R

E
LC
U
S E
R
U
IT CA
B
U
D
C
E UNDisusun oleh:
D O Hera Amalia Utami
G99142073
Icha Dithyana
G99141115
W
R

IK

Pembimbing:
Amru Sungkar, dr.,Sp.B,Sp. BP-RE

KEPANITERAAN KLINIK SMF ILMU BEDAH

FAKULTAS KEDOKTERAN UNS/RSUD DR MOEWAR
SURAKARTA
2015

DEFINITION
A pressure ulcer is any lesion caused
by unrelieved pressure, usually
over a bony prominence, that
results in damage to underlying
tissue.
Pressure ulcer and pressure sore
decubitus ulcers and bed sores
(Dharmarajan,2002)

RISK FACTORS FOR PRESSURE

ULCERS
Spinal cord

injury
Cerebrovascular
accident neurologic
Progressive
disorders
Pain

Limited
mobility

Fractures, etc
Poor
nutritio
n

Anorexia
Dehydration
Dietary restriction, etc

Intrinsic

Diabetes melitus
Comorbidites

Depression or psychosis
Malignancies
Congestif heart failure,
etc

Aging
skin

Loss of elasticity
Decreased cutaneous blood
flow
Changes in dermal
pH
Bluestein, 2008
Loss of subcutaneous fat,

RISK FACTORS FOR PRESSURE

ULCERS
Pressure from
any hard
surface

Extrinsic

Friction from
patients
inability to
move well in
bed
Shear from
involuntary
muscle
movements
Moisture

Bowel or
bladder
incontinence
Excessive
perspiration

Wound drainage
Bluestein, 2008

PATOPHYSIOLOGY

Anders,
2010

SCORIN
G

NORTON
PRESSURE
ULCER
SCORE

BRADEN
SCALE

INTERPRETATION
Low Risk : 16-20
Moderate Risk: 11-15
High Risk: 10

BRADEN SCALE
Sensory
Perception
1.
Complete
ly limited
2. Very
Limited
3.
Slightly
Limited
4. No
Limited

Moisture
1.
Constantl
y moist

Activity
1.
Bedfast

Mobility
1.
Complete
ly
Immobile

Nutritio
n

Friction
& Shear

1. Very
poor

1.
Problem
2.
Potential
Problem
3. No
Apparent
Problem

2. Very
moist

2.
Chairfast

2. Very
Limited

2.
Probably
inadequa
te

3.
Occasion
ally moist

3. Walks
Occasion
ally

3.
Slisghtly
Limited

3.
Adequate

4. Rarely
Moist

4. Walks
Frequentl
y

4. No
Limited

4.
Excellent

CLASSIFICATION

(Diaz, 2013)

NPUAP STAGING SYSTEM FOR PRESSURE

ULCER
Bluestein, 2008

Stag
eI

Intact skin with nonblanchable

redness of localized area
Usually over a bony prominence
Dark pigmented skin may not have
visible blanching
The affected area may differ from
surrounding area
The affected tissue may be painful,
firm, soft, or warmer or cooler
comparedwith adjacent tisuue

Stag
e II

Partial-thickness loss of dermis

appearing as shallow
Open ulcer with a red pink wound
bed
Without slough
May also appear as an intact or
open/ruptured serum-filled blister

Stag
e III

Full thickness tissue loss

Subcutaneous fat may be visible
Bone, tendon, or muscle is not
exposed
Slough mau be present
May include undermining and
tunneling

Stage
IV

Full thickness tissue loss with exposed

bone, tendon, or muscle
Slough or eschar may be present on
some partsof the wound bed
Often included undermining and
tunneling

Bluestein, 2008

Hartmann, 2008

Anders,
2010

(Diaz, 2013)

COMMON SITES OF DECUBITUS ULCER

FORMATION
The risk 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.
Hartmann, 2008

THE
COMMONEST
PRESSURE
SORE
LOCALISATIONS

Hartmann, 2008

COMPLICATIONS
Increased
mortality
rate

Death has been reported occur during

acute hospitalization in 67% of pstient
who develop a pressure ulcer
compared with 15% of at risk patients
without pressure ulcer. (Thomas 2001)

Osteomyeliti
s

Osteomyelitis is a frequent
complication of pressure ulcers,
reported in 38% of patients with
infected pressure ulcers. (Thomas 2001)

Sepsis

Bacteremia from pressure ulcers is

uncommon but probably underestimated.
The incidence of bacteremia from pressure
ulcers is about 1.7 per 10,000 hospital
discharges. Sepsis is a serious consequence
of pressure ulcers and a frequent cause of
death. (Thomas 2001)

Spinal
subdural
abscess

Spinal subdural abscess (SSA) represents a

loculated infection between the outermost layer of
the meninges, the dura, and the arachnoid. The
close proximity of ulcers to the sacral dural sac
and filum terminale can provide direct anatomical
connection to the subdural space. (Usoltseva,
2013)

Hartmann, 2008

Hartmann, 2008

T
N
E
M
E NT
G
E
A
M
N
A AT
M E
R
T

D
N
A

Prevention
The prevention strategies commonly used include
regular risk assessment, use of special pressure
relieving support surfaces, regular repositioning and
turning, local skin care, and nutrition support.
Assess the Pressure Ulcer
In the initial assessment, the ulcer is evaluated
according to localization, stage, size (length,
breadth, depth), pocket formation, undermining,
exudate flow etc.
Provide Good Skin Care
Moisture macerates and injures skin. Sources of
moisture include sweat, wound drainage, urine, and
feces. Several studies indicated that incontinence
increases the risk of pressure ulcer development
Hartmann, 2008

Relieve Pressure, Friction,

Shear
The different positioning techniques require
the combined use of static and dynamic aids.
A rhythm of two hours is prescribed as the
time intervalfor repositioning.

Hartmann, 2008

Hartmann, 2008

Wound cleansing

Debridement
Chemical (enzymatic)
debridement
Mechanical debridement
Autolytic debridement
(compared with the above)
Biological debridement
maggot debridement
Ontario Health Technology Assessment
Series, 2009

Dressing

Hartmann, 2008

Adjunctive physical therapies

Hydrotherapy
Electrotherapy
Electromagnetic therapy
LLL therapy
Ultrasound therapy
Negative pressure therapy
Ontario Health Technology Assessment
Series, 2009

Nutrition therapy
Protein supplement
Zinc supplement
Ascorbic acid supplement
Multi-nutrient supplements

Ontario Health Technology Assessment

Series, 2009

Surgical Management
Surgical closure of pressure ulcers results
in more rapid resolution of the wound. The
chief problems are that the ulcers
frequently recur, and many frail patients
cannot tolerate the procedure.

Ontario Health Technology Assessment

Series, 2009

Hartmann, 2008

A
H
T

K
N

U
O
Y