PRESSURE SORES

by Dr Mohit Gulati (PT)

 Pressure Ulcers
• Pressure Ulcers are localized areas of tissue
necrosis that tend to occur when soft tissue is
compressed between a bony prominence and
an external surface for a prolonged period.

• These lesions are also called bedsores,

decubitus ulcers and pressure sores
 Epidemiology
• 1-3 million Americans are affected
• Health care expenditures: $ 5 billion/year
• More than 17,000 lawsuits related to pressure
Ulcers are filed annually
• 1 in 4 persons in the USA who died in 1987
had a dermal ulcer
• Pressure Ulcers develop primarily in elderly
patients
• Setting
– Hospital 60%
– Nursing homes 18%
– Home 18%
• 1/3 of patients undergoing surgery for hip
fracture develop a pressure ulcer
• The longer the patient stays in a nursing
home, the greater the likelihood of developing
a pressure ulcer
 THERMODYNAMICS, METABOLISM
AND PRESSURE
• Thermodynamic factors - skin/surface
interface
• As temperature increases, skin becomes more
metabolically active and 02 demands increase
• With increased pressure, metabolic demands
not able to be met and skin becomes hypoxic
• Hypoxic skin more susceptible to breakdown
• Adding friction and shear to already fragile
skin is “perfect storm”
 THE 4 FORCES
1. Pressure:
Force applied to soft tissue between hard surface
and bony prominence. When skin and the
underlying tissues are trapped between bone
and a surface such as a wheelchair or bed, blood
flow is restricted. This deprives tissue of oxygen
and other nutrients -> tissue death.
2. Friction:
Resistance of one body sliding or rolling over
another. Making skin more susceptible to
pressure sores.
PRESSURE AND FRICTION
FRICTION PRESSURE
3. Shear:
o This occurs when skin moves in one direction, and
the underlying bone moves in another.
o Sliding down in a bed or chair or raising the head
of bed more than 30 degrees is especially likely to
cause shearing, which stretches and tears cell
walls and tiny blood vessels.
o Especially affected are areas such as tailbone
where skin is already thin and fragile.
4. Strain:
Tissue deformation in response to pressure.
 Pathophysiology

Prolong weight bearing and mechanical shear

forces act on areas of soft tissue overlying
bony prominence ―> when this pressure
exceeds normal capillary perfusion pressure
(32 mm Hg) ―> occlusion & tearing of small
blood vessels ―> reduced tissue perfusion ―>
ischaemic necrosis ―> Pressure sore.
 Risk factors
• Age. Older adults tend to have thinner skin,
making them more susceptible to damage
from minor pressure. They have less
natural cushioning over their bones. And
poor nutrition, delays wound healing.

• Lack of pain perception. Spinal cord

injuries and some diseases cause a loss of
sensation ―> bedsore is forming.
• Natural thinness or weight loss. Muscle atrophy and
wasting are common in people living with paralysis. If
you lose fat and muscle there is no cushion over your
bones.
• Malnutrition. Pressure sores develops if you have a
poor diet, especially one deficient in protein, zinc and
vitamin C.
• Urinary or fecal incontinence. Problems with bladder
control can greatly increase risk of pressure sores
because skin stays moist, making it more likely to
break down. And bacteria from fecal matter not only
can cause serious local infections but also can lead to
life-threatening systemic complications such as sepsis,
gangrene and, rarely, necrotizing fasciitis, a severe and
rapidly spreading infection.
• Other medical conditions. diabetes and
vascular disease affect circulation ―> tissue
damage.
• Smoking. Smokers tend to develop more
severe wounds and heal more slowly, mainly
because nicotine impairs circulation and
reduces the amount of oxygen in blood.
• Decreased mental awareness. People whose
mental awareness is lessened by disease,
trauma or medications are often less able to
take the actions needed to prevent or care for
pressure sores.
 Risk Factors
• Spinal cord injuries • Chronic systemic
• Traumatic brain injury illness
• Neuromuscular • Fractures
disorders • Aging skin
• Immobility – decreased epidermal
turnover
• Malnutrition – dermoepidermal
• Fecal and urinary junction flattens
incontinence – fewer blood vessels
• Altered level of • Decreased pain
consciousness perception
Site
• Pressure ulcers
commonly occur
over the :
– Sacrum
– Greater
trochanter
– Ischial tuberosity
– Malleolus
– Heel
– Fibular head
– Scapula
While on a wheelchair
a pressure sore
develop on:
- Tailbone or buttocks
- Shoulder blades and
spine
- The backs of arms
and legs where they
rest against the chair
- Feet
Classification/ Stages/ Grades
• Stage I
1. most superficial,
2. non blanchable redness, does not subside after
pressure is relieved.
3. The skin may be hotter or cooler than normal
4. have an odd texture, or
5. perhaps be painful to the patient.
STAGE I
• Stage II is damage to the epidermis extending
into, but no deeper than, the dermis. In this
stage, the ulcer may be referred to as a blister
or abrasion.

• The ulcer is superficial and manifest clinically

as an abrasion, blister or shallow crater
STAGE II
STAGE II
Stage III involves the full thickness of the skin
and may extend into the subcutaneous tissue
layer. This layer has a relatively poor blood
supply and can be difficult to heal.

The ulcer manifests clinically as a deep crater

with or without undermining of adjacent
tissue
STAGE III
STAGE III
Stage IV
• is the deepest, extending into the muscle,
tendon or even bone. Often include
undermining and/or tunneling”
• “Full thickness tissue loss with exposed bone,
tendon or muscle. Slough or eschar may be
present on some parts of the wound bed.
• Depth varies according to anatomic location
• Exposed bone/tendon usually directly visible
and/or palpable
STAGE IV
Stage 4

B
STAGE IV
 Complications
• Cellulitis. This causes pain, redness and swelling, all of
which can be severe. Cellulitis can also lead to life-
threatening complications, including sepsis and
meningitis.
• Bone and joint infections. These develop when the
infection from a bedsore burrows deep into joints and
bones. Joint infections (septic or infectious arthritis) can
damage cartilage and tissue, whereas bone infections
(osteomyelitis) may reduce the function of joints and
limbs.
• Sepsis. It occurs when bacteria enters
bloodstream through the broken skin and
spreads throughout the body — a rapidly
progressing, life-threatening condition that
can cause shock and organ failure.
• Cancer. This is usually an aggressive
carcinoma affecting the skin's squamous cells.
 Tests and diagnosis
• Determine the size and depth of the ulcer
• Check for bleeding, fluids or debris in the wound that
can indicate severe infection
• Try to detect odours indicating an infection or dead
tissue
• Check the area around the wound for signs of
spreading tissue damage or infection
• Check for other pressure sores on the body
• Blood test
• Wound swab – C/S
• Incision biopsy/ Tissue cultures– if malignancy is
suspected.
 Treatments and drugs
• Treating bedsores is challenging. Open
wounds are slow to heal, and because skin
and other tissues have already been
damaged or destroyed, healing is never
perfect.
• Requires a multidisciplinary approach –
nurses, physician, social worker, physical
therapist, urologist or gastroenterologist, a
neurosurgeon, orthopedic surgeon and
plastic surgeon.
 TREATMENT OBJECTIVES
1. Identification of problem
2. Debridement of necrotic tissue
3. Moist wound care without maceration
4. Control of infection/bioburden
5. Management of pain
6. Pressure redistribution/Offloading
7. Choice of wound care products is individual
preference as long as above objectives met.
A) Conservative treatment
Although it may take some time, most stage I
and stage II sores will heal within weeks with
conservative measures. But stage III and stage
IV wounds, which are less likely to resolve on
their own, may require surgery.
1. Changing positions often. Carefully follow the
schedule for turning and repositioning — approximately
every 15 minutes if in a wheelchair and at least once
every two hours when in bed. If unable to change
position on own, a family member or other caregiver
must be able to help.
2. Using support surfaces. These are special cushions,
pads, mattresses and beds that relieve pressure on an
existing sore and help protect vulnerable areas from
further breakdown.
PRESSURE REDISTRIBUTION
3. Cleaning.
– It's essential to keep wounds clean to prevent
infection.
– A stage I wound can be gently washed with
water and mild soap
– Open sores should be cleaned with a saltwater
(saline) solution each time the dressing is
changed.
– Avoid antiseptics such as hydrogen peroxide and
iodine, which can damage sensitive tissue and
delay healing.
4. Dressings.
– Moist gauze helps keep the wound moist and absorbs excess fluid.
Gauze should be damp—not wet—with saline. Too-wet gauze can
weaken surrounding tissue.
– Transparent films are thin and flexible and help protect wounds from
water and bacteria.
– Hydrocolloids absorb exudate, forming a nonadhesive gel. Maintains a
moist wound environment and protect from water and bacteria.
– Hydrogels are water-based gels and dressing sheets ,soothing and can
help ease pain.
– Alginates are highly absorptive dressings.
– Foams absorb exudate and keep the wound moist. They are used to
cover or fill wounds.
– Collagens absorb exudate and help maintain a moist wound
environment. They may also promote new tissue growth.
– Antimicrobial dressings help prevent and treat infection.
5. Removal of damaged tissue (debridement)
To heal properly, wounds need to be free of damaged,
dead or infected tissue. This can be accomplished in
several ways –
– Autolytic debridement is autolysis with the body's own
enzymes; used on smaller, uninfected wounds and
involves special dressings to keep the wound moist and
clean.
– Biological debridement, or maggot debridement therapy,
– Chemical debridement/enzymatic debridement applying
chemical enzymes and appropriate dressings to break
down dead tissue
– Mechanical debridement loosens and removes wound
debris. This may be done with a pressurized irrigation
device, low-frequency mist ultrasound or specialized
dressings.
 – Sharp debridement is the removal of necrotic tissue with a
scalpel or similar instrument.
– Surgical debridement is to remove the dead tissue, bone
and fluid from the area around the bed sore. May be
accompanied by ‘flap reconstruction’. Considered in cases
involving advanced stage bed sores (stage III and IV).
– Biological debridement / maggot debridement therapy, is
the controlled, therapeutic use of live blow fly larvae
("maggots") to treat skin and soft tissue wounds.
6. Oral antibiotics. Topical or oral antibiotics depending
upon the culture.
7. Controlling incontinence as far as possible is crucial
to helping sores
– Strategies include frequently scheduled help with
urinating, frequent diaper changes, protective lotions on
healthy skin, and urinary catheters or rectal tubes
8. Healthy diet.
– To promote wound healing, recommend an increase in
calories and fluids,
– a high-protein diet
– an increase in foods rich in vitamins and minerals.
– You may be advised to take dietary supplements, such as
vitamin C and zinc.
9. Muscle spasm relief
– Spasm-related friction or shearing can cause or worsen
bedsores.
– Muscle relaxants — such as diazepam (Valium), tizanidine
(Zanaflex), dantrolene (Dantrium) and baclofen (Gablofen,
Lioresal) — may inhibit muscle spasms and help sores
heal.
10. Educating the caregiver
B) Surgical repair by
a. Negative Pressure Wound Therapy : also
called vacuum-assisted closure.
b. Tissue Flap, Free Flap

C) Other treatment options

Researchers are searching for more effective
bedsore treatments. Under investigation are
hyperbaric oxygen, electrotherapy and the
topical use of human growth factors.
 Prevention
• Bedsores are easier to prevent than to treat,
but that doesn't mean the process is easy or
uncomplicated. Although wounds can develop
in spite of the most scrupulous care, it's
possible to prevent them in many cases.
• Position changes
– It is advisable to change position frequently with
proper cushioning.
Repositioning in a Wheelchair
• Shift weight frequently, every 15 minutes.
• If patient has enough upper body strength, do
wheelchair pushups.
• Special wheelchair, some wheelchairs allow
tilting to them, which can relieve pressure.
• Use cushions to relieve pressure and help
ensure your body is well-positioned in the
chair, such as foam, gel, water filled and air
filled.
Repositioning in a bed
• Change body position every two hours.
• If you have enough upper body strength, try
repositioning yourself using a device such as a
trapeze bar. Caregivers can use bed linens to help lift
and reposition you. This can reduce friction and
shearing.
• Use special cushions and mattresses such as, a foam,
pneumatic mattress, Ripple, Alpha or a water
mattress, Roho Cushions to help with positioning.
• Bed can be elevated at the head, raise it no more
than 30 degrees. This helps prevent shearing.
• Protect bony areas with proper positioning and
cushioning.
• Skin care
– Daily skin inspections for pressure sores are an
integral part of prevention.
– Clean the skin with mild soap and warm water or
a no-rinse cleanser. Gently pat dry.
– Use talcum powder to protect skin vulnerable to
excess moisture. Apply lotion to dry skin.
– Change bedding and clothing frequently
– Watch for buttons on the clothing and wrinkles in
the bedding that irritate the skin.
– Manage incontinence to keep the skin dry, take
steps to prevent exposing the skin to moisture
and bacteria.
• Nutrition
– A healthy diet is important in preventing skin
breakdown and in aiding wound healing.
– Good hydration is important for maintaining
healthy skin.
• Lifestyle changes –
- Quitting smoking,
- Exercise - Daily exercise improves
circulation.
PHYSIOTHERAPY TREATMENT
 PT Aims
• Physiotherapy treatment usually aimed to
consider the local wound area and prevention
and improving the general condition of the
patient.
• Local Aims :
– Increase circulation to ulcer area to promote
healing.
– Clear any infection.
– Reduce edema.
– Prevent adherence of wound to underlying
tissues.
• General aims :
– To relieve pain.
– To relieve venous congestion and edema.
– To decrease risk of wound infection.
– To improve general circulation of lower limb.
– To mobilize joints surrounding the pressure sores.
– To strengthen the muscles of surrounding the
pressure sores.
– Teach home care and management.
 PT Treatment
• Positioning:
– every 2 hourly on bed
– every 15 minutes on siiting.
• Soft tissue techniques:
– slow deep effleurage and deep kneading.
– region of wound is treated with finger and thumb
kneading to prevent induration
– scar also moved from side-to-side to prevent adherence.
– Deep manipulation is given to whole limb to reduce
edema and venous congestion;
– Begin from thigh and continuing down the limb towards
knee and ankle; in case of lower limb pressure sores.
• UVR :
– destroy microorganism and to improve
circulation.
– In open infected wound, E-4 dose of UVB or UVC
using ultraviolet opaque material for 2-3 times a
wk.
– In Uninfected wound, Floor : E-4 dose of UVB or
UVC / 2 – 3 times a week.Edges : E-1 or E-0 dose
of UVB or UVC / Daily.
– InShallow healing wound : Floor : E-1 dose/daily
,edges are being screened.
– Deep healing pressure sores : Floor :€“ E-2 dose
twice a wk.
Edges and surrounding skin : E-0 /E-1 dose daily.
• Ultrasound :
– Promoting healing.
– Soften the indurations.
– Increase vascularity in surrounding tissues.
– Dosage of 0.25 – 0.5 W / cm square for 5 -10
minutes to the surrounding skin and with use of
hydro gel sheet to the ulcer area itself.
NOTE : US is contraindicated in presence of
associated superficial or deep
vein thrombosis.
• LASER :
– to increase vasodilatation and to decrease
pain at wound site.
 – Usually visible and infra-red part of the spectrum
(600 – 950 nm) is used.
– Treatment on alternate days.
• Pulsed Electro Magnetic Energy (PEME) :
– Continuous high frequency current at sufficient
intensity produce heat in tissues.
– If PEME is applied to tissues, there is a relatively
long rest period, during which the heat is
dispersed by circulation, thus producing non-
thermal effect.
– With PEME application, there will be increase
reepithelialisation and promote healing.
• Exercises :
– Passive ROM exercises to the paralyzed limb to
improve circulation and prevent contractures are
performed several times a day.
– Re education of walking with more emphasis on
push-off must be given.
– Active assisted SLR
– Ankle pump exercises
– Strengthening of muscles and joints, without
impeding the healing of ulcer.
– Teaching corrective measures like shifting from
bed, turning positions, using assistive devices.
• IRR and Hot packs :
– have been used in chronic wounds
– apply over the proximal areas, increases local
wound and skin temperature, facilitating higher
metabolic rate and improving circulating activity
to wound.
• Other treatments are :
– IONOZONE therapy
– Non-immersion hydrotherapy
· Spray bottle
· Bulb syringes
· Saline squeeze bottle
· Piston irrigation syringe
Thank You