulcer is:
1. Persistent non-blanchable erythema of
intact skin
2. Full-thickness skin loss involving necrosis of
subcutaneous tissue that may extend down
to, but not through, underlying fascia.
3. Partial-thickness skin loss
4. Full-thickness skin loss with damage to
muscle, bone, or supporting structures (e.g.
tendon, joint capsule).

First line treatment for pressure ulcer

1. Surgical closure
2. Debridement
3. Pressure relief
4. Dressing
.Stage 3 pressure ulcer is:
1. Persistent non-blanchable erythema of
intact skin
2. Full-thickness skin loss involving necrosis of
subcutaneous tissue that may extend down
to, but not through, underlying fascia.
3. Partial-thickness skin loss
4. Full-thickness skin loss with damage to
muscle, bone, or supporting structures (e.g.
tendon, joint capsule).

THANK YOU