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GM8 Geriatric Medicine
Differential Diagnoses of Common Presentations
Toronto Notes 2019
Risk Assessment and Prevention of Pressure Ulcers
Ann Intern Med 2015;162:359-369
The American College of Physicians (ACP) strongly recommends advanced static mattresses or advanced static overlays for patients who are at an increased risk of developing pressure ulcers. The ACP also recommends against using alternating air-mattresses or alternating-air overlays.
Immobility
Complications
• cardiovascular:orthostatichypotension,venousthrombosis,embolism
• respiratory:decreasedventilation,atelectasis,pneumonia
• gastrointestinal: anorexia, constipation, incontinence, dehydration, malnutrition • genitourinary:infection,urinaryretention,bladdercalculi,incontinence
• musculoskeletal:atrophy,contractures,boneloss
• skin:pressureulcers
• psychological:sensorydeprivation,delirium,depression
Pressure Ulcers
• seePlasticSurgery,PL17
Definition
• anylesioncausedbyunrelievedpressureresultingindamageofunderlyingtissue;usuallydevelopsover bony prominence
Risk Factors
• extrinsic:friction,pressure,shearforce
• intrinsic:immobility,malnutrition,moisture,sensoryloss
• geriatric-:agerelatedskinchanges,bed-bound,cognitiveimpairment,chronicillness,useofanti-
hypertensive medications
Table 4. Classification of Pressure Ulcers
Changes include skin temperature, tissue consistency or sensation
An area of persistent erythema in lightly pigmented, intact skin; in darker skin, it may appear red, blue or purple
Partial thickness skin loss involving the epidermis, dermis or both
The ulcer is superficial and presents as an abrasion, blister or shallow crater
Full thickness skin loss involving damage or necrosis of subcutaneous tissue which may extend down to, but not through, underlying fascia
Presents as a deep crater with or without undermining of adjacent tissue
Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures
May have associated undermining and/or sinus tracts
Prevention
• pressurereduction
■ frequent repositioning
■ pressure-reducing devices (static, dynamic)
• maintainingnutrition,encouragingmobilityandmanagingincontinence
• use validated pressure injury risk assessment tools on admission for those identified to be at risk for skin
breakdown (Canadian Association of Wound Care, 2018)
Treatment
• optimizenutritionalstatus
• minimizepressureonwound
• analgesia
• allulcerswithnecrosiswarrantdebridement(mechanical,enzymaticandautolyticarenon-urgent
forms of debridement whereas, sharp debridement is performed urgently due to risk for sepsis or
cellulitis)
• dressingapplication(exudateabsorbing,barrierproductstoreducefriction)
• maintainmoistwoundenvironmenttoenablere-epithelialization
• treatmentofwoundinfections(topicalgentamicin,silversulfadiazine,mupirocin)
• diabeticfootulcers:offloadingwithremovablecastwalker(e.g.aircastboot),orthopedicshoesand
orthotics
• swabwoundsnotdemonstratingclinicalimprovementforC&S;biopsychronicwoundstoruleout
malignancy
• referraltoWoundCare
• considerothertreatmentoptions
■ negative pressure wound therapy/vacuum-assisted closure
■ biological agents: application of fibroblast growth factor, platelet-derived growth factor to wound ■ non-contact normothermic wound therapy
■ electrotherapy
Stage I Stage II Stage III
Stage IV