A Topic Presentation on Hepatoma

1. Pressure Sores
By: Dr. Noshirwan P. Gazder

2. • Pressure-induced skin and soft tissue injuries are areas of localized
damage to the skin and/or underlying tissue, usually over a bony
prominence as a result of pressure or pressure in combination with
shear (eg, sacrum, calcaneus, ischium)

3. Three primary contributing factors for
bedsores
• Pressure: Constant pressure on any part of your body can lessen the blood
flow to tissues. Blood flow is essential for delivering oxygen and other
nutrients to tissues. Without these essential nutrients, skin and nearby
tissues are damaged and might eventually die. This kind of pressure tends
to happen in areas that aren't well padded with muscle or fat and that lie
over a bone, such as the spine, tailbone, shoulder blades, hips, heels and
elbows.
• Friction: Friction occurs when the skin rubs against clothing or bedding. It
can make fragile skin more vulnerable to injury, especially if the skin is also
moist.
• Shear: Shear occurs when two surfaces move in the opposite direction. For
example, when a bed is elevated at the head, you can slide down in bed. As
the tailbone moves down, the skin over the bone might stay in place —
essentially pulling in the opposite direction.

4. Common sites for Pressure Ulcers

5. Risk Factors
• Immobility: This might be due to poor health, spinal cord injury and other
causes.
• Incontinence: Skin becomes more vulnerable with extended exposure to
urine and stool.
• Lack of sensory perception: Spinal cord injuries, neurological disorders and
other conditions can result in a loss of sensation. An inability to feel pain or
discomfort can result in not being aware of warning signs and the need to
change position.
• Poor nutrition and hydration: People need enough fluids, calories, protein,
vitamins and minerals in their daily diets to maintain healthy skin and
prevent the breakdown of tissues.

6. Pathophysiology
Pressure sore
Ischemic necrosis
Reduced tissue perfusion
Occlusion & tearing of small blood vessels
When this pressure exceeds normal capillary pressure
Various risk factors act on areas of soft tissue overlying bony prominence

8. Stage 1
• Intact skin with a localized area of
nonblanchable erythema , which may
appear differently in darkly pigmented
skin.
• The presence of blanchable erythema or
changes in sensation, temperature, or
firmness may precede visual changes.
Color changes do not include purple or
maroon discoloration; these may indicate
deep tissue pressure injury.

9. Stage 2
• Partial-thickness loss of skin with exposed
dermis.
• The wound bed is viable, pink or red,
moist, and may also present as an intact
or ruptured serum-filled blister.
• Adipose (fat) is not visible and deeper
tissues are not visible. Granulation tissue,
slough, and eschar are not present. These
injuries commonly result from adverse
microclimate and shear in the skin over
the pelvis and shear in the heel.

10. Stage 3
• Full-thickness loss of skin, in which
adipose (fat) is visible in the ulcer and
granulation tissue and epibole (rolled
wound edges) are often present.
• Slough and/or eschar may be visible. The
depth of tissue damage varies by
anatomical location; areas of
significant adiposity can develop deep
wounds.
• Undermining and tunneling may occur.
• Fascia, muscle, tendon, ligament,
cartilage, and/or bone are not exposed.

11. Stage 4
• Full-thickness skin and tissue loss with
exposed or directly palpable fascia,
muscle, tendon, ligament, cartilage, or
bone in the ulcer.
• Slough and/or eschar may be visible .
Epibole (rolled edges), undermining,
and/or tunneling often occur.
• Depth varies by anatomical location.

12. Unstageable Pressure
Injury
• Unstageable pressure injury is
characterized by full-thickness skin and
tissue loss in which the extent of tissue
damage within the ulcer cannot be
confirmed because it is obscured by
slough or eschar.
• If slough or eschar is removed, a stage 3
or stage 4 pressure injury will be
revealed.

13. Deep Tissue Pressure
Injury
• Deep tissue pressure injury is characterized as
intact or non-intact skin with a localized area of
persistent non-blanchable deep red, maroon,
purple discoloration or epidermal separation
revealing a dark wound bed or blood-filled blister.
• Pain and temperature change often precede skin
color changes.
• This injury results from intense and/or prolonged
pressure and shear forces at the bone-muscle
interface.

15. General Care
The general approach to management of a patient with a pressure-
induced skin injury should include the following:
• Reduce or eliminate underlying contributing factors by providing
pressure redistribution with proper positioning and support surfaces.
• Provide appropriate local wound care, which may include
debridement for patients with necrotic tissue, based on the ulcer's
characteristics.
• Monitor and document the patient's progress.

16. Control Pain
• Adequate pain relief should be provided, as pressure-induced injuries can
be quite painful. Local factors that may be contributing to pain such as
ischemia, infection, or breakdown of the surrounding skin should be
addressed.
• Pain may be classified as intermittent, which occurs at the time of wound
debridement, or cyclic, which occurs at the time of a dressing change, or as
persistent pain occurring all the time.
• Oral non-opioid pain medications can be used for mild pain. Opioid
analgesics may be needed for moderate-to-severe pain.
• Topical local anesthetics (eg, lidocaine) have been used and can provide
pain relief for a short period of time, but there is little evidence of
effectiveness from clinical trials. Topical opioids, such as a morphine gel,
have shown some benefit in small trials. However, many patients with deep
ulcers will require systemic therapy for pain.

17. Treat Infection
• All open ulcers are colonized with bacteria, but only clinically evident
infections should be addressed with culture and antibiotic treatment.
• Clinical signs of wound infection that might warrant antibiotic therapy
include local (cellulitis, purulence, malodor, wet gangrene,
osteomyelitis) and systemic (fever, chills, nausea, hypotension,
leukocytosis, change in mental status) symptoms.
• Systemic antibiotics are not recommended unless there is evidence of
advancing cellulitis, osteomyelitis, and bacteremia.

18. Optimize Nutrition
• Patients with pressure-induced skin often are in a chronic catabolic
state.
• Optimizing both protein and total caloric intake is important,
particularly for patients with stage 3 and 4 pressure injuries.
• Nutritional intake should be assessed by a nutritionist. Elements of
this comprehensive assessment may include protein and caloric
intake, hydration status, serum albumin, and total lymphocyte count.
Lab markers by themselves are not a sufficient marker of nutritional
status. Nutritional deficiencies should be corrected.

19. • If oral intake is not adequate to ensure sufficient calories, protein,
vitamins, and minerals, nutritional supplementation with enteral
or parenteral nutrition.
• A retrospective cohort study of 882 patients with pressure injuries at
long-term care facilities demonstrated that total caloric intake of at
least 30 kcal/kg promoted healing and decreased the size of stage 3
and 4 wounds.
• Increased dietary protein intake also promotes healing. The protein
target is usually 1.25 to 1.5 g/kg/day.

20. Redistribute Pressure
• Proper positioning and support to minimize tissue pressure should be
provided for all patients, particularly those with open wounds.
• The development of any new areas of skin damage should prompt review
of the method and intensity of preventive measures.
• Patients should be positioned and repositioned at least every two hours to
relieve tissue pressure.
• Use of nonpowered support surfaces (eg, foam mattresses or overlays) for
most patients with pressure-induced skin and soft tissue injuries.
• When cost is not a limiting factor, powered surfaces (eg air-fluidized beds)
may be appropriate for selected patients with large or multiple ulcers that
preclude appropriate positioning.

21. Prevent Contamination
• Contamination of wounds from urinary or fecal soiling may impair
wound healing. Urinary catheters or rectal tubes are often used to
help promote healing, but there is little evidence for benefit.

22. GENERAL WOUND MANAGEMENT
• Stage 1 skin injuries should be covered for protection.
• Stage 2 pressure injuries generally need little debridement and
require a dressing that maintains a moist wound environment.
• Stage 3 and 4 pressure or deeper injuries generally require
debridement of necrotic tissue and possibly treatment of infection.
Following appropriate wound bed preparation, coverage may involve
skin grafting or other tissue transfer procedures.

24. Poly-Urethane Film

25. Semi Permeable Foam Dressing

26. Hydro-Colloid Dressing/ Duoderm

27. WOUND DRESSINGS
• When a suitable dressing is applied to a wound and changed
appropriately, the dressing can have a significant impact on the speed
of wound healing, wound strength and function of the repaired skin,
and cosmetic appearance of the resulting scar. No single dressing is
perfect for all wounds; rather, a clinician should evaluate individual
wounds and choose the best dressing on a case-by-case basis.

28. An ideal dressing is one that has the following characteristics :
• Absorbs excessive wound fluid while maintaining a moist environment
• Protects the wound from further mechanical or caustic damage
• Prevents bacterial invasion or proliferation
• Conforms to the wound shape and eliminates dead space
• Debrides necrotic tissue
• Does not damage the surrounding viable tissue
• Achieves hemostasis and minimizes edema through compression
• Eliminates pain during and between dressing changes
• Is inexpensive, readily available, and has a long shelf life
• Is transparent in order to monitor wound appearance without disrupting dressing

29. MONITORING
The following parameters of care should be monitored daily and
documented
• Evaluation of the ulcer (Healing scales)
• Status of the dressing, if present
• Status of the area surrounding the ulcer
• Presence of pain and adequacy of pain control
• Presence of possible complications, such as infection

32. • EUSOL: Used for wound disinfection, ulcers cleaning and wet
dressing. It is used as an antiseptic agent and prevents the growth of
bacteria, fungi and viruses as well.
• Eusol Solution protects against infection, prevents bacterial growth
and can also be used as a normal disinfectant. Eusol Solution is only
meant for external use and users who suffer from skin disease such as
eczema should avoid using it.

33. • Magnesium Sulfate Paste: Increases collagen synthesis and
angiogenesis, providing faster and higher quality wound healing.
• In addition it provides an analgesic effect, it will also eliminate the
pain sensation caused by the wound and increase the quality of life of
the patient whose skin integrity is impaired.

34. • Zinc oxide: Medicated cream, ointment or paste that treats or
prevents skin irritation like cuts, burns or diaper rash.
• Sudocrem: Medicated cream aimed primarily at the treatment of
nappy rash. It contains a water-repellent base; protective and
emollient agents; antibacterial and antifungal agents; and a weak
anesthetic.

41. Sources
• National Pressure Injury Advisory Panel (NPIAP).
• UptoDate.
• CMDT.

42. Thank You