pressure wounds

what are extrinsic risk factors for pressure wounds?

excessive uniaxial pressure

friction and shear forces

impact injury

head

moisture

posture

what are intrinsic risk factors for pressure wounds?

immobility

sensory loss

age

disease

body type

poor nutrition

infection

incontinence

what is the etiology of pressure wounds?

pressure --> ischemia --> acidosis --> inflammation --> increased capillary permeability and edema --> local tissue anoxia

what concern is associated with pressure wounds?

extensive tissue damage may have already occurred before skin changes observed (may take 2-7 days after event to observe)

tissue with high metabolic demand develops pressure injury first - skeletal muscle

what are the most common site for pressure wounds in supine?

occipital protuberance

scapula

olecranon

sacrum

calcaneus

what are the most common site for pressure wounds in side lying?

ear

acromion process

greater trochanter femur

medial and lateral condyles of femur

lateral malleolus and fibula

what are the most common site for pressure wounds in prone?

metatarsals

patella

pubic symphysis

breasts

acromion process

zygoma

what areas are most susceptible to pressure wounds?

sacrum and coccyx

heel and ankle

greater trochanter

what are characteristics of pressure ulcers?

pain:

location:

pulses:

temp:

pain: generally somewhat painful but not always. complaint depend on tissues involved and sensation; stage I may be tender

location: over bony prominences, increased pressure and friction

pulses: normal

temp: increased in areas of reactive hyperemia; decreased in areas of ischemia

what are visual characteristics of pressure wounds?

round, craterlike shape

regular edges or rolled edges (epibole)

wound bed may be necrotic (stage 3 and 4)

may see tunneling or undermining

periwound mottled or red and/or edema

amount of drainage varies

describe stage 1 pressure wound

intact skin with localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin

presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes

color changes include purple or maroon discoloration and ay indicate deep tissue pressure injury (dark pigmented skin - change in color vs red)

describe stage 2 pressure wound

partial-thickness loss of skin with exposed dermis

wound bed is viable, pink, or red, moist and may also present as an intact or ruptured serum-filled blister

adipose is not visible and deeper tissues are not visible

granulation tissue, slough, and eschar are not present

describe stage 3 pressure wound

full-thickness loss of skin, in which fat is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present

slough and/or eschar may be visible

depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds

undermining and tunneling may occur

fascia, muscle, tendon, ligament, cartilage, and/or bone not exposed

if slough or eschar obscures extent of tissue loss, this is an unstageable pressure injury

describe stage 4 pressure wound

full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer

slough and/or eschar may be visible

epibole (rolled edges), undermining and/or tunneling often occur

depth varies by anatomical location

if slough or eschar obscures extent of tissue loss, this is an unstageable pressure injury

describe an unstageable pressure wound

full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar

if slough or eschar is removed, a stage III or IV pressure injury will be revealed

describe a deep tissue injury

intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister

pain and temp change often precede skin color changes, discoloration may appear differently in darkly pigmented skin

wound may evolve rapidly to reveal actual extent of tissue injury, or may resolve without tissue loss

deep tissue pressure injury should not be used to describe _______

vascular or traumatic cases

what would indicate a full thickness pressure injury?

if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible

what may cause a deep tissue injury?

intense and/or prolonged pressure and shear forces at the bone-muscle interface

what outcome measure is commonly used to assess/stage pressure wounds?

PUSH outcome measure

what is the associated prognosis for pressure wounds?

pressure ulcers heal slowly, cateogry is not associated with mortality

expected ulcer healing time with appropriate interventions:

-grade I and II within 1-3 weeks

-grade III and IV take an average of 8-13 weeks

what can lead to faster healing?

better baseline nutrition

what type of ulcer is more likely to get infected?

full-thickness ulcers

when should ulcers be reassessed or alternative interventions be given?

ulcers do not decrease in size within 2 weeks

what are general PT interventions?

prevention

get rid of cause - pressure relieving device (redistribution of pressure)

wound care

protect periwound (moisturize when needed, protect from excessive mositure)

control risk factors

what is the Braden Scale used for?

predicting pressure sore risk

what risk factors can be controlled by PT?

watch for infection

incontinence

mobility

diet and hydration

what is involved with prevention interventions?

NO ULCERS: nutrition and fluid status, observation of skin, up and walking or assist with position changes, lift and don't drag, clean skin and continence care, elevate heels, risk assessment, support surfaces

SKIN: surface selection, keep turning, incontinence management, nutrition

what should be considered with pressure redistribution?

consider patient needs (pressure redistribution, shear reduction, continence, temp, and moisture control

consider patient mobility (ability to reposition and transfer)

consider patient status (deformities, body weight, tissue status, risk for recurrence)

______ are not substitutes for proper skin care, turning, and repositioning

support surfaces

what is a reactive support surface?

a powered or no. powered support surface with capability to change its load distribution properties only in response to applied load

what is an active support surface?

a powered support surface with the capability to change its load distribution properties, with or without applied load

what is a non-powered support surface?

any support surface not requiring or using external sources of energy for operation

what is a powered support surface?

any support surface requiring or using external sources of energy for operation

what is an integrated bed system?

a bed frame and support surface that are combined into a single unit whereby the surface is unable to function separately

what is a mattress support system?

a support surface designed to be placed directly on the existing bed frame

what is an overlay support system?

an additional support surface designed to be placed directly on top of an exisiting surface

what is an air fluidized support surface?

a feature that provides pressure redistribution via fluid-like medium forcing air through beads as characterized by immersion and envelopment

what is an alternating pressure support surface?

a feature that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude, and rate of change parameters

what is a lateral rotation support surface?

a feature that provides rotation about a longitudinal axis characterized by degree of patient turn, duration, and frequency

what is a low air loss support surface?

a feature that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin

how thick do foam mattress or pads needs to be?

3-4" (8-10 cm) thick

what are self pressure relief strategies?

perform every 15-30 mins

hold for 30-90 seconds

best is a wheelchair push up but alternating between leading forward, touching toes, and side to side are okay if unable to do push up

what wheelchairs are used for pressure relief?

reclining back

tilt in space

what are PT interventions for local wound care?

moist wound healing

protect periwound

select appropriate dressing

debride necrotic tissue

manage/refer infection

modalities

education - skin care, control pressure, pain control

what is involved with ther ex?

flexibility exercises to minimize contractures

strengthening exercise to assist with mobility, transfers, and weight shifts

pelvic floor and abdominal muscle strengthening to assist management of incontinence

aerobic exercise to improve cardiac vascular endurance for improving mobility and activity

what is involved with functional training?

gait training

transfers and bed mobility

emphasize minimizing friction and shear, protect intact skin and any existing pressure ulcers

what are additional PT interventions that may be beneficial for wound care?

pulsatile lavage with suction/debridement

if theres no evidence of healing with standard care, can use e-stim, UV, ultrasound, negative pressure wound therapy

what are associated medical interventions?

risk factor management

antibiotics/infection control

pain control

debridement

surgery (debridement and musculocutaneous flaps)