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Thread: Dealing with pressure ulcers

  1. #1
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    Default Dealing with pressure ulcers

    Dealing with pressure ulcers

    25%–40% of SCI patients develop pressure ulcers at some time during their life.
    Pressure ulcers are classified according to the extent of tissue damage.

    SHEA CLASSIFICATION I–IV:

    I Superficial epidermis and dermal layers
    II Extends to adipose tissue
    III Full thickness skin defect down to and including muscle
    IV Destruction down to bone and or joint structures

    Levels of ulceration:

    1. Skin erythema or induration
    2. Superficial ulceration advances into dermis
    3. Extends into subcutaneous fat
    4. Extends through muscle down to bone
    5. Ulcer extends into bone/jt capsule, or body cavity

    MECHANISM OF DEVELOPING A PRESSURE ULCER:

    1. Ischemia: lack of blood supply to the tissue
    2. Prolonged pressure over bony prominences, exceeding supracapillary pressure
    3. Friction (shearing force):
    – Removes corpus striatum (stratum corneum) of the skin
    – Friction mechanically separates the epidermis immediately above the basal cells
    – Friction is a factor in the pathogenesis since it applies mechanical forces to the epidermis

    Common Locations of Pressure Ulcers

    During the acute period after SCI the most common locations of ulcers are due to the patient lying supine:
    #1 Sacrum
    #2 Heels

    In chronic SCI patients the locations of ulcers are as follows:
    Ischial decubitus (30 %)
    Greater trochanter (20%)
    Sacrum (15%)
    Heels (10%)

    Risk Factors:
    • Immobility
    • Incontinence
    • Lack of sensation
    • Altered level on consciousness

    Prevention of Pressure Ulcers
    • Minimize extrinsic factors—pressure, maceration, and friction
    • Decrease pressure forces, the patient should be turned and positioned every 2 hours
    • Pressure relief every 30 minutes when sitting
    • Proper cushioning and wheelchair seating (see wheelchairs)
    • WC pushups





    Treatment

    • Prevention of pressure ulcers should always be the first line of defense
    • Once a lesion has developed, however, rational treatment should be prescribed to reduce the progression of the ulcer; the extrinsic factors that contributed to the formation of the ulcer should be identified and treated
    • In general, healing will be promoted if the wound remains clean, moist, and debrided—a noninfected wound will also promote healing.





    POST OP MANAGEMENT OF SACRAL DECUBITUS GRAFTING

    • Positioning—Patient should be prone for 2–4 weeks
    If this is not tolerated, pressure relief bed should be prescribed to prevent iatrogenic pressure.
    • Control the patient’s spasticity.
    • Antibiotic treatment—Used to address issues of infection
    • Bowel and bladder management—To avoid contamination of the wound

    Pressure Ulcer Complications

    • Osteomyelitis
    • Dehydration

  2. #2
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    Lightbulb Prevention of Pressure Sore

    • Turning the patient every 2 hours day and night and avoiding pressure on the sore using the supine and side-lying positions.
    • Besides preventing the effects of prolonged pressure, regular turning also aids renal function by preventing stagnation in the urinary tract.
    • Use of a special mattress or bed designed to relieve pressure:
    Water bed which provides even pressure over all parts of the body
    - Ripple mattress which continually alters the pressure points
    - Net bed Ė an open mesh net provides reduced pressure and is suspended between two wooden rollers allowing easy turning of the patient
    - Air fluidized bed Ė air is pumped through a sand medium giving complete floatation. The fluidization can be switched off giving a solid surface for ease of handling
    - Low-air-loss bed Ė consists of waterproof sections filled with air to different pressures providing even pressure distribution
    - Sorbo packs which can be positioned to keep susceptible areas pressure free

    • Sheepskins can help to keep skin dry and reduce friction but are not suitable for incontinent patients. They can vary in size from a small square to one which protects the whole body. Boots lined with sheepskin help to prevent pressure sores on the feet.
    • Roho cushion Ė an air-filled cushion which moulds to any shape and spreads pressure evenly.
    • To allow adequate circulation to be maintained in the areas of maximum pressure, relief of pressure at regular intervals is essential, regardless of the type of cushion used. Patients are instructed to relieve pressure every 10 minutes for 10-15 seconds.
    Weight shifting or relief depending on level of lesion any one of the following techniques can be used.
    - Press up weight shifting technique (Lifting)
    - Lateral weight shifting technique (Leaning side to side)
    - Anterior weight shifting technique (Leaning forward)
    - Power tilt or reclining mechanism, which allows relative independence in weight shifting

    • Patient must learn to turn himself regularly in bed, to reposition pillows between the legs and to ensure as far as possible that he is not lying on any crease in the bed linen.
    • Care of the desensitized and paralyzed areas of the body must form an integral part of the patientís daily life.
    - He must learn to inspect his skin night and morning for pressure marks, abrasions and septic spots.
    - Special attention should be given to the most vulnerable areas. i.e., sacral, ischial, and trochanteric areas, plus the knees, malleoli and toes.
    - A mirror is used to inspect any areas the patient cannot view directly.
    - Those patients who are unable to inspect their own skin must be responsible for requesting that this is done.
    - If a mark is discovered it should be treated, the cause of it must be determined in order to prevent it happening again.

    • Great care must be taken in lifting the limbs whenever the patient transfers. Avoid sliding patientís body across the surfaces.
    • As the vasomotor system does not allow adjustments of the circulation, care must be taken also to ensure that the desensitized areas are protected from excessive heat or cold.
    • A balanced diet to maintain patientís general health is essential. High-protein, high-calorie diet including all vitamins and iron improves the patientís general health and promotes healing.
    The significance of a man is not in what he attains but in what he longs to attain.

  3. #3
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    Lightbulb Doís and Doníts for Pressure Sores

    • Do relieve pressure in the chair for 1.5 Ė 2 minutes every half an hour.
    • Do lift the paralyzed limbs when transferring.
    • Do use a mirror for detection of marks, abrasions, blisters and redness on buttocks, back of legs and malleoli.
    • Do watch for marks on the penis from the sheath.
    • Do have the bath water ready and not too hot.
    • Donít open the hot tap when having a bath in case hot water drips on the toes.
    • Donít have a hot bottle in bed.
    • Donít expose the body to strong sunlight; tetraplegic patients must wear a hat.
    • Donít knock the limbs against any hard object.
    • Donít carry hot drinks on the lap.
    • Donít rest the paralyzed limbs on hot water pipes or radiators.
    • Donít sit too close to the fire.
    • Donít leave the legs, particularly the feet, unprotected against car heaters.
    The significance of a man is not in what he attains but in what he longs to attain.

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