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PRESSURE SORE

Definition
Pathology
Stages
Factors Affecting outcome measure
People at high risk
Sites of Pressure sore
Etiological Factors
Pathomechanical factors
pathophysiological factors
Pressure ulcer risk assessment scale
complications
Organism
treatment


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DEFINITION

- An inflammatory, often suppurating lesion on the skin or 
  an internal mucosal surface of the body resulting in necrosis of 
  the tissue.
- A local defect or excavation on the surface of an organ or tissue 
  which is produced by sloughing of inflammatory necrotic tissue.
- An area of unrelieved pressure over a defined area, usually over a 
  bony prominence, resulting in ischemia, cell death and tissue
   necrosis.
- It is often referred to as pressure sores, bed sores, or
   decubitus ulcers

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PATHOLOGY

Ischemia  decrease in blood supply resulting in cell death
1. Ischemia will produce by prolonged pressure
2. Then uninterrupted, prolonged pressure will produce cell death
3. Death of the cell will produce tissue necrosis
4. Finally, necrotic tissue will appear as an ulcer

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STAGES

1. STAGE I  intact skin; non-blanchable erythema; induration 
            (for dark person); warmth; edema; thickened skin, 
            discoloration
 
2. STAGE 2  involvement of the epidermis and dermis; abrasion; 
             shallow crater, blister formation

3. STAGE 3  involvement of subcutaneous tissue

4. STAGE 4  involvement of tendons, joint capsule, muscle 
             and bone; there is presence of fistula and sinus tract
 
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FACTORS AFFECTING OUTCOME MEASURES
1. Size of the wound
2. Depth of tissue destruction

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PEOPLE AT HIGH RISK

1. Elderly patient
	- they develop skin atrophy as result of aging
	- rete pegs become atrophic
	- there is decrease collagen and fibroblastic activity

2. SCI patient
	- due to prolonged pressure, immobilization, and lack of 
          sensation
	- there is lack of lysine, hydroxylysine, and proline
	- the collagen of healing tissue requires hydroxylation of
          lysine, hydroxylysine, and proline

3. Patient undergoing home care treatment

4. Patient undergoing rehabilitation treatment

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SITE OF PRESSURE SORE
1. Ischium
2. Sacrum
3. Buttocks
4. Hips
5. Heel
6. Feet
7. Malleoli
8. Spinous Process

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ETIOLOGICAL FACTORS
Primary Etiological Factors:
1. Pressure
	- Deprives tissue oxygen and essential nutrients owing 
	  to ischemia and hypoxia

2. Interface pressure
	-perpendicular force per unit area between the body and 
                 support surface

3. Shear
	- mechanical stress directed parallel to the plane of 
                 interest


Secondary Etiological Factors:
1. mobility status of the patient
2. sensory-motor function
3. nutrition
4. age
5. anemia
6. diabetes mellitus
7. incontinence
8. circulatory disturbance
9. psychosocial factors: low self-esteem, low sense of 
        responsibility, low educational attainment
10. smoking

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PATHOMECHANICAL FACTORS
1. pressure
2. friction
3. shear
4. compression
5. maceration
6. immobility

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PATHOPHYSIOLOGICAL FACTORS
1. fever
2. anemia
3. infection
4. hypoxia
5. ischemia
6. malnutrition
7. neurologic disease
8. SCI
9. lean body mass
10. increase metabolic demand


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PRESSURE ULCER RISK ASSESSMENT SCALE
1. immobility
2. incontinence
3. impaired nutrition
4. altered level of consciousness

NORTON SCALE
- Consists of five factors: physical condition, mental condition, 
  activity, mobility, and incontinence. Each factor is rated 1 to 4, 
  with total scores ranging from 5 to 20; the lower the score, 
  the greater the picture.

GOSSNEL PRESSURE RISK ASSESSMENT SCALE
- Gossnel scale was based on the initial work of Norton. The 
  nutrition factor is substituted for physical conditioning, 
  incontinence, and demographic data, medical diagnosis, admission,
  and discharge data were added. Additional items on the instrument 
  included vital signs, height, weight, skin appearance, tone, 
  sensation,  medications, hydration status of the patient, and
   information as to whether a preventative device was being used. 
  Like Norton scale, the range of scores is 5 to 50. However, a 
  higher score indicates a higher risk.


BRADEN SCALE
- Consists of six factors: mobility, activity, moisture, sensory 
  perception, nutrition, and friction and shear. The subscales are 
  rated 1 to 4, except for friction and shear which are rated 1 to3. 
  A score of 4 to 23 is possible, with 16 or below being considered 
  at risk.

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COMPLICATIONS
1. amyloidosis
2. maggot infection
3. septic arthritis
4. heterotopic bone formation
5. sinus tract/abscess
6. squamous cell carcinoma
7. perineal-urethral fistula
8. osteomyelitis
9.  bacteremia
10. advancing cellulites
11. endocarditis
12. pseudoaneurysm
13. meningitis

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ORGANISM
1. Proteus mirabilis
2. group D Streptococci
3. Escherichia coli
4. Staphylococcus
5. Pseudomonas
6. Cynobacterium

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TREATMENT

1. Support surfaces 
	- Used to reduce interface pressure over a 
          bony prominence by maximizing contact and 
          redistributing weight over a larger surface area 
2. Overlays
	- Available as foam, water, gel air, or a combination of
          these materials
3. Replacement mattresses
	- have surface characteristics similar to those of the 
          overlays, but they provide pressure relief attained 
          with those systems without the additional height 
          problem of an overlay
4. Specialty beds
	- Replace the hospital bed and provide pressure relief 
      as well as decreased shearing, friction, and moisture.
	- Available as air fluidized bed, low air loss beds, and 
       kinetic specialty beds
5. Whirlpool
	- used for cleansing pressure ulcers that contain thick  
       exudates, slough, or necrotic tissue

6. Ultraviolet light
	- UV light rays with wavelengths of 253 nm is effective
       for killing bacteria by destroying essential cellular 
      components or by producing toxic substances
7. Ultrasound
	- Used to accelerate wound healing by enhancing the 
       inflammatory phase and therefore assessing the proliferative 
       phase to occur earlier.
	- US using 3 MHz are indicated for treating superficial 
       wounds and 1 MHz for deep wounds
 	- If local circulation is compromised, it is recommended 
        that pulsed US be used with wattage for treating pressure 
        sores of 0.8 Watts per square centimeter
8. Electrical stimulation
	- used for stimulation of endogenous bioelectric circuits,
        facilitating galvanotaxis, improving the transcutaneous 
        partial pressure of oxygen and increasing calcium uptake 
       and adenosine triphosphate and protein synthesis, as 
       well as for its bactericidal effect.
9. Surgical treatment
 	- include direct closure, skin grafts, skin flaps, 
       musculocutaneous flaps, and free flaps


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