PRESSURE SORE IN GENERAL HOSPITAL

Transcription

1 PRESSURE SORE IN GENERAL HOSPITAL Dr. Zamil Shia Mohammed M.B.Ch.B Diploma in Rheumatology Directorate of health in Missan SUMMARY : To evaluate pressure sore in Al-sadder General Hospital, (46) patients were included in the prospective study. Cerebrovascular accident causes were reported in (30) patients, traumatic in (6( patients, transverse myelitis ( 2) patients, tremors in (3) patients, tuberculosis in ( 2 )patients, and burn ( 3 ) patients. Seventy-two pressure sore were reported. Fifty-six pressure sore were managed by conservative measures and. (16) were managed by Surgical intervention. The most common sites for pressure sores were sacral (31.9 '(% and trochantric 23.6%.The important predisposing factors are:-loss of sensation, incontinent of bowel and bladder, spasiticity. It is concluded that pressure sore is still a big problem in general hospitals because it is not taking real awareness by most of clinicians and usually less is done for preventive measures. INTRODUCTION : The term pressure sore is preferred when referring to localized areas of tissue necrosis which tend to occur between underlying bony prominence and overlying compressing surface, prolonged local pressure is the most important factor causing these ulcers. 1. External pressure of as little as ( 60 mmhg) for one hour would produce microscopic degenerative changes of all tissue from skin to bone in dogs and that there were no detectable microscopic differences between normal or denervated muscle following the application of either constant or alternating pressure(2). The H substance resembling histamine released from traumatized cells and accumulative of metabolites such as potassium, hydrogen and lactic acid have been suggested as factors which individually or in combination dilate the blood vessel. In addition to external pressure there are other contributing factors which produce pressure sores such as localized ischemia secondary to excessive wound pressure, nutritional hyporoteinemia, anemia, circulatory impairment, 1

2 infection, sensory loss, paralysis, joint limitation and contractures, edema, poor hygiene of skin,spasticity, incontinence of bowel and bladder.(3). More than 90% pressure of sores is localized in lower part of the body (4). Protocolbased care plans using the result of risk assessment have been shown to reduce the frequency of pressure ulcers and to lower the cost of care. The protocols include frequent turning, positioning and lifting device, and pressure reducing mattresses and overlays. Skin care emphasizes daily inspection and frequent cleansing and dehydrating of dry skin. Heels and elbows need to be protected with pads or clothing to prevent friction damage during transfer (5, 6). A recently published study indicate that a slight recline with the legs supported is the best sitting position for pressure relief) 7). Once treatment has begun, the patient and the ulcer need to be reassessed on a weekly basis (8). Pressure ulcers do not heal by revising the process that led to their stage before treatment, but rather through scarring process (9). Protein is the dietary key to healing a pressure ulcer. The stress of healing an ulcer also requires extra calories. A reasonable goal is a daily intake of kcal/kg, containing ( ) g/kg of protein (10). Vitamin (C) recommended in a dose of 500 mg / d, based on delayed wound healing in the vitamin c - deficiency state (11). Nonhealing ulcer may require surgical closure, usually; myocutaneous flap procedure (12). Electrotherapy is based on evidence indicating that electrical current stimulates fibroblasts, attracts neutrophils, increased blood flow and is bactericidal (12) PATIENTS AND METHODS Forty six patients with 72 pressure sores were included in this prospective study in Al-Sadder General Hospital in Missan. The average age was (50) years (15-85) years. The average duration for developing pressure sore was 2-15 days. Pressure sores were classified into four grades: Grade I: Evidence of inflammation overlying bone prominence without ulceration. Grade II: Superficial ulceration of the skin extending into the dermis. Grade III: Deeper ulceration, commonly of an inverted configuration extending into the subcutaneous tissue, muscle or down to bone. Grade IV: The complex ulcer with wide spread extension into joints or body cavities, rectum, vagina and bladder.all patients in our study have: CBC, ESR, blood urea, serum creatinine, total serum protein, general urine examination, swab from pressure sores for culture and sensitivity, X-Ray of affected area and sinogram if needed. All pressure sores with systemic 2

3 manifestations were treated by antibiotics according to results of culture and sensitivity test.moderate and sever spasticity are treated by antispastic measures. Good nutrition for patients with anemia, iron supplement and blood transfusion when needed. Patients with urinary incontinence were managed by intermittent catherization Patients with constipation were managed by suppositories (Dulcolax) every other day. Thirty patients were managed conservatively and (16) patients were managed by surgical intervention. Thirty two patients were flaccid while the other (14) were spastic RESULTS Table-1- The diseases that are associated by bed sore Disease No. of patients Percentage Cerebrovasculare accident % Trauma % Burn % Transverse myelitis % Tuberculosis % Malignancy % Disseminated sclerosis % Total % 3

4 Table II : Location of pressure sores Site Number Percentage Sacral % Trochanteric % Ischeal % Heel % Maleoli 6 8.3% Knee 5 7.0% Others 2 2.8% Total %. Fifty-six pressure sore were managed conservatively while (16) pressure sores managed by surgical intervention; these were including: - primary closure, musculocutaneous flap, skin graft and full thickness skin graft. Table-(III): Grading of the pressure sores Grade Number Percentage II III IV Total % DISCUSSION: Pressure sore remains a significant problem. Lack of clinical awareness about the staging of pressure sore lead to delayed management of this condition. Most of clinicians regard the non blanchable erythema that characterizes the stage I 4

5 pressure sore as a normal phenomenon and not alarming sign since the skin remain in tact, while erythema indicates significant subnormal injury (15) the frequency with which pressure sores have been recorded in general hospital ranged from % (16). It is estimated that 40% of patient who suffer incomplete injuries will develop pressure sores; half of them will have pressure sores in multiple sites. Our study shows that pressure sores most frequently occurred in sacral region (31.9%), trochantric region (23.6%) and heel (11.1%). Rimmington (18) stated in this study that most common sites of sore was sacrum (28 %), trochantric (19%) and heel (9%).Predisposing factors in our study include: loss of sensation, anemia, spasticity, incontinence of bowel and bladder. Torance (19) found the moisture,anemia loss of sensation, immobility have a role in the development of pressure sores. Anderson found that moisture appeared to be an active causative factor in pressure sores formation and 39% of incontinent patients develop pressure sores (20).In our study (32) patients were managed by conservative measures these included those pressure sores with grade 1 and II, The remaining (16) patents treated by surgical intervention. Other studies show that the surgical management show success rate of 85.4% and the possible causes of failure were haematoma, infection, necrosis of the edge and gangrenous change of the graft, treatment by musculocutaneous flap had a success, ate of (93.3%) (21). Abboud in his study found that the failure rate of musculcutaneous flap in treating trochantric and sacral was 7.4% and 16% respectively and the success rate of surgical intervention for pressure sore was 82% (22 REFERENCES Spoelhaf pressure ulcers in the nursing home physician 1993; 47 (5): Kosiak M; Etiology of delubitul ulcers; Arch. Phys. Rehabil. 1961; 42: Topperman P.S; pressure sores; postgrad Med. 1977; 62: Shea J.D; pressure sores classification and management; inimical orth. Relation Res; 1975; 112: Bergstrom Ni. Strategies for preventing pressure ulcers. Clinical geriateric Med 1997; 13 (3):

6 6- Maklebust J. pressure ulcers: Deereaping the risk for older adults. Geriatric Nursing 1997; 18(6): Defloor T, grypdonck MHF. Sitting posture and prevention of pressure ulcers.appl news Res 1999; 12(3): Doergtrom N, Bennett MA, carton CE, et al. Clinical practice Guideline Number 15. Agency of for Health Care policy and Reserver; Thomar DR. Existing tools: Are the they meeting the challenge of pressure ulcers. Clinical geriatric med 1997; 13(3): Toyalar TV, Rimmers, Day B, et al. Ascorh is acid supplementation in treatment of pressure, sore. Loncent 19 74; Niazibm, surgical management of pressure ulcers. Ostmy / wound management 1997; 43 (8): Frantzra, Adjuvant therapy for ulcer care. Clinical Geriatric Med. 1997; 13(3): Guttman L; The problem of treatment of pressure sore in patient with spiral injury ; paraplegia; B,J, Plastic surgery ; 1966 ; 8 : Toler G. Management of pressure ulcers in long term care. Advances in word car 1997; 10(5): Smith DM, pressure ulcers in the nursing home. Ann Intern Med 1995; 123(6): Bennett L; skin stress and blood flow in sitting paraplegia patients; phys. Med Rehahil. 1965: 3: Deborah A; pressure sores prevention and management; spinal cord injury concept and management. 1987; Rimmington : Decubitus ulcers survey pictures at two hospital; Nurses; J., 1983; 13: Torrance C; pressure sores, predisposing factors the risk patients; Nursing times; 1982; 77:

7 20- Anderson K; prevention of pressure sores by indentifying patient at risk: B.M.J; 1982; 84: Parkash S & Banergee S; The total gluteus max. Rotation and other gluteus max. Muscular cutoneoup flay in treatment of pressure ulcer; B, J. of plastic surgery, 1986; 39; Abboud mi: surgical treatment for pressure sores. Plastic Reconstructive surgery 1992;