Download - Bed Sores: Classification and Management
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Bed Sores...
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Bed Sores
• Decubitus ulcers or pressure ulcers
• It is an ulceration in the skin that is caused by prolonged pressure on a bony or weight bearing part of the body.
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Most Common Areas
• Sacrum• Elbow• Knee • Ankle
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Risk Factors
• Unrelieved pressure• Friction• Humidity• Shearing forces• Temperature• Age• Continence• Medication
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“ A bed sore ca develop in as early as two to three hours. In its early stage, it usually appears as red blotch on the skin which is warm to touch...”(Johnson & Johnson et al)
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Causes
Bedsores are accepted to be caused by three different tissue forces:
• PressureThere is compression of tissues. It leads to
decreased tissue perfusion, ischemia occurs leading to tissue necrosis if left untreated
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Causes
• Shear forceThe force created when the skin of a patient
stays in one place as the deep fascia and skeletal muscle slide down with gravity. This can also lead to ischemia and tissue necrosis.
• FrictionIt causes shedding of layers of epidermis.
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Aggravating Factors
• Excess moisture• Age• Nutrition• Vascular Diseases• Diabetes mellitus• Smoking• Temperature: cutaneous metabolic demand rises
by 13% for every 1°C rise in cutaneous temperature
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National Pressure Ulcer Advisory Panel Classification
Stage 1• the most superficial,
indicated by non blanchable redness that does not subside after pressure is relieved.
• skin may be hotter or cooler than normal, have an odd texture, or perhaps be painful to the patient.
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National Pressure Ulcer Advisory Panel Classification
Stage 2• 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.
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National Pressure Ulcer Advisory Panel Classification
Stage 3• 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
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National Pressure Ulcer Advisory Panel Classification
Stage 4• is the deepest,
extending into the muscle, tendon or even bone.
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National Pressure Ulcer Advisory Panel Classification
Ustageable Pressure Ulcer• Are covered with dead
cells, or eschar and wound exudate, so the depth cannot be determined.
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Braden Scale for Predicting Pressure Ulcer Risk
Six Criteria:• Sensory Perception• Moisture• Activity• Mobility• Nutrition• Friction and Shear
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Braden Scale for Predicting Pressure Ulcer Risk
• 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.
• 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
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Treatment
Proper Care:• The most important care for a patient with
bedsores is the relief of pressure.
• Once a bedsore is found, pressure should immediately be lifted from the area and the patient turned at least every two hours to avoid aggravating the wound.
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Treatment
Debridement• Autolytic debridement - the use of moist
dressings to promote autolysis with the body's own enzymes.
• Biological debridement, or maggot debridement therapy, is the use of medical maggots to feed on necrotic tissue and therefore clean the wound of excess bacteria.
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Treatment
• Chemical debridement, or enzymatic debridement- the use of prescribed enzymes that promote the removal of necrotic tissue.
• Mechanical debridement - the use of outside force to remove dead tissue.
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Treatment
• Sharp debridement - the removal of necrotic tissue with a scalpel or similar instrument.
• Surgical debridement
• Ultrasound-assisted wound therapy- the use of ultrasound waves to separate necrotic and healthy tissue.
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Treatment
• Nutrition
• Infection control
• Education of caregivers
• Wound intervention
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