^T^^l^D: Skin damage and ulcers caused by pressure on weightbearing areas, typically tissue over bony prominences.
Pressure on susceptible tissues results in impaired perfusion, ischaemia, cell ^^ death and skin breakdown.
Q/OQ Extrinsic: Pressure, shear, friction, moisture.
H Intrinsic: Age, immobility, sensory impairment, incontinence, protein-calorie malnutrition (for each 10 g/L # in albumin, threefold " in risk). Common, 3-10% of hospitalised patients and nursing home residents, with > ^^ 70% in those aged > 70 years, with annual costs estimated at £321m. in the UK.
_H Area of erythema or ulcer may be noticed by carer, less frequently the patient may complain of pain in the affected area. Predisposing factors should be
O ascertained. The ischaemic injury responsible may have occurred early on in a hospital stay, e.g. while on operating table, with the majority developing within the first 2 weeks.
^lE: Vulnerable areas are over the sacrum, coccyx, ischial tuberosities, greater trochanter malleoli and heels, also the occiput and scapulae. Stage I: Nonblanching erythema with intact epidermis. Stage II: Shallow ulcer involving dermis (can be a blister). Stage III: Full thickness of dermis, extending into SC tissue. Stage IV: Extending beyond deep fascia into tendon, bone, muscle or joint. This system cannot be used to measure progression or healing (e.g. Stage IV ulcers do not always start and progress through Stages I, II and III). Colonisation of wounds by bacteria is common and unavoidable; however, infection should only be diagnosed if there is associated erythema, odour, purulent exudates or systemic signs (e.g. fever).
_P When external pressure exceeds capillary filling pressure (32mmHg), tissue perfusion is impaired resulting in ischaemia, acidosis and waste product accumulation. Early signs of tissue damage occur in the dermis with nonblanching erythema indicating perivascular haemorrhage from capillaries. With time there is cell death and tissue necrosis in the dermis, SC tissues and then the epidermis.
I: Wound swab, FBC, blood cultures if infection suspected.
Plain radiographs, bone or 67Gallium scans, MRI or needle bone biopsy if underlying osteomyelitis is suspected.
M: Prevention is the key: Risk assessment (e.g. Waterlow scores), assessing nutritional status, avoiding excessive bed rest.
Pressure reduction: Turning the patient every 2h. Avoiding pressure on vulnerable sites, especially sacrum, trochanters and heels, pressure-reducing devices (static or dynamic) such as foam or air mattresses that distribute the pressure between the patient and the bed.
Wound management: Pressure reduction. Assessing severity and optimising wound environment to promote granulation and re-epithelialisation, debridement of necrotic tissue. Use of appropriate dressings (e.g. hydrocolloid, hydro-gel or alginates). Prevention and treatment of infection, attention to nutrition (vitamin C, zinc supplementation in those who are deficient). Surgical: Restricted to Stage III or IV ulcers. Debridement of necrotic material and reconstruction of affected area with myocutaneous flaps (have a high complication rate, hence attention to pre-op optimisation and post-op care are vital).
C: Infection (e.g. cellulitis or osteomyelitis), chronic ulceration, tendency to recur.
P: Pressure ulcers are difficult to heal, Stage II may take several weeks of care, while only "3 of Stage IV have healed after 6 months; hence, prevention is vital.
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Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.