PRESSURE ULCERS

This type of wounds is a damage in the skin and other tissue around of the skin that is caused by pressure in much time.

These njuries is produced in old man with immobility and more than 70% appear in old man with more than 70 years.

It’s important to know that 95% of PU is avoided, and the best actuation we can do is the prevention in risk factors.

The areas more damaged are bone protuberance, like sacrum and upper part of the femur.

RISK FACTORS

Pathological:

  - Skin damages.

  - Oxygen transport upset.

  - Nutritional deficits: overweight, anemia, thinness.

  - Cancer, infection.

  - Coma, confusion or drugs.

  - Fracture, brain damage.

  - Sensorial deficit.

  - Urinary and fecal upset.

Treatment:

  - Immobility.

  - Chemotherapy and radiotherapy.

Situational:

  - Hygiene absence.

  - Wrinkle in the clothes.

  - Immobility caused by pain or fatigue.

By the environmental:

  - Absence of sanitary education.

  - Absence of rules in the planning to the treatment.

  - Overloading of work.

CLINIC EVALUATION

To evaluate the pressure ulcer risk we use two scales: Braden and Norton.
Braden Scale has a specify of 64 – 77%.

Norton Scale has a specify of 61 – 94%.

Localization of the wound
In the consult, we must do a global valuation, and localize and count the ulcers. We evaluate the next notes:
  - Ulcer’s precedent.
  - Personal, family and pharmacology precedents.
  - Physical exploration.
  - Treatment plain.

Define the state of the ulcer
We use the classification of Byrne and Feld that contain 4 states (this classification doesn’t include the necrotic tissue.

Before to evaluate the state, we have to move away the necrotic tissue.
  - State 1: erythema doesn’t disappear and the epidermis is intact.
  - State 2: ulcer like an abrasion or crater less deep.
  - State 3: injury or necrosis of the subcutaneous tissue.
  - State 4: affected to the muscle and maybe the bone.

State 1

State 2

State 4

State 3

Area and volume of the ulcer
Include information about the area and the volume. This last is realized by the Wolter and Cols. Technique.

This technique consist in introduce serum in the ulcer and count how much serum there is in the wound.

TREATMENT
In this video is explained the ulcers, their states and all the treatment.

Cleanliness:
We use serum with a syringe in the wound directly. We only use antiseptic when:
  - Wound with lifeless tissue that is going to be debridement.
  - Ulcers with infection by Acinobacter

Debridement:

• Surgical: move away lifeless tissue with a surgical technique. Its needed expert professional and asepsis. Video
• Enzymatic: in dry ulcers we use “colagenasa, estreptoquinasa y fibrolisina” before the debridement. Video
• “Autolítico”: is a wet heal to promote the immune system to destroy the necrotic tissue. Video

DRESSING
“Hidrogeles”: 
  • Ulcers with necrotic tissue. 
  • It has to cover with other dressing. 
  • Promote the debridement.

“Hidrocoloides”:
  • Treatment to vascular and pressure ulcers with less exude.
  • Protect the wounds.
  • This dressing can wet it.
  • When the dressing contact with the exude, it forms a gel that alleviate the pain.
  • Not use in case of infection.
  • Move away in 3 or 4 days.

“Alginatos”:

• Highly absorbent.

• Vascular and pressure ulcers, burns and exudative and infect injury.
• It has to cover with other dressing.

Foam:
  • Highly exude.
  • Compressive therapy.

“Hidrocapilares”:
  • Levels exude highly.
  • It absorbs great exude.

Antimicrobial dressing of silver:
  • In infect ulcers.

Foam

Hidrogel

Hidrocapilar

                                                  











VASCULAR NURSE EXPLORATION
  - Color and temperature of the skin: cold, pallid, red, cyanotic.
  - Atrophy cutaneous, necrosis, gangrene, arterial ulcers…
  - Ploy exploration: Allen test (video, upper extremities) and Samuels’s arch ischemic (lower extremities).

Ankle and arm rate
  - Define the arterial ulcer and classify it. Video

With this chart you can calculate the result.

Depend of the result:

  - 0,9 – 1,3: repeat it between 2 or 3 years.

  - > 1,3: control de risk factors. Periodic revisions, care of the feet.

  - 0,5 – 0,89: exercise, drugs, care of the feet.

  - < 0,5: move on vascular surgery.

When I was in my first practice, in surgery floor and in medical center, the ulcers were treated correctly, because they use the dressing according to the exude, infection, state… But I never saw if the nurses measured the ulcers.

DIABETIC FOOT
Include the diseases causes by ischemic, neuropathy or infection. These can cause the apparition of ulcers because of a traumatism.

Wagner classification:

Risk factors
  - Neuropathy.
  - Infection.
  - Tobacco and alcohol.
  - Feet alterations.

Education to the patient

• Inspect the feet, their colors, wounds, blister or some graze.
• Prevent the injuries: always wearing some type of shoes, never barefoot; avoid burns, use adequate utensils to the hygiene of skin and nails.
• Wash with tepid water, soap with neutral pH, meticulous drying and moisturize the skin.
• To cut the nails: after de shower, straight.
• Wounds:  wash the wound, dry it and use antiseptic.

NUTRITION
According to some articles, like Revisión sistemática del soporte nutricional en las úlceras por presión or Valoración del riesgo de úlceras por presión en una Unidad de geriatría, the nutrition is very important such as in prevention as in treatment of ulcers.

The patients who are more nourished, the healing of their ulcers are faster than the patients who are undernourished.

I think this point is very important because when the patients are hospitalized is our labor to give their correct nutrition and evaluate their nutritional state.

Finally this subject is too important because in Spain the population is very old and there are a lot of old people who require special cares comparing with young people.