Decubitus Ulcer GB 09

7/25/2019 Decubitus Ulcer GB 09

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Phase-specific

wound managementof decubitus ulcer

medicaledition

Wound Management

The HARTMANN medical edition

series of publications deals with

current subjects from the areas

of medicine and nursing.They emphasise not only basic

knowledge, but also present

specialist and interdisciplinary

developments. The information

goes beyond the products and

is particularly important.

At a time of rapidly evolving

scientific knowledge, information

must above all be up to date.

With this in mind, this series of

books aims to be a source of

advice not only for experiencedworkers. Those who are approach-

ing new areas of medicine and

nursing for the first time are

shown modern treatment methods

and are given useful tips.

PAUL HARTMANN AG

P.O. Box 14 20

89504 HeidenheimGermany

ISBN 978-3-929870-68-8 B34(0708)086XXX/X

HARTMANN

medicaleditionPhase-specificwoundmanagemen

tofdecubitusulcer


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Phase-specificwound managementof decubitus ulcer


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[2.3]

Published by

PAUL HARTMANN AG

89522 Heidenheim

Germany

http://www.hartmann.info

Concept, design, editing and

production:

CMC Medical Information

89522 Heidenheim

Germany

Scientific supervision:

Prof. Dr. med. Walter O. Seiler,

University Geriatric Clinic;

Basel Cantonal Hospital

Friedhelm Lang,

Head of Surgical Department

Leonberg District Hospital

PAUL HARTMANN AG

May 2008

2nd edition

ISBN 978-3-929870-68-8

Translated from the German

edition (ISBN 978-3-929870-62-6)

Paper bleached by a chlorine-free

process

Table of contents

Preface 5

Development of decubitus a multifactorial process 6

Common sites of decubitus ulcer formation 9

Decubitus hazards and risk factors 10 Classification and degrees of severity of decubitus 18

Management of decubitus general principles 20

Relief of pressure as the basis of all treatment 27

Phase-specific moist wound treatment 30

Ident if icat ion and treatment of fac tors in terfering with wound heal ing 39

Hydroactive wound dress ings for phase-specific, moist wound treatment 46

TenderWet wound pad with superabsorber 48

Sorbalgon calcium alginate dressings with excel len t con formabil it y 53

PermaFoam hydroactive foam dressing 57

Hydrocoll absorbent hydrocolloid dressing 60

Hydrotul hydroactive impregnated dressing 63

Hydrosorb transparent hydrogel dressing 65

Hydrosorb Gel for dry wounds rehydration 68

Atrauman Ag silver containing ointment dressing 69

Zetuvit Plus wound dressing for heavily exuding wounds 70

Nursing activities for decubitus prophylaxis 78

Supplementary aids for treatment and nursing care 81

Glossary and list of key terms 85

References and list of illustrations 87


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[4.5]

Preface

One of the most serious complications of immobility is the

development of a decubitus ulcer (pressure ulcer, pressure

sore). For the person affected, it is always a serious health

impairment, quite apart from the enormous amount of

nursing input and cost involved in treating pressure sores.

The problem of pressure ulcer impacts all areas of nursing

care and it has come to be regarded as an indicator of the

quality of nursing care if a pressure sore does not develop.

Under this aspect, increased attention has therefore been

devoted in recent years to the problems associated with

pressure sores. It has been attempted in scientific and clin-

ical studies to elaborate guidelines for practicable prophy-

lactic and therapeutic activities and establish them as

standard practices.

Despite these efforts, pressure ulcer with an annual inci-

dence of 150,000 cases in Stages III and IV still remains a

major problem for a number of reasons. The growing num-

ber of elderly and aged persons of restricted mobility and

often pronounced multimorbidity is a significant factor in

this respect. Especially in the elderly, the management of

pressure ulcer presents a challenge which all too often

remains unmastered.

This HARTMANN medical edition provides essential know-

ledge relating to the pathogenesis of pressure ulcer andsets out successful therapeutic principles which, if applied

consistently, promise good prospects of a cure. It should

nevertheless be emphasized that the management of decu-

bitus ulcer requires both knowledge and skill and a high

degree of discipline on the part of all those involved in

delivering wound management. In many cases, traditional

methods and approaches have to be reconsidered; the

widespread practice of polypragmasy is to be avoided in

favour of consistently structured therapeutic concepts.


5/46Development of decubitus [6.7]

Development of decubitus a multifactorial process

Immobility and the resulting abnormally long period ofexposure to pressure is without doubt the central causalfactor in the pathogenesis of pressure ulcer.

However, a large number of other risk factors specific toindividual patients also contribute to the development ofpressure sore, which makes the process highly complex anddifficult to define. Nevertheless, a program of treatment andnursing care will attempt to address the patients needs ona holistic basis and not merely treat the pressure ulcer as anisolated phenomenon.

A decubitus ulcer is defined as damage to the skin result-

ing from persisting local exposure to pressure. Its process

of development may be outlined in the following general

terms:

When sitting or lying, the human body exerts pressure on

the surface supporting it, which in turn exerts counterpres-

sure on the area of skin bearing upon it. The degree of

counterpressure varies depending on the hardness of thesupporting surface, but is usually above the physiological

capillary pressure of approx. 25-35 mmHg arterial. For

short periods, the skin can tolerate exposure to even high-

er pressures. If the pressure persists, however, compression

of the capillaries carrying the blood in the area of skin

affected results in a reduction of blood flow and oxygen

deficiency (hypoxia). The body responds to this incipient

damage by producing pressure pain as a warning sign,

which causes a healthy person capable of movement to

change position to relieve the load on the compressed

area of skin. Even slight movements are sufficient to inter-

rupt the exposure to pressure and stimulate the impaired

blood circulation back into activity. This pressure pain

mechanism also functions involuntarily during sleep, which

is why persons capable of movement do not develop a

pressure sore.

If these persons are unable to perceive the warning pain,

however, for example because of unconsciousness, anes-

thesia, severe dementia and/or if they are no longer strong

enough to move unaided in response to pain, the com-pression of the skin continues. The impairment of blood

circulation worsens and leads to an accumulation of toxic

metabolism products in the tissue accompanied by an

increase in capillary permeability, vasodilation, cellular

infiltration and edema.

If the pressure on affected area of skin is then removed

completely, the cells are still capable at this point of regen-



erating completely because the inflammatory responses

promote the elimination of the toxic metabolism products.

If exposure to pressure remains, however, the worsening

ischemia and hypoxia result in irreversible death of the

skin cells with necrosis and ulcer formation.

The main causes of pressure ulcer are thus the factors

pressure x time acting on a given area of skin.

Clinically relevant factors in this respect are the degree of

pressure and the length of time. A high degree of pressure

results in tissue damage sooner than a low degree. As

regards the factor time, high pressure peaks over a short

period are well tolerated by the skin. In contrast, persistingpressure only slightly above the capillary pressure damages

the skin after only a few hours. This fact has practical

consequences: For prophylaxis, patients at risk of pressure

ulcer should be repositioned after a period of not more

than two hours.

It should always be remembered, however, that this aver-

age tolerance range of the skin is subject to considerable

variations which are determined by the individual patients

Causes of pressure sore:

For short periods, the skin can

survive exposure even to heavy

pressure without being damaged.

If the pressure persists, however,

the affected skin cells become

completely ischemic because of

the increasing impairment of

blood circulation and the skin

cells die.

risk factors such as the degree of immobility, the condition

of the skin, various basic illnesses etc. What specific risk

factors are involved and what role they play in causing

pressure sores are considered in the section Decubitus

hazards and risk factors on page 10 onwards.

Common sites of decubitus ulcer formation

Depending on where the skin is exposed to pressure, a

pressure ulcer can develop anywhere on the body. Therisk is greatest at those sites, however, where the bearing

pressure of the body and the counterpressure exerted by

the supporting surface act perpendicularly on an area of

skin located over convex skeletal regions which have little

pressure dispersing elastic muscle and subcutaneous fatty

tissue. Accordingly, the classical sites of predilection

(about 95 % of all pressure sores develop here) are the

sacral region, the heels, the ischial bones, the greater

trochanter and the lateral malleoli.

Pressure / pressure exposure time

local impairment of blood flow

oxygen deficiency / increase in toxic

metabolism products

increase in capillary permeability,

vascular dilatation, cellular infiltration,edema formation

blister formation

complete ischemia,

irreversible death of skin cells

Ulcer / necrosis

Examples of classical sites of

predilection for pressure sores:

1) Sacral region

2) Heel

3) Trochanter

4) Lateral malleolus

1 2

3 4



Another characteristic feature of pressure acting on convex

bony contours is that the pressure increases from the

larger skin surface towards the deeper-lying convex bone

surface. This results in necroses in the subcutaneous fatty

tissue and muscles until, often not until several days have

passed, the skin ulceration becomes apparent.

This lesion may be relatively small and does not always

reflect the already considerable damage in the deeper

regions. Sometimes the skin shows only reddening andslight damage of the epidermis (closed decubitus).

Besides the pressure acting perpendicularly on an area of

skin, shear forces are probably also involved in causing

pressure sores. Shear is a term denoting tangential shifts

in the skin layers in relation to each other, which also

constrict and compress the blood vessels. Tangential forces

may be expected to arise particularly in the sacral region,

for example when the patient is pulled instead of lifted

into a new position or slides in bed due to inadequate

support for the feet.

Experimental studies on the effects of perpendicularly

acting shear forces allow the conclusion that when a

combination of shear forces and pressure is present, even

slight pressure is enough to reduce the oxygen partial

pressure in the tissue to a critical level (Bennet et al., von

Goosens et al.).

Decubitus hazards and risk factors

The most important risk factor is immobility, since it iscausally related to the duration of pressure exposure. The

hazard increases with the patients degree of immobility.

The commonest pressure

sore localisations

Pressure ulcer develops preferentially over bony prominences hardly

cushioned by muscle and subcutaneous fatty tissue. These are in dorsal position: sacral bone and coccyx, heels and Achilles tendons,

elbows, shoulder blades and occipital bone in abdominal position: frontal bone, elbows, breastbone and costal

arches, iliac crest, kneecaps and tips of the toes in lateral position: great trochanter, ear and zygomatic bone, lateral

ribs, shoulder joint, iliac crest, inner and outer knee joint, calf bone

and lateral malleolus in sitting position: ischial tuberosity, occipital bone, spine and heels;

if poorly supported, there is also a potential hazard from shear forces


8/46

Development of decubitus [12.13]

Total immobility: If spontaneous movements are no

longer possible, the patient is absolutely at risk. Total

immobility is seen, for example, in unconscious, anes-

thetised or completely paralysed patients. The patients

age is irrelevant.

Relative immobility: A high hazard potential is present

because spontaneous movements are more or less re-

stricted, for example due to sedation, fractures, severepain, multiple sclerosis, paraplegia, hemiplegia and

disorders of sensitivity of widely varying origin, such as

polyneuropathy.

It should especially be remembered that the risk factor

immobility is influenced by general nursing care activities

and is thus inevitably subject to diurnal variations. For

example, whereas the immobile patient is repeatedly

moved during the day for basic care activities and feeding,

during the night there is usually a critically long period of

immobility. These problems are observed especially in

association with age related reductions in mobility, which

also results in a critical decrease in spontaneous body

movements (motility) during the night. When additional

diseases are present, such as fever (pneumonia) or severe

pain, the number of nocturnal body movements may

decrease to practically zero, and without prophylaxis the

patient is at risk of developing a pressure sore.

Secondary risk factors

Further secondary risk factors include all states and illness-es which affect especially the function and resistance of

the skin. The skin then becomes more sensitive to pressure

and even brief periods of exposure to pressure can result

in damage.

These risk factors include:

Insufficient blood supply to the skin: Insufficient blood

supply to the skin means a reduced supply of oxygen and

impaired metabolic processes in the skin cells, with the

result that the skins tolerance of hypoxia also decreases.

Blood perfusion can be impaired by a multiplicity of fac-

tors, such as hypovolemic, cardiogenic or septic shock,

low blood pressure, dehydration, heart failure, diabetes

mellitus, arteriosclerosis etc.

Fever: Fever leads to an intensified metabolism of the

skin cells and an increased oxygen demand, as a result of

which inadequate blood perfusion already occurs at

subdecubitogenic pressures. Moreover, in febrile states the

immobility of geriatric patients is often worsened, and

fever is therefore classified as the most important second-

ary risk factor for this patient population.

Incontinence: Moisture and the aggressive decomposition

products of urine and/or feces irritate and soften the skin,

which is also highly bacterially contaminated. If these

effects are not mitigated by the use of adequate skin care

and provision of appropriate aids, the upper layers of skin

become macerated, lowering the skins resistance to

pressure. Incontinence is thus another risk factor affecting

especially elderly, bedbound patients. It is, however, incor-

rect to assume that incontinence alone can cause a pres-

sure sore. The causal factor in pressure ulcer is pressure,

and incontinence is a contributory factor.

Debilitated general condition: Chronic or severe illness-

es, malignant processes, infections, malnutrition character-

ized by protein, vitamin and zinc deficiency, anemia, exsic-

cosis, cachexia etc. also increase the risk of pressure sore.

Many of the diseases greatly restrict the patients mobility/

motility and impair the skins metabolism.


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Physiological aging of the skin: Independently of co-

existing diseases, geriatric skin is itself a risk factor for

developing a pressure ulcer. The age related depletion of

cellular and fibrous elements makes the skin generally

thinner, and the skins connective tissue loses elasticity. As

a result, the skins ability to tolerate mechanical loading

decreases, and exposure to pressure can lead to the for-

mation of a pressure ulcer within a very short time.

Operation-specific risks

The primary causes of intraoperatively acquired pressure

ulcer are essentially the same as those in other areas of

medicine and nursing: pressure (poorly padded or

unpadded operating tables acts over a period of time

(operation time) on certain areas of the patients skin and

damages them. However, there are also secondary, opera-

tion-specific risks due firstly to patients themselves and

secondly to the surgical procedure. Besides the factors

already described, such as effects of acute and systemic

diseases, fever, age etc., risks presented by patients them-

selves include existing skin damage, e.g. due to confine-

ment to bed before the operation or extension treatment

until the patient is capable of being operated.

Risks arising during the surgical procedure may include:

anesthesia-induced loss of skin tone, incorrect reposition-

ing (especially of the extremities, which may lead to

extremely high pressure points), extreme shear forces and

exposure to pressure during treatment of fractures on the

extension table, assistants leaning on the patient for sup-port, patient hypothermia, incorrect use of disinfectants

(especially in the coccyx region, which can also lead to

excessive cooling of the skin because iodine- and alcohol-

containing disinfectants collect here at the lowest point),

long vessel clamping times or excessively long bloodless

times.

Risk factors for decubitus

Primary risk factors that reduce motility and lead to total/relative immobility

Secondary risk factors that especially reduce tissue tolerance

Neurological disorders with paralysis (all): cerebrovascular stroke, hemiplegia, hemiparesis, paraplegia,

tetraplegia, comatose states of any origin

Surgical interventions: anesthesia (premedication, anesthesia, recovery phase), long operation times

Psychiatric illnesses and psychotropic medications: acute psychoses such as catatonia and acute

depression, sedative medications like neuroleptics, benzodiazepines and similar

Consumptive diseases and severely painful states

Factors reducing intravascular pressure

Arterial hypotension: shock (hypovolemic, septic, cardiogenic), overdose of antihypertensive agents

Dehydration: diuretics, diarrhea, summer heat

Factors reducing oxygen transport to the cell

Anemia: Hemoglobin < 9 g/dl

Peripheral arterial occlusive disease

Diabetic microangiopathy

Hypotension, bradycardia

Hypovolemic shock

Factors increasing oxygen consumption in the cells

Fever: > 38 C

Hypermetabolism

Infections, cytokinemia

Factors resulting in nutrient deficiency in the cells

Malnutrition: deficiency of protein, vitamins, minerals, trace elements

Cachexia: immobility due to muscular weakness and catabolism

Lymphopenia associated with malnutrition: immune deficiency, disorder of wound healing

Factors weakening the skins resistance

Geriatric skin: thin, atrophic, with few immune cells Skin diseases: eczema, candidiasis

Dry, cavernous skin: promotes bacterial and fungal skin infections

Pressure-damaged, reddened skin: as a sign of harmful shunt circulation

Macerated, softened skin: in incontinence due to breakdown products of urine and feces

Heat, inflammatory reddening: circumvention of nutritive microcirculation

Steroid induced skin atrophy: thin, easily injured skin

(Source: Seiler, 2002)


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Assessment of hazard from pressure ulcer

Estimating each patients risk of developing a pressure

ulcer is the first step in planning of prophylaxis.

This activity may be assisted by using various rating scales

such as the Norton scale, the Waterlow scale or the

Braden scale. In Germany, the extended Norton scale is

widely used in medical nursing, while the Waterlow scale

relates more specifically to the risks of surgical patients.

The Braden scale is used more commonly in the USA.

Common to all these scales is that they take similarly into

account the patients mental and physical state as well as

their level of activity and mobility, and are thus all useful

instruments. It should be noted, however, that the assess-

ment of hazard from pressure ulcer and hence the delivery

of adequate prophylaxis should not only begin at the stage

when reddening has already developed at the risk sites.

Furthermore, the points score should be checked at regular

intervals to allow timely identification of changes and

a suitable response to be made in terms of modifying

activities. The assessment of pressure ulcer hazard is thus

part of a thorough program of documentation.

Physical state Incontinence Activity Mobility Psychological

state

4 good 4 none 4 no assistance

required

4 completely 4 clear

3 fair 3 sometimes 3 possible with

assistance

3 hardly

restricted

3 apathetic /

disinterested

2 poor 2 usually urine 2 wheelchair

required

2 very restricted 2 confused

1 very poor 1 urine and

feces

1 bedbound 1 completely

restricted

1 stuporous

Willingness to

cooperate

Age State of the skin Concomitant diseases

4 completely 4 < 10 4 normal 4 none

3 few 3 < 30 3 scaling dry 3 immune weakness, fever,

diabetes, anemia

2 partially 2 < 60 2 moist 2 MS, Ca, elevated hematocrit, obesity

1 none 1 60 1 allergy wounds,

fissures

1 arterial occlusive disease

According to the original Norton scale (above) patients with

a points score of 14 and less are to be classified as being at risk

of developing a pressure sore. In the extended Norton scale

(original scale above + extension below, devised by C. Bienstein

et al.) which allows a more differentiated assessment of the

patients status, a risk of pressure ulcer is present at a score of

25 points and less. Prophylactic measures must be planned andimplemented immediately.


11/46


Classification and degrees of severity of decubitus

Considering the origins of pressure ulcer, it is clear why

the ulceration develops in stages: The longer the area of

skin is exposed to pressure, the more severe the tissue

damage becomes.

The classification of degrees of severity is therefore based

on an evaluation of which layers of skin have already been

destroyed by the pressure damage. Various decubitus clas-sifications are used, such as Daniels classification into five

degrees of severity, which is used particularly in the surgi-

cal field, or the most commonly used classification into

four degrees of severity developed by the National Pres-

sure Ulcer Advisory Panel in 1989.

Stage I: Sharply defined area of reddening on intact skin

that, when pressed, is non-blanchable. Indicative signs

may also include hyperthermia of the skin, induration or

edema, and persons with dark skin coloration may show

depigmentation. With consistent pressure relief the red-

dening pales after several hours or days, depending on the

severity of the prior impairment of blood perfusion.

Stage II: Partial loss of epidermis as far as the dermis.

This is a superficial ulcer which may manifest clinically as

an abrasion, blister or shallow crater.

Stage III: Damage to all layers of skin (epidermis, dermis

and subcutis), which may extend as far as the fascia

beneath the skin, although the fasciae are not yet affect-ed. Clinically, the pressure ulcer looks like an open sore

with or without undermining of the surrounding tissue.

Classification of the severity of

pressure ulcer is based on which

tissue layers have already been

destroyed by exposure to pressure.

Stage IV: Loss of skin involving the entire skin thickness

with extensive tissue necrosis and damage to muscles,

tendons and bones. Undermining and pocket formation

are also commonly seen.

Identifying the current stage of the ulceration may be

difficult in practice. For example, skin damage in Stage I

is often not reliably assessed, especially in patients with

dark skin pigmentation. As already mentioned, a Stage I

may already be a sign of deeper lying damage in the form

of a closed decubitus, for example secondary to intraop-

erative exposure to pressure. An ulcer covered with scaband necrotic debris may also impede correct evaluation

unless the devitalised tissue has first been removed.

The assessment of pressure sores may also be difficult in

patients with plaster casts and other orthopedic devices.

Epidermis

Dermis

Subcutis

Muscles,

Tendons,

Bones

Stage I

Stage II

Stage III

Stage IV


12/46

Management of decubitus [20.21]

Management of decubitus general principles

A decubitus ulcer not infrequently takes many months toheal and in elderly persons often presents a challenge thatremains unmastered. Not least, this may be because of the

extreme difficulty in translating the complexity of pressureulcer causation and chronic wound healing into easilyunderstandable, standardized therapeutic concepts.Medicine and nursing are therefore called upon to developa treatment which as far as possible takes into account theindividual patients specific disease and life circumstances.

Because so many influencing variables and risk factors

are present concurrently and have to be given adequate

consideration in the management of pressure sore, it is

recommended to pursue a consistent approach based on

a treatment schedule. This schedule should not be seen as

a rigid structure, but should rather take the form of a care-

fully assembled check list helping to ensure that nothing

is overlooked. A quality assured management program

will include the following steps: Initial assessment of the overall situation, both of the

local state of the ulcer and the patients general status

Completely relieving the pressure on the damaged area

of skin to restore the blood supply.

Phase-specific moist wound treatment with debridement

and infection control; the possibilities of plastic surgical

defect coverage are to be explored and applied if

appropriate

Adjuvant therapies to improve the patients general

condition and nutritional status and to provide ade-

quate pain control; factors interfering with wound

healing are to be treated.

Careful documentation for quality control and security

under liability law aspects.

Assessment of decubitus ulcer

In the initial assessment, the ulcer is evaluated according

to localization, stage, size (length, breadth, depth), pocket

formation, undermining, exudate flow etc. The schedule

provided on page 25 offers a possible approach to initial

assessment. The ulcer localization is sketched in thedrawing field. It is also recommended to include a colour

photograph of the ulcer in the documentation.

To exactly determine the size and volume of an ulcer,

volumetric measurement of the wound is a practicable

approach requiring little time and effort. The wound is

covered with a foil and filled with sterile liquid (e.g.

Ringers solution) using a syringe.


13/46

Initial assessment of overall situation

Causal therapy

Local ulcer therapy

Adjuvant therapies

Treatment

Ulcer healing?

Localization of the ulcer, severity, general

condition of the wound

Evaluation of the patients status, compliance

Complete relief of pressure to restore the blood

supply throughout the treatment period until the

ulcer has healed

Adequate surgical debridement

Infection control, when appropriate

Moist dressing treatment for further wound

cleansing, conditioning and epithelisation

Plastic surgery techniques as appropriate

Improve the general condition

Improve the nutritional status

Pain management

Identify local and systemic factors interfering

with wound healing and eliminate them as far

as possible

Course of treatment for decubitus ulcer supervision

and continuation of therapy according to treatmentschedule

Careful monitoring of activities (especially whether

pressure relief is adequate)


Volumetric measurement of the

wound is an exact and simple

method of determining the size

and volume of a wound.

The wound is covered with a foil

(left) and filled with sterile liquid

using a syringe(right).The number

of injected ml or ccm correspond

to the volume.

The injected ml or ccm represent the volume. Volumetric

measurement should also be performed repeatedly during

wound healing, since the values recorded are prognostically

valuable and represent valuable objective data for inclusion

in case records. As a positive secondary effect, volumetric

measurement is also useful as a form of wound irrigation.

If it is known under what circumstances and through the

application of what pressure the ulcer developed, these

details are also to be entered in the initial assessment:

For example, application of pressure during surgery, inassociation with a febrile disease, as the result of a fall and

lying too long at home etc. This information is particularly

important for assessing the continuing risk of developing

a pressure sore.

Assessment of the patients status

The assessment of the patient should include the general

condition, possible complications and concomitant dis-

eases, the nutritional status, the severity of any pain, but

also a careful inventory of the psychosocial situation.

General physical condition: Wound healing is not mere-

ly a local process, but is linked to processes in the entire

body on many levels; consequently, an improvement in the

patients general condition can have a major influence on

wound healing.

yes

no

Course of treatment

for decubitus


14/46


Depending on the patients age and illness, however, an

improvement in the general condition cannot always be

achieved within a short time, and may even be severely

impaired, for example in multimorbid geriatric patients.

In practice, the necessary data can be obtained from the

patients medical record and if not, are to be elicited by

taking a careful and comprehensive medical history and

conducting a physical examination.

With pressure ulcers, moreover, the physician should be

alert to the possibility of complications, such as endo-

carditis, meningitis, septic arthritis, pocket and abscess

formation, malignant processes in the ulcer area, and for

systemic complications of the topical therapy, such as

iodine toxicity or allergy. Serious complications associated

with infection include osteomyelitis, bacteremia and

generalized sepsis.

Nutritional status: Numerous studies have established

a relationship between the poor healing tendency of pres-sure sores and malnutrition. Cachectic states associated

with protein deficiency, however, are observed particularly

often in elderly persons, and the nutritional status should

therefore be evaluated at regular intervals in these cases.

Elderly patients are often also suffering from zinc deficiency

which can also lead to delays in wound healing and

should therefore be checked.

Malnutrition should be treated, taking into account the

patients wishes, by providing adequate dietary intakewith an increased protein content and sufficient vitamins

and minerals. The requirement for nutrients in illness and

catabolism in the elderly is reported as follows per kilo-

gram of body weight and per day (Seiler, 2001): 30 to

40 kcal, 1.5 g proteins, 1.0 g fats, 10 mg vitamin C, 15 mg

calcium, 0.5 mg zinc, vitamin B12 parenterally substituted

(target dose 10 mg total or 0.15 mg per kg body weight

within one month; Interval: every 3 days 1 mg i. m.)

Record form for assessment of decubitus

Name

Age

Date / time of recording

Size

Length breadth depth

Severity / structures affected

Stage I: skin reddening with intact epidermis

Stage II: superficial ulcer, partial loss of epidermis as far as dermis

Stage III: deep, open ulcer, damage to all skin layers as far as the fasciae

Stage IV: extensive tissue necroses, damage to all skin layers including

muscles, tendons and bones

Yes No

Pocket formation

Undermining

Necrotic tissue: closed black necrotic cap

scab

slimy layers

Exudate: serous-bloody

purulent

Granulation: loose, spongy

red, firm

Epithelium formation visible

Pain

Signs of infection: III sligt reddening

III reddening, swelling, pain

III plus fever, leukocytosis

Causation

General condition / other


15/46


and a high-dose multivitamin preparation. If normal

dietary intake is insufficient or impossible, a fully balanced

liquiddrinking diet or a parenteral diet shouldbe considered.

Adequate fluid intake should also be ensured.

Pain: Even if patients do not give expression to their pain

or do not react to it, this does not mean that it is not

present. Pressure ulcer is usually associated with chronic,

diffuse pain affecting the entire body and making every

change of position extremely painful. Unfortunately, pain

management is still not always accorded the importance

demanded by many experts. Usually, such treatment

consists merely in the administration of analgesics on

demand. Pain management, however, should aim to

achieve the greatest possible freedom from pain, which

requires the regular administration of individually dosed

analgesics.

Psychosocial assessment: Regardless of whether the decu-

bitus patient is being treated in hospital, in a nursing facil-ity or at home, the same therapeutic principles should be

applied to the same standard quality, since otherwise there

is little prospect of a cure. The individual psychosocial situ-

ation, however, sometimes presents greatly differing base-

line conditions in terms of the patients ability to fully

understand the therapeutic requirements and cooperate

with the treatment. The aim of the psychosocial assess-

ment is therefore to obtain information about the degree

of willingness to cooperate that may be expected from the

patient and his/her relatives and what can be done (e.g.by informative interviews, training, use of suitable aids etc.)

in order to assure consistent adherence to the treatment

and nursing schedule. A realistic assessment of the psy-

chosocial situation is thus of major importance especially

in domiciliary care context. Aspects to be evaluated

include the patients mental state, ability to learn, signs

of depression, the social environment, relationship to the

caring relatives as well as lifestyle and ethnicity related

problems. The resources available for treatment and nurs-

ing are also to be evaluated, e.g. the availability and

specialized qualification of carers, financial resources,

equipment etc. If despite all endeavours it is not possible

to create an environment conducive to compliance with

the treatment and nursing schedule, transferring the

patient to the hospital setting should be considered.

Relief of pressure as the basis of all treatmentDecubitus ulcers develop as the result of unrelieved expo-

sure of the skin to pressure, leading via ischemic processes

to the death of skin cells. The causal principle underlying

all decubitus treatments is therefore to restore the blood

supply to the affected area of skin by providing complete

relief of pressure. Without pressure relief, healing is not

possible, and all other activities are pointless. The pressure

relief is also to be maintained throughout the entire treat-

ment period. Any exposure to pressure, even for a few

minutes, causes new damage and sets back the progress

of healing.

Transcutaneous oxygen measurements on the skin under

simulated and clinical conditions in young volunteers have

shown that adequate pressure relief is followed by imme-

diate restoration of the microcirculation and oxygen supply

of the skin (Seiler, 1993). When pressure relief is assured,

not only oxygen, but also all the other cells necessary for

the repair process as well as the biologically important

substances such as hormones, enzymes, vitamins and

growth factors enter the wound area. For complete press-ure relief, the patient is to be positioned such that he/she

under no circumstances can come to bear weight onto the

wound. Even on a bed fitted with supersoft bedding for

pressure relief, the wound area must be kept free from

contact. The positioning that is possible depends on the

localization of the pressure ulcer (see table). The 30 degree

oblique position is regarded as the position involving the

lowest risk.


16/46


The 90 degree oblique positioning should no longer be

used, either for prophylaxis or for treatment, because most

of the bodys weight then bears on the trochanter. Even

before beginning any treatment, therefore, the type of

positioning suitable for each patient should be estab-

lished, and should lead to the establishment of binding

guidelines for all those involved in the treatment and

nursing of the patient.

The different positioning techniques require the combined

use of static and dynamic aids. Static aids, such as posi-

tioning cushions, should be selected under specific criteria.

Their elasticity should be such that it is also preserved

under pressure. If the material bunches together, new

pressure points result. Especially when using products for

free positioning, such as seating rings, superficial pressure

distribution must be assured. There is no point in free posi-

tioning individual parts of the body and exposing other

parts to pressure.

The patient must also lie securely and without the risk of

Decubitus localisation Correct positioning Remarks

Right trochanter dorsal position 30 degree

oblique position, left

all lateral positioning

is prohibited

Left trochanter dorsal position 30 degree oblique

position, right

all lateral positioning

is prohibited

Sacral region 30 degree oblique position, right30 degree oblique position, left

135 degree positioning

Heel 30 degree oblique position, right

30 degree oblique position, left

contact-free on special cushions

if absolutely contact-free positioning

is guaranteed, then also dorsal

position is possible

Ischial bone 30 degree oblique position, right

30 degree oblique position, left

135 degree positioning

sitting prohibited, dorsal

position is possible if the

patient is also freely positioned

slipping on the positioning aids. With inexpert positioning,

the unfavourable weight distribution creates shear forces.

For larger decubitus ulcers, patients with multiple risk fac-

tors for pressure ulcer, and postoperatively after decubitus

surgery, anti-decubitus mattresses of the low air loss

type are used to ensure absolutely certain pressure relief.

A rhythm of two hours is prescribed as the time interval

for repositioning. For patients with a very high decubitus

hazard it may be necessary to reduce this interval further.

A certain amount of experience is generally needed toposition patients correctly according to their requirements.

It is by no means sufficient simply to slide a cushion some-

where underneath the patient. Nursing personnel should

be fully aware that positioning is not intended to provide

pressure relief in isolated areas, but is a means of influenc-

ing the patients body feeling as a whole. In the worst

case, inadequate positioning can rapidly give rise to

considerable further impairments such as respiratory or

circulatory problems, stiffening of joints or contractures.

The correct positioning of the

patient depends on the localiza-

tion of the decubitus ulcer.

The basic positioning variants

shown here are also suitable

for prophylaxis.

Examples of positionings for

pressure relief with the aid of

special cushions:Due to its special

design, the cushion bed (left)

offers effective pressure relief for

patients in dorsal position.

At the points where the cushions

meet, deeper areas are created,

so that risk zones such as shoul-

der blades, the bony profile of the

spine, the sacrum, coccyx and

heels are positioned almost com-

pletely free.

For the 30 degree oblique posi-

tioning (right) the patient is

placed on a soft mattress with the

head well supported by a smaller

pillow. The 30 degree oblique

position is created by placing a

long, soft cushion laterally under-

neath the patients back.

The knees can additionally be

padded with a cushion.


17/46


Phase-specific moist wound treatment

Decubitus ulcer is a secondary healing wound, usually with

a poor healing tendency. Providing adequate phase-specific

support for wound treatment is thus particularly important.

These measures include thorough debridement, continuous

cleansing of the wound, conditioning with formation of

granulation tissue and the promotion of epithelisation.

Also included are measures for preventing and/or control-

ling infection. Moist wound treatment, in which modern

hydroactive wound dressings secure the effectiveness of

the method and facilitate its execution, is now regarded

as the standard therapeutic approach for cleansing and

conditioning wounds and promoting epithelisation.

This conservative management of decubitus ulcer by moist

treatment may under some circumstances be possible up

to Stage III of a decubitus ulcer. Stage IV with muscle and

bone involvement and osseous infection, however, is an

indication for wound closure by flap plasty following

adequate surgical treatment and wound conditioning.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Schematic diagram of the timing of the wound healing phases:

Inflammatory phase:

Cleansing

Proliferative phase:

Fibroblast migration and formation of granulation tissue

Differentiation phase:

Maturation and increasing

wound contraction / epithelisation

Therapeutic principles and the problems involved in plastic

surgical coverage especially in geriatric patients are briefly

described from page 37.

Cleansing phase and debridement

In the cleansing phase, devitalised tissue and microorgan-

isms are removed by autolytic processes. Since the extent

of devitalised tissue in a Stage II to III decubitus ulcer is

so great that wound cleansing cannot be accomplished

by the bodys own resources unaided, however, the wound

requires external assistance in the form of thorough

debridement. This can be accomplished surgically and/or

physically by means of moist wound treatment.

The most rapid method of removing necrotic material is

surgical debridement with a scalpel or scissors. Necrotic

tissue must be surgically excised as soon as possible, since

an infection under a necrotic crust can spread unnoticed

into deeper tissues. The risk of decubital sepsis or

osteomyelitis then increases rapidly. Moreover, necrosesprevent healing since they maintain the chronicity of the

wound.

Necroses are thus always removed. One exception is

necrosis on the heels. This material is only debrided if a

prior angiographic examination has ruled out the presence

of arterial occlusive disease or a recanalisation operation

has been successfully completed.

The indication for, type and proper execution of wounddebridement are activities reserved for the physician in

both the inpatient and outpatient settings. The physicians

obligation to provide a personal service does not however

exclude delegating these activities to assistant personnel

in certain cases, provided he has made sure that the

person entrusted with the task is adequately qualified for

the task.

The more effective the cleansing

of the ulcer, the better the quality

of the subsequent granulation tis-

sue will be. Hydroactive wound

dressings perform valuable service

in this respect.


18/46


The situation, all too common in clinical practice, of some-

one snipping around at an ulcer, should not in fact occur

if the legal regulations are properly observed.

Surgical debridement should be performed under adequate

anesthesia in the operating room because of the pain

involved and the possibility of complications.

Especially extensive areas of necrosis, but also ulcerations

of as yet unknown depth should be debrided under oper-

ating room conditions. Debridement at the bedside is

increasingly being abandoned. At most smaller ulcers can

be debrided at the bedside, provided that adequate pain

control is provided, e.g. using local anesthetic creams.

If surgical debridement is not possible, for example in very

elderly patients in a poor general condition, patients

receiving marcumar or heparin therapy, patients with fever,

lung inflammation, recent cerebral stroke etc., physical

debridement is the alternative. Physical debridementmeans softening and detaching necrotic material and fibri-

nous layers with the aid of hydroactive wound dressings.

This approach offers several practical advantages:

it is selective, because only devitalised tissue is softened

and detached, while healthy tissue is not traumatised.

Furthermore, the moist wound environment spares the

cells responsible for cleansing and proliferation and pro-

motes their activity. The method is also safe and free from

side effects and easy to perform in all medical and nursing

settings, for instance for the domiciliary care of decubitusulcer.

Course of surgical debridement

under operating room conditions

for a decubitus on the trochanter.

The damage was found already to

extend much more deeply than

suspected of this relatively small

lesion.

However, one disadvantage of the method should be

remembered: Physical debridement is not as rapid andeffective as surgical debridement and cleansing will take a

longer time, a fact which demands a patient and conscien-

tious attitude on the part of the treating person.

Various hydroactive wound dressings are available for the

practical implementation of physical debridement. The

specific modes of action and suitability for different wound

conditions are explained in the descriptions of hydroactive

wound dressings provided on page 46 onwards.

Wound irrigation, for example with Lavasept or Ringers

solution, may be helpful to support moist wound treatment.

This can be done continuously through an indwelling

catheter, e.g. for slimy, infectious wounds, or on changing

the dressing.


19/46


Infected decubitus with pus for-mation; if bacterial toxins are

transferred through the lymph

tracts and blood stream to other

organs, bacteremia or sepsis may

result. The formation of granulation

tissue can only take place in a

homogeneously moist wound

environment. Promoting and

maintaining this moist wound

environment is therefore the most

important task of a wound dress-

ing in this phase.

Infection prophylaxis and control

Local infection and peri-ulcer bacterial dermatitis are very

common complications. If they are not recognized in time,

acute decubital sepsis or unnoticed osteomyelitis can

develop. Local infection usually presents with the classical

symptoms: reddening and hyperthermia of the area of skin

around the ulcer, burning pain on the ulcer floor and peri-

wound area as well as tenderness and edema at the ulcer

margin and surrounding area. Expected systemic effects

are fever, leukocytosis and elevated C-reactive protein,

although these symptoms are often absent in elderly

patients. A small tissue biopsy for the bacteriological cul-

ture is very helpful, as it allows selective antibiotic therapy

to be prescribed if there is a sudden outbreak of decubital

sepsis.

The prophylactic use of disinfectants often observed in

practice is no longer recommended because of their some-

times considerable inhibitory effects on wound healing and

the toxic properties of some antiseptic substances. If theulcer exhibits clinically overt infection and if antiseptics are

to be used for a short period, when choosing the antisep-

tic it should be ensured that it causes no pain and does

not considerably compromise wound healing. In particular,

an absorption-associated risk should be ruled out, an

aspect of particular importance in deep and extensive

pressure sores with their protracted treatment period.

Even greater problems are presented by the topical use

of antibiotics, a practice now regarded as obsolete. Itinvolves the risk of resistance development and a change

of the pathogens as well as a greater risk of allergy de-

velopment than is the case with antiseptics. Furthermore,

it is difficult to achieve a sufficient active agent concentra-

tion deep inside the wound and to estimate the inhibition

of wound healing processes.

In patients with severe infections, the systemic administra-

tion of antibiotics is indicated, and a microbial determina-

tion and resistance test is to be performed if possible to

optimize the therapy.

The granulation phase

Decubitus ulcer is a wound healing by secondary intention,

which means that replacement tissue, known as granula-

tion tissue, must be produced to fill the defect.

Getting through this phase and supporting the wound in

the best possible manner often presents considerable diffi-

culties in practice because it usually requires much time

and demands absolute consistency in adhering to the

therapeutic concept.

Formation of granulation tissue can only take place if the

following conditions are fulfilled: The ulcer must remain

completely relieved of pressure throughout the entire peri-

od so that blood supply to the wound area remains intact

and is not impaired by renewed exposure to pressure.

The wound floor must never be allowed to dry out and

must be kept permanently moist. If the wound becomes

dry, the cells necessary for vascularisation and tissue

generation die. A moist wound environment, in contrast,

promotes the proliferation of the cells and is thus the best

form of care for the granulation tissue. The available

hydroactive wound dressings make it possible to keep the

wound permanently moist (see description of hydroactive

wound dressings from page 46 onwards).

The wound must be protected against both chemical and

mechanical irritation. Local antiseptics should therefore

not be used in this phase. If certain parts of the wound are

still in the cleansing phase and if they are still to be disin-

fected, particular care should be exercised in the areas

around the granulation tissue.


20/46


Mechanical irritations occur when the wound dressing

adheres to the wound and newly formed tissue is detached

on changing the dressing (= cell stripping). To prevent this

considerable disruption of wound healing, the wound

dressings used must have atraumatic properties, i.e. they

must not adhere to exuding wounds even during pro-

longed application. All hydroactive wound dressings are

atraumatic and thus also offer the desired safety of wound

care in this respect.

The wound must also be protected against secondary

infections, which is why dressings should always be

changed under sterile conditions. Dressing changes should

also be performed under sterile conditions in the home

care delivery setting. If the pressure ulcer is located at a

site on the body highly subject to bacterial contamination,

e.g. in the sacral region, wound dressings with bacteria-

proof surfaces such as the hydrocolloid dressing Hydrocoll

provide effective protection against infection.

In the endeavour to speed the formation of granulation

tissue until the onset of spontaneous epithelisation, a

large number of topical therapeutic agents are still used in

practice, although scientifically validated studies demon-

strating effectiveness are available for hardly any of these

preparations. The off-label use of these medicinal products

or medical devices without official approval is not without

problems and is only justifiable in a few exceptional cases

after the currently available therapeutic options have been

observed to fail and if their use is expressly allowed by thepatient. As a general principle, powders and pastes, but

also certain preparations in ointment form, should not be

introduced into open wounds. They impede assessment of

the wound and can also impair fluid and gas exchange.

Moreover, interfering residues frequently remain in the

wound when dressings are changed (Winter, 2005). A side

effect free substitute for most of these topical wound ther-

apeutic preparations is permanent moist wound treatment.

The epithelisation phase

Epithelisation by mitosis and migration of epithelial cells

from the wound margin completes the wound healing

process. In this phase too, keeping the wound surface

permanently moist and protecting the young epithelium

from cell stripping when changing dressings are the most

important aspects of treatment, apart from the fact that

complete relief from pressure must continue to be main-

tained.

However, especially decubitus ulcers tend to epithelise

poorly. As Seiler et al. were able to demonstrate in 1989,

epithelial cells in the immediate vicinity of the ulcer margin

show greatly restricted migration. The growth rate was

only 2-7 %, whereas healthy skin usually showed a growth

rate of about 80 %.

During the long chronic course of healing of decubitus

ulcer, the constellation is not infrequently seen that the

wound margins epithelise and protrude inwards. Since nofurther epithelisation can then take place from the wound

margins, the wound margins should be refreshed by trim-

ming with a scalpel or sharp scissors.

Defect coverage by plastic surgery

Open wound management for decubitus ulcer is subject to

complex problems: It causes pain and impairs the patients

already debilitated general condition. In addition, conser-

vative treatment is always protracted, which is not only

unsatisfactory for the patient and therapist but also placesan enormous burden on the health service. A surgical

procedure, on the other hand, offers advantages mainly in

terms of time, relief of stress on the patient and cost-effec-

tiveness. Whenever possible, therefore, not only younger

patients but, increasingly, elderly patients with more

severe decubitus ulcers should benefit from this procedure.

Increasing wound contraction andepithelisation from the wound

margin due to cell mitosis and

migration of epithelial cells com-

plete the wound healing process.

A moist wound environment is

also required in this phase.

f b l i l b f ll f hi l i l l i i d b id l i


21/46


Plastic surgical coverage of a

large sacral decubitus (case study

by Jian Farhadi, Basel):

Decubitus measuring 7x6 cm after

debridement, dissection of a

perforator vessel from the direct

vicinity of the defect, flap trans-

posed into the defect, gluteus

maximus fully intact, problem-free

closure of graft site. Flap com-

pletely tension-free in the defect

after closure of graft site.

Defect coverage by plastic surgery can only be fully suc-

cessful if the patient is optimally prepared for the proce-

dure. Basically, six principles should be followed, and are

always implemented in the same order: Pressure relief,

debridement, wound conditioning, treatment of risk fac-

tors, plastic surgery and continuation care or prophylaxis.

The indication for operative closure is dependent on a

large number of parameters and is differentiated into vital,

absolute and relative indications. Vital indications for an

emergency operation are septic decubitus and arrosion

bleeding. Although these events are rarely encountered

clinical situations, their recognition and immediate treat-

ment can be life saving. An absolute indication for surgery

is present when bones or joints are exposed or where the

wound extends through to internal organs. Cicatricial

cancer developing from long-standing unstable scar areas

is also an absolute indication for radical debridement and

defect coverage of decubitus. Although cicatricial cancer is

very rare, with chronic wounds a biopsy should be taken

for histological analysis prior to debridement. Relative

indications for surgery are present in Stage III and IV

decubitus ulcers to allow early and timely mobilisation of

patients, spare them pain and also to shorten the input-

intensive period of nursing care.

Identification and treatment of factors interfering

with wound healing

Chronic skin ulcers like decubitus show the typical clinical

signs of impaired wound healing in an area which has

usually suffered major metabolic derangement. The para-

mount aim of every ulcer therapy is therefore to restore

the physiological conditions, since the repair processes of

wound healing can only take place in the correct chrono-

logical sequence if physiological conditions resembling the

normal situation as closely as possible are present in the

wound. If wounds or chronic ulcers heal poorly or not at

all, factors delaying healing are present which prevent

physiological conditions developing. It is therefore an

important aspect of decubitus management to search forsuch interfering factors in each individual patient. If all

the interfering factors can be successfully identified and

eliminated and physiological conditions thereby restored,

healing can begin.


22/46


General factors interfering

with wound healing

Infections Pneumonia (acute, chronic) Chronic bronchitis Urinary tract infections

(acute, chronic) Osteomyelitis Sepsis Local infection of the ulcer Ulcer necrosis Fever Leukocytosis CRP elevation Lymphopenia

Malnutrition Catabolism Loss of appetite Dehydration Low-protein diet Protein-free diet

Meat-free diet Albumin deficiency Transferrin deficiency Ferritin deficiency Cholinesterase deficiency Low cholesterol Vitamin B12 deficiency Folic acid deficiency Hyperhomocysteinemia Zinc deficiency Iron deficiency Vitamin D deficiency

(Source Seiler, 2002)

Therapeutic options

Therapy of specific underlying

causes, whenever possible, or

optimized treatmentUse of antibioticsRemoving of devitalized tissue

(debridement)Reduction of feverProvision of quality nutrition

Searchfor causesof catabolism Search for cause of

malnutrition (multifactorial):

e.g. gastric ulcer, depression, zinc

deficiency

Causal therapy of malnutrition Optimal diet

Proteins: 1.0-1.5 g /

kg body weight

Calories: 30-50 kcal /

kg body weight

Fats: 30 % of daily calories

Drinking volume: > 20 ml /

kg body weight

Vitamin B12: 10 x 1 mg s.c.

Folic acid 1 mg oral

Zinc (org.) 20 mg / day oral

Iron, always intravenous dose

depending on severity. Fully balanced drinking diet up

to 1500 ml / d

Multivitamin preparation

Calcium-Vitamin D preparation

General factors interfering

with wound healing

Diseases Depression, social isolation Anemia Dehydration Diabetes mellitus Immune weakness Heart failure Renal failure Diseases of the gastro

intestinal tract Paralysis Immobility Nicotine abuse

Medications Corticosteroids Sedative medications Cytostatics

Immunosuppressive agents Toxic topical therapeutic

agents,e.g. hydrogenperoxide

Therapeutic options

Always treat diseases

optimally, since diseases lead

to catabolism Depression: SSRI, care Hemoglobin > 11 g / dlDrinking volume:

> 20 ml / kg body weightDiabetes mellitus: optimal

glucose levelsHeart failure, e.g. no leg

edema!White blood count > 2000

(abs.) Serum zinc > 12 mmol / LMobilise

Always check topical therapeu-

tics and medications for nega-

tive effects on wound healing

Sedative medications immo-bilise and impede pressure

relief

Local interfering factors

(local findings)

Inadequate pressure relief Whitish wound margin Visible, rectangular or round

pressure mark at ulcer margin

due to excessively thick

dressing (> 2 mm)

Necrosis

Slimy coatings Black necrotic crusts Elevated infectious parameters

Local infection Ulcer margin: reddened,

hyperthermic, edematous,

tender painful Elevated infectious parameters

Wound area without

granulation, dried out Wound area dried out Dressing adhering After dressing change:

bleeding sites, tissue sticking to

dressing; pain during and after

dressing change

Toxic topical therapeutic

preparations

The following are toxic for tissue: hydrogen peroxide strong disinfectants

dyed solutions, etc.

Procedure

Optimize pressure relief Use only thin, moist dressings

Debridement Optimize pressure relief Use only thin, moist dressings Systemic antibiotics if infec-

tious parameters elevated

Debridement Keep permanently moist Dressing change 4 x daily

Wound irrigation with Ringers

solution Keep permanently moist with

suitable hydroactive wound

dressings, e.g. hydrocolloid

dressings

Check wound preparations for

topical tissue toxicity

1) Trochanter decubitus with local Further local or systemic factors that interfere with wound


23/46


1) Trochanter decubitus with local

infection with clearly visible red-

dening and edema (shiny skin);

blackish-yellow necrotic crust,

from under which a drop of pus is

exuding at the right edge

2) Sacral decubitus with multiple

large and deep fistulous tracts;

fistulous tracts always indicate

the presence of osteomyelitis

3) Local infection with Candida

albicans (thrush); typical, the red-dening close to the ulcer edge

4) Whitish, hyperkeratotic lesions

(incipient callus formation) are a

typical sign of insufficient pres-

sure relief on a too firm mattress

1 2

3 4

It is rarely possible to eliminate all interfering factors. For

example, the factor advanced age, which delays wound

healing, cannot be eliminated. Even partially and succes-

sively addressing factors that delay healing, however, canprovide benefits. The search for interfering factors is a task

that should be integrated into the daily routine, since they

are either permanently present or, like fever for example,

come and go. Usually, several factors delay healing in the

same patient.

In decubitus, the recurrent, pressure induced ischemia

predominates as an interfering factor of the first degree.

The most important and most effective means of prevent-

ing ischemia and improving the microcirculation in the

skin areas at risk remains permanent and complete relief

of pressure (see also page 27). Achieving this condition

in practice, however, is not always easy.

Further local or systemic factors that interfere with wound

healing are, to mention only a few: local bacterial and

fungal infection, sepsis, osteomyelitis which is often diffi-

cult to recognise as such due to the paucity of symptoms,

necroses, chronic application of tissue toxic substances,

diabetes mellitus, cytostatics, corticosteroids, dried wound

dressings, malnutrition with zinc deficiency, protein defi-

ciency, the patients mental state, depression, social isola-

tion, fever etc. The elimination of interfering factors thus

represents an attempt to restore the physiological wound

conditions and address the patients needs in a holistic

manner.

Documentation of decubitus management

Exact wound documentation describes all the criteria

applied both for therapy planning and estimating the

prognosis, monitoring of therapy and the progress of

healing. It thus forms the basis of all effective wound

management, but should also be seen and accepted as

an indispensable instrument for assuring the quality oftreatment.

Careful recording of the data serves all those involved in

delivering wound management as a binding guideline and

facilitates adherence to a consistent procedure, starting

with a diagnosis of the cause of the wound, establishing

an adequate causal therapy and evaluating the state of

the wound preparatory to deciding the local wound therapy.

As a result, the persons delivering the treatment address

the wound related problems in a comprehensive manner.

In combination with the search for interfering factors,

this improves the prospects of healing the decubitus more

rapidly.

Wound documentation is also an effective means of reli- a system of documentation may already contain definitive


24/46


Wound documentation is also an effective means of reli-

ably estimating progress, stagnation or even setbacks in

wound management, and allows therapeutic activities to

be rationally modified whenever necessary.

Above all, wound documentation guarantees the flow of

information between the physician and nursing personnel.

In this way, it can for example be prevented that conflict-

ing activities may be carried out from one dressing change

to another, merely because another person is in charge of

wound care.

Documented evidence that medical and nursing have been

delivered in accordance with current standards has been

made a routine obligation regulated by law, and written

documentation is thusindispensablefor assuring the stand-

ards of medical and nursing performance as required by

(liability) law. Verbal agreements, made for example on

changing from one ward to another or at the ward meet-

ing, are not a suitable means of providing the legallyrequired proof of quality of treatment and care.

Whenever possible, data should be entered in the records

immediately after the wound treatment has been provided.

The state of the wound is then still fresh in the mind of the

person concerned and no important information is lost.

The records are then always up to date during the course

of a shift. The occasionally observed practice of collecting

all the entries and entering them all at once just before

ward transfer is to be rejected as inadmissible and impre-

cise.

A suitable choice of language which exactly describes

the state of the wound is of considerable importance for

the information value of the documentation. In practice,

however, this often causes difficulties and statements are

often imprecise. To eliminate uncertainties in this respect,

a system of documentation may already contain definitive

descriptions of the various parameters which only need

to be ticked off. Alternatively, the descriptions to be used

can be established in the team and laid down as the

standard for the documentation which is then binding

for the wound team.

A particularly effective means of definitively and accurately

recording the course of healing is to include photographic

documentation. Incorrect interpretations of the type that

can arise when wound descriptions are recorded only in

writing, are ruled out. As regards photographic documen-

tation, however, certain legal aspects must be taken into

account, relating mainly to the patients informed consent.

As regards practical implementation, it is important that

photographs documenting the course of wound healing

should always be taken under the same conditions to

allow informative comparisons to be made between photo-

graphic records taken at different times.

All the images must be durable

and not fade and retain their

evidential power even after years

if necessary. Thus the careful

administration of files is necessary.This includes establishment of the

meaningful file designation (thus

e.g. Name_Surname_Date.jpg),

regular backup of all files and,

additionally, filing the hardcopy in

the patient records, if applicable

As regards the aperture setting

used, it should be remembered

that not only the central wound

area but also the surrounding

parts of the body should besharply imaged; a flash may be

used if necessary. The background

should be asneutral as possible,

i.e. without structure (right).

The photographic apparatus

should be as parallel as possible

with its exposure level to the

photographed object. If the

exposure plane and the photo-graphed object are not parallel,

the picture will be distorted

and will not reproduce the size

conditions exactly.

1 2 3

Hydroactive wound dressings The scientific principles of moist therapy were established


25/46

Hydroactive wound dressings [46.47]

Hydroactive wound dressingsfor phase-specific,moist wound treatment

Moist wound treatment is today the standard approach forall secondary healing wounds with tissue formation. It is

particularly successful in the management of chronic problemwounds. Practitioners have at their disposal a range ofhydroactive wound dressings for moist therapy which coverthe entire spectrum of therapeutic requirements in the formof a phase-specific therapeutic system.

The scientific principles of moist therapy were established

by the studies of G. D. Winter (1962, first published in

Nature). This author demonstrated that a moist and

permeable wound dressing and the associated moist

wound healing results in more rapid healing than a dry

wound environment exposed to the air. Moist wound treat-

ment has positive effects on all phases of wound healing.

During the cleansing phase, moist wound dressings

achieve a thorough cleansing of the wound and render

possible mechanical debridement without damaging

cells. Inactivation of immunocompetent cells can also be

avoided by the moist environment (Seiler).

During the granulation phase, a physiological microclimate

similar to a cell culture medium is created within the

wound which encourages cellular proliferation and conse-

quently the formation of granulation tissue. Turner / Beatty

et. al (1990) have reported that permanent moist therapy

causes a significantly more rapid reduction in the size ofthe wound area and a larger amount of granulation tissue.

In the epithelisation phase, the conditions for mitosis and

migration of epithelial cells improve under moist dressings.

This generally results in more rapid epithelisation with

better cosmetic results. Patients frequently report that their

pain is relieved under moist wound treatment.

In addition, the dressing change itself is atraumatic and

causes less pain because modern dressings, as used for

moist wound treatment usually do not stick to the wound,

i.e. have atraumatic properties. At the same time, this

nonstick effect eliminates the stripping off of cell layers

when the dressing is changed the undisturbed state of

the wound so important for healing is preserved.

Tulle bandaging materials adhere

to the wound (above), newly

formed tissue is also detached

when the dressing is changed.

This disruption of wound healing

can be easily prevented by using

atraumatic wound dressings suchas gel forming calcium alginate

dressings (below).

However, the success of moist wound treatment depends ingrowth is possible (3). The moisture and the electrolytes


26/46


However, the success of moist wound treatment depends

on a critical prerequisite: the wound requires a permanent,

uninterrupted, balanced supply of moisture. If at any stage

drying out is allowed to occur, the cells inevitably die as a

consequence. Further necroses develop and can even

eventually deepen the wound.

Wound dressings for the moist wound treatment

For practical implementation of the moist therapy is now

the series of hydroactive wound dressings available, by

which can be covered, within the meaning of phase-specif-

ic wound management, the entire scope of the therapeutic

needs.

TenderWet wound pad with superabsorber

TenderWet is an extremely effective wound dressing for the

treatment of chronic, infected and non-infected wounds

during the cleansing phase and at the start of the granula-

tion phase. This high efficiency is attributable to a special

principle of action which allows continuous rinsing ofthe wound.

TenderWet is a multilayered dressing pad containing super-

absorbent polyacrylate (SAP) as the central component

of its absorbent core. The non-medicated superabsorber is

activated before use with an appropriate volume of

Ringers solution which is then supplied continuously to

the wound over a period of hours. The constant delivery

of Ringers solution softens, detaches and rinses away

necrotic tissue (1).

At the same time, however, microbially contaminated

wound exudate is absorbed and bound into the absorbent

core. This exchange Ringers solution is delivered and

proteins are absorbed functions because the superab-

sorber has a greater affinity for the protein-containing

wound exudate than for the sodium-containing Ringers

solution (2) and so the wound exudate displaces the

The principle of action of

TenderWet

1

2

3

ingrowth is possible (3). The moisture and the electrolytes

contained in the Ringers solution, such as sodium, potas-

sium and calcium, contribute to the cell growth.

TenderWet has no contraindications and can also be used

on infected wounds. In certain cases, there is an apparent

increase in the size of the wound during the initial cleans-

ing phase with TenderWet. This means that with this

method devitalised tissue which was not recognisable as

such was removed.

In the case of deep wounds, TenderWet should be packed

in loosely to ensure the direct contact needed for the fluid

exchange. The physical characteristics of the superabsorber

in combination with the outer covering of knitted fabric on

the wound pad give TenderWet the necessary packing

characteristics. With extensive wounds, the TenderWet

wound pads should be applied with a slight overlap the

tiling.

TenderWet comes in a range of presentations and is avail-

able in round and rectangular shapes to meet differing

application requirements.

For greater ease of use, TenderWet and TenderWet 24 are

supplied in already activated form as TenderWet active

cavity and TenderWet 24 active. These active wound pads

are saturated ready to use with Ringers solution and can

be applied immediately. This dispenses with time consum-

ing preparations. Another advantage of the already activat-

ed wound pads is that a much greater volume of Ringers

solution can be introduced into the absorbent core than is

possible with manual impregnation. As a result, the wound

can be kept moist longer.

TenderWet 24 active is already

activated with Ringers solution

ready for use. The integrated pro-

tective layer makes the dressing

well suited for treatment under a

compression bandage.

Moreover, the pads are soft and easy to shape, especiallyTreatment of a pressure sore on


27/46


, p y p , p y

in case of TenderWet active cavity, which can be used to

pack even cavernous wounds without difficulty. In con-

trast, TenderWet 24 active should not be packed into the

wound because of its moisture-repellent protective backing

layer.

The classical TenderWet must be saturated with Ringers

solution before use. How much Ringers solution is required

to activate the dressing depends on the size of the com-

press and is indicated on the packing accordingly. For easy

activation of TenderWet (and also of TenderWet 24),

TenderWet solution is supplied in ready to use vials. The

composition of the sterile, pyrogen-free and isotonic solu-

tion corresponds to that of Ringers solution.

TenderWet 24 active and TenderWet 24 are designed so

that the absorbing and rinsing effect is sustained for up to

24 hours. To protect the dressing from strike through,

moisture repellent layer is integrated inside the dressingon the side facing away from the wound. The side of the

compress with the integrated protective layer is identified

by the presence of parallel coloured strips to allow secure

positioning of the wound pad. Because of this protective

layer, TenderWet 24 should not be packed into the wound.

The following applies generally to all TenderWet wound

dressing pads: They are not self-adhesive and require

adequate fixation, e.g. complete-cover dressing retention

with elastic adhesive nonwoven fabric (e.g. Omnifix) or

elastic conforming bandages (e.g. Peha-crepp, Peha-haft).

the heel with TenderWet (Case

study by Antje Wagner,Leinfelden-

Echterdingen): 84-year-old female

patient, coronary heart disease,

arterial occlusive disease, increas-

ing dementia; decubitus on the

left heel. Start of TenderWet treat-

ment on 23 April 99, the necrosis

of the heel extended almost as far

as the bone (Fig. 1). By 22 May

necrotic tissue on the heel hadbegun to scale away. The wound

is well supplied with blood; some

granulation tissue had begun to

form (Fig. 2). Consistently contin-

uing this treatment, the heel sore

was completely clean by 11 June

(Fig. 3). Treatment was continued

unaltered until the wound healed

completely (Fig. 4, 14 August).

Packing of a deep decubiti withgauze strips impregnated with

antiseptics (Fig. 1) does not

always ensure sufficient cleansing,

thus alternatively ensuring of a

quick and thorough debridement

by using of wound pads Tender-

Wet active cavity shall be consid-

ered (documentation of F. Meu-

leneire, Belgium). Preliminary a

palpation by finger is carried out

to determine the size of the

wound cavity, corresponding

marking to the skin surface (Fig.2) and adjustment of a proper

TenderWet compress size (Fig. 3).

TenderWet active cavity can be

well adjusted due to its plasticity

(Fig. 4).

1

3

2

4

1

3

2

4

TenderWet 24 active and Tender-

Wet active cavity are already

activated with Ringers solution

ready for use.

Treatment of a coccyx decubitus Sorbalgon calcium alginate dressings


28/46

1 2

3 4

5 6


with TenderWet (Case study by

Eduard Rath, Bernried): 84-year-

old female patient, diabetes

mellitus,compensated heart failure,

poor general condition, pressure

sore in coccyx region, S/P femoral

neck fracture on both sides.

On admissionon 18 March 96, the

pressure sore was necrotic and

purulent with an overt anaerobic

infection, surgical debridementwas performed on 19 March.

On 27 March, treatment of the

wound was changed to the dress-

ing pad TenderWet (Fig. 1),

activated with an antiseptic

instead of Ringers solution

(Fig. 2).

On 9 April, the wound was free

from purulent secretions, clean

granulation tissue was visible

(Fig. 3). Further treatment was

administered using TenderWet

activated by Ringers solution.The buildup of granulation tissue

was continuing.

The superficially damaged areas

of the wound had epithelised

well after three and five weeks

(Fig. 4/5). TenderWet treatment

was continued until 19 June, then

changed to Hydrocoll. Wound size

1,5x3 cm on 26 June (Fig. 6).

Patient discharged from hospital

on 1 July.

with excellent conformability

Sorbalgon is the wound dressing ideally suited for cleans-

ing and for supporting the build-up of granulation tissue

in superficial and deep infected and non-infected wounds.

By virtue of its excellent packing characteristics, Sorbalgon

also provides effective cleansing and conditioning in deep

wounds.

Sorbalgon is a nonwoven dressing made of high-qualitycalcium alginate fibres which are introduced in the dry

state into the wound (1). As they absorb sodium salts,

present for example in blood and wound exudate, the

fibres start swelling and undergo transformation into a

hydrophilic gel which expands and fills out the wound (2).

Since Sorbalgon adapts closely to the wound surfaces,

microorganisms are also taken up deep inside the wound

and are reliably absorbed into the gel matrix (3). This pro-

vides efficient microbial reduction and helps avoid reconta-

mination. Wounds are swiftly cleansed, and Sorbalgon hastherefore proved especially successful in the treatment of

chronic and infected wounds.

Very good wound healing properties of Sorbalgon are

among the other things due to type of suction properties

of calcium succinate fibres. They absorb 10 ml exudates

per gram of weight and thus have very high absorption

capacity. On the other side, the absorption capacity is not

achieved mainly among the fibres as by gauze, but the

Decubitus Ulcer GB 09

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