Prevention of new UP: Have higher risk of developing new UP those who already have or had UP. Place greater emphasis on prophylaxis in these patients. * Support Nutrition: Good nutrition support promotes healing and may prevent the development of new lesions. The nutritional needs of a person with UP are increased and the diet should ensure a minimum:
calories: 30-35 kcal per kg. body weight per day.
Proteins: 1.25-1.5 g / kg. weight day. In cases of hypoproteinemia may need up to 2 g / kg.
Minerals: Zinc, iron and copper.
Vitamins: C, A and B. Support
water: 30 cc of water per day per kg. weight. If this is not covered with the usual diet supplements hyperproteic use of oral enteral nutrition to prevent deficiency states and placing the patient in a positive nitrogen balance.
* Support emotions: There is a decrease in functional ability that affects both the individual and the family. Keep in mind the psychological support and education when developing the plan of care and monitoring.
ULCER CARE : 1 .- Basic Plan 1 - Debridement of devitalized tissue. 2 - Clean the wound. 3 - prevention and treatment of infection. 4 - Choosing a dressing. In any case, the strategy of care will depend on the overall situation of the patient.
2 .- debridement. The wet tissue and devitalized promotes the proliferation of pathogenic organisms and interferes with the healing process. The method of debridement chosen depending on the patient's overall situation and the characteristics of the tissue to debride. Different methods that are exposed can be combined for best results.
· Surgical debridement is considered the fastest way to eliminate areas of dry scars attached to deeper levels, moist areas of necrotic tissue or areas of devitalized tissue in extensive ulcers. Also be used when there is an urgent need desbridaje (eg progressive cellulitis or sepsis). It is a cruel method that requires skill, technical skills and appropriate material. Small wounds can be made at the bedside, but will be extended in the operating room or in a suitable room. Be carried by planes and several sessions (except the radical desbridaje surgery) starting at the center and seeking to achieve early release of devitalized tissue on one side of the lesion. When debriding Stage IV ulcers should be considered in surgical bone biopsy to rule out underlying osteomyelitis.
To avoid pain during these operations it is advisable to use a topical analgesic (lidocaine gel 2%). If there is bleeding control can be made by direct compression, hemostatic dressings, etc.. If the bleeding will not yield to resort to suture the bleeding vessel, once controlled you should use a dry dressing for 8 to 24 hours and subsequently exchanged for a wet.
· Chemical or enzymatic debridement: Rate this zero tolerance approach when surgical debridement and no signs of infection. There are proteolytic and fibrinolytic products, such as collagenase. These enzymes hydrolyze the matrix surface and soften necrotic eschar desbridaje prior to surgery. It is recommended to protect the fabric periulceroso with a paste of zinc or silicon and increase the humidity of the wound to enhance their action. This method is ineffective to remove a hardened scar tissue or large amounts in deep beds, in these cases would require several applications which also costs more expensive and more tissue damage adyacente.
· Desbridamiento autolítico: Se realiza mediante el uso de apósitos sintéticos concebidos en el principio de cura húmeda. Al aplicarlos sobre la herida permiten al tejido desvitalizado autodigerirse por enzimas endógenos. Es un método más selectivo y atraumático. No requiere habilidades clínicas y es bien aceptado. Su acción es más lenta en el tiempo y no deben emplearse si la herida está infectada. Se emplea en general cualquier apósito capaz de producir condiciones de cura húmeda y de manera más específica los hidrogeles de estructura amorfa (geles). Estos geles se consideran una opción de desbridamiento en el caso de heridas con tejido esfacelado, ya que por su acción Moisturizing facilitate the removal of nonviable tissue
· mechanical debridement: This technique is not selective and traumatic. Is performed by mechanical abrasion by forces of friction (rubbing), use of dextranomer, irrigation pressure or use of wet gauze type dressing with 0.9% sodium chloride at dry 6-8 hours past adhere to necrotic tissue, but also healthy, that starts with its withdrawal. At present techniques obsolete.
3 .- debridement. Clean lesions at baseline and every cure. Used as standard saline using an atraumatic technique using a low mechanical strength and less coarse materials both in cleaning and drying. Using an effective cleaning pressure to facilitate drag without causing trauma to the bottom of the wound. The effective cleaning pressure ulcer between 1 and 4 kg/cm2. To achieve a pressure of 2 kg/cm2 over the wound, it is recommended to use 35 ml syringe with a needle or catheter of 0.9 mm.
not use local antiseptics (povidone-iodine, chlorhexidine, hydrogen peroxide, acetic acid, hypochlorite solution) or skin cleansers. All products are cytotoxic to the new tissue and its use can sometimes cause systemic problems due its absorption. Other agents that slow the healing is topical. 4 .- Prevention and Care infection. The UP stage III and IV are colonized by bacteria. In most cases cleaning and debridement appropriate bacterial colonization prevents the progression to clinical infection. The diagnosis of infection associated with UP should be primarily clinical. The classic symptoms include inflammation (erythema, edema, heat), pain, odor, and purulent discharge. Infection of a UP may be influenced by factors specific to the patient (nutritional deficiency, obesity, drugs, immunosuppressants, cytotoxic- comorbidities, advanced age, incontinence) and others related to the injury (stage, presence of necrotic tissue and sloughing, tunneled, sensory disturbances, poor circulation in the area). If there
signs of infection, most only have to step up cleaning and debridement. We must insist on the general rules of asepsis, sterile gloves, washing hands, and begin healing the UP less polluted. If after 2-4 weeks of treatment persist signs of local infection or UP not progressing well, should be treated with topical assay against Gram-negative, Gram positive and anaerobic bacteria, which are microorganisms that infect the UP more often. The most commonly used topical antibiotics in these situations is the sulfadizaina silver and fusidic acid. Should be monitored for allergic sensitization or other adverse reactions to these drugs. If after a maximum of two weeks of treatment with topical antibiotics, the lesion progresses or persists bleeding should be performed quantitative cultures of bacteria from soft tissue and osteomyelitis rule. If there is suspicion or evidence of cellulitis, osteomyelitis, or bacteremia, the patient is susceptible of urgent medical attention. Exudates
crops not used to diagnose infection, and that all PUs are colonized on the surface. Cultures should be performed by percutaneous needle aspiration or tissue fragments obtained by biopsy of UP.
Healing may be impaired by bacteria levels above 105 organisms per gram of tissue. Treatment with systemic antibiotics according to antibiogram will.
Empirical therapy pending susceptibility testing be performed against the most common organisms: S. aureus, Streptococcus sp, P. mirabilis, E. Colli, P. aeruginosa, Klebsiella sp, and anaerobes such as B. fragilis.
Although the diagnosis of osteomyelitis is the gold standard bone biopsy, this invasive technique is not always appropriate in patients with UP. 5 .-
Election dressing. To promote healing of the UP dressings should be used to keep the bottom of the ulcer continuously wet. The ideal dressing should be: biocompatible, which protects the wound, keep the bed moist and the surrounding skin dry, allowing the removal and control of exudate and necrotic tissue, leaving the least amount of waste.
gauze dressings do not meet most of these features. Gauze dressings that stick to the wound, drying should only be used for debridement and we must differentiate dressings saline gauze permanent fund that keep the wound moist.
The selection of wet dressings depends on: location of the lesion, stage and severity, amount of exudate, tunneled perilesional skin condition, signs of infection, performance status, level of care and resources, cost-effectiveness and facilities self-care.
To prevent abscess formation should be removed partially filling the dead space between half and three quarters of the cavities and tunnels with wet curing products that will prevent "false closure."
The frequency of dressing changes will depend on both the product characteristics of the wound. Dressings are applied near the anus are difficult to keep intact for what to monitor and adjust stretching the edges "framed" with tape.
· wet dressings: There is a growing number of these products on the market. For the clinician it is important to familiarize yourself with the different classes and know and use but a limited number of them
Overall occlusive dressings should be avoided if clinical infection. If used must be controlled prior infection or increase the frequency of dressing changes. 6 .-
adjuvant treatment. Electrical stimulation is the only additional therapy may be recommended. UP may be raised in stage III and IV who have not responded to conventional treatment. Be made only with adequate equipment and qualified staff will follow a protocol, the efficacy and safety has been demonstrated in controlled trials. 7 .-
surgical repair. Considered in patients with clean UP stage III or IV do not respond to proper care. Assess potential candidates medically stable, adequate nutritional status, which can tolerate blood loss surgery and postoperative immobility.
additional considerations to keep in mind: quality of life patient preferences, treatment goals, risks of recurrence and expected outcomes of rehabilitation. 8 .-
Palliative Care and UP. A patient is terminal is not "surrender." In this case the action shall be addressed to: Do \u200b\u200bnot blame the environment. Avoids aggressive techniques. • Maintain the wound clean and protected to avoid infection. • Use of dressings to allow priests frequency distance. Avoids the pain and bad smell (odor absorbing dressings). • In agony situation assess the need for repositioning.
9 .- Evaluation and improvement of the quality . The evaluation process is essential to improve the effectiveness of the procedures. It should establish a systematic quality improvement, with continuous interdisciplinary approach that can be monitored, evaluated and modified. Periodic surveys should take incidence and prevalence in order to make a measurement of the results of the protocols. Data should be collected preferably concurrently rather than retrospectively.
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