4. 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 2×3×2 cm with necrotic
non viable base , painless, on the sacrum.
What is the most likely diagnosis ?
Venous Ulcer
Diabetic ulcer
Pressure ulcer
5. A localized area of soft-tissue injury
resulting from compression between
a bony prominence and an external
surface.
It a type of a vascular necrosis
10. The Norton Scale•
Patients at risk of
developing Pus can be
identified clinically by:
Norton Scale
It detect the physical
and mental condition,
the activity, mobility and
incontinent
A score 10-12------High
risk of PUS development
11.
12.
13. 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
21. focuses on:
Skin care
Mechanical loading
Support surfaces
22. Daily systematic skin inspection and cleansing
factors that promote dryness
Avoid massaging over bony prominences
moisture (incontinence, perspiration, drainage)
It requires gentle washing and drying
Minimize friction and shear
23. Reposition at least every 2 hours (may use pillows,
foam wedges)
Keep head of bed at lowest elevation possible
Use lifting devices to decrease friction and shear
Remind patients in chairs to shift weight every 15
min
“Doughnut” seat cushions are contraindicated,
may cause pressure ulcers
Pay special attention to heels (heel ulcers account for
20% of all pressure ulcers)
24. **Use for all older persons at risk for ulcers**
Static
Foam, static air, gel, water, combination (less expensive)
Dynamic
Alternating air, low-air-loss, or air-fluidized
25. Heal protector
Air mattress; Alternate
pressure / low air loss / air
fluidized
Other media; gel / water/
foam
http://www.diamond-medical.com/images/database/medlinesupracxc.jpg
27. Health problems (e. g, urinary
incontinence)
Nutritional status
Pain level
28. ULCER MONITORING
ASSESSMENT: HEALING
Location Document all
Stage
observations over
time
Area
Depth Describe each ulcer
Drainage to track progress of
Necrosis healing
Granulation Use validated tools
(eg, PUSH)
Cellulitis
29. 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
30. Dressings
By wet to dry saline or 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
32. Sepsis (aerobic or anaerobic bacteremia)
Localized infection, cellulitis, osteomyelitis
Pain
Depression
Mortality rate = 60% in older persons who
develop a pressure ulcer within 1 year of
hospital discharge
33. The mainstay in
pressure ulcer
treatment is
prevention of risk
factors.
34. 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
35. a)Pressure ulcer = decubitus ulcer= bed sores.
b)Stage 1 PU is partial skin thickness loss.
c)One important risk factor for PU development
is moisture.
d)One of the complications of PU is cellulitis.
e)A cornerstone in management of PU is
debridement
36. 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).
37. 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).
Notes de l'éditeur
Intrinsic: physiologic factors or disease states that increase the risk for pressure ulcer developmentAgeNutritional statusDecreased arteriolar blood pressureLocal skin disorderSoft tissue edema, under nutrition, dehydration, atherosclerosis lead to impaired tissue repair and healing.DiabetesAnemia: decreases O2 to the woundNutritional State (Serum chemistries, Albumin, Prealbumin)Weight Loss (oxandrelone)Coagulopathic state Multiple comorbiditiesIncontinence;foleyImmobility:turning q2 hours Extrinsic: external factors that damage skinPressure, friction, shearMoisture, urinary, or fecal incontinence
Epidermal turnover rates decrease by 30% to 50% by the age of 70, resulting in rougher skin with decreased barrier function, delayed wound healing.The dermal- epidermal junction fattens resulting in decreased contact between the two layers. As a result the two layers may easily separate, making older skin more likely to tear and blister.Basal and peak levels of cutaneous blood flow are reduced by about 60%, resulting in compromised vascular responsiveness during injury or infection.Collagen synthesis decreases and degradation increases, resulting in a loss of the connective tissue matrix and impaired wound healing.Elastic fibers decrease in number and size, resulting in decreased skin elasticity. Subcutaneous fat decreases with age, decreasing its ability to protect deeper structures from injury. Distribution of subcutaneous fat changes (decreasing in face and hands, increasing in thighs and abdomen), which decreases pressure diffusion over bony prominences.
Stage I: Persistent non-blanchable erythema of intact skinStage II: Partial-thickness skin loss involving epidermis, dermis, or both. Ulcer is superficial and presents as an abrasion, blister, or shallow craterStage 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 present.
by site, sensation, surrounding inflammation, underlying pressure points, viability of the floor