Transcript How to Prevent & Cure Bed Sores

How to Prevent & Cure
Pressure Ulcers
Home Mobility & Park House
Solutions
Overview
• Pressure Ulcer
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Definition
Causes
Predisposing Risk Factors
Grades
Effects on Patient
• Solutions
– Risk Assessment
– Skin Wound Protocol
Pressure Ulcer
Causes of Pressure Ulcer Development
Pressure
Pressure Ulcer
What is Pressure Ulcer?
• A localized area of cellular damage resulting from:
– Direct pressure: skin and other tissues are directly
compressed between bone and another surface
(bed, chair). Tissue damage will depend on intensity
and duration of exposure to pressure.
– Shearing: tissues are wrenched in opposite
directions, resulting in disruption or angulations of
capillary blood vessels.
– Friction: skin rubs against another surface (sheet)
causing epidermis to be stripped away.
• Also called Pressure Sores, Decubitus Ulcers or
Bed Sores
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Bony Prominences at Risk
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Predisposing Risk Factors
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Level of Mobility
Nutrition
Continence
Medication
Concurrent disease
Age
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Grades of Ulcers
Two Hours …
… That’s what it takes to develop a
pressure ulcer.
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Grades of Ulcers
Grade 1
Epidermis
Dermis
Subcutaneous Fat
Muscle
Bone
Redness that does not
disappear when pressure
is applied
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Grades of Ulcers
Grade 2
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Grades of Ulcers
Grade 3
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Grades of Ulcers
Grade 4
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Grades of Ulcers
Very Fast Process
Grade I: 14 Days
Grade II: 45 days
Very Slow Process
Grade III: 90 days
Grade IV: 120 Days
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Effects on Patient
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Pain
Systemic illness
Reduced self-esteem
Altered body image
Delayed rehabilitation measures
Amputation
Death
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Solution
Pressure Ulcer
Risk Assessment
• Why?
– Because we can prevent Pressure Ulcers
– Because we can cure Pressure Ulcers
• To Whom?
– All person with reduced mobility / activity or sedated
• When?
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Admission
Regular Intervals
Change in patient conditions
During day and night
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Risk Assessment
• Benefits?
– Act as aid-memory
– Target preventive care
– Effective use of scarce resources
– Provide quantifiable data of audit
– Provides objective criteria to base care
pathways
• How?
– Use Risk Assessment Tools
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Risk Assessment Tools
• Braden
• Douglas
• Gosnell
• Knoll
• PSPS (Lowthian)
• Medley
• Norton
• N.P.R.U
• Walsall
• Waterlow
Pressure Ulcer
Skin Wound Protocol
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Pressure Reduction
Pressure Relief
Incontinence Care
Nutrition Consult
Moisturize Skin
Positioning
Wound Care
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Skin Wound Protocol
Pressure Reduction
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Pressure Reduction
• Reduce the intensity of pressure and shear :
Blood irrigation occlusion diminish  O2 flows in tissue
– Intensity is determined by contact surface (mattress
or cushion). When the surface is increased, pressure
is more evenly redistributed decreasing pressure.
– Avoid several tissue layers because they increase the
pressure
– Avoid anything that reduces the size of the pressure
surface (ring cushions)
• Should be combined with scheduled alternated
repositioning of the patient.
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Pressure Reduction
• Pressure Reduction can be done through
specialized mattresses / Cushions
• Static Mattresses are non electric system that
reduces intensity of the pressure and shear by
increasing contact surface
• Overlay is placed over standard mattress and
has the same effect as static mattress
• The nature and composition of the material
modify the form and the consistency of the
mattress that is subject to patient body pressure.
Pressure Ulcer
Pressure Reduction
Different Materials:
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Water
Static Air
Gel
Fiber
Foam
• CMHR: Combustion Modified High
Resilient
• Visco-elastic
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Pressure Reduction
Water Mattress Advantages:
• Cheap
• Distributes weight evenly
Water Mattress Disadvantages:
• A spontaneous or assisted change in the
positioning is more difficult  favours
longer period in the same position 
higher risk of pressure ulcer development.
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Pressure Reduction
Water Mattress Disadvantages:
• Very difficult to position the patient in Lateral
Decubitus @ 30° (this position is recommended
for long stay periods)  Low comfort and
increased pressure  higher risk of pressure
ulcer development.
• Cannot be used on profiling beds (electrical)
because of the weight of the mattress and the
bed inclination
• Cold sensation from the water  patient
discomfort
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Pressure Reduction
Water Mattress Disadvantages:
• Extremely heavy weight  can causes back
injury to carer
• The mattress can break  inundation 
unpleasant situation for both patient and carer.
• Rocking effect  may cause dizziness to
predisposed patients
• Not durable
• Requires a second mattress below
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Pressure Reduction
Static Air Mattress Advantages:
• Easy use: once filled with air, it does not require an
electric pump.
• Heat build up and moisture are greatly reduced, due to
the air holes throughout the mattress.
• Light weight.
• Best in its class for seating (cushions); however should
be thick enough to prevent bottoming effect
Static Air Mattress Disadvantages:
• Contact surface is not increased enough to reduce
pressure.
• Not durable
• Requires a second mattress below
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Pressure Reduction
Gel Mattress Advantages:
• Comfortable
• Viscous gel migrates through sectioned bladders
to relieve pressure around bony prominences.
Gel Mattress Disadvantages:
• Contact surface is not increased enough to
reduce pressure.
• Gel can dissociate and loose all its properties.
• Not durable
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Pressure Reduction
Fiber Mattress advantages:
• High quality patient comfort
• Lasting durability
• Easy Maintenance
• Body is enveloped by the fiber
• Used for very frail bony patients
• Light weight
Fiber Mattress Disadvantages:
• Pressure reducing properties are not enough
• Rocking effect  may cause dizziness to predisposed
patients
• Requires a second mattress below
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Pressure Reduction
Foam Mattress CMHR advantages:
• Longer useful life than non-HR foam
• High tear strength
• Ability of material to revert to its original shape after pressure 
optimal lying comfort
• Easy Maintenance
• More Supple
• Moulds body shape  Maximize weight distribution  Reduce
pressure
• Extremely fire retardant, complies to institutional regulatory
standards
Foam Mattress HR Disadvantages:
• Used for Low to Medium risk patients only
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Pressure Reduction
Foam Mattress Visco-Elastic advantages:
• Best in its class for static mattresses.
• High quality patient comfort
• Lasting durability
• Easy Maintenance
• Moulds the body allowing patient immersion thus
increasing the contact surface and decreasing the
pressure.
• High Memory Foam
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Pressure Reduction
Foam Mattress Visco-Elastic advantages:
• Heat sensitive property allows the top of the
mattress to be more supple whereas the deeper
parts remains firm for a proper support. This
maintains the physiological position of the
patient maximizing the weight distribution.
• Used for Medium to High Risk Patient
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Pressure Reduction
Cover of the mattress is very important and should
provide the following:
• Two way stretch  Reduce friction and sheer
effects.
• Elastic, otherwise it will limit the capacity of the
mattress to reduce pressure
• Vapor Permeable  evacuate heat  patient
comfort
• Fire Retardant  Fire safety  patient safety
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Pressure Reduction
• Water Resistant  Prevent fluid contamination
 patient hygiene & safety
• Concealed Zip Fastening  Prevent fluid
contamination  patient hygiene & safety
• Fully Fitted  moulds to the shape of the bed 
Reduce friction and sheer effects
• Detachable cover  machine washable  easy
to clean  patient hygiene
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Skin Wound Protocol
Pressure Relief
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Pressure Relief
• Purpose is to reduce the duration of
pressure and shear by changing the points
of pressure.
• Pressure Relief can be done in two ways:
– Scheduled alternated positioning
– Specialized mattresses
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Pressure Relief
• Scheduled alternated positioning
– Change the position of the patient in a way that body
prominences at risk (points of pressure) are different.
– Frequency per 24 hours/day, 7 days/week:
Laying Position
• Every two hours if no pressure reduction mattress is used 
Almost impossible to manage.
• Every four hours when a good and appropriate pressure
reduction mattress is used
Seating Position
• Every one hour if no pressure reduction cushion is used
• Every two hours when a good and appropriate pressure
reduction cushion is used
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Pressure Relief
• Specialized Mattresses are electric system that
reduces the duration of the pressure and shear.
• Consist of an inflatable mattress and an electric
pump.
• Overlay is placed over standard mattress and
has the same effect as an active mattress.
• The cells / compartments of the mattress inflates
and deflates in alternation.
• The form of the mattress, that is subject to
patient body pressure, changes due to external
factors (air pump).
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Pressure Relief
• Differentiation points:
– Pump characteristics
– Availability of an “intelligent” feed-back
system
– Diameter of the cells
– Distinct compartments
– Additional facilities
– Cell structure
– Cover
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Pressure Relief
• Pump characteristics:
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Quiet
Lightweight and Compact
Clear user instructions
Snap fit connectors, color coded
Adjustable pressure control (better if it is automatic)
Audio – visual alarms
Different settings: Pulsate, Therapy & Static
Comfort control
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Pressure Relief
• Pump characteristics:
– Equalized cell pressure when mattress is
disconnected from power unit (transport /
power failure)
– Duration of the pressure: 9 to 10 minutes
cycle.
– External fusibles to protect the pump from
current fluctuations.
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Pressure Relief
• Availability of an “intelligent” feed-back
system :
– Senses movement of patient
– Automatic adjustment to individual patient
weight and position
– Optimum pressure is delivered at all times
regardless of body mass.
– Back-Raise sensor for semi-recumbent
position  push more air in torso section for
better support  prevents bottoming-out
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Pressure Relief
• Diameter of the cells :
– Small cells (less then 10 cm) even when
inflated to the maximum, do not allow the
body to elevates enough above the deflated
cells.
– Cells larger then 10 cm are recommended.
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Pressure Relief
• Distinct compartments:
– Individual cells  easy replacement
– Tri zonal: comfort for head, torso & heel
– Sloping heel section
• Additional Facilities:
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Timed static facility
Static facility for fast transfer
CPR facility near head section for faster deflation
Intubation's facility
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Pressure Relief
• The cell structure - number and form:
– Double layer cell structure is more efficient then single
layer.
– Cells are linked between each others by series of 3 and
same cycle is applied for both layers simultaneously:
1st max. inflation, 2nd half inflation, 3rd total deflation
1st half inflation, 2nd max. inflation, 3rd half inflation
1st total deflation, 2nd half inflation, 3rd max. inflation
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Pressure Relief
• Cover :
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Two way stretch  Reduce friction and sheer effects.
Elastic  maintain reduction property of mattress.
Vapor Permeable  evacuate heat  patient comfort
Fire Retardant  Fire safety  patient safety
Water Resistant  Prevent fluid contamination  patient
hygiene & safety
Concealed Zip Fastening  Prevent fluid contamination 
patient hygiene & safety
Fully Fitted  moulds to the shape of the bed  Reduce friction
and sheer effects
Detachable cover  easy cleaning
Hoses covered  as per disinfections properties
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Pressure Relief
• Special mattresses:
– Fluidized Air: Mattress is composed of silicom
particles inside a synthetic cover. When hot
air is injected the silicon particles liquefies.
– Low air-loss: Reduce humidity build-up to to
the air-loss.
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Pressure Relief
Fluidized Air Advantages:
• The body is totally immersed in the mattress which
maximizes the contact surface between the body and the
mattress
• Excellent system for treating burns or wounds with high
exudates.
Fluidized Air Disadvantages:
• Very expensive
• Extremely difficult to clean
• Cannot be moved from 1 patient to another before a
special cleaning process has taken place.
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Pressure Relief
Low Air loss Advantages:
• Designed to provide very high degree of comfort
• Constant air flow will help dry up wounds
• Separate mattress system can be easily moved
from patient to patient and from bed to bed.
• Easy to clean and decontaminate
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Skin Wound Protocol
Incontinence Care
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Incontinence Care
• Clean skin at time of soiling
• Provide quick drying surface (under pads)
to the skin.
• Avoid hot water and too much soap while
bathing.
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Skin Wound Protocol
Nutrition Consult
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Nutrition Consult
• Diet should have adequate calories and
protein, vitamins and mineral
supplements.
• Consult your dietician and doctor.
• There is no direct link between bad
nutrition and pressure ulcer prevention
however nutrition optimization ameliorates
the general condition of the patient and
helps the cicatrisation process.
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Skin Wound Protocol
Moisturize Skin
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Moisturize Skin
• Maintain good hygiene
• Wash with mild soap and warm water,
rinse well and pat dry carefully and gently.
• Use moisturizers for dry skin
• Minimize environmental factors leading to
dry skin (Low humidity, cold air)
• Do not massage skin over bony parts of
the body (can damage tissue)
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Skin Wound Protocol
Positioning
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Positioning
• The intensity of the pressure is determined
by the weight of the patient, his positioning
and the hardness of the material he is
seated in.
• The contact surface depends on the
positioning: Surface  redistribution of
pressure Pressure
Pressure Ulcer
Positioning
• Some facts:
– In laying position: Avoid bottoming effect where the
patient is not sustained by the mattress but lies
directly on the sub-adjacent surface, specially for
obese patients.
– With a simple manual verification, we should not
feel patient body.
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Positioning
• Some facts:
– In laying position: when the bed head is
elevated, the pressure and shear effects
increase.
– In seating position, the weight is
redistributed in a small surface: more
pressure then laying position.
– In seating position, a lateral or vertical
inclination increases the pressure.
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Positioning
• Dorsal Decubitus
– Head and legs of the bed are elevated 30°:
maximum reduction of pressure and shear.
– Preferred positioning for long periods.
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Positioning
• Lateral Decubitus
– Body forms a 30° angle with the mattress aided by a 30° cushion
– The sacrum should not be under pressure.
– Above leg is positioned behind the other one, tilted 30° at the
level of the hip and 35° at the level of knee.
– Positioning can be made more comfortable with cushions
– Use of inflatable cushions is not
recommended due to the effect of shear.
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Positioning
• Alternated positioning
Mobilisation
alternée
– Use as often as possible
Dorsal Decubitus
positioning
– Alternate with lateral
Decubitus positioning
• When using appropriate
pressure reducing
mattress, the schedule
can be every 4 hours
instead of 2 hours.
12
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1
10
2
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9
4
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L
30°
R
30°
Semi-Fowler 30° - 30°
30°
Lat. 30°
Nom
:
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Positioning
• Seating position in bed
– Limit seating positions in bed because it is the cause
of shearing.
– Preferred position is 60° but should be limited in
duration.
– Use this position only for eating time.
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Positioning
• Ventral Decubitus
– Should be used with soft mattress for comfort
– To prevent pressure on feet, either place a cushion or remove
end of bed and slide down patient so that feet are outside
mattress.
– Should observe pressure points: shoulder, thorax, basin, knees,
feet, ears.
Décubitus ventral
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Positioning
– Heel
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Positioning
• Seating
– Slight dorsal inclination, legs resting on
support and heels free of pressure
– In case dorsal inclination is not possible,
straight seating with both feet on floor
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Positioning
• Seating
– Limit the duration of seating position: time spent on
chair should be less then time spent in fauteuil which
is less then the bed.
– Armchair help stabilize the positioning of the person.
– Avoid lateral and vertical sliding from chair.
– Make sure that the person is well seated to provide
optimum contact surface.
– Cushion and backs help to keep a right positioning.
The type should be studied case by case.
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Skin Wound Protocol
Wound Care
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Wound Care
- Debride – Ask your doctor
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Surgical: most rapid, recommended for large necrotic areas.
Mechanical: hydrotherapy, wound irrigation
Enzymatic: collagenase to slow infection if present.
Autolytic: via enzymes in wound fluid (very slow)
- Pick a dressing (must provide a-moist wound healing)
- Transparent semi permeable films (eg Opsite, Tegaderm) for
Grade I & II
- Hydrocolloids (e.g. DuoDerm, Comfeel, Restore) for non infected
Grade II & III
- Saline soaked gauze (covered by occlusive wrap) gently pack dead
space for Grade II to IV
- Alignates: (eg. CalciCare, Kaltostat) for +++ exudates
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Wound Care
- Watch for infection and treat - Ask your doctor for
proper treatment.
- Use dry lubricants (cornstarch) or protective
coverings to reduce friction injury.
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Healing signs
- The pressure ulcer will get smaller
- Pinkish tissue usually starts forming along the edges
of the sore.
- Smooth or bumpy surfaces of new tissue
- Some bleeding may be present which shows good
blood circulation.
Pressure Ulcer
Any Questions
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