Pressure Ulcer Prevention
Review of the Literature
Introduction
Pressure ulcers “lesions caused by unrelieved pressure resulting in damage of underlying tissue” (Agency for Health Care Policy and Research [AHCPR], 1992, p. 6), are considered to be a major health problem (Pase, 1994). The prevalence rate itself indicates pressure ulcers are a significant health risk (AHCPR, 1992). The prevalence rate for pressure ulcers in hospitals ranges from 3.55% to 29.5% (Maklebust, Magnan, 1994). Nursing homes have a prevalence rate ranging from 2.4% to 23% (Burd et al., 1994). Limited studies of home settings established a prevalence rate of 8.7% (AHCPR, 1992). The prevalence rate increases as the length of stay in nursing homes and hospitals increase (AHCPR, 1992).
One objective of the National Pressure Ulcer Advisory Panel is to develop prevention strategies to decrease by half the prevalence rate of pressure ulcers by the year 2000 (Helme, 1994). Prevention is a logical strategy to utilize. Much literature already exists regarding the risk factors related to th development of pressure ulcers. AHCPR (1992) developed guidelines related to preventing pressure ulcers for clinicians. AHCPR (1992) feels most pressure ulcers can be prevented, and Stage 1 pressure ulcers are treatable without allowing further progression of the ulcer.
Pressure ulcers per client cost over $40,000.00 to treat in 1984 (Olson, 1989). In the nursing home setting, treatment for pressure ulcers monthly cost $267-$1,191 per resident (Burd et al., 1994). An elderly client’s risk of death increases fourfold when the client has pressure ulcers (Pase, 1994). If the ulcers do not heal, the risk increases six fold (Pase, 1994). Prevention is obviously the best method in managing this health problem.
Pressure ulcers are “caused by unrelieved pressure or from tissue layers sliding over other tissue layers” (Lewis, Collier, Heitkemper, 1996, p.521). Three main causative factors related to pressure ulcers are pressure, shear, and friction (Maklebust, Magnan, 1994). Pressure ulcers can result from (a) a person remaining in one position for any length of time (Knox, Anderson, Anderson, 1994), (b) a person positioned in such a way their skin remains fixed while the tissue underneath slides (shearing) (AHCPR, 1992) and/or, (c ) a person moving against a coarse surface such as bed linens voluntarily or involuntarily (friction) (AHCPR, 1992).
When pressure or shearing exist, there is decreased circulation to the affected area (Knox et al., 1994). Knox et al. (1994) state normal capillary pressure is 13-34 mm HG, blockage of circulation occurs at 35 mm HG, irreversible tissue damage due to ischemia occurs at 70 mm HG over two hours, and skin necrosis occurs at pressure greater than 80 mm HG over prolonged periods of time. The actual time and pressure needed to create pressure ulcers varies according to the client’s risk factors (Knox et al., 1994).
Pressure ulcers occur most frequently in the pelvic region (Maklebust, Magnan, 1994). Over 90% of pressure ulcers occur over the lower half of the body’s bony prominences primarily in the sacral and trochanter area (Knox et al., 1994). Research indicates the blood supply to the pelvic region decreases when lying on a hospital bed (Knox et al., 1994). Pressure increases between the surface of the bone “compressing all tissue in between” (Knox et al., 1994, p. 48). Perspiration develops due to increased temperature related to contact between the client and the bedding (Knox et al., 1994). Moisture leads to skin breakdown (AHCPR, 1992).
The elderly are at risk for developing pressure ulcers due to natural changes occurring during the aging process. Aging causes the blood supply to decrease, lessening the nutrients supplied to the skin for regeneration; subcutaneous fat decreases and the epithelial layers thin, allowing for increased pressure on bony prominences; and elastin formation decreases due to collagen fibers stiffening, and decreased glutamic acid and lysine enzymes (Knox et al., 1994).
The elderly also have decreased pain sensitivity which does not allow them to readily change body positions as needed to promote circulation and prevent pressure ulcers (Knox et al., 1994).
Olson (1989) lists a number of risk factors related to developing pressure ulcers. The risk factors are:
1. Neurological impairments, paralysis. A person with a neurological impairment has loss the ability to feel or experience pain and pressure to the full extent. The person is unable to shift their weight accordingly to decrease pressure and prevent ulcers.
2. Decreased level of consciousness. A person with this deficit is unable to respond appropriately to pressure and friction on their body’s parts to prevent ulcers.
3. Thinness or obesity. Decreased subcutaneous fat allows pressure to increase on bony prominences which increases the risk for pressure ulcers (Knox et al., 1994).
4. Orthopedic problems such as fractures and broken bones. Orthopedic problems lead to immobility. An immobile person is unable to shift their weight or reposition themselves properly to prevent pressure ulcers (AHCPR, 1992).
5. Chronic diseases such as diabetes, cancer, congestive heart failure and circulatory problems. Decreased oxygenation and circulation to affected area results in ischemia and necrosis (Warner, 1992).
6. Friction and shearing injuries.
7. Malnutrition. Malnutrition leads to decreased nutrients needed for skin strength, elasticity and regeneration (Knox et al., 1994), and leads to reduced tissue tolerance for pressure (Pase, 1994).
8. Excess moisture related to incontinence, perspiration and drainage.
9. Old age.
Once the nurse has determined a client is at risk for pressure ulcers, the nurse should perform an initial skin assessment. The Braden Scale is an assessment tool available to assist the nurses in determining the client’s level of risk for pressure ulcers (Burd et al., 1994). If the client has pressure ulcers the nurse traditionally would classify the ulcer using the guidelines established by the National Pressure Ulcer Advisory Panel.
The National Pressure Ulcer Advisory Panel recommends pressure ulcers be classified according to “anatomical depth of tissue destruction” (Maklebust, Magna, 1994, p. 27). The four stages are:
1. Stage 1. Reddened area a lasting more than thirty minutes after a change in position or non blanchable erythema of intact skin; no break in skin integrity.
2. Stage 2. Partial thickness skin loss involving epidermis or dermis, blister, abrasion, or shallow crater.
3. Stage 3. Full thickness skin loss involving subcutaneous tissue; may be a deep crater with or without undermining.
4. Stage 4. Full thickness skin loss with tissue necrosis or damage to muscle bone or supporting structures (Burd et al., 1994).
The nurse after identifying the client at risk and assessing the client’s skin integrity, must determine what factors are related to the cause of the pressure ulcer and what can be done to alleviate the condition. Management of pressure ulcers is a team concept. The nurse must work along with the physician, physical therapist, nutritionist and nursing assistants in caring for the client (Helme, 1994).
Interventions to prevent or treat pressure ulcers have been utilized by nurses for years. Some of the more traditional interventions for preventing pressure ulcers according to Anderson (1994) are:
1. Repositioning the immobile client every two hours. Research has determined a client’s risk for pressure ulcers decreases if they are turned every two hours (AHCPR, 1992).
2. Keep the skin dry. “Moisture alone can make skin more susceptible to injury” (AHCPR, 1992, p. 18).
3. Inspect pressure areas for signs of redness every 4-6 hours. “Skin inspection provides the information essential for designing interventions to reduce risk” (AHCPR, 1992, p.16).
4. Keep bed linens dry and wrinkle free. Folded linens can irritate skin causing friction and skin to break down (AHCPR, 1992).
5. Use sheets to lift clients when moving them. Sheets help decrease the possibility of friction which can lead to skin breakdown (AHCPR, 1992).
6. Wash, rinse and dry skin. Apply lotion gently over bony prominence. “Daily activities result in metabolic wastes and environmental contaminants accumulation on the skin. For maximum skin vitality, these potentially irritating substances should be removed frequently” (AHCPR, 1992, p.17). Dry skin leads to cracking and fissures. Skin, therefore, should be hydrated appropriately with lotion (AHCPR, 1992).
7. Wash the client after each defecation and urination. Urine and stool have substances which can irritate the skin and cause it to be more susceptible to tissue injury (AHCPR, 1992).
8. Use preventive methods such as air mattresses, flotation mattresses, silicone pads, sheep skin, and foam cushions for wheelchairs. Pressure relieving devices lower the client’s risk for developing pressure ulcers (AHCPR, 1992).
9. Order a dietary consult. A high protein diet is usually recommended to help with tissue healing (AHCPR, 1992).
Once pressure ulcers developed, the nurse should initiate interventions based on the grade, size and presence of infection” (Lewis et al., 1996, p. 524). The nurse should measure the length, width and depth of the ulcers. Pictures should be taken initially and as treatment progresses (Lewis et al., 1996). Treatment for each stage of pressure ulcers are:
Stage 1. Remove pressure from the affected area. Do not massage the affected area. Further tissue damage can result from the massage (Olsen, 1989). Cover affected area with a transparent dressing. The dressing will protect the area from moisture and bacteria while being permeable to oxygen and moisture vapor. Keep the dressing in place until the site is healed. The healing process should take 1-2 weeks.
Stage 2. Irrigate site with prescribed solution. Cover site with a transparent dressing. Dressing should have a pouch to collect drainage. Reapply new dressing when edges are no longer intact. Healing process is about 2-4 months.
Stage 3. Irrigate site daily with prescribed solution. Change dressing daily. Dressing should have a pouch to collect drainage.
Stage 4. Treat site with debridement, intravenous fluids and antibiotics. Apply daily a wet to dry gauze dressing after irrigation. Irrigate with prescribed solutions. Pack wound with a saline-soaked gauze dressing using sterile technique. The site may take several months to years to heal (Lewis et al., 1996).
The nurse in caring for the client with pressure ulcers must monitor caloric intake. Proper nutritional balance is needed to restore client to prior level of functioning. Caloric intake may be as high as 4200 calories a day (Lewis et al., 1996).
Previously listed were some prevention methods and intervention strategies nurses have implemented for years. Current research supports some methods and does not support others. In the current literature Olson (1989) supported not using massage as a way to increase circulation to the affected area. She found that massage decreases the skin temperature in the affected area which may indicate ischemia. Olson (1989) feels “massage may cause tissue damage to an already compromised area.
Tymec, Pieper, Vollman (1997) studied the use of a pillow in relieving the pressure on the heel versus a Foot Waffle. The results of the study indicate the pillow is the best method currently for relieving pressure on the heel. Problems with utilizing the pillow are (a) the pillow may move, (b) the client may move and, (c ) when the client is repositioned the pillow may not be adjusted properly.
Barnett and Ablarde (1994) found in their research the best position for a client to reduce their risk of pressure ulcers is the “side lying position with legs extended.” They suggested however that repositioning the client more than every two hours may be the best method of prevention. This does not support the traditional practice of turning the client every two hours.
Knox et al., (1994) support Barnett and Ablarde (1994) assumption that clients need to be repositioned more than every two hours. Knox et al. Suggest “that a one and a half hour turning policy be established.” Turning should however be individualized. If after one and one-half hours redness occurs, the schedule for turning should be shortened to one hour. If after one hour redness occurs, pressure relieving devices hold be utilized.
