Pressure Sore

By – N C Patel [email protected]

Pressure Sore •

Definition

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Etiology

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Causes

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Pathology

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Prevention of Pressure Sore

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Assessment

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Local Examination

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General Examination

Physiotherapy Treatment •

Physiotherapy Aims

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Physiotherapy Plans – Conservative

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Physiotherapy Plans – Surgical

Pressure Sore Definition : The term pressure sore is used to describe any pressure injury which may vary from an area of erythema to a deep-seated ulceration exposing the underlying tissues and even bone. Etiology : Age

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It can occur at any age, but commonly found in elderly people.

Sex

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Both the sex equally affected.

Conditions

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More commonly affect the patient with neurological disorders, like paraplegia and hemiplegia.

Site

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More common at the parts of the body where the skin and Subcutaneous tissues that overlies bony prominence. The parts where the pressure sore most often found are shown in the picture.

Lying

Side lying

Sitting in a wheel-chair

Some of the area more susceptible for pressure sore to develop includes : • • • • • • • •

Heel Maleolli Thigh Hip Sacrum Buttocks Shoulder Elbow etc.

Causes : This could be external factors (in the environment) or internal factors (in the body itself) External factors :

• • • • • • • •

Post-operative pain. Immobilization following any surgery or fracture. Unconsciousness. Loss of sensation. Prolonged bed rest. Friction / shearing during transfers or turning. Moistures, sweat, urine soaked cloths. Secondary infection.

Internal factors :

• • • • • •

Bony prominences e.g. sacrum, trochanter; causes pressure to build up internally. Increased muscle tone, with resultant shearing forces between bony surfaces. Illness reducing the nutritional state. Poor general skin conditions. Loss of vaso-motor control. Weak or wasted muscle bulk causes poor protection for the underlying tissues.

Pathology : Prolonged and constant unrelieved pressure causing deficiency of the blood supply to the area of loss of sensation. The tissue damage will depend on the amount and the type of pressure applied. •

Shear force

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Friction force : In friction force, the skin surface moves over the bed surface causing a superficial abrasion.

: In shear force, the skin remains stationary and the underlying tissues move forward, destroying the circulation.

The tissue damage can be of two types : 1. Superficial Sores :

This begins with breakdown of the skin surface resulting in destruction of the epidermis and dermis and possibly subcutaneous tissues.

2. Deep Sores :

This begins in subcutaneous tissues overlying bony prominence. It results in necrosis of the subcutaneous tissues, fascia and possibly muscle tissues. The only sign may be a slight reddening of the skin surface. In severe cases, destruction may spread superficially through the skin until a deep cavity is exposed. In both the types, the pressure compresses the tissues of having loss of sensation, which occludes the blood supply and the nutrition is cut off, resulting in necrosis and development of pressure sores. Prevention of Pressure Sore : 1. Turning the patient every 2 hours a day and night and avoiding pressure on the sore when the patient is lying and a push-up every 10 – 15 minutes when the patient is sitting in a wheel-chair.

Pressure relieve technique for the patient sitting in a wheel-chair

2. Use of special mattress or bed designed to relieve pressure. • • • •

Ripple mattress which continually alters the pressure points. Water bed which provides even pressure over all parts of the body. Air fluidized bed – air is pumped through a sand medium giving complete flotation. Roho cushion – an air filled cushion which moulds to any shape and spreads pressure evenly.

3. The patient is encouraged to inspect the pressure site at regular intervals for danger signals, which includes, • • • • •

Pinkness / redness. Paleness. Darkness. Warmth. Tenderness.

4. Encourage the patient to be ambulatory as early as possible and encourage short walks initially.

5. Treatment of the associated disease will help to prevent skin breakdown. Incontinence must be treated, edema reduced and anemia corrected. 6. Good instructions in turning and lifting the patient, to the patient, the patient’s relatives and carers are necessary. 7. A balanced diet to maintain the patient’s general health is essential.

Assessment : It includes detailed examination of pressure sore areas including the causes and duration of the sores. leg, above maleolli. Local Examination : It includes complete local inspection including , History of any vascular or neurological disorders

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Mechanism of injury

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Date of onset

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Progression of wound, since onset

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Site of pressure sores

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Size of pressure sore wound

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Shape of pressure sores

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Number pressure sores

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Discharge

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Character of the discharge – amount and smell, should be noted.

Surrounding area

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surrounding skin usually edematous, eczematous and pigmented. Skin may be tendered and with increased temperature.

General Examination : Whole limb should be examined in case of lower limb pressure sores. Presence of associated paralysis and other neurological and vascular disorders are evaluated. Life style pattern of the patient should be evaluated especially with regards to smoking, use of alcohol and eating habits. Patient’s complete previous medical and surgical history should be

evaluated.

The underlying cause of the pressure sores is traced and treated to prevent further tissue damage. Pain aggravating factors and pain relieving factors are assessed.

Physiotherapy Treatment : Physiotherapy Aims : Physiotherapy treatment usually aimed to consider the local wound area and prevention and improving the general condition of the patient. Local Aims include : • • • •

Increase circulation to ulcer area to promote healing. Clear any infection. Reduce edema. Prevent adherence of wound to underlying tissues.

General aims include : • • • • • • •

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.

Physiotherapy Plans : Conservative : 1. Positioning :

Turning the patient every 2 hours a day and night and avoiding pressure on the sore when the patient is lying and a push-up every 10 – 15 minutes when the patient is sitting in a wheel-chair. 2. Soft Tissues technique :

Deep manipulation is given to whole limb to reduce edema and venous congestion; beginning from thigh and continuing down the limb towards knee and ankle; in case of lower limb pressure sores. The most effective manipulations being slow deep effleurage and deep kneading. The region of wound is next treated with finger and thumb kneading to soften the indurations and preventing the wound and scar being adhere to the underlying tissues. The scar also moved from side-to-side to prevent adherence. 3. Ultraviolet Rays :

The ultraviolet rays have been effective in treatment of ulcers to destroy microorganism and to improve circulation. Infected pressure sore : As an open wound doesn’t contain any skin, an E-4 dose of UVB or UVC is given to the floor of ulcer with edges being screened by using ultraviolet opaque material with help of Kromayar lamp or Air cooled mercury vapour lamp. This is repeated two to three times a week.

If edges are clear of infection, E-1 or E-0 (half the E-1 dose) dose of UVB or UVC may be given to the edges and surrounding skin daily to promote healing. Floor : E-4 dose of

UVB or UVC / 2 – 3 times a week.

Edges : E-1 or E-0 (half the E-1 dose) dose of UVB or UVC / Daily. Healing pressure sore : The application of UVR is aimed to improve circulation and to promote granulation tissues. Shallow healing wound

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Floor – E-1 dose is administered daily to the Floor with the edges are being screened.

Deep healing pressure sores

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Floor – E-2 dose is given two times a week.

Edges and surrounding skin

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E-0 (half the E-1 dose) or E-1 daily.

4. Ultrasound :

The application of ultrasound for ulcer is aimed towards : • • •

Promoting healing. Soften the indurations. Increase vascularity in surrounding tissues.

Dosage of 0.25 – 0.5 W / cm square is applied for 5 – 10 minutes with use of coupling gel to the surrounding skin and with use of hydro gel sheet to the ulcer area itself. The application of US is contraindicated in presence of associated superficial or deep vein thrombosis. 5. LASER :

LASER beams can be used due to their ability to increase vasodilatation and to decrease pain at wound site. Usually visible and infra-red part of the spectrum (600 – 950 nm) is used. The ulcer should be as dry as possible and oil free before application of LASER. The probe is held at 90 degree to the wound just off the surface of the wound. Treatment should be given on alternate days. 6. Ionozone Therapy :

This is the production of steam which is ionized by being passed over a mercury vapour arc into a mixture of ionized water, ozone and oxygen. It is applied at approximately 35 cm from ulcer and surrounding area for 10 – 20 minutes. This will help in : • • •

Promote healing, Reduce pain, Overcome infection.

The steam is directed horizontally with the patient approximately positioned. The treatment is applied daily to infected pressure sores and reduces 2 – 3 times a week as healing occurs.

7. Hot Saline and Magnesium Pad :

Hot saline and Magnesium padding is applied for a week , with infra-red radiation at 18 inches for 15 minutes until the local swelling has subsided. 8. Electrical Stimulation :

Electrical stimulation has demonstrated effectiveness in facilitation of healing, decreasing edema and inflammation, in both acute and chronic wound. By using high Voltage Pulsed Direct Current – HVPC directly in the wound, there can be attraction of neutrophils, macrophages and epidermal cells which facilitate debridement and re-epithelialization. 8. Radiant Heat :

Infra-red radiation or hot packs applied over the proximal areas increase local wound and skin temperature facilitating higher metabolic rate and improving circulating activity to wound. It has been effective in treating chronic wound even in the presence of vascular compromise. 9. 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 reepithelialization and promote healing. 10. Hydrotherapy :

Hydrotherapy in case of pressure sore is applied by non-immersion technique. The major indication of hydrotherapy is for mechanical debridement of non-viable tissues and to promote development of granulation tissues. The effect of non-immersion technique for wound care is as follows : Non-immersion Cleansing Removal of wound debris and soften necrotic tissues Decrease bacterial load Wound healing. The non-immersion hydrotherapy devices include : • • • •

Spray bottle Bulb syringes Saline squeeze bottle Piston irrigation syringe

11. Exercises :

Passive ranges of motion 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.

12. Wound Dressing and Cleaning :

Wound must be cleaned prior to applying any modalities and soft-tissues manipulations. Cotton wool balls soaked in saline – for clean ulcer, and hydrogen peroxide or eusol – for infected ulcer, are used for cleaning. Variety of ointments, solutions and preparations are available for dressing the wound and surrounding skin. A gauze compress covering up to 2 cm of the ulcer and surrounding skin is used, if the wound is shallow. For deep wound, silastic foam (a silicon based fluid which sets to the shape of ulcer) may be used. Finally the wound is dressed in a non-absorbent dressing with help of rubber pad. Surgical : By Skin Grafting.

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