The Physiology and Treatment of Pressure Sores Essay

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The Physiology and Treatment of Pressure Sores Essay

Pressure sores have remained a global health care program even to this day. There are several factors that contribute to the development of pressure sores. However, there is limited clarity on the exact influence of these factors on the development of pressure. Furthermore, just as there are different terms for the same health care challenge there are a wide range of interventions that have been used over a long period of time in the management of pressure sore, with some even extending into the exotic in the form of magic potions, as the search for the right intervention in the management of pressure sores carries on. The body of knowledge on pressure sores currently has expanded into a large volume of literature that is used as evidence in developing intervention strategies for pressure sores. The Physiology and Treatment of Pressure Sores Essay. Yet, quite often the value of the evidence received from research on pressure sores is quite often undermined by the poor research design, with particular emphasis on methodically sound empirical investigations and randomized controlled studies. This has hampered the expanding of the right understanding of pressure sores and the taking of correct informed decisions in the management of pressure sores.
The true incidence and prevalence of pressure sores also remain a puzzle. Pressure sores do not constitute a reportable health event in every health care environment and so the data available on the incidence and prevalence cannot be taken as a correct picture. Irrespective of this impediment pressure sores remain a serious health challenge in all countries around the world.

Pressure ulcers remain a major health problem affecting approximately 3 million adults.¹ In 1993, pressure ulcers were noted in 280,000 hospital stays, and 11 years later the number of ulcers was 455,000.² The Healthcare Cost and Utilization Project (HCUP) report found from 1993 to 2003 a 63 percent increase in pressure ulcers, but the total number of hospitalizations during this time period increased by only 11 percent. Pressure ulcers are costly, with an average charge per stay of $37,800.² In the fourth annual HealthGrades Patient Safety in American Hospitals Study, which reviewed records from about 5,000 hospitals from 2003 to 2005, pressure ulcers had one of the highest occurrence rates, along with failure to rescue and postoperative respiratory failure.³ Given the aging population, increasingly fragmented care, and nursing shortage, the incidence of pressure ulcers will most likely continue to rise. The Physiology and Treatment of Pressure Sores Essay.

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Preventing pressure ulcers has been a nursing concern for many years. In fact, Florence Nightingale in 1859 wrote, “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing”⁴ (p. 8). Others view pressure ulcers as a “visible mark of caregiver sin”⁵ (p. 726) associated with poor or nonexistent nursing care.⁶ Many clinicians believe that pressure ulcer development is not simply the fault of the nursing care, but rather a failure of the entire heath care system⁷—hence, a breakdown in the cooperation and skill of the entire health care team (nurses, physicians, physical therapists, dietitians, etc.).

Although the prevention of pressure ulcers is a multidisciplinary responsibility, nurses play a major role. In 1992, the U.S. Agency for Healthcare Research and Quality (AHRQ, formerly the Agency for Health Care Policy and Research) published clinical practice guidelines on preventing pressure ulcers.⁸ Much of the evidence on preventing pressure ulcers was based on Level 3 evidence, expert opinion, and panel consensus, yet it served as a foundation for providing care. Although the AHRQ document was published 15 years ago, it still serves as the foundation for providing preventive pressure ulcer care and a model for other pressure ulcer guidelines developed afterward. Nurses are encouraged to review these comprehensive guidelines. The document identifies specific processes (e.g., risk assessment, skin care, mechanical loading, patient and staff education, etc.) that, when implemented, could reduce pressure ulcer development, and the literature suggests that following these specific processes of pressure ulcer care will reduce the incidence of ulcers. Research also suggests that when the health care providers are functioning as a team, the incidence rates of pressure ulcers can decrease.⁹ Thus, pressure ulcers and their prevention should be considered a patient safety goal.

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Incidence, Mortality, and Costs

The incidence rates of pressure ulcers vary greatly with the health care settings. The National Pressure Ulcer Advisory Panel (NPUAP) says the incidence ranges from 0.4 percent to 38 percent in hospitals, from 2.2 percent to 23.9 percent in skilled nursing facilities, and from 0 percent to 17 percent for home health agencies.¹⁰ There is ample evidence that the majority of pressure ulcers occur relatively early in the admissions process. For patients in the hospital, they can occur within the first 2 weeks.¹¹ With the increased acuity of elderly patients admitted and decreased lengths of stay in hospital, new data suggest that 15 percent of elderly patients will develop pressure ulcers within the first week of hospitalization.¹² For those elderly residents admitted to long-term care, pressure ulcers are most likely to develop within the first 4 weeks of admission.¹³

Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge.¹⁴^,¹⁵ Most often, pressure ulcers do not cause death; rather the pressure ulcer develops after a sequential decline in health status. Thus, the development of pressure ulcers can be a predictor of mortality. Studies further suggested that the development of skin breakdown postsurgery can lead elders to have major functional impairment post surgical procedure.

The cost to treat pressure ulcers can be expensive; the HCUP study reported an average cost of $37,800.² Cost data vary greatly, depending on what factors are included or excluded from the economic models (e.g., nursing time, support surfaces).The Physiology and Treatment of Pressure Sores Essay. It has been estimated that the cost of treating pressure ulcers is 2.5 times the cost of preventing them.¹⁶ Thus, preventing pressure ulcers should be the goal of all nurses.

Etiology

Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Since 1930, we have understood that normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm Hg is considered the average.¹⁷ Thus, keeping the external pressure less than 32 mm Hg should be sufficient to prevent the development of pressure ulcers. However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to hemodynamic instability and comorbid conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group of patients. Pressure ulcers can develop within 2 to 6 hours.¹⁸^,¹⁹ Therefore, the key to preventing pressure ulcers is to accurately identify at-risk individuals quickly, so that preventive measures may be implemented.

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Risk Factors

More than 100 risk factors of pressure ulcers have been identified in the literature. Some physiological (intrinsic) and nonphysiological (extrinsic) risk factors that may place adults at risk for pressure ulcer development include diabetes mellitus, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension.²⁰ A hypothesis exists that these physiological risk factors place the patients at risk due to impairment of the microcirculation system. Microcirculation is controlled in part by sympathetic vasoconstrictor impulses from the brain and secretions from localized endothelial cells. The Physiology and Treatment of Pressure Sores Essay.Since neural and endothelial control of blood flow is impaired during an illness state, the patient may be more susceptible to ischemic organ damage (e.g., pressure ulcers).²¹

Additional risk factors that have been correlated with pressure ulcer development are age of 70 years and older, current smoking history, dry skin, low body mass index, impaired mobility, altered mental status (i.e., confusion), urinary and fecal incontinence, malnutrition, physical restraints, malignancy, history of pressure ulcers, and white race.^22–25 Although researchers have noted that the white race is a predictor of pressure ulcers, the small number of nonwhite patients in most pressure ulcer studies makes this finding questionable. The few studies that have included sufficient numbers of black people for analysis purposes have found that blacks suffer more severe pressure ulcers than nonblacks.²⁶^,²⁷ Only one nursing study found that blacks had a higher incidence rate of pressure ulcer than whites.²⁸ In a study funded by AHRQ using the New York State Inpatient Data Set 1998–2000, Fiscella and colleagues²⁹ found that African Americans were more likely to develop pressure ulcers than other races in hospitals. Moreover, a 2004 study investigating black/white differences in pressure ulcer incidence found that after controlling for eight resident characteristics and three facility characteristics, race was significantly associated with pressure ulcer incidence (hazard ratio comparing blacks with whites = 1.31, 95% confidence interval = 1.02–1.66).³⁰

Risk Assessment

What tool and how often a pressure ulcer risk assessment should be done are key questions in preventing pressure ulcers. Due to the number of risk factors identified in the literature, nurses have found the use of risk assessment tools helpful adjuncts to aid in the identification of patients who may be at high risk. Most health care institutions that use pressure ulcer risk assessment tools use either the Braden Scale or Norton Scale, with the Braden scale being the most widely used in the United States. The Braden Scale is designed for use with adults and consists of 6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.³¹ It is based on the conceptual schema of linking the above clinical situations to the intensity and duration of pressure or tissue tolerance for pressure.³² The copyrighted tool is available at http://www.bradenscale.com.braden.pdf.The Physiology and Treatment of Pressure Sores Essay. The scores on this scale range from 6 (high risk) to 23 (low risk), with 18 being the cut score for onset of pressure ulcer risk. Research has shown that hospital nurses could accurately determine pressure ulcer risk 75.6 percent of the time after an interactive learning session on the Braden scale.³³ Nurses were best at identifying persons at the highest and lowest levels of risk and had the most difficultly with patients with mild levels of risk (scores of 15–18).³⁴

The Norton Scale was developed in the United Kingdom and consists of five subscales: physical condition, mental condition, activity, mobility, and incontinence.³⁵ The total score ranges from 5 (high risk) to 20 (low risk).

The Braden Scale and Norton Scale have been shown to have good sensitivity (83 percent to 100 percent, and 73 percent to 92 percent, respectively) and specificity (64 percent to 77 percent, and 61 percent to 94 percent, respectively), but have poor positive predictive value (around 40 percent and 20 percent, respectively).³⁶ The Norton and Braden scales show a 0.73 Kappa statistic agreement among at-risk patients, with the Norton Scale tending to classify patients at risk when the Braden scale classifies them as not at risk. The net effect of poor positive predictive value means that many patients who will not develop pressure ulcers may receive expensive and unnecessary treatment. Moreover, optimal cutoff scores have not been developed for each care setting (e.g., medical intensive care versus operating room). Thus, nurses still need to use their clinical judgment in employing preventive pressure ulcer care. A recent systematic review of risk assessment scales found that the Braden Scale had the optimal validation and the best sensitivity/specificity balance (57.1 percent/67.5 percent) when compared to the Norton Scale (46.8 percent/61.8 percent) and Waterlow Scale (82.4 percent/27.4 percent).³⁷ It should be noted that the Waterlow skill is a pressure ulcer prediction tool used primarily in Europe. The Physiology and Treatment of Pressure Sores Essay.

In recent years, several new prediction tools have been developed (FRAGMMENT Score and Schoonhoven Prediction Rule); however, these tools lack sufficient evidence to evaluate their predictive validity.³⁸^,³⁹ Thus, the use of a validated pressure ulcer risk assessment tool like the Braden Scale should be used, given the fair research-based evidence. The U.S. Centers for Medicare and Medicaid Services (CMS) recommends that nurses consider all risk factors independent of the scores obtained on any validated pressure ulcer prediction scales because all factors are not found on any one tool.⁴⁰

The usefulness of clinical informatics to assess and prevent pressure ulcers has been explored. A quality improvement study involving 91 long-term care facilities evaluated the usefulness of Web-based reports alerting nursing staff to a resident’s potential risk for pressure ulcers.⁴¹ Only one-third of long-term care facilities used the Web-based reports regularly to identify at-risk patients. Several key characteristics of facilities that were high users emerged:

Administrative level and nursing staff buy-in and support
Development of an actual process integrating the risk reports into ongoing quality improvement processes
Having “facility champions” to keep the effort focused and on track

There is no agreement on how frequently risk assessment should be done. There is general consensus from most pressure ulcer clinical guidelines to do a risk assessment on admission, at discharge, and whenever the patient’s clinical condition changes. The appropriate interval for routine reassessment remains unclear. The Physiology and Treatment of Pressure Sores Essay. Studies by Bergstrom and Braden⁴²^,⁴³ found that in a skilled nursing facility, 80 percent of pressure ulcers develop within 2 weeks of admission and 96 percent develop within 3 weeks of admission. The Institute for Healthcare Improvement has recently recommended that in hospitalized patients, pressure ulcer risk assessment be done every 24 hours⁴⁴ rather than the previous suggestion of every 48 hours.⁴⁵

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Implementing a Prevention Plan

Preventing pressure ulcers can be nursing intensive. The challenge is more difficult when there is nursing staff turnover and shortages. Studies have suggested that pressure ulcer development can be directly affected by the number of registered nurses and time spent at the bedside.⁴⁶^,⁴⁷ In contrast, however, one recent study suggested that there was no correlation between increasing the nurse-to-patient ratio and the overall incidence of pressure ulcers.⁴⁸ Donaldson and colleagues⁴⁹ noted that this particular study was limited by the fact that the researchers could not affirm compliance with ratios per shift and per unit at all times. Given that the cost of treatment has been estimated as 2.5 times that of prevention, implementing a pressure ulcer prevention program remains essential.

A growing level of evidence suggests that pressure ulcer prevention can be effective in all health care settings. One study examined the efficacy of an intensive pressure ulcer prevention protocol to decrease the incidence of ulcers in a 77-bed long-term care facility.⁵⁰ The pressure ulcer prevention protocol consisted of preventive interventions stratified on risk level, with implementation of support surfaces and turning/repositioning residents. The sample included 132 residents (69 prior to prevention intervention and 63 after prevention intervention). The 6-month incidence rate of pressure ulcers prior to the intensive prevention intervention was 23 percent. For the 6-months after intensive prevention intervention, the pressure ulcer incidence rate was 5 percent. This study demonstrated that significant reductions in the incidence of pressure ulcers are possible to achieve within a rather short period of time (6 months) when facility-specific intensive prevention interventions are used. The Physiology and Treatment of Pressure Sores Essay. A subsequent study by the same researchers was undertaken to evaluate the cost effectiveness of the pressure ulcer prevention protocol after a 3-year period. The implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in pressure ulcer incidence were lost over time. However, clinical results of ulcer treatment improved and treatment costs fell during the 3 years.⁵¹

A more recent nursing study examined the effects of implementing the SOLUTIONS program, which focuses pressure ulcer prevention measures on alleviating risk factors identified by the Braden Scale, in two long-term care facilities.⁵² The quasi-experimental study found that after 5 months of implementing the SOLUTIONS program, Facility A (150 beds) experienced an 87 percent reduction in pressure ulcer incidence (from 13.2 percent to 1.7 percent), which was highly significant (P = 0.02). Facility B (110 beds) experienced a corresponding 76 percent reduction (from 15 percent to 3.5 percent), which was also highly significant (P = 0.02). Gunningberg and colleagues⁵² investigated the incidence of pressure ulcers in 1997 and 1999 among patients with hip fractures and found significant reductions in incidence rates (55 percent in 1997 to 29 percent in 1999). The researchers attributed these reductions in pressure ulcer incidence rates to performing systematic risk assessment upon admission, accurately staging pressure ulcers, using pressure-reducing mattresses, and continuing education of staff. Thus, the use of comprehensive prevention programs can significantly reduce the incidence of pressure ulcers in long-term care. The Physiology and Treatment of Pressure Sores Essay.

The use of quality improvement models, where systematic processes of care have been implemented have also been shown to reduce overall pressure ulcer incidence. In one study involving 29 nursing homes in three States, representatives of the 29 nursing homes attended a series of workshops, shared best practices, and worked with one-on-one quality improvement mentors over 2 years.⁵³ This study found that six of eight prevention process measures (based on AHRQ prevention guidelines) significantly improved, with percentage differences between baseline and followup ranging from 11.6 percent to 24.5 percent. Another study using similar methods involving 22 nursing homes found 8 out of 12 processes of care significantly improved.⁷ Moreover, the study found that pressure ulcer incidence rates decreased in the nursing homes. Nursing homes with the greatest improvement in quality indicator scores had significantly lower pressure ulcer incidence rates than the facilities with the least improvement in quality indicator scores (P = 0.03).

In the acute care setting, several studies have attempted to demonstrate that the implementation of comprehensive pressure ulcer prevention programs can decrease the incidence rates. However, no studies could be found that eliminated pressure ulcers. One large study evaluated the processes of care for hospitalized Medicare patients at risk for pressure ulcer development.⁷ This multicenter retrospective cohort study used medical record data to identify 2,425 patients ages 65 and older discharged from acute care hospitals following treatment for pneumonia, cerebral vascular disease, or congestive heart failure. Charts were evaluated for the presence of six recommended pressure ulcer prevention processes of care. This study found that at-risk patients who used pressure-reducing devices, were repositioned every 2 hours, and received nutritional consults were more likely to develop pressure ulcers than those patients who did not receive the preventive interventions. One explanation for this finding may be the amount of time (48 hours) before the preventive measures were implemented. The Physiology and Treatment of Pressure Sores Essay. Given the acuity of patients entering hospitals, waiting 48 hours may be too late to begin pressure ulcer prevention interventions. Thus, despite this one study, there is significant research to support that implementing comprehensive pressure ulcer prevention programs reduces the incidence of pressure ulcers.

A key component of research studies that have reported reduction of pressure ulcers is how to sustain the momentum over time, especially when the facility champion leaves the institution. It is clear from the evidence that maintaining a culture of pressure ulcer prevention in a care setting is an important challenge, one that requires the support of administration and the attention of clinicians.

Skin Care

Although expert opinion maintains that there is a relationship between skin care and pressure ulcer development, there is a paucity of research to support that. How the skin is cleansed may make a difference. One study found that the incidence of Stages I and II pressure ulcers could be reduced by educating the staff and using a body wash and skin protection products.⁵⁴

The majority of skin care recommendations are based on expert opinion and consensus. Intuitively nurses understand that keeping the skin clean and dry will prevent irritants on the skin or excessive moisture that may increase frictional forces leading to skin breakdown. Individualized bathing schedules and use of nondrying products on the skin are also recommended. Moreover, by performing frequent skin assessments, nurses will be able to identify skin breakdown at an early stage, leading to early interventions. The Physiology and Treatment of Pressure Sores Essay. Although there is a lack of consensus as to what constitutes a minimal skin assessment, CMS recommends the following five parameters be included: skin temperature, color, turgor, moisture status, and integrity.⁴⁰

The search for the ideal intervention to maintain skin health continues. One study compared hyperoxygenated fatty acid compound versus placebo compound (triisotearin) in acute care and long-term care patients.⁵⁵ These researchers found that using hyperoxygenated fatty acid significantly (p-0.006) reduced the incidence of ulcers. Pressure ulcer incidence was lower in an intervention group of acute care patients when topical nicotinate was applied (7.32 percent) compared to lotion with hexachlorophene, squalene, and allantoin in the control group (17.37 percent).⁵⁶

There are several key recommendations to minimize the occurrence of pressure ulcers. Avoid using hot water, and use only mild cleansing agents that minimize irritation and dryness of the skin.⁸^,⁵⁷ Avoid low humidity because it promotes scaling and dryness, which has been associated with pressure ulcer development.²³ During skin care, avoid vigorous massage over reddened, bony prominences because evidence suggest that this leads to deep tissue trauma. Skin care should focus on minimizing exposure of moisture on the skin.⁵⁸ Skin breakdown caused by friction may be mitigated by the use of lubricants, protective films (e.g., transparent and skin sealants), protective dressings (e.g., hydrocolloids), and protective padding. The Physiology and Treatment of Pressure Sores Essay.

Mechanical Loading

One of the most important preventive measures is decreasing mechanical load. If patients cannot adequately turn or reposition themselves, this may lead to pressure ulcer development. It is critical for nurses to help reduce the mechanical load for patients. This includes frequent turning and repositioning of patients.

Very little research has been published related to optimal turning schedules. The first such nursing study was an observational one that divided older adults into three turning treatment groups (every 2 to 3 hours [n = 32], every 4 hours [n = 27], or turned two to four times/day [n = 41]).⁵⁹ These researchers found that older adults turned every 2 to 3 hours had fewer ulcers. This landmark nursing study created the gold standard of turning patients at least every 2 hours. Some researchers would suggest that critically ill patients should be turned more often. However, one survey study investigating body positioning in intensive care patients found that of 74 patients observed, 49.3 percent were not repositioned for more than 2 hours.⁶⁰ Only 2.7 percent of patients had a demonstrated change in body position every 2 hours. A total of 80–90 percent of respondents to the survey agreed that turning every 2 hours was the accepted standard and that it prevented complications, but only 57 percent believed it was being achieved in their intensive care units. A more recent study by DeFloor and colleagues⁶¹ suggests that depending on the support surface used, less-frequent turning may be optimal to prevent pressure ulcers in a long-term care facility. Several nurse researchers investigated the effect of four different turning frequencies (every 2 hours on a standard mattress, every 3 hours on a standard mattress, every 4 hours on a viscoelastic foam mattress, and every 6 hours on a viscoelastic foam mattress). The nurse researchers found that the incidence of early pressure ulcers (Stage I) did not differ in the four groups. However, patients being turned every 4 hours on a viscoelastic foam mattress developed significantly less severe pressure ulcers (Stage II and greater) than the three other groups. The Physiology and Treatment of Pressure Sores Essay. Although the results of this study may indicate less turning may be appropriate when using a viscoelastic foam mattress, additional studies are needed to examine optimal turning schedules among different populations. Reddy and colleagues⁶² have raised questions about the methodology in the Defloor and colleagues study, leading them to recommend that it may be too soon to abandon the every-2-hours turning schedule in favor of every 4 hours based on this one study. Thus, there is emerging research to support the continued turning of patients at least every 2 hours.

How a patient is positioned may also make a difference. Lateral turns should not exceed 30 degrees.⁶³^,⁶⁴ One randomized controlled trial that studied a small sample of 46 elderly patients in the 30-degree-tilt position and the standard 90-degree side-lying position found no significant difference in the development of pressure ulcers between the two groups.⁶⁵

Support Surfaces

The use of support surfaces is an important consideration in pressure redistribution. The concept of pressure redistribution has been embraced by the NPUAP.⁶⁶ You can never remove all pressure for a patient. If you reduce pressure on one body part, this will result in increased pressure elsewhere on the body. Hence, the goal is to obtain the best pressure redistribution possible.

A major method of redistributing pressure is the use of support surfaces. Much research has been conducted on the effectiveness of the use of support surfaces in reducing the incidence of pressure ulcers. A comprehensive literature review by Agostini and colleagues⁶⁷ found that there was adequate evidence that specially designed support surfaces effectively prevent the development of pressure ulcers. However, a major criticism of the current support surface studies was poor methodologic design. Agostini and colleagues noted that many studies had small sample sizes and unclear standardization protocols, and assessments were not blind.

Reddy and colleagues⁶² have provided a systematic review of 49 randomized controlled trials that examined the role of support surfaces in preventing pressure ulcers.The Physiology and Treatment of Pressure Sores Essay. No one category of support surface was found to be superior to another; however, use of a support surface was more beneficial than a standard mattress. A prospective study evaluating the clinical effectiveness of three different support surfaces (two dynamic mattress replacement surfaces and one static foam mattress replacement) found that an equal number of patients developed pressure ulcers on each surface (three per surface).⁶⁸ The researchers concluded no differences in the support surface effectiveness, yet large differences in the cost. (Dynamic mattress replacements cost approximately $2,000 per mattress, compared to $240 per mattress for static foam mattress replacements.) Given the similar clinical effectiveness, cost should be considered in determining the support surface.

Four randomized controlled trials evaluated the use of seat cushions in pressure ulcer prevention, and found no difference in ulcer incidence among groups except between foam and gel cushions.⁶² Despite the dearth of research that correlates seat cushions and preventing pressure ulcers, expert opinion supports the use of seat cushions.

The CMS has divided support surfaces into three categories for reimbursement purposes.⁶⁸ Group 1 devices are those support surfaces that are static, they do not require electricity. Static devices include air, foam (convoluted and solid), gel, and water overlays or mattresses. These devices are ideal when a patient is at low risk for pressure ulcer development. Group 2 devices are powered by electricity or pump and are considered dynamic in nature. These devices include alternating and low-air-loss mattresses. These mattresses are good for patients who are at moderate to high risk for pressure ulcers or have full-thickness pressure ulcers. Group 3 devices, also dynamic, comprises only air-fluidized beds. These beds are electric and contain silicone-coated beads. When air is pumped through the bed, the beads become liquid. These beds are used for patients at very high risk for pressure ulcers. More often they are used for patients with nonhealing full-thickness pressure ulcers or when there are numerous truncal full-thickness pressure ulcers. The NPUAP has suggested new definitions for support surfaces that move away from these categories and divide support surfaces into powered or nonpowered.⁶⁹ Whether these new definitions will be embraced by CMS is yet to be determined. The Physiology and Treatment of Pressure Sores Essay.

There remains a paucity of research that demonstrates significant differences in the effectiveness of the various classifications of support surfaces in preventing or healing pressure ulcers. Therefore, nurses should select a support surface based on the needs and characteristics of the patient and institution (e.g., ease of use, cost). It is imperative to have the pressure redistribution product (e.g., mattress or cushion) on the surface where the patients are spending most of their time, in bed or a chair. However, being on a pressure-redistributing mattress or cushion does not negate the need for turning or repositioning.

Nutrition

Controversy remains on how best to do nutritional assessment for patients at risk for developing pressure ulcers. The literature differs about the value of serum albumin; some literature reports that low levels are associated with increased risk.⁷⁰ While the AHRQ pressure ulcer prevention guideline suggests that a serum albumin of less than 3.5 gm/dl predisposes a patient for increased risk of pressure ulcers, one study reveals that current dietary protein intake is a more independent predictor than this lab value.⁸^,⁴² In the revised Tag F-314 guidance to surveyors in long-term care, CMS recommends that weight loss is an important indicator.⁴⁰ Evaluation of the patient’s ability to chew and swallow may also be warranted.

The literature is unclear about protein-calorie malnutrition and its association with pressure ulcer development.⁷⁰ Reddy and colleagues⁶² suggested that the widely held belief of a relationship between nutrition intake and pressure ulcer prevention was not always supported by randomized controlled trials.The Physiology and Treatment of Pressure Sores Essay. Some research supported the finding that undernourishment on admission to a health care facility increases a person’s likelihood of developing a pressure ulcer. In one prospective study, high-risk patients who were undernourished on admission to the hospital were twice as likely to develop pressure ulcers as adequately nourished patients (17 percent and 9 percent, respectively).⁷¹ In another study, 59 percent of residents were undernourished and 7.3 percent were severely undernourished on admission to a long-term care facility. Pressure ulcers occurred in 65 percent of the severely undernourished residents, while no pressure ulcers developed in the mild-to-moderately undernourished or well-nourished residents.¹⁵

Reddy and colleagues⁶² concluded that nutritional supplementation was beneficial in only one of the five randomized controlled trials reviewed in their systematic analysis of interventions targeted at impaired nutrition for pressure ulcer prevention. Older critically ill patients who had two oral supplements plus the standard hospital diet had lower risk of pressure ulcers compared to those who received only the standard hospital diet.⁷²

Empirical evidence is lacking that the use of vitamin and mineral supplements (in the absence of deficiency) actually prevents pressure ulcers.⁷³ Therefore, oversupplementing patients without protein, vitamin, or mineral deficiencies should be avoided. Before enteral or parental nutrition is used, a critical review of overall goals and wishes of the patient, family, and care team should be considered.⁷⁴ Despite the lack of evidence regarding nutritional assessment and intervention, maintaining optimal nutrition continues to be part of best practice. The Physiology and Treatment of Pressure Sores Essay.

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Management of Pressure Ulcers

When a pressure ulcer develops, nursing’s patient safety goal is to assist the health care team in closing the ulcer as quickly as possible. Nursing is also concerned with preventing further ulcer deterioration, keeping the ulcer clean and in moisture balance, preventing infections from developing, and keeping the patient free from pain.

Many aspects of managing pressure ulcers are similar to prevention (mechanical loading, support surfaces, and nutrition). Clearly, the health care team has to address the underlying causes (intrinsic and extrinsic) or the pressure ulcer will not close. In 1994, AHRQ published clinical practice guidelines on treating pressure ulcers.⁷⁵ Much of the evidence related to treating pressure ulcers was based on Level C evidence, requiring one or more of the following: one controlled trial, results of at least two case series/descriptive studies in humans, or expert opinion. Although the AHRQ document was published 13 years ago, it provides the foundation for treating pressure ulcers. The Physiology and Treatment of Pressure Sores Essay. The document identified specific indices (e.g., wound assessment, managing tissue load, ulcer care, managing bacterial colonization/infection, etc.). The following section supplements this document.

Cleansing

Once the pressure ulcer develops, the ulcer should be cleaned with a nontoxic solution. Cleaning the ulcer removes debris and bacteria from the ulcer bed, factors that may delay ulcer healing.⁷⁶ No randomized control studies could be found that demonstrated the optimal frequency or agent for cleansing a pressure ulcer. A Cochrane review of published randomized clinical trials found three studies addressing cleansing of pressure ulcers, but this systematic review produced no good trial evidence to support any particular wound cleansing solution or technique for pressure ulcers.⁷⁷ Therefore, this recommendation remains at the expert opinion level. Nurses should use cleansers that do not disrupt or cause trauma to the ulcer.⁷⁸ Normal saline (0.9 percent) is usually recommended because it is not cytotoxic to healthy tissue.⁷⁹ Although the active ingredients in newer wound cleansers may be noncytotoxic (surfactants), the inert carrier may be cytotoxic to healthy granulation tissue.⁸⁰ Thus, nurses should be cognizant of the ingredients in cleansing agents before using them on pressure ulcers.

Assessment and Staging

The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing.⁴⁰^,⁷⁵ There are no universal parameters for assessing a pressure ulcer. Most experts agree that when a pressure ulcer develops its location, size (length, width, and depth), and color of the wound; amount and type of exudate (serous, sangous, pustular); odor; nature and frequency of pain if present (episodic or continuous); color and type of tissue/character of the wound bed, including evidence of healing (e.g., granulation tissue) or necrosis (slough or eschar); and description of wound edges and surrounding tissue (e.g., rolled edges, redness, hardness/induration, maceration) should be assessed and documentd.⁷⁵^,⁸¹ Upon identifying the ulcer characteristics, the initial stage of the should be completed. The Physiology and Treatment of Pressure Sores Essay.

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The staging system is one method of summarizing cert ain characteristics of pressure ulcers, including the extent of tissue damage. Hence, whether the nurse observes the epidermis, dermis, fat, muscle, bone, or joint determines the stage of pressure ulcer. Knowing the appropriate stage aids in determining the management of the pressure ulcer. However, staging of pressure ulcers can vary, because different nurses may observe different tissue types. In a survey of nurses’ wound care knowledge, less than 50 percent of new nurses (fewer than 20 years of nursing experience) did not feel confident in consistently identifying all stages of pressure ulcers, as compared to 30 percent of the more experienced nurses (more than 20 years of nursing experience).⁸² Achieving consistency in staging will provide optimal pressure ulcer management.

Pressure ulcer staging systems differ, depending on geographic location. The Europeans use a four-stage system.⁸³ For Grade 1, nonblanchable erythema of intact skin, discoloration of the skin, warmth, edema, and induration or hardness may be used as indicators, particularly on individuals with darker skin. For Grade 2, indicators include partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. Grade 3 includes full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Grade 4 includes extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures, with or without full thickness skin loss. The Physiology and Treatment of Pressure Sores Essay.