Nutritional support
Nutrition plays an important role in the holistic approach of healing the wounds. A good fovorece nutritional support not only the healing of pressure ulcers but also can avoid the appearance of them. An important part of the healing of these is local and occurs even with nutritional dysfunction, although the scientific community agrees that a poor nutritional status, a delay or inability to complete healing of injuries and encouraging the emergence of new ones.

Cynically severe malnutrition is diagnosed if serum albumin is less than 3.5 mg / dL, total lymphocyte count is below 1800/mm3, or if body weight decreased more than 15%. The nutritional needs of a person with pressure ulcers are increased.

The diet of patients with pressure ulcers should ensure a minimum contribution of:
* Calories (30-35 Kcal x Kq.peso / day)
* Proteins (1.25 to 1.5 g / Kg.peso / day) (may be necessary to increase up to 2gr./Kg. weight / day).
* Minerals: Zinc, Iron, Copper
* Vitamins: Vit C, Vit A, B Complex
* Contribution water (1 cc. Kcal.día Water x) (30 cc Water / day x Kg.peso)

If the patient’s usual diet does not cover these needs should be used to supplement oral enteral nutrition hyperproteic to avoid situations of deficiency.

Emotional Support
The presence of a skin lesion may cause a significant change in activities of daily living because of physical, emotional or social challenges that can translate into a deficit in self-care demand and the ability to provide these self-care. In the case of pressure ulcers they may have important consequences on the individual and his family, in variables such as autonomy, self-image, self esteem, etc.. therefore be borne in mind this important dimension to the time to plan your care.

Care of the ulcer
A basic plan of local care of ulcer should consider:

• Debridement of necrotic tissue
• Clean the wound
• Prevention and treatment of bacterial infection
• Choosing a product that continually keep the ulcer bed moist and body temperature.

Debridement
The presence in the wound bed necrotic tissue and eschar either black, yellow, .. , Wet or dry in nature, serving as ideal medium for bacterial growth and impedes the healing process. In any case the overall situation of the patient condition debridement (patients with bleeding disorders, patients with terminal illness, etc.). The characteristics of the tissue to debride also guide the type of debridement performed.

From a practical way we can classify the methods of debridement:
“sharp (surgical)”, “chemical (enzymatic)”, “suicidal” and “mechanical”.
These methods are not mutually incompatible, so it would be advisable to combine them for best results.

• Sharp or surgical debridement

Surgical debridement is a bloody procedure that requires knowledge, skill and technique and sterile equipment. Moreover, the policy of each institution to determine level of care performed by whom and where. Sharp debridement should be carried out by planes and in different sessions (except radical surgical debridement), always starting from the central area by seeking early release of devitalized tissue on one side of the lesion.

Faced with the possibility of the occurrence of pain in this technique, we recommend the implementation of an antalgic t6pico (2% lidocaine gel, etc.).. The bleeding can be a common complication that usually we can control by direct pressure, hemostatic dressings, etc.. If the situation did not yield the above measures will be used to suture the bleeding vessel. Once controlled the bleeding would be desirable to use for a period of 8 to 24 hours a dry dressing, changing later by a wet dressing.

• The wet (enzyme)

Chemical or enzymatic debridement is a method to assess when the patient does not tolerate surgical debridement and no signs of infection. There are several products on the market enzymatic (proteolytic, fibrinolytic, …) that can be used as chemical agents detersión necrotic tissue. Collagenase is an example of such substances.

There is scientific evidence indicates that it favors debridement and granulation tissue growth. When intended to be used, you should protect your skin using a paste periulceral zinc siliciona, etc.., Like, that increasing the level of moisture in the wound to enhance their action.

• Autolytic Debridement

Autolytic Debridement be fostered through the use of products introduced in the moist healing principle. It is caused by three factors, hydration of the bed of the ulcer, fibrinolysis and the action of endogenous enzymes on devitalized tissue. This form of debridement is more selective and atraumatic, requiring no specific clinical skills and being generally well accepted by patients.

It has a slower action in time. Any dressing capable of producing wet curing conditions, generally and the hydrogels in a specific amorphous structure are capable of producing products autolytic debridement. For wounds with tissue sloughing, the hydrogels in amorphous structure (gels), for its moisturizing facilitate the elimination of non-viable tissue and should therefore be considered as one option for debridement

• Mechanical debridement.

This technique is not selective and traumatic. Mainly done by mechanical abrasion by friction forces (friction), use of dextranomer, through irrigation pressure wound dressings or wet utilizaci6n that last 4-6 hours drying adhere to necrotic tissue, but also the woven healthy, that starts with his retirement. At present techniques obsolete.

• Cleaning the lesion

Clean the injury initially and every priest.
Use as standard saline.
Use minimal mechanical force to clean the ulcer and for their subsequent drying.
Use effective pressure washing to facilitate hauling of debris, bacteria and remnants of previous treatments, but without ability to produce healthy tissue trauma.

The most effective pressure washing is provided by gravity or by example that we do through a 35 ml syringe with a needle of 0.9 mm catheter that projects the saline over the wound at a pressure of 2 kg ./cm2.

Pressure washing of the ulcer effective and safe ranges between I and 4 kg./cm2.

Can not clean the wound local antiseptic (povidone iodine, chlorhexidine, hydrogen peroxide, acetic acid, hypochlorite solution,) or skin cleansers.

All chemicals are cytotoxic to the new tissue and in some cases their continued use can cause systemic problems in their absorption into the body.

Prevention and treatment of bacterial infection

• Choice of dressing

The available scientific evidence demonstrating the clinical effectiveness and the perspective cost-benefit (spacing of priests, handling minor injuries …) of the technique of wound healing in a moist environment versus traditional or cure.

An ideal dressing should be biocompatible, protect the wound from external aggression physical, chemical and bacterial, to keep the ulcer bed continuously moist and dry the surrounding skin, eliminating and controlling exudate and necrotic tissue by absorption, leaving the minimum amount of waste in the lesion, being adaptable to difficult locations and be easy to apply and remove.

The gauze can not meet most of the above requirements.

“The selection of an oppositional cure in a moist environment must take place by considering the following variables:
Location of injury
Stadium
Severity of ulcer
Amount of exudate
Presence of tunneling
State of surrounding skin
Signs of infection
General condition of the patient
Level of care and availability of resources
Cost-effectiveness

Ease of application in contexts of self-care
To avoid the formation of abscesses or “false closure” of injury, be required to complete part (between half and three quarters) and tunneling cavities with products based on the principle of wet cure.

The frequency of dressing changes each pair is determined the specifics of the chosen product.

Dressing should be selected to enable optimal management of exudates without Allowing it to dry out the bed of the ulcer or periulceral tissue injury.

• Adjunctive Treatment

Currently, the electrical stimulation is the only adjunctive therapy with complementary features enough to justify the recommendation. May arise in those two pressure ulcers Stage III and IV who have not responded to conventional therapy. In any case you should make sure that it has adequate equipment and personnel trained in their use, following the protocols that have Demonstrated safety and efficacy in controlled trials.

• Colonization and bacterial infection in pressure ulcers

All pressure ulcers are contaminated by bacteria, which is not to say that injuries are infected. In most cases, effective cleaning and debridement impossible for bacterial colonization to progress to clinical infection. The diagnosis of infection associated with pressure ulcer, should be primarily clinical.

The classic symptoms of local infection of the skin ulcer are:
Inflammation (erythema, edema, tumor, heat)
Pain
Odor

Purulent discharge
The infection of an ulcer may be influenced by patient-specific factors (nutritional deficiencies, obesity, drugs, immunosuppressants, cytotoxic, concomitant diseases, diabetes, tumors, …, old age, incontinence, etc.). And others related to the injury (stage , presence of necrotic tissue and sloughing, tunneling unstressed injuries, circulatory disturbances in the area, etc. ..) In the presence of local signs of infection should be intensified cleaning and debridement.

If, within two to four weeks, the ulcer is not progressing well or continuing with signs of local infection, having ruled out the presence of osteomyelitis., Cellulitis or sepsis, should be implemented a treatment regimen with a local antibiotic effectiveness against microorganisms most frequently infected pressure ulcers (eg silver sulfadiazine, fusidic acid …) and for a maximum period of two weeks.

If the injury does not respond to local treatment must be carried out then, bacterial cultures, qualitative and quantitative, preferably by percutaneous needle aspiration biopsy tissue, avoiding, if possible, the collection of exudate smear can detect only surface contaminants and not the real organism responsible for infection.

Identified the germ will pose specific antibiotic therapy, reevaluate the patient and the injury.

Infection control.

• Follow precautions for body substance isolation
• Use clean gloves and change them with each patient
• Hand washing between procedures with patients is essential.
• Can multiple ulcers in patients, starting with the least contaminated
• Use sterile instruments surgical debridement of pressure sores
• Do not use local antiseptics.
• Systemic antibiotics should be given a prescription low in patients with bacteremia, sepsis, advanced cellulitis or osteomyelitis.
• Comply with waste disposal regulations of their institution.

Surgical repair of pressure ulcers
It should consider surgical repair in patients with pressure ulcers stages III or IV, unresponsive to conventional therapy. Similarly, elements will be necessary to assess the quality of life, risk of recurrence, patient preferences, and so on. Along with the potential to be a candidate for surgical treatment (postoperative immobility avoiding pressure on the affected region, proper nutrition, medically stable, etc.)..

Educations and improving the quality of life
The education program should be an integral part of quality improvement. Educational programs are an essential component of care for pressure ulcers. They must integrate basic knowledge about these lesions and should cover the full spectrum of care for prevention and treatment. They will be directed towards patients, families, caregivers and health professionals.

Palliative care and pressure ulcers
Whether a patient is in terminal stage of their illness does not justify to be made claudicaren order to avoid the occurrence of pressure ulcers. In the event that a patient have pressure ulcers should act:

• It blames the care environment of the occurrence of injuries.
• It is a common complication in many cases at that stage, probably inevitable.
• Raising realistic therapeutic goals according to the chance of cure, avoiding as possible aggressive techniques.
• Keeping the wound clean and protected, to prevent the development of infection.
• Selecting dressings which allow the frequency distance of the cures to prevent discomfort caused by this procedure.
• Improving patient comfort, avoiding pain and trying to control, if any, the stench of the lesions (using activated charcoal dressings, Metronidazole gel, etc.).
• In dying situation will be necessary to assess the need for repositioning the patient.

Evaluation indicators and benchmarks
The evaluation process is an essential tool for improving the effectiveness of the procedures employed in the care of pressure ulcers. It is necessary to establish a quality program with the aim of improving care provided to patients, facilitate teamwork and make objective clinical practice.

The problems of these injuries must be approached from an interdisciplinary approach. The results of the care can be measured based on the incidence and prevalence of pressure sores. The incidence and prevalence studies should be conducted periodically by the ideal would monitor them and integrate them into a local policy on a pressure ulcer.

As an instrument to assess the evolution of these injuries can use the severity index. Descriptive other variables can be used to evaluate the process time. Concerning the lesion (staging, number of injuries, length, volume, source etc.). Or refer the patient (age, gender, risk assessment scale for pressure ulcers etc.)..

Pressure ulcers can and should be avoided with good nursing care within an overall plan that includes the multidisciplinary work of the physician, nurse, patient and family. We must find the ideal treatment for each type of ulcer and in many cases, using different treatments, as observed evolution.

1 .- Poll
2 .- Relief of pressure on tissues
3 .- General Care
4 .- Ulcer Care
5 .- bacterial colonization and infection in pressure ulcers
6 .- repair pressure ulcers
7 .- Education and improving the quality of life
8 .- par Palliative care and pressure ulcers
9 .- Evaluation Indicators and Benchmarks
Select an item or move the cursor down

1 .- VALUATION:

It would be inappropriate to focus exclusively on the assessment of pressure ulcers and not taking into account the overall assessment of the patient.
A comprehensive evaluation the patient with pressure ulcers requires a review in three dimensions:
“Patient State”, “injury” and “your care environment.

1.1 Initial assessment of the patient
History and complete physical examination, paying particular attention to:
· Risk factors for pressure ulcers (immobility, incontinence, nutrition, mental status ,…)
· Identification of diseases that may interfere with the healing process (and collagen vascular disorders, respiratory, metabolic, immunologic, neoplastic, psychosis, depression ,…)

Advanced age ·
· Habits Toxic snuff, alcohol.
· Habits and health status
· Drug therapy (corticosteroids, nonsteroidal antiinflammatory drugs, immunosuppressants, cytotoxic drugs, …

Nutritional assessment
· Use a simple tool for identifying nutritional assessment and malnutrition (calories, protein, serum albumin, minerals, vitamins ,…)
· Regularly reassess

Psychosocial Assessment
· Check the capacity, ability and motivation of the patient to participate in their treatment program.

1.2 Assessment of the care environment
Identification of the primary caregiver. Assessment of attitudes, skills, knowledge and possibilities of the caregiver (family, informal carers ,…)

1.3 Assessment of injury
When assessing an injury, it should be able to be described by unified parameters to facilitate communication between different professionals involved, which in turn will allow the properly verify your progress. It is important to the assessment and registration of the injury at least once a week and whenever there are changes they suggest.

2 .- PRESSURE RELIEF ON THE TISSUE

Relieving the pressure is preventing tissue ischemia, thereby increasing the viability of soft tissue injury or placing optimal conditions for healing. Each performance will be directed to reduce the degree of pressure, friction and shear.
This decrease in pressure can be achieved by using techniques of position (lodging or sitting) and the choice of a suitable surface.

2.1 Techniques position

2.1.1. With the patient sitting.
When an ulcer has formed on the seating surfaces should be avoided that the individual remains seated. As always exceptional and could ensure the pressure relief devices using special support that position will allow for limited periods of time, thereby maintaining good functionality of the patient. The sitting position of individuals that showed no injury at that level must be changed at least every hour, by facilitating exchange for support of their weight every fifteen minutes with postural change or conducting drives.  If it was not possible to change the position every hour, must be sent back to bed.

2.1.2. With the patient bedridden.

Bedridden individuals should not support on pressure ulcers. When the number of injuries, the patient’s condition or treatment goals will prevent attainment of the above guideline, you should reduce the exposure time or increasing the frequency of pressure changes. You can use a wide variety of support surfaces that can be helpful in achieving this goal.

In both positions:
Never use float or ring-type devices.
Always make a written individualized plan.
The different levels of care and especially in the context of community care will be necessary to involve the carer in the implementation of activities aimed at relieving pressure.

2.2. Support Surfaces

The practitioner must consider several factors when selecting a support surface, including the patient’s clinical status, characteristics of the institution or the level of care and the very nature of that surface. The use of support surfaces is important from the standpoint of prevention, as measured from the perspective of helping in the treatment of lesions in place.

The choice of support surfaces should be based on its ability to counter the elements and forces that may increase the risk for these injuries or worsen, and the combination of other values such as ease of use, maintenance, costs, and patient comfort.   The bearing surfaces can act at two levels, surfaces reduce pressure, lower levels of the same, though not necessarily below the values that prevent capillary closure. In the case of systems of pressure relief is a reduction in the level of pressure in soft tissue below capillary occlusion pressure in addition to eliminating friction and shear.

It is important to remember that support surfaces are a valuable ally in relieving pressure, but in no case replace the “repositioning”.

In this sense, the guidelines are:
Use a surface that reduces or relieves the pressure, according to the specific needs of each patient.
Use a static area where the individual can assume various positions without supporting your weight on pressure ulcer.
Use a dynamic support surface if the individual is unable to assume various positions without the weight falls on the / s ulcer / s by pressure.

It is recommended that resource managers of different levels of care, both in hospitals and communal, where patients are treated with pressure ulcers or susceptible, the desirability of some of these areas for the benefit of its use can obtained.

It recommend the allocation of resources according to patient risk, so we suggest the systematic use of a rating scale of the risk of developing pressure ulcers that are validated in the scientific literature that fits the needs of context reference assistance.

ULCER DEFINITION:
We can define pressure ulcers as localized areas of necrosis that tend to occur when soft tissue is compressed between two planes, one bony prominences of the patient and the other an external surface. Affecting 9% of all hospitalized patients and 23% of those admitted to nursing homes. The early detection and treatment speeds recovery and reduces complications.

PATHOGENESIS:
They are produced by a prolonged and constant external pressure over a bony prominence and a flat disk, which causes ischemia of the vascular membrane, which causes vasodilation in the area (look red), extravasation of fluid and cellular infiltration. If co pressure decreases, there is an intense local ischemia in the surrounding tissues, venous thrombosis and degenerative changes, leading to necrosis and ulceration.

This process can continue and reach deeper levels, the destruction of muscles, fascia, bones, blood vessels and nerves.

The forces responsible for their occurrence are:

1 .- Pressure: A force acting perpendicular to the skin as a result of gravity, causing a crushing tissue between two planes, one belonging to the patient and an external to him (couch, bed, probes, etc.).. Pressure capillary ranges between 6 – 32 mm. Hg. Pressure exceeding 32 mm. Hg., occlude capillary blood flow in soft tissues causing hypoxia, and if not relieved, necrosis of the same.

2 .- Friction: It is a tangential force that acts parallel to the skin, producing friction, or drag motion

3 .- Vascular Impingement External Force: Combine the effects of pressure and friction (eg Fowler’s position that produces sliding of the body, can cause friction and pressure on the sacrum same area).

OTHER RISK FACTORS:
These are factors that contribute to the production of ulcers and can be grouped into five major groups:

1 .- Pathophysiological:

As a result of different health problems.
- Skin lesions: edema, dry skin, lack of elasticity.
- Disorder in the Oxygen Transport: Peripheral vascular disorders, venous stasis, cardiopulmonary disorders …
- Nutritional Deficiencies (default or excess): Thinness, malnutrition, Odessa, hypoproteinemia, dehydration ….
- Immune Disorders: Cancer, infection …….
- Altered State of Consciousness: Stupor, confusion, coma ……
- Shortcomings Motorcycles: paresis, paralysis …….
- Sensory Impairments: Loss of pain sensation ….
- Impairment of Disposal (urinary / bowel): Urinary incontinence and bowel.

2 .- Derived Treatment:

As a consequence of certain therapies or diagnostic procedures.
- Imposed immobility, result from specific therapeutic alternatives: devices / equipment such as casts, tractions, respirators ……….
- Treatments or drugs that have action inmunopresora: Radiotherapy, corticosteroids, cytostatics ……
- Polls for diagnostic and therapeutic: bladder catheterization, nasogastric ……

3 .- Situation:

Result of changes in personal, environmental, habits, etc..
- Immobility: associated with pain, fatigue, stress …..
- Wrinkle in linens, nightgown, pajamas, rubbing objects, etc. ..

4 .- Development:

Related to the maturation process.
- Children Infants: baby diaper rash …
- Elderly: Loss of skin elasticity, dry skin, restricted mobility …..

5 .- The Environment:

- Loss of self-image of the individual in the disease.
- The lack of health education to patients.
- The lack of unified criteria in the planning of the priests by the care team.
- The lack or misuse of prevention material, both the basic and supplementary.
- The motivation for the lack of professional training and / or specific information.
- The professional’s workload.

LOCATION:
Usually in areas of support that match bony prominences or maximum relief. The areas most at risk would be the sacral region, heel, ischial tuberosities and hips.