" I COULDN'T WAIT FOR HIM TO UNDRESS ME. I SLOWLY SURRENDERED
MYSELF....ALLOWING HIS SKILLFUL HANDS TO WORK ON ME. IN THE END
HE
DUTIFULLY DRESSED ME UP AGAIN AND LEFT THE ROOM. NEEDLESS TO SAY
IT FELT
MUCH MUCH BETTER..."
STOP..! STOP...! If you were reading between those naughty
lines...please don't go too far. That was merely a true testimony
given
by a healing ' Stage IV ' ulcer in the hands of a Physical Therapist
who
had just finished performing a Sharp Debridement and wound dressing
at a
long term care setting in the United States. It has to be seriously
recognised that a geriatric patient with a chronic Pressure Ulcer
has a
four fold risk of death versus a geriatric patient without a Pressure
Ulcer. The single most factor in Pressure Ulcer formation is the
immobility of the patient and no doubt that the ' Bed ' is the
most
dangerous splint devised by man.
Recently Physical Therapists have been successful in bringing
Oasis to
the wound climate. They are those who are either trained in Wound
Management or certified as a " Wound Specialist " by
the American
Physical Therapy Association. Some of them recommend the type
of
treatment to the Physician or Nursing, whereas most of them function
as
a lead member of the wound care team, being primarily responsible
for
daily treatments and staff education in the health care setting
whether
it be a hospital, nursing home or home health environment. This
article aims to shed more light on the etiology, assessment and
treatment of a Pressure Ulcer in an uncomplicated medical terminology.
It will be beyond the scope of this article to describe in-depth
, the
clinical responses versus the modality used.
" The major determinant of a Pressure Ulcer is not how
sick the
individual is, but how good the care giver is ". This is
very true
especially when the patient is immobile and bed bound. Wound Management
is a multidisciplinary team approach consisting of the Physician,
Nurse,
Physical Therapist, Dietitian, Occupational therapist, nursing
aides,
patient and/or family. The Physical Therapist has to genuinely
attempt
to heal the wound because if he can't get the wound covered, the
re-imbursement from insurance companies will not be covered either.
The simple theory behind the Wound Management is, " If
it is
wet...Absorb it. If it is dry ...moisten it ." It is very
exciting to
see a wound close up it's edges through the process of granulation,
contraction and epithelialization. Granulation tissue is an immature
tissue which invades and replaces the dying and dead tissue. Physical
Therapists ought to know the Anatomy, functions of skin and the
Physiology of Wound repair ie., the Reaction, Regeneration and
Remodelling phases of wound healing.
Aging results in a decrease of hydration, vascularisation,
subcutaneous
blood vessels, elasticity, flexibility and subcutaneous fat in
limbs. We
all know too well that the primary causes of skin breakdown are
Pressure, Shear, Friction and Moisture. Perhaps what we may not
know is
the cause of Ulcer development. The causative factor is "
reduced blood
perfusion". A larger pressure applied over a skin for a shorter
period
of time is as worse as a smaller pressure applied for a longer
period of
time. The capillary pressure in sitting position is 300 mmHg/cm2
and in
side lying is 100 mmHg/cm2. The normal value is 32 mmHg/cm2 and
therefore capillaries when exposed to external pressure exceeding
32
mmHg may collapse and occlude the blood flow which in turn causes
tissue
anoxia. Whatever the cause of the pressure ,the result is a compromised
circulation to an area of the body, causing capillary distortion,
tissue
ischemia and ultimately the breakdown of skin and muscle tissue.
The use of the term ' decubitus ulcer' is now replaced by "Pressure
Ulcer" as the former is a misnomer. The National Pressure
Ulcer Advisory
Panel ( NPUAP ) has classified the pressure ulcer into four stages.
Stage I Ulcer closely resembles almost like a blushed cheek
of a teen
girl. ( Non-blanchable erythema of intact skin, the heralding
lesion
leading to skin ulceration ). Stage II ulcer looks like the inside
of an
orange skin peeled in one small area as a shallow crater.( Partial
thickness skin loss involving epidermis, dermis or both ) Blisters
and
abrasions are included in this category. Stage III and IV may
not be
that pleasant to describe as they contain quite a few interesting
colorful paraphernalia which are either loose or adherent and
are
squishy, mushy and bouncy. Stage III ulcers are full thickness
skin loss
involving damage to or necrosis of subcutaneous tissue that may
extend
thro' underlying fascia with or without undermining to the adjacent
tissue. Stage IV ulcers are full thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle, bone , tendon,
joint
capsule etc., Undermining and sinus tracts may be associated with
Stage
IV ulcers.
Despite the knowledge base that exists in our cerebral convolutions,
we
have continued to simply carry over the techniques and modalities
handed
down from the ages without asking ourselves if that procedure
was
effective. We can't afford to do that while it comes to treating
pressure ulcers due to cost and safety reasons. Apart from the
Anatomy
and Physiology, it's imperative that we have a profound knowledge
and
the updated information of the modalities and wound care supplies
respectively.
Generally the Ahimsa method of treatment contains three categories:
1. Dressings/ Coverings
2. Use of Modalities
3. Mechanical / Autolytic / enzymatic debridement
The Ahimsa method doesn't always work for stubborn unhealing
wounds and
therefore the last but very effective tool is the Non-ahimsa method
ie.,
4. " Sharp debridement ".
Tissue load management is achieved thro' prevention and early
intervention. The patient is usually referred to the Physical
Therapist
when he or she develops a multiple stage II, stage III or a stage
IV
ulcer. PT does a thorough evaluation of the wound following review
of
the medical chart for resident's medical history including wound
etiology, medications, nutritional habits etc. Risk factors and
possible
contra-indications are noted and a functional evaluation is done
to
determine ROM, strength, etc .The wound assessment includes the
determination and documentation of the ulcer's location, size,
depth,
phase of healing, color, drainage,odor, undermining, tunneling,
sinus
tract, pain , edema, periwound status etc,. Photographic documentation
also serves as an evidence to compare and analyze the healing
process.
A dressing that will keep the wound bed moist & the periwound
dry will
usually yield good results. The types of dressings include hydrogel,
hydrocolloid, foam, Moisture vapor permeable film, alginates,
hydrofiber
etc. Modalities include Whirlpool, High Pressure Irrigation of
wound
using Pulsed Lavage, E.Stim w/ Monophasic high Voltage Pulsed
current,
Ultrasound, Compression therapy using Intermittent Compression
Pump or
Sequential gradient compression, systemic Hyperbaric oxygen, Warm-up
therapy ( non contact thermal wound therapy ) etc. Soft Debridement
on
the other hand includes enzymatic debridement and autolytic debridement.
The former works amazingly on non viable tissue such as the black
eschar
tissue or the yellow necrotic tissue.
Sharp debridement is chosen to remove extensive devitalised
tissue
which are non-adherent. The debridement kit contains a tissue
forceps,
scissors and a scalpel. The PT has to not only create a sterile
field
around the area to be treated, but has to also follow strict
sterile precautions during contact with the open wounds during
selective
debridement.
The course of treatment of any Pressure Ulcer will be incomplete
and
unsuccessful without the consideration of the patient's hydration
and
Nutrition. The essential nutrients required for an accelerated
wound
healing are protein, glucose, copper, zinc, calcium and Vitamins
C, A,
E, K , Riboflavin, Thiamine and Pyridoxine.
We as Physical Therapists can take the pride of not only healing
an
elderly's wound , but also the wounded hearts of the patient's
family.
Physical Therapists as always should not forget the legal implications
of a wrongful choice of treatment leading to potential harm to
the
patient. After all " the whole issue is about healing the
tissue. "
Raveendran Thangavel PT
Rochester, NY.