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What are pressure ulcers?

 

Pressure ulcers (decubitus ulcer)

 

Initially, it is possible to observe a slight redness in the affected area (the first sign of tissue damage). The underlying tissue dies due to deficient blood supply. Several layers of skin, muscles and bones can be affected. The sacrum region, the heels, the elbows and the shoulder blades are areas considered to be atrisk high.

It is possible to prevent the occurrence of most pressure wounds by minimizing risk factors through preventive measures such as formal risk assessment and the minimization of specific risks (pressure relief, preventive skin care).

After the development of a pressure sore, it is important to design a coordinated treatment plan in order to induce healing and eliminate all harmful factors. The basic prerequisites for wound healing must be fulfilled. These prerequisites include a clean wound, sufficient circulation and adequate nutrition for both calories and nutrients, as well as adequate fluid intake. This last aspect is often a problem when it comes to the elderly (as a basic rule, daily fluid intake should correspond to 40 ml per kg of body weight).

Depending on the extent of tissue damage, pressure ulcers are classified into four stages:

Stage 1

There is no opening of the skin, but the redness does not turn white when pressed.

Stage 2

Damage affects the epidermis, the dermis or both. In clinical terms, the damage observed is abrasions or blisters. The surrounding skin may be red.

Stage 3

The damage extends through all the superficial layers of the skin, adipose tissue, directly and including the muscle. The ulcer looks like a deep crater.

Phase 4

Damage includes the destruction of soft tissue and bone structures or joint structures.

Anyone can develop a pressure sore, but elderly, bedridden, paralyzed and malnourished patients are at a higher risk.

The identification of individuals who are at risk of developing pressure ulcers and the start of preventive measures are very important steps to reduce this type of incident. The individual risk of developing a pressure ulcer can be determined using risk assessment tools such as the Braden Scale.

The Braden Scale is a rating scale composed of 6 subscales that assess:

  • Sensory perception (ability to significantly react to pressure-related discomfort)
  • Humidity (level of skin exposure to moisture)
  • Activity (level of physical activity)
  • Mobility (capacity to change and control the position of the body)
  • Nutrition (habitual eating pattern)
  • Friction and sliding

The most important aspect in the prevention and treatment of pressure sores is undoubtedly pressure relief. The best way to achieve this is through frequent repositioning and mobilization of the patient, but also with the use of a suitable mattress or specific equipment to reduce the pressure. Proper treatment should include thorough cleaning of the wound, removal of non-vital tissues and a wound environment free of urine and feces. Stage 3 and 4 ulcers often require surgical debridement.

 

PressurePrevention and Control Ulcer

Ulcerclassification based on the EPUAP / NPUAP guidelines, 20111

Next you will find the description and treatment of pressure ulcers of the various grades, from grade I to grade IV. In the treatment, products of the B-Braun brand are indicated, but other similar products may be used.

 

Ulcer classification: 1

Description:
  • Intact skin, with unbleachable redness over a bony protuberance.
  • Skin discoloration, heat emanation, edema, stiffness or pain may also occur when compared to adjacent tissues.
 
Treatment goals:
  • Skin repair.
  • Restoration of hair growth
Local wound treatment:
  • Promote skin integrity using products based on hyperoxygenated fatty acids (eg Linovera®1)
  • Prevent the occurrence of skin lesions caused by friction or sliding using skin barrier products

 

Classification ulcer: 2 - uninfected

description:
  • partial thickness skin injury (bubble)
  • presents a dry surface ulcer or bright without crust or hematoma (the presence of indicating hematoma are deep tissue injuries)
  • Check for skin maceration


 

Objectives treatment:
  • Provide a clean wound bed for tissue granulation
Local wound treatment: Wound
  • bed preparation: use an irrigation solution and / or antiseptic gel for wounds (egProntosan® Wound Irrigation Solution, Prontosan ® Wound gel)
  • Superficial and deep: wet absorbent dressing / low adhesion (egAskina® Foam)
  • Heel ulcer: dressing w wet absorbent / low adhesion with the shape of the heel (egAskina® Heel/)
  • Sacral: wet absorbent dressing / low adhesion with the shape of the heel (eg. Askina®DresSil Sacrum)

 

 

Ulcer classification: 3 - Not infected

Description:
  • Total damage to skin thickness. The subcutaneous fat layer may be visible, but the bone, tendons or muscle are not exposed.
  • Crusting may occur, but this does not hide the depth of tissue loss.
 
Treatment goals:
  • Remove the crust
  • Provide a clean wound bed for tissue granulation
Local wound treatment:
  • Preparation of the wound bed: use an irrigation solution and / or antiseptic gel for wounds (eg Prontosan® Solution of Wound, IrrigationProntosan® Gel for Wounds)
  • Deep: add a wet absorbent dressing to the wound cavity (eg Askina®Absorb + / Foam Cavity)
  • Heel ulcer: absorbent wet dressing / low heel-shaped adhesion (by eg:Askina® Heel/ Askina®DresSil Heel) Sacral 
  • : moist absorbent dressing / low adhesion with the shape of the heel (eg Askina®DresSil Sacrum) 

 

 

Ulcer classification: 4 - Not infected

Description:
  • Damage in all thickness of the tissue, with exposure of the bone, tendon or muscle.
  • Crust or bedsores may form. It often includes subcutaneous and tissue destruction. 
Treatment goals: 
  • Remove the crust.
  • Create a clean wound bed to allow tissue granulation.
Local wound treatment:
  • Preparation of the wound bed: use an irrigation solution and / or antiseptic gel for wounds (eg Prontosan® Wound Irrigation Solution, Prontosan® Wound Gel)
  • Deep: add a wet absorbent dressing to the cavity (eg Askina®Absorb + / Foam Cavity) 
  • Heel ulcer: moist absorbent dressing / low adhesion, in the shape of the heel (eg Askina®Heel / Askina®DresSil Heel) Sacral
  • : wet absorbent dressing (egAskina®DresSil Sacrum)

 

Ulcer classification: 2 - 4 - Infected 

Description:
  • Signs and symptoms of infection such as: discoloration, swelling, irradiation of pain and heat
Treatment goals: 
  • Reduce bacterial load
  • control exudate / odor 
  • Prevent / remove biofilm 
  • Create a clean wound bed for tissue granulation 
Treatment wound site:
  • Preparation of the wound bed: use an irrigation solution and / or antiseptic gel for wounds (eg Prontosan® Wound Irrigation Solution, Prontosan® Wound Gel)
  • Surface: Antimicrobial dressing (eg Askina ® Calgitrol® Ag3)
  • Deep: Antimicrobial dressing (eg Askina® Calgitrol® Paste3)
  • Heel ulcer: Antimicrobial dressing (eg Askina® Calgitrol® THINSacral3)
  • : Antimicrobial dressing (eg Askina® Calgitrol® Paste3)

To complement click here  and consult the PDF about pressure ulcers, which addresses the following issues?

  • Who is at risk of developing pressure ulcers?
  • What precautions are taken to prevent the appearance of pressure ulcers?
  • How to optimize the treatment of pressure ulcers?

 

 

 

GRADES 

1. Recommended use according to EPUAP guidelines, 2012 see: http://www.epuap.org

2. NOTE: Since Phase IV PUs may involve cartilage exposure, special attention is required. Some products (eg Prontosan®) are contraindicated for use in hyaline cartilage. A risk-benefit assessment should be carried out in all cases. The decisions about the products used are up to the attending physician and, when indicated, instead of Prontosan®, a normal saline solution should be used

3. As a secondary dressing, use a suitable low-adhesion wet absorbent dressing, with a flat and anatomical shape ( eg Askina® Foam / Askina® Heel / Askina® / Askina® DresSil Heel / Askina® DresSil Sacrum)

(in: https://www.bbraun.pt/en/produtos-e-terapias/tratamento-da-pele-e -of-wounds / pressure-ulcers.html)