WHAT IS A PRESURE ULCER?
Pressure ulcers (also called decubitus ulcers or "bedsores") develop when there is injury to the skin and underlying tissue due to pressure for an extended period of time. This constant pressure reduces the blood supply to that area, preventing the delivery of vital nutrients and oxygen. Pressure ulcers most commonly occur in patients confined to a wheelchair or bed.
WHAT DO PRESSURE ULCERS LOOK LIKE?
Pressure ulcers can appear differently depending on the severity of the injury. They can appear simply as a discoloration (or redness) of the skin or as complex as dead, black tissue (called necrosis) with exposure of underlying structures like muscle and bone. Sometimes the injury may appear as a purplish bruise, which suggests that there is damage to deeper underlying tissues. If you notice persistent redness, any suspicious discoloration or skin breakdown over a bony prominence, you should notify your doctor immediately.
WHAT ARE THE RISK FACTORS FOR GETTING A PRESSURE ULCER?
- BEING CONFINED TO A WHEELCHAIR
- IMMOBILITY OR BEING BEDRIDDEN FOR ANY REASON (PARALYSIS, HIP FRACTURE, COMA)
- URINARY OR BOWEL INCONTINENCE WHICH IRRITATES THE SURROUNDING SKIN
- POOR NUTRITION
- DECREASED SENSATION AROUND AFFECTED AREAS
- RECENT SURGERY OR ILLNESS
WHAT CAN I DO TO PREVENT A PRESSURE ULCER?
- REPOSITION YOURSELF WHILE IN BED AT LEAST EVERY 2 HRS, IN A CHAIR AT LEAST EVERY HOUR
- KEEP THE HEAD OF THE BED LOWERED TO LESS THAN 30 DEGREES
- ELEVATE YOUR HEELS OFF THE BED USING A PILLOW UNDER YOUR LOWER LEGS
- USE A PRESSURE RELIEVING MATTRESS OR A CUSHION IN YOUR CHAIR
- USE PROTECTIVE CREAMS IF YOU HAVE INCONTINENCE
- MAINTAIN A BALANCED DIET
- MAINTAIN PROPER HYDRATION
★ Contact your physician if your wound site becomes more painful, odorous, larger or if the amount of fluid coming out from the wound increases
THE IMPORTANCE OF WOUND CARE
Successful treatment of difficult wounds requires assessment of the entire patient and not just the wound. Systemic problems often impair wound healing; conversely, nonhealing wounds may herald systemic pathology.
Consider the negative effects of endocrine diseases (eg, diabetes, hypothyroidism), hematologic conditions (eg, anemia, polycythemia, myeloproliferative disorders), cardiopulmonary problems (eg, chronic obstructive pulmonary disease, congestive heart failure), GI problems that cause malnutrition and vitamin deficiencies, obesity, and peripheral vascular pathology (eg, atherosclerotic disease, chronic venous insufficiency, lymphedema).
MEDICAL USES OF HBOT
In the United States the Undersea and Hyperbaric Medical Society, known as UHMS, lists approvals for reimbursement for certain diagnoses in hospitals and clinics. The following indications are approved (for reimbursement) uses of hyperbaric oxygen therapy as defined by the UHMS Hyperbaric Oxygen Therapy Committee:
- Air or gas embolism
- Carbon monoxide poisoning
- Carbon monoxide poisoning complicated by cyanide poisoning
- Central retinal artery occlusion
- Clostridal myositis and myonecrosis (gas gangrene)
- Crush injury, compartment syndrome, and other acute traumatic ischemias
- Decompression sickness
- Enhancement of healing in selected problem wounds
- Diabetically derived illness, such as diabetic foot, diabetic retinopathy,diabetic nephropathy
- Exceptional blood loss (anemia)
- Idiopathic sudden sensorineural hearing loss
- Intracranial abscess
- Necrotizing soft tissue infections (necrotizing fasciitis)
- Osteomyelitis (refractory)
- Delayed radiation injury (soft tissue and bony necrosis)
- Skin grafts and flaps (compromised)
- Thermal burns
Evidence is insufficient as of 2013 to support its use in autism, cancer, diabetes, HIV/AIDS, Alzheimer's disease, asthma, Bell's palsy, cerebral palsy, depression, heart disease, migraines, multiple sclerosis, Parkinson's disease, spinal cord injury, sports injuries, or stroke. Despite the lack of evidence, in 2015, the number people utilizing this therapy has continued to rise.
Recent studies have indicated that HBO therapy is recommended and warranted in those patients with idiopathic sudden deafness, acoustic trauma or noise-induced hearing loss within 3 months after onset of disorder.
HBOT in diabetic foot ulcers increased the rate of early ulcer healing but does not appear to provide any benefit in wound healing at long term follow-up. In particular, there was no difference in major amputation rate. For venous, arterial and pressure ulcers, no evidence was apparent that HBOT provides an improvement over standard treatment.
There are signs that HBOT might improve outcome in late radiation tissue injury affecting bone and soft tissues of the head and neck. In general patients with radiation injuries in the head, neck or bowel showed an improvement in quality of life after HBO therapy. On the other hand, no such effect was found in neurological tissues. The use of HBOT may be justified to selected patients and tissues, but further research is required to establish the best patient selection and timing of any HBO therapy.
There is tentative evidence for HBOT in traumatic brain injury. As of 2012 there is insufficient evidence to support its general use in TBI. In stroke HBOT does not show benefit. HBOT in multiple sclerosis has not shown benefit and routine use is not recommended.
A 2007 review of HBOT in cerebral palsy found no difference compared to the control group. Neuropsychological tests also showed no difference between HBOT and room air and based on caregiver report, those who received room air had significantly better mobility and social functioning. Children receiving HBOT were reported to experience seizures and the need for tympanostomy tubes to equalize ear pressure, though the incidence was not clear.
In alternative medicine, hyperbaric medicine has been promoted as a treatment for cancer, but there is no evidence it is effective for this purpose.
The ONLY absolute contraindication to hyperbaric oxygen therapy is untreated tension pneumothorax. The reason is concern that it can progress to tension pneumothorax, especially during the decompression phase of therapy. The COPD patient with a large bleb represents a relative contraindication for similar reasons.
Patients SHOULD NOT undergo HBO therapy if they are taking or have recently taken the following drugs:
- Doxorubicin (Adriamycin) – A chemotherapeutic drug. This drug has been shown to potentiate cytotoxicity during HBO therapy.
- Cisplatin – Also a chemotherapeutic drug.
- Disulfiram (Antabuse) – Used in the treatment of alcoholism.
- Mafenide acetate (Sulfamylon) – Suppresses bacterial infections in burn wounds
ESCHAR— A hardened black crust of dead tissue that may form over a wound.
PRESSURE ULCER— Also known as a decubitus ulcer, pressure ulcers are open wounds that form whenever prolonged pressureis applied to skin covering bony outcrops of the body. Patients who are bedridden are at risk of developing pressure ulcers.Pressure ulcers are commonly known as bedsores.
SEPSIS — A severe systemic infection in which bacteria have entered the blood stream.
The physician or nurse will begin by assessing the need for debridement. The wound will be examined, frequently by inserting a gloved finger into the wound to estimate the depth of dead tissue and evaluate whether it lies close to other organs, bone, or important body features. The area may be flushed with a saline solution before debridement begins, and a topical anesthetic gel or injection may be applied if surgical or mechanical debridement is being performed.
After surgical debridement, the wound will be packed with a dry dressing for a day to control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist dressings are also used after mechanical, chemical, and autolytic debridement. Many factors contribute to wound healing, which frequently can take considerable time. Debridement may need to be repeated.
It is possible that underlying tendons, blood vessels or other structures will be damaged during the examination of the wound and during surgical debridement. Surface bacteria may also be introduced deeper into the body, causing infection.
Removal of dead tissue from pressure ulcers and other wounds speeds healing. Although these procedures cause some pain,they are generally well tolerated by patients and can be managed more aggressively. It is not uncommon to debride a wound again in a subsequent session.
American Academy of Wound Management. 1255 23rd St., NW, Washington, DC 20037. (202) 521-0368.〈http://www.aawm.org〉.
Wound Care Institute. 1100 N.E. 163rd Street, Suite #101, North Miami Beach, FL 33162. (305) 919-9192.http://woundcare.org.
Gale Encyclopedia of Medicine. Copyright 2008 The Gale Group, Inc. All rights reserved.
débridement [da-brēd-ment´] (Fr.)
the removal of all foreign material and all contaminated and devitalized tissues from or adjacent to a traumatic or infected area until surrounding healthy tissue is exposed.
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"Appropriate debridement undertaken early is likely to accelerate healing, improving patient health and wellbeing and reducing the cost of chronic wound management."
WHAT IS DEBRIDEMENT
Debridement speeds the healing of pressure ulcers, burns, and other wounds. Wounds that contain non-living (necrotic) tissuetake longer to heal. The necrotic tissue may become colonized with bacteria, producing an unpleasant odor. Though the wound is not necessarily infected, the bacteria can cause inflammation and strain the body's ability to fight infection. Necrotic tissuemay also hide pockets of pus called abscesses. Abscesses can develop into a general infection that may lead to amputation or death.
Not all wounds need debridement. Sometimes it is better to leave a hardened crust of dead tissue, called an eschar, than to remove it and create an open wound, particularly if the crust is stable and the wound is not inflamed. Before performing debridement, the physician will take a medical history with attention to factors that might complicate healing, such asmedications being taken and smoking. The physician will also note the cause of the wound and the ways it has been treated.Some ulcers and other wounds occur in places where blood flow is impaired, for example, the foot ulcers that can accompany diabetes mellitus. In such cases, the physician or nurse may decide not to debride the wound because blood flow may beinsufficient for proper healing.
In debridement, dead tissue is removed so that the remaining living tissue can adequately heal. Dead tissue exposed to the air will form a hard black crust, called an eschar. Deeper tissue will remain moist and may appear white, or yellow and soft, or flimsy. The four major debridement techniques are surgical, mechanical, chemical, and autolytic.
Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other instrument to cut dead tissue from a wound. It is the quickest and most efficient method of debridement. It is the preferred method if there is rapidly developing inflammation of the body's connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the bloodstream. The procedure can be performed at a patient's bedside. If the target tissue is deep or close to another organ,however, or if the patient is experiencing extreme pain, the procedure may be done in an operating room. Surgical debridement is generally performed by a physician, but in some areas of the country an advance practice nurse or physician assistant may perform the procedure.
The physician will begin by flushing the area with a saline (salt water) solution, and then will apply a topical anesthetic gel to the edges of the wound to minimize pain. Using a forceps to grip the dead tissue, the physician will cut it away bit by bit with a scalpel or scissors. Sometimes it is necessary to leave some dead tissue behind rather than disturb living tissue. The physician may repeat the process again at another session.
In mechanical debridement, a saline-moistened dressing is allowed to dry overnight and adhere to the dead tissue. When the dressing is removed, the dead tissue is pulled away too. This process is one of the oldest methods of debridement. It can be very painful because the dressing can adhere to living as well as nonliving tissue. Because mechanical debridement cannot select between good and bad tissue, it is an unacceptable debridement method for clean wounds where a new layer of healingcells is already developing.
Chemical debridement makes use of certain enzymes and other compounds to dissolve necrotic tissue. It is more selective than mechanical debridement. In fact, the body makes its own enzyme, collagenase, to break down collagen, one of the major building blocks of skin. A pharmaceutical version of collagenase is available and is highly effective as a debridement agent. As with other debridement techniques, the area first is flushed with saline. Any crust of dead tissue is etched in a cross-hatched pattern to allow the enzyme to penetrate. A topical antibiotic is also applied to prevent introducing infection into thebloodstream. A moist dressing is then placed over the wound.
Autolytic debridement takes advantage of the body's own ability to dissolve dead tissue. The key to the technique is keeping the wound moist, which can be accomplished with a variety of dressings. These dressings help to trap wound fluid that contains growth factors, enzymes, and immune cells that promote wound healing. Autolytic debridement is more selective than any other debridement method, but it also takes the longest to work. It is inappropriate for wounds that have become infected.
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