Pressure Ulcer Management & Back Care
PRESSURE ULCER DEFINITION: Any lesion caused by unrelieved pressure that results in damage to underlying tissue
SYNONYMS Decubitus ulcer Bedsores
PATHOLOGY Pressure Blood vessel collapse Necrosis (tissue death)
MECHANISM External pressure –compress blood vessels Friction and shearing forces-tear and injure blood vessel
EXTERNAL PRESSURE www. drjayeshpatidar. blogspot. in
FRICTION AND SHEARING FORCES Friction-two surfaces rub against each other Shearing-one layer of tissue slide over another
FACTORS AFFECTING PRESSURE ULCER DEVELOPEMENT Aging Immobility-paralysed, unconscious, lengthy surgery Nutrition-malnourished, vit-c deficiancy
FACTORS AFFECTING PRESSURE ULCER DEVELOPEMENT Hydration-dehydration, oedema Moisture-sweating Warmth-fever Poor hygiene Incontinence
PRESSURE ULCER STAGING STAGE I - Nonblanching Erythema With Skin Intact. STAGE II - Partial Thickness Skin Loss(epidermis)- Blister / Abrasion
PRESSURE ULCER STAGING STAGE III – Full thickness Skin Loss Necrosis Of Hypodermic Tissue STAGE IV – Full thickness Skin Loss Extensive Damage to Muscle, bone or Supporting Structures
STAGE I
STAGE II
STAGE III
STAGE IV
PREVENTING PRESSURE ULCER 1. Identify at risk patients 2. Assess their skin daily 3. Keep skin clean & dry always keep pressure off skin 4. Avoid massage over bony prominences 5. Minimize injury from friction 6. Nutritional interventions 7. Improve mobility 8. Document measures used
Massage Therapy
WHAT IS MASSAGE THERAPY? • • • Mechanical modality Used to manipulate the body’s tissue Effective in promoting local & systemic relaxation, increasing local b. flow, breaking down adhesions, & encouraging venous return Act of rubbing, kneading, or stroking the superficial parts of the body with the hand or an instrument for the purpose of modifying nutrition, restoring power of movement or breaking up adhesions Time-consuming
TREATMENT CONSIDERATIONS & GUIDELINES • • Need to know underlying pathology Need to know basic massage principles Must also exhibit patience & courteousness. Hands must be clean, warm, dry & soft. Nails must be short and smooth. Hands should be warm. Avoid constant hyperextension or hyperflexion of any joints which may lead to hypermobility.
TREATMENT CONSIDERATIONS & GUIDELINES • Must obtain correct positioning that will allow for relaxation, prevent fatigue & permit free movement of arms, hands, & body. • Must obtain good posture to prevent fatigue & backache. • Weight should be evenly distributed on both • feet. • • You must be able to fit your hands to the contour of the area being treated. A good position is required to allow for correct application of pressure and rhythmic strokes during the procedure.
POINTS FOR CONSIDERATION • • • Pressure regulation should be determined by the type & amount of tissue present. Also, pressure is governed by the condition & which tissues are affected. Each stroke must have equal pressure & time (rhythm present). Duration depends on pathology, size of area, speed of motion, age, size, & condition of athlete. Also, massage may not be warranted on a daily basis (e. g. friction massage).
POINTS FOR CONSIDERATION • If swelling is present in an extremity, treatment should begin proximally. • • “Uncorking the bottle”, “uncorking effect” Massage should never be painful, except possibly for friction massage. It should not cause ecchymosis. • Direction of forces should be applied in the direction of the muscle fibers. • Each session should begin & end with effleurage. • Make sure the patient is warm and in a comfortable, relaxed position.
POINTS FOR CONSIDERATION • Also, make sure the patient is properly draped. • The body part may be elevated if necessary. • • • Massage should begin with superficial stroking. Each stroke should start at the joint or just below the joint (unless contraindicated) and finish above the joint so that strokes overlap. Pressure should be in line with venous flow. Bony prominences & painful joints should be avoided if possible.
MASSAGE MEDIA • Used to decrease friction between the patient’s skin and the clinician’s hand • • Lotions, peanut oil, powder, analgesic balms • • • Massage can be given without any medium being used More medium should be used on hairy areas During petrissage – lubricants interfere with the kneading & lifting During friction massage – lubricants may interfere with the certain results you want to obtain
MASSAGE STROKES • Effleurage/ Stroking Petrissage Friction (circular, transverse) Rolling Vibration Myofascial release techniques • Various other forms – some may combine strokes • • •
PHYSIOLOGICAL EFFECTS OF MASSAGE THERAPY Depending on the amount of pressure applied & the speed of the stroke, many results can occur ● ● ● Light, slow stroking – evokes systemic relaxation Fast, deep strokes increase blood flow to the area Cardiovascular changes – deep friction or vigorous ● massage was thought to produce vascular changes Research failed to support those theories No increase in cardiac output, b. p. , or increased arterial b. flow were revealed Massage can produce decreased heart rate, breathing rate, & b. p. if the purpose is for inducing system relaxation ● ● ●
PHYSIOLOGICAL EFFECTS Petrissage has been shown to decrease neuromuscular excitability, but only during the massage (effects confined to muscle being massaged) ● Deep effleurage, circular & transverse friction has shown to improve flexibility ● Massage is less effective in decreasing muscular recovery time, but may be effective (2 hrs post) in reducing amount of DOMS ● Little reduction in m. fatigue when performing between exercise (pitcher, sprinter) ●
PHYSIOLOGICAL EFFECTS Edema reduction – when performed properly it can increase venous & lymphatic flow & Reduces pain ● By decreasing pressure from swelling, mechanical pain can be reduced By interrupting m. spasm, mechanical pain can be reduced By reducing edema, mechanical pain can be reduced By increasing b. flow & encouraging waste removal, chemical pain can be reduced Activates sensory nerves – inhibits pain ● ● ●
MECHANICAL EFFECTS Techniques that stretch a muscle, elongate fascia, or mobilize soft-tissue adhesions or restrictions are all mechanical techniques ● Mechanical effects are always accompanied by some reflex ● effects ● As mechanical stimulus becomes more effective, reflex stimulus becomes less effective Muscle – massage is done either for mechanical stretching or ● to relieve pain associated with trigger points
MECHANICAL EFFECTS Skin – massage has been shown to increase skin temperature, increase sweating & decrease resistance to electrical current ● ● It has been shown to toughen yet soften the skin Acts directly on the surface of the skin to remove dead cells ● ● Stretches & breaks down fibrous tissue
STROKING TECHNIQUES Effleurage (stroking): Soothing, long, ● gliding strokes made with the entire flat surface of the hands that may be deep or superficial. The major purpose of this movement is to heighten circulation and increase depth of relaxation. ●
EFFLEURAGE Stroking of the skin Performed with palm of hand ● Stimulates deep tissues Performed with fingertips Stimulates sensory nerves Superficial, rhythmic stroking: Contours the body or relates to direction of underlying muscles ● Deep stroking: ● Follows course of veins & lymph vessels
● Petrissage (kneading): Firmly but gently grasping the skin and surface muscles with thumb and fingers, and rolling, squeezing, or wringing them, and dropping them back into place. It allows detailed work on the body. ● Petrissage is recommended on children and older adults. ●
PETRISSAGE Lifting & kneading of skin, subcutaneous tissue, & muscles ● Performed with fingers or hand. Skin is gently lifted between thumb & fingers or fingers & palm & gently rolled & kneaded in the hand. Often performed without lotion Frees adhesions by stretching & separating muscle fiber, fascia, & scar tissue while assisting with venous return & milking out waste products
Percussion: • Stimulating, rapid movements using both hands in alternate: 1. Tapping - using fingertips; 2. Hacking –using chop movements with stretched fingers; 3. Cupping - using cupped hand movements; 4. Slapping - using flat, open palms; or 5. Pounding - using both fists; 6. Tapotement- the lightest percussion-using drumming movements with fingertips. It is stimulating to the muscles and may be stimulating or calming to the nerves.
PERCUSSION Series of brief, brisk, rapidly applied contacts of the hand in alternating movements. ● ● Used on fleshier parts of the body Stimulates nerveendings & the circulatory ● system.
Friction: May be long, slow, firm stroking ● movements or rolling circular movement in which the hand is kept in contact with the skin and the superficial tissues are moved over the deeper underlying ones. Used in treatment of joints and around bony prominences to break down adhesions, clear out congestion and toxic waste build-up. It raises local temperature and should be followed by effleurage.
FRICTION Goal is to mobilize muscle & separate adhesions that restrict movement & cause pain Facilitates local blood profusion Not necessarily a “pleasing” treatment Circular: ● ● ● Applied with thumbs working in circular motion Effective in treating muscle spasm & trigger pts.
FRICTION ● Transverse: Applied with thumbs or fingertips stroking the tissue from opposite directions Can use elbow, end of rolling pin, etc. for larger areas Reaches deep tissues Begin lightly and then move to firmer strokes Muscle should be placed in relaxed position Should be avoided in acute conditions Effective in tendonitis or other joint adhesions ● ● ● ●
TAPOTEMENT • • Gentle tapping or pounding of the skin Most common form uses ulnar side of wrist to contact skin“karate chop” Wrist & fingers are usually limp, alternate method “cups” the hand Promotes relaxation & desenitization of irritated nerve endings
VIBRATION ● ● ● Rapid shaking of the tissues Soothes peripheral nerves A mechanical device can be used
