Podcast Episode 43: Pressure Ulcers (Part 3 of 3)

Hello, my name is Sylvie Hampton and I'm an independent tissue viability nurse consultant and I work throughout the UK. I've nearly 30 years experience in wound care and in this podcast part 3 I'm going to explain pressure ulcer treatment. I've only got 10 minutes to put the points across in the podcast so information is likely to sound a little like bullet points. I have a lot to discuss. Pressure ulcers occur for one reason and one reason only and that's unrelieved pressure, whether that is due to direct pressure where somebody doesn't move or due to shearing forces where somebody is sliding down and squeezing the tissues. This means obviously that the blood is not reaching the area and the skin is dying. Therefore treatment should very strongly be based on restoring the blood supply and this is the same for any wound, restore the blood supply and the wound will go on to heal. Therefore always look for the cause long, long before you look for the dressing. One doctor said the only thing you should never put on a pressure ulcer is the patient and basically that's the secret to healing or preventing a pressure ulcer. Personally I have faith in the 30 degree tilt which I've used over 30 years. As the person is being taken off of the bony prominence where the vast majority of pressure ulcer occurs they are less likely to get a pressure ulcer and this works when in the bed but it's not as successful when in a chair. Again personally I would always recommend a profiling bed, a tilt-in-space wheelchair and or a recliner chair as they could be tilted independently and regularly in order to change the point of pressure. A profiling bed ideally would never be raised higher than 30 degrees at the back because that enables people to slide down the bed and when the back is raised the knee should always be raised at the same time in order to prevent that sliding down in the bed, the knee break actually anchors the person. Ensure heels are always protected even on air mattresses or those mattresses that have heel protection. The heel of someone with poor blood supply should never be in contact with any surface. If there's a category 2 pressure ulcer, it simply needs protection. The client's not on it and they are not sitting or lying in a way that they can slide which is almost undoubtedly what caused the injury so should be prevented. If it is a category 3 or 4 then treatment will be different because they're different wounds, different types to category 2. Firstly the dead tissue must always be removed and never be dead tissue in category 2's because it's only superficial. Category 3 and 4 will always have dead tissue or slough. Sharp debridement should only be used by someone who's actually been trained in the art of debridement. It should never be used by someone who's unsure of the structures that are beneath the area being debrided. Debridement can always be undertaken by the use of moist dressings and by the specialist pads that are now being produced in order to debride wounds. Of course there's always maggots which are absolutely amazing creatures at debridement and are always worth consideration. Once the wound's debrided then the selection of dressings becomes important. I've got a method to assist with selection. Use a wet dressing to a dry wound other than when somebody is arterially compromised in their heels or someone who's dying, so a wet dressing to a dry wound. Put a dry dressing to a wet wound. There are amazing super absorbents on the market today that absorb several times their own weight and are very useful if you have a very highly exuding wound. If it's moderately exuding then hydrofibers and foams and so on are perfectly adequate. Use an antibacterial dressing to a wound that has a strong odour, as odour is associated with bacteria. Therefore I would suggest there are selection of dressings available such as one that will donate fluid to the wound, that would be hydrogels and so on, an antibacterial such as honey, an iodine codexamer, silver etc. There are many antibacterials on the market. Super absorbents that I've spoken about already, There are those that have a gel core that actually hold the water completely in the core or those that have highly absorbent filler in the core which are very useful and they do hold several times their own weight of fluid. You need a foam that can be used as a secondary dressing or to hold others in place or to be the protective dressing in a wound that is actually healing. I will always consider topical negative pressure therapy in a category 3 or 4 pressure ulcer once it is debrided. My thought, which is definitely unproven, is that negative pressure should be used on the wound if there is any positive pressure from a surface that cannot be removed. So sort of thinking that negative pressure perhaps negates the positive pressure. definitely not provable. If the wound is healing with good granulation then it should always be left as long as possible with a simple dressing such as a foam in order to protect it. If there is a granulation tissue then you have done an excellent job and the wound will go on to heal itself providing no pressure is permitted on that area. Repositioning is always the most appropriate method of prevention and treatment and I cannot highlight that enough. However, there are systems on the market that will automatically reposition our clients and offer protection. This doesn't mean we should never move our clients as they can stiffen if their position is not altered, but it does mean they can sleep at night without disturbance and does support carer safety as they are not having to reposition as often and of course if the client's in pain it's lovely that they've got something that gently repositions them and there are many systems that are now on the market that will do that automatically and they are not all expensive. The conclusion of this talk is reposition, reposition, reposition. I cannot highlight that enough. enough. 30 degree tilt, try never to put them onto a bony prominence if at all possible. That's not always possible. Sometimes they will turn themselves back on their back or will turn themselves on their side and you can't do a lot about that. And if they're sitting in a chair, it's almost impossible to get them off of those two little ischial tuberosities. And if they are getting redness on those tuberosities, then you know it's from sitting because the only way you can get pressure on that area is when they're sitting upright. Always clean the wound, try and debride it even if it's with the use of dressings and always think what dressing can provide the optimum wound healing environment. So does it need to be kept moist? Does it need to be kept dry? Think about what the situation is with the wound itself. Most of all, reposition. That is the single most important thing that you can do in order to treat or prevent a pressure ulcer. Thank you very much for listening and I hope that helps.