Inhaltsverzeichnis

Vorwort

Foreword I

I consider it a great privilege to have been asked to write the foreword for this book. The European Pressure Ulcer Advisory Panel (EPUAP) is less than 10 years old having been founded in 1997.1 had the honour of being the first president of this group and have been amazed and delighted at the progress and achievements the panel have made since that time. The progress is remarkable, not only because it is a truly European group consisting of a wide range of clinical and academic interests but also because it has retained its focus on the prevention and treatment of pressure ulcers.

The officers and board should be congratulated in developing a range of educational and research opportunities in this important but often neglected aspect of clinical practice. Not only have they organised a series of successful annual conferences that have been held in a number of a European countries but they have developed a number of other exciting initiatives. These have included setting up working groups, developing guidelines, undertaking prevalence studies and research projects. The latest addition to these activities is the publication of this book which I am confident will rapidly become the standard textbook for all interested in this subject-not only in Europe but on a global scale.

The editors of this book-who are all internationally known for their work in this area-are all key individuals in the success of the EPUAP. They have pulled together a comprehensive review of this subject written by a range of experts from different professional backgrounds representing many European countries. This is no mean feat and they should be congratulated on their vision and determination.

The 22 chapters address key issues in this condition and range from updates in research through to epidemiological aspects on to assessment of patients and equipment. The book also debates local wound care either by conservative or surgical methods, complications such as infection onto issues around developing and implementing guidelines and the increasingly important subject of litigation in this area. Many special interest groups claim to be working in a 'Cinderella' area but few conditions other than pressure ulceration can really justify that description. In an increasingly diverse world the challenges of providing pressure ulcer care in developing countries are different but no less challenging than those of providing care in so called developed or advanced healthcare systems. It is perhaps surprising that in such advanced healthcare systems some cancer can be cured, heart disease can be prevented and organs can be transplanted but many patients in such systems can not guarantee that they will receive prompt and appropriate interventions to prevent or treat pressure ulceration. The challenge to all caring for such patients is considerable but this book provides a reference source for anyone who needs to understand the basis of many aspects of patient care in this area. In addition, the colour section provides excellent clinical illustrations that demonstrate a number of key points in pressure ulceration.

This subject is receiving increasing attention from a number of professional, governmental and legal directions. The importance, cost and ability to use aspects of this clinical problem as an indicator of the quality of health care delivery is to be encouraged but how robust is the research base, the development of standards of clinical care and consistency of healthcare practices in pressure ulceration on a local national and international basis?

This book will not replace all of the work needed to address these problems but it will provide a strong foundation from which we can build our understanding of this condition for improved standards of care to patients in what has been a long standing but neglected clinical challenge.

I congratulate the editors, authors and publishers for remaining focused on their task-to provide the best and most comprehensive and up to date review of this subject. I commend this book to you as an essential companion to help you improve standards of care for your patients.

Keith Harding, MD

Foreword II

One of the outcomes of advancing medical technology is that people are living longer. As life is extended, the complex issue of managing persons with chronic diseases becomes increasingly important. The increased number of persons with chronic wounds such as pressure ulcers is already being realized. The health-care burden of managing these chronic wounds can only be lessened if effective prevention programs are aggressively implemented and evidence-based management protocols are developed and followed.

The information contained in this book provides the critical elements for developing effective, evidence-based protocols for the prevention and management of pressure ulcers. What this book cannot provide is the commitment required to create an environment where the development of a pressure ulcer on a person is unacceptable. Protocol development is only one component of a comprehensive program for prevention and management of pressure ulcers. Everyone involved in patient care from administration to bedside provider has to make the commitment that pressure ulcers will not occur in their facility.

This book is a tremendous resource, but it needs to be used effectively. In the United States, the government sponsored the development of evidence-based guidelines on prevention and management of pressure ulcers. These guidelines became available in the early nineties. Since their publication, the prevalence of pressure ulcers in the United States has not changed at the national level. However, in those facilities that chose to use the guidelines to develop and implement new protocols for prevention and management of pressure ulcers, the incidence of pressure ulcers was reduced to zero or to a very low level.

The information in this book can be used to prevent new pressure ulcers from developing, and rapidly healing those that have unfortunately already developed. The only thing missing is the commitment to make change. I hope that everyone who reads this book makes the personal commitment to prevent pressure ulcers from occurring and to optimize the management of those that occurred at a different facility.

George T. Rodeheaver, PhD
Founding Member and Past President
National Pressure Ulcer Advisory Panel

Klappentext

Science and Practice of Pressure Ulcer Management establishes the clinical and scientific basis behind effective pressure ulcer management. Essential reading for dermatology clinicians and vascular surgeons, and having been developed under the auspices of EPUAP (European Pressure Ulcer Advisery Panel), this text is the primary reference for pressure ulcers from diagnosis and prevention to management and treatment options. Dermatology nursing and clinic staff, as well as interns, gain important insight from reading this book.

The contributing authors are all experts in the management of pressure ulcers and will provide a valuable clinical compendium for this difficult area of medicine. Numerous detailed illustrations, many in color, and tables are included to enhance the text.

ISBN 1-85233-839-3

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Index

A

Acetic acid, 143
Acid mantle, 96
Acinetobacter calcoaceticus, 151
Acticoat, 156
Actisorb, 156
Africa, 194
Agency for Health Care Policy and Research, USA (AHCPR), 169
Aging, 190-191
- of skin, 78
AGREE.See Appraisal of Guidelines for Research and Evaluation

AHCPR.See Agency for Health Care Policy and Research, USA

AIDS, 191, 193
Albumin, 32-33, 101
Alcohol hand rinses, 154
Alginate, 135
Allogeneic constructs.See Bioengineered skin

Alternating pressure mattress, 7, 8
Antibiotics, 111
Antibody labeling scanning, 153
Antimicrobials, 155
Antioxidant vitamins, 85, 87
Antiseptics, 142-143
- alcohols and, 142
- biguanides and, 142
- dressings and, 135
- for enzymatic debridement, 134
- halogen compounds and, 142
- iodine and, 143
- organic acids and, 143
- peroxides and, 143
- tinctures and, 143
Apligraf®, 115
Appraisal of Guidelines for Research and Evaluation (AGREE), 174
Aquacel-AG, 156
Arginine, 85, 87
Arglaes, 156
Autolytic debridement, 134-135
- alginate dressings and, 135
- cellulose dressings and, 135
- hydrocolloids and, 134
- hydrogels and, 134
- occlusive dressings and, 135
- polyacrylates and, 135
- Ringer's solution and, 135

B

Bacitracin zinc, 155
Bacteremia, 145
Bacteria.See Infection
Benzoyl peroxide, 155
Betadine, 143
Bioengineered skin, 104
- keratinocyte sheets and, 104
- neonatal foreskin cells and, 104
Biopsy
- of bone, 153
- of tissue, 149
Birty Pressure Risk Assessment scale, 53
Blanching hyperemia, 29
Bone scintigraphy, 153
Braden Q scale, 53
Braden scale
- parameters of, 50-51
- validation studies on, 51-52
Braden score, 3, 45

C

Cadexomer iodine, 135, 154-155
Capillary closure pressure, 11, 29
Case mix method, 4
CBO.See Dutch Institute for Healthcare Improvement

Cellular deformation in muscle tissue, 21, 23
- pathogenesis and, 20
Cellular senescence, 103
Cellulose, 135
Cetrimide, 143
Charcot foot, 148
China, 195
Chlorhexidine, 142
Classification, 37-40
- controversies in, 38
- dark skin assessment for, 39
- EPUAP systems for, 3, 37-38
- grade 1 ulcers and, 38-39
- criteria for, 39
- definitions of, 38
- erythema and, 38
- reactive hyperemia and, 38
Classification (continued)
- incontinence lesion identification for, 40
- inter-rater reliability of, 37
- NPUAP system for, 37
- PUCLAS and, 40
- reverse grading and, 39-40
- Stirling Grading System for, 37
Clinical practice guidelines (CPG), 44-45, 86, 169-175
- barriers to, 173-174
- clinical indicators and, 174
- implementation aids and, 174
- consensus-based, 170
- Delphi methods for, 170
- literature searches for, 170
- weighed consensus techniques for, 170
- evidence-based, 170-173
- draft of, 171
- evaluation of, 172-173
- external review of, 171-172
- implementation of, 172-173
- publication and dissemination of, 172
- scope of, 170-171
- international development of AGREE and, 174
- GIN and, 175
- national development of AHCPR and, 169
- CBO and, 169
- EPUAP and, 169
- NICE and, 169
- on nutrition, 86
Collagen, 22, 30, 32, 11
Collagenase, 133
Compression.See Pressure

Computed tomography, 153
Computerized planimetry, 93
Confocal laser scanning microscopy, 21
Contreet Foam, 156
Contreet -HC, 156
Cornell Ulcer Risk Score, 53
Costs, 183, 186
C-reactive protein, 153
Cryopreserved skin, 115
Cubbin-Jackson scale, 53
Culture-grown fibroblasts, 115
Culture-grown keratinocyte, 115
Culture-grown skin, 115
Cutaneous flaps, 121
Cytokines, 101

D

Dakins, 142
Damage law, 23
Data collection, 1
Debridement, 129-136, 144-145
- antiseptic dressings for, 135
- cadexomer iodine for, 135
- honey for, 135
- hypochlorite solutions for, 135
- silver for, 135
- autolytic method of, 134-135
- alginate dressings and, 135
- cellulose dressings and, 135
- hydrocolloids and, 134
- hydrogels and, 134
- occlusive dressings and, 135
- polyacrylates and, 135
- Ringer's solution and, 135
- bacteremia and, 145
- contraindications for, 130-131
- black heels and, 130
- obliterative arterial disease, 130
- pyoderma gangrenosum and, 131
- terminally ill patients and, 130
- enzymatic method of, 133-134
- antiseptics and, 134
- collagenase use for, 133
- deoxyribonuclease use for, 134
- fibrinolysin use for, 134
- papaina use for, 134
- eschar and, 129
- maggot method of, 132-133
- antibacterial effects of, 133
- propylene glycol and, 133
- proteolytic enzymes and, 133
- necrotic tissue and, 129
- perfusion and, 131
- sharp method of, 131-132
- complications with, 132
- contraindications for, 132
- slough and, 129
- TIME concept and, 103-104, 140, 144
- wound bed preparation and, 103
Decubitus Ulcer Potential Analyzer, 53
Dental impression materials, 94
Deoxyribonuclease, 134
Dermagraft®, 115
Dermatitis, 80
Dermatology, 192-194
Dermis.See Skin
Developing world, 189-195
- access of, 190
- Africa and, 194
- aging and, 190-191
- China and, 195
- dermatology in, 192-194
- signs of early skin failure and, 193
- encouraging care in, 192
- EPUAP and, 189-190

- family and, 191
- HIV/AIDS in, 191, 193
- India and, 194-195
- inexpensive treatment solutions for, 190
- information technology in, 191-192
- International Foundation for Dermatology and, 193
- litigation and, 191
- medical curricula in, 194
- NPUAP and, 189
- poverty and, 191
- skin assessment in, 192
Devitalized tissue.See Debridement
Dressings, 111-114.See also Debridement adsorbents for, 111
- antibiotics for, 111
- antiseptics for, 111, 135
- gauzes for, 111
- granulation encouraging products for, 112
- growth factor group of, 115
- guidelines for, 113
- hydrocolloids for, 112
- hydrogels for, 112
- interactive methods for, 113, 114
- cultured cell group of, 115
- metalloprotease inhibitor group of, 115
- skin substitute group of, 115
- surgical group of, 115
- non-allopathic types of, 113
- philosophy of, 112
- polyurethane films for, 112
- Polyurethane foams for, 112
- proteolytic enzymes for, 111-112
- technical devices for, 113
- hydrotherapy related, 116-117
- topical negative pressure therapy related, 114, 116
- warming therapy related, 117, 118
Dutch Institute for Healthcare Improvement (CBO), 169

E

EGF.See Epidermal growth factor

Ek scale, 48-49
Elastography, 20
Engineered derma, 115
Enzymatic debridement, 133-134
- antiseptics and, 134
- collagenase use for, 133
- deoxyribonuclease use for, 134

- fibrinolysin use for, 134

- papaina use for, 134
Epidermal growth factor (EGF), 104
Epidermis.See Skin

Epithelial cancer, 92
EPUAP Review, 86-87, 185-186
- Equipment, 59-65 efficacy of, 59
- pressure reduction with, 60
- powered systems for, 60
- static systems for, 60
- pressure relief with air fluidized systems for, 60-61
- alternating pressure mattresses for, 60
- selection of, 61
- aesthetics and, 64
- alarm systems and, 64
- cleaning and, 64
- contraindicated conditions and, 62
- electrical power sources and, 63
- exudate levels and, 62

- financial considerations for, 64

- handling requirements and, 62

- home care and, 62-64

- mattress height and, 62
- resuscitation and, 62
- storage and transportation for, 64
- temperature control and, 62
- weight limits and, 63
Erythema, 38, 146-147
Erythrocyte sedimentation rate, 153
Eschar, 129
Ethyl alcohol, 142
Etiology
- capillary closure pressure and, 11
- interface pressures and, 11-12
- pressure and, 27-30
- blanching hyperemia and, 29
- at capillary closure, 29
- capillary occlusion and, 29
- formula for calculation of, 27
- friction and, 28
- in healthy capillary bed, 29
- humidity and, 28
- nonblanching hyperemia and, 29
- perfusion and, 30
- shear and, 27-28
- tissue collagen levels and, 30
- transmission of, 28-29
- prolonged pressure and, 11
- shear forces and, 11
European Pressure Ulcer Advisory Panel (EPUAP), 183-186, 201
- classification systems by, 3, 37-38
- CPGs and, 169
- definition of pressure ulcers by, 2

- developing world and, 189-190
- development of, 183-184
- educational initiatives of EPUAP Review and, 185-186
- PUCLAS and, 40, 186
- guidelines by
- nutritional, 185
- prevention, 8, 184
- treatment, 8, 185
- Marks of Quality and, 190
- NPUAP and, 184
- open meetings of, 184-185
- survey by, 2-3

- website of, 185
Eusol, 142, 189-190
Exudate
- enzyme levels in, 82
- maceration from, 82
- peri-wound skin protection from barrier preparations for, 82
- corticosteroids for, 82
- dressings for, 82
- wound bed preparation and, 102

F

Fasciocutaneous flaps, 122
FEA.See Finite element analysis

FGF.See Fibroblast growth factor

Fibrin, 105
Fibrinogen, 101
Fibrinolysin, 134
Fibroblast growth factor (FGF), 104
Fibroblasts, 102, 115
Finite element analysis (FEA), 18
Flamazine, 156
Fluorodeoxyglucose-positron emission tomography, 153
Free flaps, 124
Frequency, 1
Full-thickness skin grafts, 121
Fusidin ointment, 155

G

Gene therapy, 104-105
gene gun injection for, 104-105
- naked plasmid DNA and, 104-105
- viruses for, 104-105
Gentamicin, 155
Gentian violet, 143, 190
GIN.See Guidelines International Network

Glycerol skin, 115
Gosnell scale, 48-49
Grafts, 115
Growth factors
- dressings and, 115
- hypoxia and, 102
- trapping of, 101
- for wound bed preparation, 104
Guidelines.See also Clinical practice guidelines
- for control of infection, 140
- for dressings, 113
- by EPUAP, 8, 184-185
- litigation and, 166
- for management of incontinence, 81
Guidelines International Network (GIN), 175

H

Heterologous culture-grown skin, 115
History, 183
HIV, 191, 193
Honey, 135, 190
Hyalograft 3D®, 115
Hyalograft 3D KC®, 115
Hyalomatrix®, 115
Hydrocolloids, 112, 134, 156
Hydrogels, 112, 134-135
Hydrogen peroxide, 143
Hydrotherapy, 116-117
- high-pressure microjet technology for, 117
- hydromassage for, 117
- immersion pools for, 116
- irrigation pressure in, 117
- syringe method of, 117
Hygeol, 142
Hyperemia, 29, 38
Hypoalbuminemia, 33
Hypochlorite solutions, 135
Hypothermia, 117
Hypoxia, 102, 151

I

Incidence rates, 1-6, 177
Incontinence, 79-81
- dermatitis from, 80
- fecal, 79-80
- guidelines for management of, 81
- healthcare institutions and, 79
- maceration from, 80
- parous women and, 79
- skin-care product use for, 81
- skin pH levels and, 80
- soap use for, 80
- urinary
- overflow induced, 79
- stress induced, 79
- urge induced, 79
India, 194-195
Indian Dermatology Congress, 194
Infection, 139-158
- antiseptics for, 142-143
- assessment of, 145-148
- covert infections and, 148
- discoloration and, 146
- erythema and, 146-147
- infrared thermometry for, 148
- pain and, 146
- purulent discharge and, 146
- symptoms list for, 147
- warmth and, 146-147
- bacterial species in, 150-152
- aerobic, 150
- anaerobic, 150
- Gram-negative, 150
- Gram-positive, 150
- predictable progression of, 150-151
- relevance of, 151
- synergistic effects of, 151
- bacterial tests for, 148-150
- MRSA and, 148
- neutrophils and, 148
- swab technique for, 150
- tissue biopsy and, 149
- VRE and, 148
- debridement and, 144-145
- bacteremia and, 145
- foreign material, 145
- guidelines for control of, 140
- host resistance and, 139
- local wound care for, 144
- TIME concept and, 144
- MRSA vectors and, 153
- nonhealable ulcers and, 142
- organism numbers and, 139
- organism virulence and, 139
- osteomyelitis and, 152-153
- bone biopsies for, 152
- imaging studies of, 153
- laboratory tests for, 153
- sterile probe use on, 152
- patient-centered concerns regarding, 141
- treatment of, 153-158
- infection control measures for, 153-154
- iodine use for, 154-155
- nanocrystalline silver use for, 157-158
- Infection (continued) silver preparations for, 155-157
- topical antimicrobials for, 155
Infrared spectroscopy, 20
Infrared thermometry, 148
Innovations, 197-202
- in clinical practice, 197-198
- with pressure-redistributing mattresses, 198
- with tissue viability nurse specialists, 197
- with total bed management, 198
- in logistics, 200-201

- from EPUAP, 201

- from NPUAP, 201

- with pressure ulcer audit, 200

- using prevalence surveys, 200

- in research, 198-199
- on interface pressure, 199
- on ischemia-reperfusion cycles v. constant loading, 199
- on pressure-redistributing mattresses, 199
- in societal views, 201-202
Integra®, 115
Interface pressures, 11-13
- incorrect threshold for, 11-12
- pressure monitoring systems and, 12
- FSA and, 12
- Novel and, 12
- Oxford Mk I/II, 12
- Talley Pressure Monitoring system and, 12
- Talley-Schimedics single cell system and, 12
- Tekscan and, 12
- pressure profiles and, 12-13
- relationship of interstitial pressures and, 18-19
Internal mechanical environment, 18-20
- bony prominences and, 18-19
- computational modeling of, 18-19
- elastography and, 20
- FEAand, 18
- infrared spectroscopy, 20
- MRI and, 20
- MRI/MRS and, 20
- ultrasound and, 20
- global external loads' effect on, 18
- material properties of soft tissue and, 19-20
- subcutaneous tissues and mechanical integrity of, 18
- thickness of, 18
- tone of, 18
- wick catheter and, 18
International Foundation for Dermatology, 193-194
Interstitial pressures, 18-19
Iodine, 143
Ischemia, 20, 199.See also Etiology; Pressure

Isopropyl alcohol, 142

K

Keratinocyte growth factor-2, 104
Keratinocytes, 104, 115

L

Larval debridement.See Maggot debridement
Laser Skin®, 115
Laser triangulation scanner, 94
Lateral lying position, 70
Leishmaniasis, 193
Leprosy, 193
Leukocytes, 153
Litigation, 163-167
- in developing world, 191
- documentation and, 166-167
- prevention measures with, 166
- treatment measures with, 167
- negligence and, 165
- accountability and, 165
- causation and, 165
- standard of care and, 166
- pressure ulcer guidelines and, 166
- prevalence rates and, 163
- typical awards from, 164
Loading
- hierarchical modeling of, 21
- postoperative care and, 125
- research on, 199
- tissue status under Doppler fluxmetry and, 13
- metabolite levels and, 15
- reflective spectrophotometry and, 13
- transcutaneous oxygen tensions and, 13-14
Lymphatic filariasis, 193

M

α-2 macroglobulin, 101
Maggot debridement, 132-133, 190
- antibacterial effects of, 133
- propylene glycol and, 133
- proteolytic enzymes and, 133
Magnetic resonance imaging (MRI)
- internal mechanical environment and, 20
- of muscle tissue, 23
- for osteomyelitis, 153
Magnetic resonance spectroscopy (MRS), 179
- internal mechanical environment and, 20
- muscle tissue and, 23
Malnutrition.See Nutrition

Matrix metalloproteinases, 102
Mattresses.See also Equipment
- alternating pressure, 7, 8
- pressure-redistributing, 198-199
- quality of life and, 7
- research on, 199
- viscoelastic, 68
McClemont cone of pressure, 28
Melinda and Bill Gates Foundation, 192
Mercurochrome, 143
Metalloprotease inhibitors, 115
Methicillin-resistant staphylococcus aureus (MRSA), 148, 151, 153, 155
Metronidazole, 155
Minimum physiological mobility requirement (MPMR), 31
Mortality rates, 178
MPMR.See Minimum physiological mobility requirement

MRSA.See Methicillin-resistant staphylococcus aureus Mupirocin, 155
Muscle-sparing perforator flaps, 124
Muscle tissue
- cellular deformation in, 21, 23
- dead cell distribution from, 23
- compression-induced cellular breakdown in, 21-23
- agarose gel construct and, 21
- cell membrane disintegration and, 21
- collagen scaffold and, 22
- confocal laser scanning microscopy and, 21
- contractile protein disintegration and, 21
- damage threshold model of, 22
- histological examination for, 23
- inflammation and, 21
MRI and, 23
MRS and, 23
- nuclear pyknosis and, 21
- damage law for, 23
- cell tolerance parameter and, 23
- damage evolution parameter and, 23
- dimensionless strain energy density
- parameter and, 23
material parameters and, 23
- pathogenesis and, 20
- reperfusion and, 23
Myocutaneous flaps, 122-123

N

Nanocrystalline silver, 156-158
National Institute for Clinical Excellence, UK (NICE), 169
National Pressure Ulcer Advisory Panel, USA (NPUAP), 201
- classification system by, 37
- developing world and, 189
- EPUAP and, 184
Necrotic tissue, 129.See also Debridement

Negative pressure therapy.See Topical negative pressure therapy

Negligence, 165-166
- accountability and, 165
- causation and, 165
- standard of care and, 166
Neutrophils, 148, 153
NICE.See National Institute for Clinical Excellence, UK

Nonblanching hyperemia, 29
Nonresponse rate, 4
- Norton scale, 45
- derivatives of, 48-49
- limits of, 48
- parameters of, 47
- validation studies on, 48
Nova-4 scale, 48-49
NPUAP.See National Pressure Ulcer Advisory
- Panel, USA Nuclear magnetic resonance, 179
Nuclear pyknosis, 21
Nutrition, 32-33, 85-89
- assessment of, 87-88
- CPGs on, 86
- decision tree on, 88
- intervention with, 87-88
- oral feeding and, 85, 87
- protein and, 87
- risk factors related to
- collagen production and, 32
- hypoalbuminemia and, 33
- muscle wasting and, 32
- odds ratio assessments for, 33
- relative risk assessments for, 33
- serum albumin levels and, 32-33
- screening for, 87-88
- supplements for, 87
- tube feeding and, 85, 87

O

Odds ratio assessments
- for age, 32
- for mobility, 31
- for nutrition, 33
Osteomyelitis
- bone biopsies for, 152
- imaging studies of, 153
- laboratory tests for, 153
- sterile probe use on, 152

P

Papaina, 134
Pathogenesis
- cellular deformation and, 20
- interstitial transport and, 20
- ischemic damage and, 20
- lymphatic system and, 20
- muscle tissue and, 20
- pressure-induced ischemia and, 20
- reperfusion damage and, 20
PDGE See Platelet-derived growth factor

Perfusion subcutaneous pressure and, 30
Perfusion MRI, 23
Peri-wound skin, 82
pH
- skin and, 80
- wound assessment and, 96-97
Photogrammetry, 93
Platelet-derived growth factor (PDGF), 102, 104
Platelet gels, 115
Polyacrylates, 134-135
Polymyxin B sulfate, 155
Polyurethane, 112
Povidone iodine, 154
Pressure, 27-30
- blanching hyperemia and, 29
- at capillary closure, 11, 29
- capillary occlusion and, 29
- formula for calculation of, 27
- friction and, 28
- in healthy capillary bed, 29
- humidity and, 28
Pressure (continued)
- nonblanching hyperemia and, 29
- perfusion and, 30
- relief of equipment for, 60-61, 179, 198-199
- surgical treatment and, 125
- shear and, 27-28
- avulsion of capillaries from, 28
- regional stretching from shear, 28
- vascular occlusion from, 27
- tissue collagen levels and, 30
- transmission of, 28-29
- McClemont cone of pressure and, 28
Pressure-redistributing mattress, 198-199
Pressure ulcer classification system (PUCLAS), 40, 186
Pressure ulcer risk assessment scales.See Risk assessment scales

Prevalence rates, 1-6
- by body site location, 2
- in children, 2
- by country, 3
- by grade, 3
- as healthcare quality indicator, 163
- litigation and, 163
- research on, 178
Prevention
- costs of, 178
- EPUAP guidelines for, 8, 184
- litigation and, 166
- quality of life and, 7-8
- risk assessment scales for, 43
Promogran®, 115
Prone lying position, 70
Propylene glycol, 133
Protein, 87
Proteolytic enzymes
- dressings and, 111-112
- maggot debridement and, 133
Pseudomonas aeruginosa, 150-151, 155
PUCLAS.See Pressure ulcer classification system

Q

Quality of life, 7-9, 179-180
- auxiliary devices and, 7
- economical treatments and, 8
- mattresses and, 7
- nurses and, 7
- pain treatment and, 7
- physiotherapists and, 8
- prevention of ulcers and, 7-8

- spinal cord injuries and, 7

- young patients and, 7
- skin condition and, 7
- sleep and, 7
- wound care and, 7
Quantitative microbiology, 149

R

Radiolabeled leukocytes, 153
Rates, 1-6
- calculation of, 3-4, 5
- Braden score and, 3
- case mix method and, 4
- cutoff points and, 3-4
- nonresponse rates and, 4
- risk group definition and, 3-4

- of incidence, 1-6

- litigation and, 163
- of mortality, 178
- of prevalence, 1-6
- by body site location, 2
- in children, 2
- by country of origin, 3
- in geriatric patients, 5
- by grade, 3

- prevalence v. incidence, 3, 5
- multiple pressure sores and, 3, 5
- progression to higher grades and, 3, 5

- research on, 177-178
- time period and, 2
Reeve, Christopher, 189
Regranex®, 115
Relative risk assessments for mobility, 31

- for nutrition, 33
Reperfusion muscle tissue and, 23
- pathogenesis and, 23
Repositioning, 67-72

- frequency of, 68-69
- research on, 68
- pressure-reduction with, 69-70
- adapted repositioning scheme for, 70
- lateral lying position for, 70
- prone lying position for, 70
- semi-Fowler 30° position for, 69-70
- supine lying position for, 69
- upright-sitting position and, 70
- bending and stretching in, 71
- chair type for, 71
- optimal posture for, 71
- pressure-reducing cushions for, 71
Research, 11-23, 177-180, 198-199
- capillary closure pressure and, 11
- on costs of prevention and treatment, 178
- on diagnostic imaging techniques, 179
- on incidence rates, 177
- incorrect measures and, 11
- on interface pressure, 199
- interface pressures and, 11-12
- on ischemia-reperfusion cycles v. constant loading, 199
- on mortality rates, 178
- on patient quality of life, 179-180
- on physiological response to mechanical factors, 178-179
- on pressure-redistributing mattresses, 199
- on pressure relieving devices, 179, 198-199
- on prevalence rates, 177-178
- on wound healing, 180
Ringer's solution, 135
Risk assessment scales, 43-59
- Braden scale Risk assessment scales (continued)
- parameters of, 50-51
- validation studies on, 51-52
- characteristics of, 46-47
- applicability and, 47
- definite criteria and, 47
- ease of use and, 47
- predictive value and, 47
- sensitivity and, 46
- specificity and, 46
- CPG recommendations about, 44-45

- for intensive care patients, 53
- Norton scale, 45
- derivatives of, 48-49
- limits of, 48
- parameters of, 47
- validation studies on, 48

- for pediatric patients, 53

- preventative measures based on, 43

- systematic review of, 46
- Waterlow scale appraisals of, 50
- parameters of, 49
- validation studies on, 50
Risk factors, 30-34
- age and, 31-32
- odds ratio assessments for, 32
- pathological skin changes and, 32
- mobility and, 30-31
- MPMRand, 31
- odds ratio assessments for, 31
- relative risk assessments for, 31
- spontaneous nocturnal movement and, 31
- nutrition and, 32-33
- collagen production and, 32
- hypoalbuminemia and, 33
- muscle wasting and, 32
- odds ratio assessments for, 33
- relative risk assessments for, 33
- serum albumin levels and, 32-33
- reference table of, 34
- tissue tolerance and, 30

S

Scale.See Risk assessment scales

Semi-Fowler 30° position, 69-70
Sensate myocutaneous flaps, 123-124
Sharp debridement, 131-132
- complications with, 132
- contraindications for, 132
Shear, 11
- avulsion of capillaries from, 28
- regional stretching from shear, 28
- vascular occlusion from, 27
Silvadene, 156
Silver, 133, 135, 155-158
- adsorbed, 156
- allergic sensitization to, 156
- minimum inhibitory concentrations of, 157
- nanocrystalline, 157
- preparations of, 156
- salts, 156
Silver-calcium-sodium phosphates, 156
Silver charcoal, 156
Silver coated foam, 156
Silver combined with hydrocolloid, 156
Silver nitrate, 156
Silver-sodium carboxymethylcellulose, 156
Silver sulfadiazine, 156
Sinus tracts, 92
Skin, 75-82
- acid mantle, 80
- aging of drying during, 78
- elasticity loss during, 78

- fatty layer reduction during, 78

- thinning during, 78

- bioengineered, 104

- dark colored, 39

- dermal layer of collagen fibers in, 77
- elastin fibers in, 77
- ground substance of, 77
- lymph vessels in, 77
- nerve endings in, 78
- sebaceous glands in, 78
- sweat glands in, 78
- tissue mast cells in, 77
- tissue microphages in, 77
- epidermal layer of basal layer of, 77
- clear cell layer of, 77
- dermal junction with, 77
- granular layer of, 77
- horny layer of, 76
- prickle cell layer of, 77

- failure of, 193

- functions of, 75-76

- protection, 76

- sensation, 76

- thermal regulation, 76

- vitamin D production, 76

- grafts of, 120-123

- incontinence and, 75, 80-81

- peri-wound, 82

- pH levels of, 80

- quality of life and, 7

- wound assessment and, 92
Skin bank, 115
Skin flaps, 121
Slough, 129
Sodium hypochlorite, 142
Spectrophotometry, 13
Split-thickness skin grafts, 120-121
SSD Cream, 156
Staphylococcus aureus, 150-151, 152, 155
Stem cell therapy, 105

- fibrin use for, 105

- pluripotentiality of, 105
Stereophotogrammetry, 93-94
Stereophotography, 93-94
Stirling Grading System, 37
Stratum basale, 11
Stratum corneum, 76, 81, 82, 96
Stratum granulosum, 11
Stratum lucidum, 11
Stratum spinosum, 11
Streptococci, 150, 153, 155
Sunderland scale, 53
Supine lying position, 69
Surgical treatment, 119-125
- debridement during, 120
- patient selection for, 119-120
- postoperative care after, 124-125
- diet during, 125
- load conditioning during, 125
- physical training during, 125
- pressure relief during, 125
- reconstruction with direct closure for, 121
- fasciocutaneous flaps for, 122
- flaps without skin coverage for, 123
- free flaps for, 124
- full-thickness skin grafts for, 121
- muscle-sparing perforator flaps for, 124
- myocutaneous flaps for, 122-123
- sensate myocutaneous flaps for, 123-124
- skin flaps for, 121
- split-thickness skin grafts for, 120-121
- tissue expansion for, 124
- staff for, 119
Swaminathan Foundation, 191
Sweat, 78.
See also Tissue biochemistry

T

T2-weighted MRI, 23
Tagging MRI, 23
TGF-ßl.See Transforming growth factor-ßl
TIME.See Tissue debridement, infection/inflammation, moisture balance, edge effect

Tissue biochemistry, 14-18
- carbon dioxide levels and, 16-17
- metabolite levels under loading and, 14-15
- oxygen levels under, 16-17
- sweat lactate levels and, 15, 16-17
- sweat metabolite constituents and, 14
- sweat purines and, 16
- sweat urea levels and, 16
Tissue debridement, infection/inflammation, moisture balance, edge effect (TIME), 103-104, 140, 144
Topical negative pressure therapy, 114, 116
- contraindications for, 116
- duration of, 116
- indications for, 116
- target pressure of, 116
- Vacuum Assisted Closure device for, 114, 116
Transcutaneous oxygen tension, 13-14, 102
Transforming growth factor-ßl (TGF-ßl), 101, 102

U

Ultrasound, 20, 153, 179
Upright-sitting position, 70-71

V

Vacuum Assisted Closure, 114, 116
Vancomycin-resistant enterococcus (VRE), 148
Vascular endothelial growth factor (VEGF), 102
VEGF See Vascular endothelial growth factor

Viscoelastic mattresses, 67, 68
Vitamins, 76, 85, 87
VRE.See Vancomycin-resistant enterococcus

W

Warming therapy, 117-118
- blood flow and, 117
- hypothermia and, 117
Waterlow pressure ulcer risk scores, 33
Waterlow scale appraisals of, 50
- parameters of, 49
- validation studies on, 50
World Health Organization, 192
Wound assessment, 91-97
- area and volume measurements in, 91, 93-94
- computerized planimetry for, 93
- dental impression materials for, 94
- image processing for, 93
- laser triangulation scanner use for, 94
- metric grid use for, 93
- photogrammetry use for, 93
- sheet tracing for, 93
- stereophotogrammetry use for, 93-94
- stereophotography use for, 93-94
- three-dimensional scanner use for, 94
- exudate and, 92
- infection and, 92-93
- odor and, 92
- pH measurements in, 96-97
- colorimetric technique for, 96
- flat glass electrode use for, 96
- pH transistor technology for, 97
- surrounding skin and, 92
- tissue density measurements in, 94-95
- echogenicity values and, 95
- ultrasonography use for, 94-95
- tissue perfusion measurements in, 95-96
- laser Doppler flowmetry use for, 95
- laser Doppler imaging use for, 96
- undermining tissue and, 92
- viable tissue quantity and, 92
- wound edges and, 92
Wound bed preparation, 99-105
- bacterial burdens and, 100
- bioengineered skin and, 105
- biofilms and, 101
- debridement and, 103
- gene therapy for, 104-105
- growth factors for, 104
- PDGF and, 104
- sequential treatment with, 104
Wound bed preparation (continued) growth factor trapping and, 101
- hypoxia and, 102
- fibroblast proliferation and, 102
- growth factors and, 102
- impaired healing and, 100
- phenotypic wound cell alteration and, 102-103
- cellular senescence and, 103
- healing capacity and, 103
- stem cell therapy for, 105
- TIME concept for, 103-104
- wound fluid and, 101-102
- exudate levels and, 102
- matrix metalloproteinases and, 102

X

X-rays, 153