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Saturday, December 6, 2014

Decubitus Ulcer - Pressure Ulcers

What is decubitus ulcer ?


Decubitus or pressure necrosis, bedsore wounds, pressure sore or bedzeer Formation of wounds caused by pressure, shear or friction or combination of them in the tissue. Through constant pressure are small blood vessels compressed. The tissue will then be enough oxygen and nutrients with the result that the skin and underlying tissues die. It is not so much a skin injury (though it thus goes hand in hand), but a death of subcutaneous tissue and muscle.

A number of factors that contribute to the formation of pressure ulcers are the duration of the pressure on the tissue, the force of the pressure or shear forces, nutritional state, level of consciousness, mobility, blood flow, the weight of the person, tissue tolerance and medication use.

There are several places on the body that are especially susceptible to pressure ulcers. These are especially places where the bone is close to the surface (tailbone, heels, elbows, shoulder, hip, ankle) back, knees or something where pressure on the body.

Whenever a patient in a hospital pressure ulcers, the total nursing time is extended. Because patients with pressure ulcers relatively much in need of care, this is unfavorable to the hospital because there is less care is available for patients in need of care.

General


The phenomenon of pressure ulcers is as old as mankind: in mummies from ancient Egypt, the disease has already been found. The Dutch surgeon Fabricius Hildanus wrote in 1593 in his notes, "Decubitum gangraena et sphaleco tractatus methodicus" multiple causes for pressure ulcers could arise:

-External causes
-Causes of the inside
-Interruptions in blood and food supply.

The word decubitus was introduced in 1777 by Wohlleben. He spoke of gangraena per decubitum, ie: necrosis by lying. Lying is as we now know not the only cause of pressure ulcers; this observation was incomplete.

Pressure ulcers are now defined as follows (CBO consensus 2002): Under pressure ulcer is defined as any form of necrosis, caused by the action on the body of pressure, shear and friction, or a combination thereof.

Decubitus to go so tissue changes in advance. It is important to recognize these changes at an early stage so that action can be taken in time. In addition, it is essential to identify the risk factors.

Although not always, it can prevent pressure sores in many cases. Decubitus means for the patient pain and inconvenience. Healthcare an increase of the health needs and an explosive increase in costs.

Causes


-Pressure on the tissues
-Shear and friction, and in the tissues

Under normal conditions occurs at constant pressure on the tissues a painful stimulus as a result of oxygen deprivation. Someone who is tall will therefore, often unconsciously, regularly changing leg. Someone who is tall will regularly change his attitude. Someone who sleeps will take approximately every fifteen minutes a different attitude.

For short-term high pressure loads, but especially during prolonged sustained pressure will fail the blood flow and tissue necrosis occur.

This will be accelerated when the blood vessels by the shear and friction be bent or torn. They are often small things that may trigger a pressure ulcer. For example, at a fold in the bottom sheet, or if the patient is on a catheter hose is locally cause a dangerous increase in pressure. Similarly, when a patient is put in the upright cushions must be lifted and can not be slid over the underlayer. This is to avoid unnecessary shear and friction. For the same reason there must be a patient in bed or in a wheelchair upright and can not slumping. In a humid environment, the resistance between skin contact layer. The chance of damaging shear and friction forces is thus increased. When sweating (fever or high temperature) should be provided with adequate ventilation. When the humidity of incontinence is the result of the patient, the risk of decubitus takes extra increases because the skin is extra vulnerable due to the action of the urine to mechanical damage and infection. The patient is incontinent of urine and faeces, then the risk is even greater.

Risk factors


-Bedridden, wheelchair users or others who sit or lie long in the same position;
-Suffer from overweight or even extremely thin;
-Problems with moisture such as excessive sweating, incontinence, poor hygiene and so on;
-In premature children is through their thin skin and general vulnerability more likely that pressure ulcers will occur.

Crumbs (in bed or wheelchair), clothing, jewelery, folds in the bottom layer of the bed or chair can provide additional pressure and skin damage. Also played carelessness of the caregivers, the general condition of the person, circulatory disorders, eating disorders (eg, lack of protein, vitamins and moisture), numbness of the skin, fever (high body temperature and sweating) a role.

Pressure ulcers generally heal poorly as long as the person with the wounds are malnourished, the same posture has or ever in the same place has something to exert some pressure on the tissue, in short, as long as the cause of the wound is not removed by itself. In order to combat and prevent pressure sores, it is essential that the pressure and shear forces, and the duration of the pressure remain as low as possible. This is to ensure by so-called repositioning or for wheelchair users "lifts". By change of posture is a different part of the body there is burdened with the weight of the body and the tissue can recover from the exerted compressive forces.

Patient with an increased risk of


Based on the above causes and risk factors can distinguish several categories of patients are at increased risk of pressure ulcers.

Patients who are not sufficiently able to move independently
Patients may in certain condition not sufficiently respond to the unpleasant sensations of pressure, this occurs in:

-Unconsciousness
-Severe neurological disorders with motor deficits, for example spinal cord lesion and hemiplegiepatiƫnten
-Less mobile patients with severe rheumatoid arthritis
-Forced immobility after fracture or surgery
-Decreased responsiveness as a result of certain psychotropic drugs
-Patients with an insufficiency of pain sensation.

Patients who tolerate prolonged high pressure
They do not feel they are through; takes place partly overlapping with above mentioned categories of patients:

-Unconsciousness
-Severe neurological disorders such as spinal cord lesion and sensory failure hemiplegiepatiƫnten
-Patients taking antidepressants, sedatives or analgesics
-A separate category is the patient with diabetes mellitus with complications, polyneuropathy and micro) angiopathy. Feeling Disorders and regurgitant blood flow occur especially at the feet of these patients. This means that there is an additional risk of the occurrence of pressure ulcers / decubitus ulcers on the feet.

Patients with a reduced tolerance to pressure
In these patients, damage to skin tissue and subcutaneous tissue rather than under normal conditions:

-Inadequate circulation (atherosclerosis, hypotension, edema)
-Metabolic disorders (eg. diabetes) and anemia
-Nutritional deficiencies / cachectic patients / catabolic patients with a negative nitrogen balance
-Atrophy of the skin after use of corticosteroids.

Patients with specific characteristics, wherein the combination with other factors, leads to decubitus
-Very thin patients
-Very thick patients
-very elderly patients
-(Long-term bedridden) patients with hypotonia and muscle atrophy
-Patients with severe lung disease, whereby a decreased, oxygen in all tissues
-Patients with severe anatomical abnormalities as kyphosis, scoliosis and contractures
-Patients with spasm.

Patients taking occurs by increased humidity or temperature history of skin damage
-Incontinence
-Fever / sweats
-Very thick patients with blemishes.

Classification
Since 2009 there is an international pressure ulcer classification system which the degree of damage can be divided into four categories:

-I: Redness of the intact skin, not wegdrukbaar. Discoloration of the skin, warmth, edema and hardening of the tissue are other possible characteristics.
-II: Skin Injuries confined to the epidermis and with blistering and / or excoriation. A burst open blister is counted for stage two.
-III: Skin breakdown with damage or necrosis (necrosis) of skin and subcutaneous tissue. The damage can extend to the underlying connective tissue. Clinically, the lesion is visible as a crater with or without undermining of adjacent tissue.
-IV: Extensive tissue necrosis or damage to muscle, bone or supporting tissues. The injuries of the skin covers the entire skin thickness.
The four stages are considered to be four different forms of pressure ulcers, as phases which are not necessarily follow each other. Pressure sores can sometimes start as a blister or a superficial or deep ulcers. Sooms a blister can evolve directly to a black necrosis spot.

Prevention and Treatment


Pressure ulcers can be prevented in many cases by consistently to ensure that the body changes position regularly (eg every four hours to apply repositioning), to ensure that the person is in a good nutritional status, and as little as possible pressurizing or shear-enhancing work factors on the tissue. A clean dry layer is important. Alternating the attitude is essential. Tools to support the treatment are: pillows with delicate filling in various forms, an alternating pressure mattress, gel cushion and gel mattress, water mattress or a static air mattress - alternating mattress - to reduce the pressure and lift. In recent years, there is also used a lot of memory foam (memory foam mattresses) which gives very good results.

The search for the solution to prevent pressure sores or heal is endless. One can argue that there is ever new resources coming on the market that are better for the prevention of bedsores. The recommendation to use a sheepskin or to put ice packs if treatment is not outdated. Years ago this operation as "not useful" means. The revised (2002) national guideline of the CBO confirms this view. Also, other interventions described above may be out of date in the future, and are referred to as "non-meaningful".

There are various "risk scales' to assess the risk of pressure ulcers. The Belgian Decubitus Guidelines give preference to the so-called Braden scale which takes account of six elements: physical state (nutritional), mental state, activity, mobility, humidity (incontinence). Scores may range between 6 and 23. The most commonly used cut-off point is 17 (a patient with a score below 17 is considered a risk patient). A low score is associated with a higher risk of pressure ulcers.

Wounds should always be sterile and groomed some advanced wounds may require surgical treatment.

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