BRIEF DISSCUSION ON

BED SORE

Moderator: Dr. Deepak M. Naik

Presenter: Dr. Shameem A. Khan

Bed sore

Known by many names;

Pressure sore
Decubitus ulcer
Ischaemic ulcer
Necrotic ulcer

Ancient Egypt, reports of pressure ulcer

mummified bodis &
heilographics

Epidemiology

Setting

Hospital 60%
Nursing homes 18%
Home 18%

1/3 of patients undergoing surgery for hip

fracture develop a pressure ulcer

The longer the patient stays in a hospital,

the greater the likelihood of developing a
pressure ulcer

Definition

A Pressure Sore is
an area of the skin
or underlying tissue
that is dead or
dying as a result of
the loss of blood
flow to the area

Location of Pressure
Sores

Location of Pressure
Sores

Areas where pressure

sores most often
occur

Sacrum

Location of Pressure
Sores

Areas where pressure

sores most often
occur
Sacrum
Heel

Location of Pressure
Sores

Areas where
pressure sores most
often occur
Sacrum
Heel
Ischium

Location of Pressure
Sores

Areas where
pressure sores most
often occur

Sacrum
Heel
Ischium
Foot (bony areas like
the ankle)

Location of Pressure
Sores

Areas where
pressure sores mos
often occur

Sacrum
Heel
Ischium
Foot (bony areas like
the ankle)
Trochanter

Most Common Sites

Sacrum (tail bone)- most common site

-Semi-fowlers position
-Slouching in bed or chair
-higher risk in tube fed or incontinent pts.

Heels- 2nd most common

-Immobile or numb legs
-Leg traction
-Higher risk with PVD & diabetes neuropathy

Other Bony Prominences

Trochanter (hip bone)

-Side lying
-Highest risk in contractured patients
-Ulcers on lateral foot rather than heel
itself

Ischium (sitting erect bone)

-highest risk in paraplegics

Causes

Pressure

Shear

Diminish circulation

Friction

Interrupt circulation

Superficial and easily reversed

Moisture

Weaken the cell wall of individual skin

cells

Aetiology
STUDIES:
Landis,1930 microinjection method of
determining capillary blood pressure,
discovered an averege pressure of 32 mmhg
Hussain, 1953 sustained pressure of 100
mmhg over 2 hrs time period caused
irreversible changes in muscles of rats
Kosiak, 1961 pressure against time using
rats (critical pressure 35mmhg-1hr time)
Reswick & Rogers, 1976 once critical
pressure thresold and time value exceeded,
tissue damage proceeds at a similar rate
regardless of magnitude of pressure applied

Function of both time and pressure

(hyperbolic curve)
-70mmHg pressure for two hours produces
irreversible injury
-greater pressure takes less time
-lower pressure takes more time

Pressure exerted by bony prominences on

the body that stop capillary flow to the
tissues.
Deprives tissues of oxygen and nutrients
causing cell death.
Pressure greater than 32mmHg exerted by
bony prominences to disrupt blood flow.

Stage 1 Pressure Ulcer

Stage 2 Pressure Ulcer

Stage 2 Pressure Ulcer

Stage 3 Pressure Ulcer

Stage 4 Pressure Ulcer

Stage 4 Pressure Ulcer

Morbidity & Mortality

Pain

Infection

Quality of life

Death

Cost

KEY Pressure Ulcer Risk

Factors

Impaired bed or chair

mobility

Urinary/fecal incontinence

Chronic systemic illness

Poor nutritional status

History of pressure ulcer

PVD / Diabetes Mellitus /

Neuromuscular dis.

Traumatic spinal
cord/brain injuries

Management of Pressure
Ulcers

Risk factors
addressed

debridement
wound cleansing
dressings
adjuvant therapies
Prevention, diagnosis &
treatment of infection

Continence care
Nutritional
improvement
Mobility

Pressure reduction

Wound Care

Consider operative
procedure

Admission Assessment for

Risk Factors

Mobility status

Urinary continence

Pressure ulcer
history

Recent weight loss

Height & weight

Skin exam

Bowel continence
Feeding assistance
needed

General skin care

Cleanse skin with warm water & mild

soap
Cleanse skin after soiling
Use non-alcohol based moisturizers
Use skin protectants or barriers
Do not massage over bony prominences
Institute bowel or bladder training
programs
Use briefs or absorbent underpads

Pressure Reduction

Rehabilitation to improve mobility

Repositioning schedule (individualized)

Minimum turn Q2 hours in beds
Minimum shift Q1 hour in chair (15 mins)
Heel relief

Pressure reduction devices

Beds
wheelchairs/chairs

Rule of 30

the head of the bed

is elevated to 30
degrees or less

the body is placed in

a 30-degree laterally
inclined position,
when repositioned
to either side

Low air loss system

Types of Dressings

Gauze
Transparent films
Hydrocolloid
Hydrogel

Alginates
Foam
Composite

Debridement

Selective autolytic ( hydrocolloid,

calcium alginate)
enzymatic (collagenase)
biosurgical (maggot therapy)

Non Selective mechanical

surgical

Negative pressure wound

therapy

Adjunctive Therapies

The therapies included :

hyperbaric oxygen
infrared and ultraviolet light
low-energy laser irradiation
ultrasound
miscellaneous topical agents ( cytokine
growth factors, rPDGF, nerve growth factor
etc)

Operative Repair

Operative procedures to repair pressure

ulcers include one or more of the following:
Direct closure
Skin grafting
Skin flaps
Musculocutaneous flaps
Free flaps.

Skin rotation flap

Gluteal musculocutaneous
flap

Assessment of Ulcer
Healing

Evaluate at least weekly

If general condition deteriorates, the ulcer

should be reassessed

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

Complications

Amyloidosis
Endocarditis
Heterotopic bone formation
Maggot infestation
Meningitis
Perineal-urethral fistula
Pseudoaneurysm
Septic arthritis
Sinus tract or abscess
Squamous cell carcinoma in the ulcer
Systemic complications of topical treatment
Osteomyelitis
Bacteremia
Advancing cellulitis

Thank you

Other sources of pressure

Boots/boot straps

Oxygen tubing

Stockings

Any device that can lead to pressure

induced ischemia on the skin

Pressure Ulcers StagingLimitations

Identification of Stage I pressure ulcers

may be difficult in patients with darkly
pigmented skin.

When eschar is present, accurate staging

of the pressure ulcer is not possible until
the eschar has sloughed or the wound has
been debrided.

Early Sign of Pressure

Sore

An appearance of red area, or red spot on

the skin

If redness does not clear within 30

minutes of relief from pressure, a
pressure sore has begun

Norton scale

Modified Norton scale

Prevention = Treatment

95% of all pressure sores are preventable

Maintaining healthy skin is the key to

preventing a pressure sore

Wound Cleansing

Remove necrotic tissue, exudate, and

metabolic wastes from the wound.

Minimum of chemical and mechanical trauma.

.

Do not clean ulcer wounds with skin cleansers

or antiseptics. Use normal saline for
cleansing.

Dressings

Keep the ulcer bed continuously moist

No differences in pressure ulcer healing

outcomes with diverse dressings

Keep the surrounding intact skin dry

while keeping the ulcer bed moist.

Control exudate but do not desiccate the

ulcer bed.
Eliminate wound dead space by loosely

Managing Bacterial
Colonization and Infection

Stage 3 & 4 pressure ulcers are invariably

infected

Consider 2-week trial of topical antibiotics for

clean pressure ulcers that are not healing or
producing exudate

Perform quantitative bacterial cultures of soft

tissue and evaluate for osteomyelitis when ulcer
does not respond to topical antibiotic therapy

Nutrition

Provide nutritional support to patients

with an identified deficiency

Decisions about nutritional

support/supplementation should be
based on:
- nutritional assessment
- general health status
- patient preference
- expert input (dietician/specialists)
22

Managing Bacterial
Colonization and Infection

Systemic antibiotic therapy for patients

with bacteremia, sepsis, advancing
cellulitis, or osteomyelitis.

Do not use topical antiseptics

Protect pressure ulcers from exogenous

sources of contamination

..Operative Repair

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)

Why are pressure ulcers

important?

An estimated 410% of patients admitted to a hospital

develop a pressure ulcer

Major cause of sickness, reduced quality of life and morbidity

Associated with a 24-fold increase in risk of death in older

people in intensive care units

Substantial financial costs