1. Pressure
ulcers
Dr. Doha Rasheedy

3.  Definition
 Risk factors
 Diagnosis, staging
 prevention
 Treatment

4. A 75yrs elderly male pt, with PH of DM,
recurrent CVS, bed ridden of 2 yrs duration
and has urinary incontince. On exam. There
was an ulcer about 2×3×2 cm with necrotic
non viable base , painless, on the sacrum.
What is the most likely diagnosis ?
Venous Ulcer
Diabetic ulcer
Pressure ulcer

5.  A localized area of soft-tissue injury
resulting from compression between
a bony prominence and an external
surface.
 It a type of a vascular necrosis

7. RISK
FACTORS
Intrinsic Extrinsic

9. Clinical picture
and Stages

10. The Norton Scale•
Patients at risk of

developing Pus can be
identified clinically by:
Norton Scale
It detect the physical
and mental condition,
the activity, mobility and
incontinent
A score 10-12------High
risk of PUS development

13.  Unstageable: Full thickness tissue loss
in which slough (yellow, tan, gray,
green or brown), eschar (tan, brown
or black), or both in the wound bed
cover the base of the ulcer.
Pictures - Royal College of Surgeons of Edinburgh

14. Sites

15.  Any skin exposed to continuous
pressure.
 Internal viscera exposed to
unusual pressure, as trachea
pressed by balloon of endotracheal
tube

16.  Over Bony Prominences
1. Occiput
2. Ears
3. Scapula Internal
4. Spinous Processes organs
5. Shoulder
6. Elbow
7. Iliac Crest
8. Sacrum/Coccyx
9. Ischial Tuberosity
10.Trochanter
11.Knee
12.Malleolus
13.Heel
14.Toes

17.  Any skin surface
subject to excess
pressure
 Examples include
skin surfaces under:
◦ Oxygen tubing
◦ Urinary catheter
drainage tubing
◦ Casts
◦ Cervical collars

18. Differential diagnosis

19. Not all
Pressure ulcer to heel
ulcers are Neuropathic diabetic foot ulcer
pressure
ulcers
Arterial ulcer on toes and forefoot Venous leg ulcer
19

20. Prevention
and
treatment

21. focuses on:
Skin care
Mechanical loading
Support surfaces

22.  Daily systematic skin inspection and cleansing
 factors that promote dryness
 Avoid massaging over bony prominences
 moisture (incontinence, perspiration, drainage)
It requires gentle washing and drying
 Minimize friction and shear

23.  Reposition at least every 2 hours (may use pillows,
foam wedges)
 Keep head of bed at lowest elevation possible
 Use lifting devices to decrease friction and shear
 Remind patients in chairs to shift weight every 15
min
“Doughnut” seat cushions are contraindicated,
may cause pressure ulcers
 Pay special attention to heels (heel ulcers account for
20% of all pressure ulcers)

24. **Use for all older persons at risk for ulcers**
 Static
 Foam, static air, gel, water, combination (less expensive)
 Dynamic
 Alternating air, low-air-loss, or air-fluidized

25. Heal protector
Air mattress; Alternate
pressure / low air loss / air
fluidized
Other media; gel / water/
foam
http://www.diamond-medical.com/images/database/medlinesupracxc.jpg

26. GENERAL
ASSESSMENT
Risk factor elimination
ULCER ASSESSMENT,
MONITORING HEALING
MANAGEMENT Cleaning
Debridement
Dressings
SURGICAL
REPAIR

27.  Health problems (e. g, urinary
incontinence)
 Nutritional status
 Pain level

28.  ULCER  MONITORING
ASSESSMENT: HEALING
Location  Document all
 Stage
observations over
time
 Area
 Depth  Describe each ulcer
Drainage to track progress of
 Necrosis healing
 Granulation  Use validated tools
(eg, PUSH)
 Cellulitis

29.  Cleaning Avoid topical antiseptics because of their tissue toxicity
 Debridement
Is necessary to remove dead tissue it include
1. Autolytic debridement using hydrocolloid or foam dressings
2. Enzymatic debridement using exogenous collagenase
(IRUXOL)
3. Mechanical debridement
4. Surgical, sharp Scalpel, scissor to remove dead tissue; laser
debridement
5. Bio surgery: Larvae to digest dead tissue

30.  Dressings
By wet to dry saline or hydrocolloid (duo-derm), or
polyurethane, in exudative wounds fill the wound by
aligniates or hydro gel.
 SURGICAL REPAIR
May be used for stage III and IV ulcers
Direct closure, skin grafting, skin flaps,
musculocutaneous flaps, free flaps

31. Complications

32.  Sepsis (aerobic or anaerobic bacteremia)
 Localized infection, cellulitis, osteomyelitis
 Pain
 Depression
Mortality rate = 60% in older persons who
develop a pressure ulcer within 1 year of
hospital discharge

33. The mainstay in
pressure ulcer
treatment is
prevention of risk
factors.

34.  Older adults are at high risk for development of
pressure ulcers
 Pressure ulcers may result in serious morbidity
and mortality
 Techniques that reduce pressure, moisture,
friction, and shear can prevent pressure ulcers
 Pressure ulcers should be treated with proper
cleansing, dressings, debridement, or surgery as
indicated

35. a)Pressure ulcer = decubitus ulcer= bed sores.
b)Stage 1 PU is partial skin thickness loss.
c)One important risk factor for PU development
is moisture.
d)One of the complications of PU is cellulitis.
e)A cornerstone in management of PU is
debridement

36.  First line treatment for pressure ulcer
1. Surgical closure
2. Debridement
3. Pressure relief
4. Dressing
 Stage 3 pressure ulcer is:
1. Persistent non-blanchable erythema of intact
skin
2. Full-thickness skin loss involving necrosis of
subcutaneous tissue that may extend down
to, but not through, underlying fascia.
3. Partial-thickness skin loss
4. Full-thickness skin loss with damage to
muscle, bone, or supporting structures (e.g.
tendon, joint capsule).

37.  First line treatment for pressure ulcer
1. Surgical closure
2. Debridement
3. Pressure relief
4. Dressing
 Stage 3 pressure ulcer is:
1. Persistent non-blanchable erythema of intact
skin
2. Full-thickness skin loss involving necrosis of
subcutaneous tissue that may extend down
to, but not through, underlying fascia.
3. Partial-thickness skin loss
4. Full-thickness skin loss with damage to
muscle, bone, or supporting structures (e.g.
tendon, joint capsule).