DR.

MONOBINA SARKER
(MOIC,CCU)
HOWRAH DISTRICT HOSPITAL
 An ulceration of skin and underlying
tissues deprived of adequate blood
supply by prolonged pressure or
exposure to shear forces or friction.

 It is painful often reddened area of

degenerating ulcerating skin caused
by pressure and lack of movement
and worsened by pressure ,lack of
movement and also worsened by
exposure of urine and other
irritating substances on the skin.
Untreated ,can become seriously
infected or gangrenous. Bedsores
are major problem for patients who
are confined to bed or wheelchair.
 Bedsoresdevelop on
skin that covers
bony areas of the
body such as
heels,ankles,hips,or
tailbone.
 Are those with a medical condition
that limits their ability to change
posture or those who spend most
of their time in a bed or
wheelchair.
 Tailbone or buttocks,shoulder
blades ,spines,back of arms and
legs,back or sides of
head,heels,ankles and skin
behind the knee.
 ISCHIUM-28%
 SACRUM-17-27%
 TROCHANTER-12-19%
 (bears weight when patient is in
sitting position)
 OTHER COMMONLY AFFECTED
SITES
 coccyx,heel,malleolus
 (a) Unusal changes in skin colour
or texture
 (b) swelling
 (c) pus like drainage
 (d) an area of skin that feels
cooler or warmer to the touch
than other areas
 (e) tender areas
 (A) Pressure-Constant pressure
on any part of the body lessen
blood flow to the tissues. Blood
flow is essential to delivering
oxygen and other nutrients to
tissues without these essential
nutrients, skin and nearby
tissues are damaged and might
eventually die. More
pressure=less time to form an
ulcer. Press. under 32 mm of Hg
are generally believe safe but this
values are influenced by tissue
stiffness, tissue composition and
pt’s body contour.
(B) Friction—occurs
when the skin rubs
against clothing or
bedding.It makes fragile
skin more vulnarable to
injury specially if the
skin is also moist.
 (C) FORCES:

 (1)Shear-occurs when 2 surfaces

moves in the opposite directions
e.g when a bed is elevated at the
head ,patient slide down in bed.
As the tailbone moves down
,the skin over the bone might
stay in place-essentially pulling
in the opposite direction-sacral
ulcers.

 (2)Axial-Perpendicular to skin
surface.Unrelieved axial presure
4-6 times the systolic pressure
can cause necrosis in less than
60 mins
 A) IMMOBILITY -due to poor
health, spinal cord injury,
fracture
 B)LACK OF SENSORY PERCEPTION
–spinal cord injury, neurological
disorders—unable to feel pain or
discomfort
 C) POOR NUTRITION OR
HYDRATION—Patient need
enough fluid, calorie ,protein,
vitamins ,minerals to maintain
healthy skin and prevent
breakdown of tissues.
 A) Cellulitis
 B) Bone and joint infections-
septic arthritis, osteomyelitis
 C) Cancer-long term non healing
wound(MARJOLIN’S ulcer)
 D) Sepsis
Can be prevented by
 (a)repositioning frequently to
avoid stress on the skin
 (b).Good care of the skin should
be taken.
 (c)maintain good nutrition and
fluid intake
 (d) stop smoking
 (e) daily physiotherapy
 (a) shift weight frequently
 (b) select mattress, cushions
 (c) adjust elevation of bed to
prevent shearing
 KEEP SKIN CLEAN AND DRY
 USE TALCOM POWDER
 CHANGE CLOTHING,BEDDING
FREQUENTLY
 AVOID WRINKLING OF SHEET
 INSPECT SKIN DAILY
 A) IF THE AFFECTED SKIN IS NOT
BROKEN WASH,CLEAN, DRY
 B) OPEN SORES CLEAN WITH SALINE
WATER
 C) BANDAGE –speeds healing by
keeping wound moist.creates a
barrier against infection and keeps
surrounding skin dry.
 D) REMOVAL OF DAMAGED TISSUES
-DEBRIDEMENT can be done by
gently flushing the wound or
cutting out damage tissue
 E) drugs to control pain before
repositioning
 F) drugs to combat infection
 G) healthy diet
 H) Negative pressure therapy-
vacuum assisted device to clean
wound with suction
 I)Surgery –one method of surgical
repair is to use a pad of patient’s
muscle, skin and other tissues to
cover the wound and cushion the
affected bone(flap
reconstruction)
 Sharp debridement
 Mechanical nonselective
debridement
 Enzymatic debridement
 Autolytic debridement
 a)Removal of devitalized
tissue/eschar via surgical means.
Small wounds can be debrided at
bedside, more extensive one in the
OT.
 b)It is the most effective and
quickest method of removing
necrotic tissue. Debridement done
to the point where the tissue bleeds
with forceps and a scalpel.
 c)clinical skill and judgment
necessary to be able to dicern the
difference between vitalized or
nonvital tissue.

Disadvantage-can damage healthy

tissue
 a)WHIRLPOOL
 b)IRRIGATION
 c)Wet to dry dressing with normal
saline, place moist gauze on the
wound ,let dry.When the dressing is
removed the necrotic tissue comes
off.
 d)Wet to moist-maintain a clean
moist wound bed and are removed
before they are dry.They have to be
changed more frequently.

 DISADVANTAGE-HEALTHY TISSUES
CAN BE DAMAGED
 a)Utilizes chemical agents (such
as ACCUZYME) in the form of
ointments which work on the
necrotic wound debris and do not
affect viable tissue.
 A)GAUZE
 B)Transparent adhesive
dressing:Tegaderm,Opsite-these
are semipermeable,occlusive,allows
gaseous exchange, water vapor
transfer from skin ,prevent peri
wound maceration.cannot be used if
wound is exudative or the patient is
diaphoretic.GOOD for stage 1 and 2
wounds without debris
 C)Hydrocolloid dressings:Duoderm-
interact with wound exudate and
make a gel.keep wound surface
moist.enhance healing.minimize
shear.Good for stage3 sacral ulcers
 D)Gel dressing
 E)Calcium alginate dressing: Made
from brown
seaweed(Sorbsan).sterile,semi
occulusive,highly absorbable,good
for exudative or contaminated
wound.need to change frequently
 a)The bodies own enzymes break
down dead tissue. Wound cells
secrete proteases,collagenases
that digest eschar.Hydrocolloid
dressings helps to promote this
type of debridement.Very
effective in noninfected
wound.AN occlusive dressing
allows wound fluid to collect.
 DISADVANTAGE- IF INFECTED
AN ABSCESS WOULD BE FORMED
 Each category is rated on a scale of
1 to 4, excluding the 'friction and
shear' category which is rated on a
1-3 scale. This combines for a
possible total of 23 points, with a
higher score meaning a lower risk
of developing a pressure ulcer and
vice versa. A score of 23 means
there is no risk for developing a
pressure ulcer while the lowest
possible score of 6 points
represents the severest risk for
developing a pressure ulcer.[6] The
Braden Scale assessment score
scale:
 Very High Risk: Total Score 9 or less
 High Risk: Total Score 10-12
 Moderate Risk: Total Score 13-14
 Mild Risk: Total Score 15-18
 No Risk: Total Score 19-23
 A)Proper medical care
 B)Turn pt every 2 hrly
 C)Frequent dressing changes
 D)maintain proper nutrition-high
protein diet because high
amount of protein is lost through
wound
 E)Pressure relief in
wheelchair,specially support
surfaces
 F)continued wound assessment
 Include overlays(water,gel,foam)
 Speciality bed-a)low air loss
beds(FLEXICARE) have cushion
filled with air that keep pressures
below the capillary closing
pressures
 Air fluidized bed(CLINITRON) USE
WARM AIR FORCED THROUGH
SILICONE BEADS TO MIMIC A
FLUID MEDIUM
 No study has conclusive evidence
 Must be individualized
 If a pt has STAGE 3 OR 4 ULCER,a
pressure relief product should be
utilised
 When to suspect a wound
infection:
 FOUL ODOUR,GREENISH
DRAINAGE,DULL WHITE
BASE,SWELLING,TENDERNESS
locally
 Chill,anorexia,nausea,vomiting,fe
ver,increased white cell
count,mental status changes,
 NORT0N’S SCALE
 FOR PRESSURE/ULCER RISK ASSESMENT
 Whirlpool therapy, or hydrotherapy, is one
of the oldest adjuvant forms of treatment
for wounds still in use today.1,2 It was
originally used in the management of
pain, but later found a use in wound
management, in particular in the
management of burns patients. It is now
commonly used to facilitate debridement
in infected wounds, nondraining wounds,
on wounds with thick eschar, and on
wounds with loosely adherent necrotic
tissue or thick exudate.1 Typically,
whirlpool therapy is used in 20–30-
minute sessions, three to four times per
week. As a rule, this form of therapy is
only maintained for a brief period, and is
unsuitable for longer-term use.
 As well as facilitating debridement,
whirlpool therapy appears to have a
number of other benefits. Use of a
whirlpool allows dressings to be
removed slowly and gently reducing
the pain of dressing changes in
patients with sensitive wounds such
as crush injuries, venous stasis,
pyoderma gangranosum, arterial
insufficiency, and animal bites, for
example. In addition, the warmth of
the water promotes increased
circulation to the wound surface,
and can be soothing for the patient.
Finally, large Hubbard-type tanks
are able to provide resistance and
buoyancy to help patients with
physical therapy.
 Despite the popularity and wide use of whirlpool
therapy, and the abundance of anecdotal evidence
concerning its benefits, there is actually a lack of
evidence from prolonged clinical trials demonstrating
its efficacy.3 There are also some disadvantages and
contraindications to whirlpool therapy which should
be taken into account when considering its use. For
example, the force generated at the wound surface
can be greater than then recommended force,
potentially damaging developing granulation tissue,
hindering migrating epidermal cells, and causing
maceration. In addition, the limb position that is
required to use whirlpool therapy on the lower
extremities can actually counterproductively increase
venous hypertension and vascular congestion.
Finally, there is a serious risk of bacterial cross
contamination between patients using the same tank,
although this can be overcome by the careful use of
antibacterial agents.
 The opportunity to weigh up the benefits of
whirlpool therapy and investigate further the
evidence that is currently available for this modality
can be provided by undertaking training for a wound
care certification. This training allows wound care
professionals to explore topics in greater detail and
to become expert in many key areas.
 Zinc deficiency may produce
the following symptoms:

 •Altered/loss of taste and

smell.
 •Anorexia (lack or loss of
appetite)
 •Apathy.
 •Ataxic gait (uncoordinated
movements)
 •Decreased immunity.
 •Depression.
 •Diarrhea.
 •Excessive hair loss.
 Here are 8 signs and symptoms
of vitamin A deficiency.

 •Dry Skin.
 •Dry Eyes. Eye problems are
some of the most well-known
issues related to vitamin A
deficiency. ...
 •Night Blindness. ...
 •Infertility and Trouble
Conceiving. ...
 •Delayed Growth. ...
 •Throat and Chest Infections. ...
 •Poor Wound Healing. ...
 •Acne and Breakouts.
 Here are the most common signs
and symptoms of vitamin C
deficiency.

 1.Rough, Bumpy Skin. ...

 2.Corkscrew-Shaped Body Hair.
...
 3.Bright Red Hair Follicles. ...
 4.Spoon-Shaped Fingernails With
Red Spots or Lines. ...
 5.Dry, Damaged Skin. ...
 6.Easy Bruising. ...
 7.Slowly Healing Wounds. ...
 8.Painful, Swollen Joints.
 One of the new interventions developed to treat
pressure ulcers is transdermal or topical wound
oxygen therapy (TWOT). Studies show that
delivering oxygen directly to the wound site
accelerates the angiogenesis, the collagen
synthesis, the fibroblast growth processes, and
suppresses the bacterial growth, which in turn
facilitate tissue regeneration (3, 15, 16). This
method has several advantages, including
fewer complications and lower costs and more
safety (17). Despite the potential effects of
TWOT on wound healing, pressure ulcers are
mainly managed pharmacologically. Therefore,
there is a literature reporting the application of
topical oxygen to heal wounds (15), and the
results of researches declared that TWOT
positively affected the pressure ulcers healing
process (18-20) or had less significant effect
on healing the pressure ulcers (21). Although
there were not such researches in Iran; and
well-designed clinical trials are needed to
prove this notion.
2. Objectives
 The current study aimed to
evaluate the effects of TWOT on
the healing of pressure ulcers.

3. Patients and Methods

 It was a single-blind multi-center
randomized controlled trial
conducted in 2009.
H yperbaric oxygen therapy is one

option for bed sore treatment, typically reserved

for patients with severe sores. The goal of
hyperbaric oxygen therapy is to increase the
oxygen supply in the body to promote skin
healing. It uses the same technology – a
pressurized chamber – as treatments for scuba
divers with oxygen depletion. Hyperbaric
oxygen therapy could improve oxygen flow to
the affected area of skin, stimulating cell growth
and helping to fight bacterial infections.
A bed sore, or pressure ulcer, forms when something cuts off
the supply of blood to an area of the skin, such as prolonged
pressure on the area. Bed sores arise when the skin tissues
suffer damage or die because of the lack of blood over time.
They are painful skin lesions that may break open and pose a
risk of infection. In its late stages, a bed sore can show dead
patches of skin and reach deep enough to affect the
underlying muscles and ligaments.
In severe bed sore cases, a doctor may prescribe hyperbaric
oxygen therapy to rapidly increase the supply of oxygen to an
area of skin that has damaged, dying, or necrotic tissues. This
type of therapy may work even when other treatments have
not resulted in wound improvement. During hyperbaric oxygen
therapy, a patient will breathe in pure oxygen in a special
compression chamber or through a tube. It is the same
process as a well-established treatment for deep-sea divers
who require decompression.
Hyperbaric oxygen therapy has been in use for around 50
years. Physicians use it to treat patients with diabetic ulcers,
to significantly reduce the odds of amputation. In patients with
chronic or nonhealing wounds, hyperbaric oxygen therapy
could increase the rate of skin healing and trigger restoration.
Breathing in pure oxygen can activate immune cells, control
inflammation, and begin the process of tissue regeneration. It
could be an effective treatment for patients with stage three or
four pressure ulcers.
Many bed sores become nonhealing because of a
susceptibility to infection. Exposed chronic wounds
are at high risk of bacterial infections that continue to
damage tissues and increase free radical production.
Infection can cause inflammation in the bed sore
region, along with an imbalance of chemicals
released into the tissues. This imbalance can
ultimately inhibit the entry of important nutrients into
the wound; thus, inhibiting healing. Steps to control
and prevent infections are vital to the successful
treatment of bed sores.
Oxygen is a main component of wound healing.
Oxygen-rich conditions can trigger the healing
process in the skin while controlling the inflammatory
phase. One study that evaluated the effects of
oxygen therapy on pressure ulcers found that after
12 days of oxygen therapy, a significantly greater
number of patients had complete wound healing
compared to the control group. The group that
received oxygen therapy also had smaller wound
areas after 12 days.
Hyperbaric oxygen therapy is generally not a
dangerous form of treatment for patients with
severe bed sores. Some patients report feeling
tired or hungry after treatment. However, rare
complications do occur. Potential complications
include temporary eye lens changes and
nearsightedness, middle ear injuries from
changes in air pressure, lung collapse, and
seizures from oxygen toxicity.
Fire is also a potential risk involved with oxygen
therapy. It is important for patients undergoing
this therapy to remove fire hazards before
treatment, as an oxygen-rich environment poses
a larger risk of fires. Some treatments involve a
compression room that can accommodate
several patients at once, while others use units
designed for one person, with a table that slides
into a plastic tube. Within the chamber or tube,
the air pressure in the room will be two to three
times that of a normal environment.