Currently, over 34 million Americans are age 65 and over. This figure is expected to double to over 68 million by the year 2030. As a result, there has been a tremendous growth in nursing homes and the related federal regulations that oversee these facilities. Pressure ulcers are particularly problematic in this patient population. According to the Agency for Health Care Policy and Research (AHCPR) guidelines, the incidence of pressure ulcers (often referred to as bedsores) in long-term care facilities was estimated to be as high as 23 percent in 1989.
Pressure ulcers (also called decubitus ulcers and trophic ulcers) may develop over any bony prominence or any area of the soft tissue that is subjected to periods of prolonged pressure. A pressure ulcer is described as local damage to the skin that is caused by a disruption of the blood supply to the area, usually due to pressure, friction or shear. Pressure is the most critical factor as these ulcers are frequently the result of soft tissue being compressed between bony prominences for an extended period of time. Shear separates the skin from underlying tissues. Friction will abrade the top layer of the skin and will also lead to pressure ulcer formation.
While some literature suggests pressure ulcers may never be entirely eliminated, the development of a new pressure ulcer is considered to be a poor outcome in patient management. However, it doesn’t take long for these ulcers to develop. Indeed, pressure ulcers can form in less than two hours. Therefore, clinicians should be proficient in identifying the high-risk patient in order to prevent the development of pressure sores and associated complications. Patients at risk for pressure ulcers include the following:
• paralyzed patients;
• patients with diminished pain awareness;
• patients who have a chronic illness that requires them to be bedridden;
• those recovering from a hip fracture;
• patients who are dehydrated;
• patients who are malnourished;
• patients who previously had pressure ulcers that healed;
• those with altered mental status;
• those who have incontinence; and
• immunosuppressed patients.
A Few Thoughts About Prevention
Most pressure ulcers are preventable. Even if there is a stage one pressure ulcer, it should not deteriorate in most circumstances. High-risk patients may be a different story as even the most effective nursing care and patient management may not prevent the development and deterioration of ulcers. Nevertheless, we must aim aggressive therapy at reducing the patient’s risk factors and implement preventive measures as well.
In addition to maintaining and improving tissue tolerance, we must protect patients against adverse external forces, friction, shearing and pressure. According to the AHCPR guidelines, one of the keys in preventing pressure ulcers is emphasizing the moving, lifting and turning of patients who are bedridden or in wheelchairs. Patients should be moved every two hours, with small turns in between the positional changes. Also recommend smooth bedsheets and padding for the bed or wheelchair. Patients or their caregivers should also strive to keep the skin clean and dry. Ongoing educational programs can help reduce the incidence of these ulcers as well.
Recognizing The Signs And Stages Of Pressure Ulcers
Keep in mind that an early sign of pressure ulcer development is blanching erythema that you may be able to verify with finger compression. Pressure ulcers often will resolve once you decrease or eliminate the pressure to the area of bony prominence. A non-blanching erythema is a more serious sign that tissue damage is forthcoming or that it may have occurred. A chronic pressure ulceration will have a well-defined border and a surrounding nonblanchable erythema.
Proper documentation begins with an accurate assessment of the stage of the pressure ulcer. You must also document many local factors, such as the location, size, amount, type and any odor of exudate, and the type of present tissue (such as epithelial, granulation, necrotic, eschar or slough). You should also document any signs of clinical infection, such as induration, fever, erythema, edema, purulent drainage or other infections.
Here are the various stages of pressure ulcers, as per the AHCPR guidelines:
• A stage one pressure ulcer may be superficial. It is a non-blanchable erythema of intact skin; the heralding lesion of skin ulceration. When treating individuals with darker skin color, be aware that discoloration of the skin, warmth, edema, induration or hardness of the skin may all be indicators.
• A stage two pressure ulcer reveals partial thickness skin loss involving the epidermis, dermis or both. This ulceration is superficial and presents clinically as an abrasion, blister or a shallow crater.
• A stage three pressure ulcer is a full thickness skin loss that involves damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. This type of ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
• A stage four pressure ulcer is a full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures, such as tendon and joint capsule. Keep in mind that undermining and sinus tracts may be associated with this type of pressure ulcer. Stage four pressure ulcers are associated with high morbidity and mortality, and may lead to legal complications.
The staging of a pressure ulcer is a very small part of the overall assessment of your patients. Remember, the staging system merely describes the depth of tissue involvement. Examining the surrounding skin is essential. The presence of inflammation, induration or ischemia may help provide you with essential information concerning the prognosis of the ulcer.
Indeed, your initial assessment and documentation is only the beginning of managing patients who have pressure ulcers. You also need to thoroughly document the patient’s systemic factors, such as nutritional status, particularly the serum albumin levels. (See “Why The Patient’s Nutritional Status Is Critical For Healing” on page 57.) You must also document any underlying illnesses (like diabetes, COPD, PVD and anemia) and current medications (such as corticosteroids, chemotherapy and NSAIDs). Also be sure to note the patient’s immune status, age, stresses and continence status.
Essential Treatment Tips
Our treatment goals are directed toward protecting the wound from further trauma, promoting a clean wound bed, preventing infection, maintaining a moist wound environment and ensuring proper medical attention to all systemic conditions.
Local care for a pressure ulcer typically involves debridement, wound cleansing, choosing the most appropriate wound dressing and, if indicated, selecting adjunctive medical therapies. Debriding and removing all necrotic tissue increase the likelihood for wound healing and decrease the chances of infection.
It is also very important to clean the wound. Removing all foreign material helps facilitate optimal wound healing. You also want to keep the wound hydrated via appropriate wound dressings. Moisture dressings prevent desiccation and promote the formation of granulation tissue. While no one dressing type can provide an optimal environment, remember that each dressing has its advantages and disadvantages. The dressing you select depends directly on the wound characteristics. You can choose from the following dressing categories: alginates, collagens, foams, hydrocolloids, transparent films, wound fillers, debriding agents, leg wraps, hydrogels and gauzes.
Adjunctive treatments include growth factors, electrical stimulation, hyperbaric oxygen, ultrasound, vacuum-assisted closure and bioengineered skin. Operative repair is an option for stage three and stage four ulcers that do not respond to conservative treatments.
Also be aware that clinical studies indicate that as deep pressure ulcers heal, the lost muscle, fat and dermis are not replaced. The wound defect fills in with granulation tissue and then re-epithelialization takes place. Therefore, reverse staging is inappropriate. For example, a stage three pressure ulcer does not become a stage two or a stage one as the wound is healing.
As per the aforementioned AHCPR Guidelines, you must document wound progress by assessing any improvement in the wound characteristics, whether you notice changes in size, depth, the amount of necrotic tissue and/or the amount of exudate.
As clinicians, we must be proficient in identifying patients who are at risk for the development of pressure ulcers. Proactive measures, such as daily skin examinations, patient turning schedules and selection of appropriate bed surfaces, are essential for prevention.
Pressure ulcers are more common than you may be aware, especially when it comes to the nursing home population. Pressure ulcers are very costly and have potentially devastating ramifications for patients. Treating these patients often requires frequent assessments and evaluations in order to prevent further complication such as sepsis and death.
Early intervention, management of all underlying medical conditions, timely referrals and the team approach are critical factors for ensuring optimal care for our patients.
Dr. Fishman is the Chairman of the Wound Care Institute in North Miami Beach, Fla.
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2.Nurse’s Clinical Guide, Second Edition, Cathy Thomas Hess, RN, BSN, CETN, Springhouse Corporation, Springhouse PA, 1998.
3.Chronic Wound Care, Diane Krasner, RN, MS, CETN, Health Management Publications, Inc, King Of Prussia, PA, 1990.
4. Chronic Wound Healing, R. Mani, V. Falanga, CP Shearman, D. Sanderman, W. B. Saunders Company, LTD, London, 1999.
5. AHCPR Guidelines - Quick Reference Guide for Clinicians, Number 15, December 1994. Publication No. 95-0653.
6. Black Law Dictionary: 6th Edition Centennial Edition (1891-1991). St. Paul, Minn. West Publishing Company. 1990.