Prevention Of Pressure Ulcer

Pressure ulcers, or bed sores, or have been affecting humans for ages, and addressing the overall prevention of pressure ulcers is now a prominent national healthcare issue. Despite of all the advances in medicine, surgery, nursing care, pressure ulcers still remains a major cause of mortality. Pressure sore is a common problem among old people and those who are immobilise or limited activity like post-operative and other bedridden patients. (Bergstorm, 2005) Many studies state that elderly are prone for pressure ulcer throughout the world and its becoming a crucial issue (Nakagami et al., 2007). Pressure ulcer can be defined as a type of injury that affects areas of the skin or underlying tissue of the body due to application of too much pressure on it. (Grey et al 2006) It develops as a result of tissue necrosis of the skin over the bony prominence, due to the obstruction of the blood vessels flow caused by the application continual pressure on it. (Lyder, 2003)

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The total expenditure for the prevention of pressure ulcer is substantially less when compared to its treatment (Lapsley H M and Vogels R, 1996). It can cause severe infirmity and high health-care expenditure. The estimated annual expense for the prevention and treatment of pressure ulcers has been expected nearly £1.4 to £2.1 billion in the United Kingdom and is measured as a massive economic problem (Bennet et al., 2004). After cancer and cardio vascular disease, pressure ulcers are the third most money consuming disease (Schoonhoven et al., 2002)
According to European Pressure Ulcer Advisory Panel (EPUAP) the occurrence rates of pressure ulcers are ranging from 8-23%. In acute care hospitals in the western countries the reported prevalence has wide-ranging between 9-22%. Improving the standard of pressure ulcer care could in¬‚uence the estimated annual expenditure and quality of life (Tannen A et al., 2004). According to Whittington et al (2000) the prevalence of 15% of pressure ulcers are recorded on admission, whereas for the 60% of the individuals there was no specific information about the presence or absence of the pressure ulcers. In another study, it is clear that 12.8% have already had the infirmity on their admission.
According to Rycroft-Malone, (2000) pressure ulcers can develop at any area of the body, but commonly occurs over bony prominences. ( Murdoch, 2002; Jones, 2001) The areas can supposed to develop pressure sores are sacrum, heels, elbows and back of the head. The appearance of pressure sore is very fast and hence the early assessment and steps to prevent is very necessary (George and Malkenson, 2008). Pressure intensity and duration are the two main factors for the pressure ulcer formation because of pressure. Pressure intensity is the volume of external pressure applied on internal tissues whereas duration is the amount of external force is sustained by internal tissues (Cullum et al., 2000)
According to NICE guidelines (2003) the risk factors influencing to develop pressure ulcer in an individual includes intrinsic risk factors and extrinsic risk factors. The intrinsic risk factors such as reduced mobility or immobility, sensory impairment, acute illness, level of consciousness, extremes of age, vascular disease, severe chronic or terminal illness, previous history of pressure damage, malnutrition and dehydration. And extrinsic risk factors are pressure, shear, and friction. Shear is defined as the applied force that can cause an opposite, parallel sliding motion in the planes of an object. The amount of pressure exerted has got a direct affect on Shear. (Pieper B, 2007, Nix DP, 2007). Friction is defined as a superficial, mechanical force directed against the epidermis, resulting in increased susceptibility to ulceration (Pieper B., 2007).
Pressure ulcers are classified according to different stages as defined by the National Pressure Ulcer Advisory Panel (NPUAP). Originally there were only four stages, but in February 2007 these stages were revised and two more categories such as deep tissue injury and unstageable were added to it.
Stage I -Redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; as its colour may differ from the surrounding area.
Stage II – loss of partial thickness dermis showing as a shallow open ulcer with a red or pink wound bed, without any slough. It may also present as or open or ruptured serum filled blisters.
Stage III – The layer of subcutaneous fat may be seen but bone, muscle or tendons are not exposed. Slough may be present but does not cover the depth of tissue loss.
Stage IV – exposure of bone, tendon or muscle. Slough or may be present on some parts of the wound bed.
Unstageable – Loss of the thickness of the skin in which in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) in the wound bed.
Deep tissue Injury – Purple or maroon localized area of discolored skin or blood-filled blister due to damage of underlying soft tissue due to pressure. The area may be preceded by tissue that is firm, painful, and mushy compared to adjacent tissue. (NPUAP 2007)
To prevent the formation of pressure sores nurses are adopting a variety of measures such as risk assessment and risk assessment tools, changing the position of the bedridden patients regularly, inspecting the pressure area regularly and while doing personal care, applying ointments or creams over the pressure areas, providing comfortable mattresses such as air bed, water mattress for the bedridden and immobilise patients, placing pillows under the places prone to form pressure ulcer for the vulnerable peoples, maximise nutritional status, etc. However the efficiency of all these methods is in discussion and argument. This essay report will collate all the various available literatures regarding the prevention of pressure ulcer and suggest the better and good practice to prevent the formation of pressure sore among the high risk people.
The standard of nursing care is very important for the prevention and management of pressure ulcers. The caring of patients, who are at risk with pressure ulcer, is the main challenge for nurses (Sinclair et al., 2004). According to Lewis M et al 2003 the first step nurses should make out is the risk assessment of patients and it is better to identify the patient at risk in the early stages, so we can prevent the pressure sores. It consists of level of mobility, nutritional status, level of consciousness and neurological status, incontinence, sensory impairment, complete patient history, and physical and psychosocial examination assessing mental status and cognitive ability. To support caregivers there are assessment scales to identify the patients at risk.
According to Walker D K et al 2010 skin care and moisture are essential to prevent pressure sore. Maintaining skin integrity is important for the patient`s at risk. Moreover excessive of moisture and dryness can breakdown the skin`s resistance. Wherever moisture is present,it is important to clean the portion thoroughly. Patients identified at risk should be bathed once a day. PH balanced cleanser is used to protect the skin from moisture and dryness,it is a natural protection mechanism of a skin. When cleansing the skin daily or in the presence of moisture, it is necessary not to use extreme force or friction. Eventhough moisture cannot be controlled, use skin barriers to protect skin from moisture. Dry skin also needs to be prevented by using a pH-balanced moisturizer.
The studies conducted by saleh et al,(2008) and Lindergren et al., (2002) evidenced that use of risk assessment scale is successful in predicting the formation of pressure sore(Decubitus Ulcer).The studies substantiated the role of risk assessment scales and their usefulness in the prevention and management of pressure sores. According to Lindergren et al., 2002 states the reliability of risk evaluation scale in the prediction of pressure sore formation. However, the revision conducted by saleh et al. (2008), argues about the reduction in the occurrence of clinical acquired pressure scores through the regular application of risk assessment scales. Their learning also states that judgement of clinical assessment is also same valuable as associate with the detection of pressure sore through risk assessment scale.
In addition, Defloor and Grypdonck, (2004) also stated that assessment tools have a vital role for the prevention of pressure sore. There are many limitations for the risk assessment tools which may lead to provide wrong positive results. The reliability, specificity and feeling of the scale are influenced by the preventive method applications. Nurses are using a variety of risk assessment tools based on practical experience they acquired. The risk assessment tools are assessed by means of numerical scores. The variables like level of continence,medications and nutritional status will give an average score for the risk patients(Whitening, N. L., 2009). Braden scale is the universally used risk assessment scale which includes the variables like sensory perception, activity, mobility, moisture and the nutritional status. The risk assessment scale works in such a way that as soon as the patient admitted in the hospital two step evaluation is carried out within the first six hours. The two steps include the skin assessment and the risk assessment to identify the possibility of formation of pressure sore (O’ Neil, 2004). Frequent evaluation and assessment should be done in every consequent evaluation at every 12 hours on patients who are at high risk .In the same way patients who are at low risk also needs to be evaluate frequently to observe or to identify any new risk factors and providing suitable preventive measures (O’ Neil, 2004).
The most commonly used tool assessing the pressure sore in U.K is the Waterlow pressure ulcer risk assessment tool. And it is user friendly and recommended by the nurses in U.K. Pancorbo-hidalgo et al. (2006), suggests that the Waterlow pressure ulcer risk assessment tool has well pressure sore guessing ability and sensitivity which may result to get wrong positive results. With the waterlow pressure ulcer risk assessment tool among the seven assessment studies conducted by pancorbo-hidalgo, P.L. et al. (2006) they got only few findings with corrects values.
Bergstorm et al. (2001) agrees that risk assessment is done by scales like Braden scale or the Norton scale in the hospitals which is more reliable. However there is no universally accepted risk assessment tool to be adopted to prevent pressure sore. Besides this, the utilization of the risk assessment tools has their own limits in clinical systems. Alternatively, Saleh et al. (2008) argues that medical judgement is successful as risk assessment tools to determine the suitable to be delivered. Nevertheless, Pancorbo-Hidalgo et al, (2006) Braden and Norton scales were noticed to be well again at risk calculation than the scientific judgements. On the other hand, according to NICE guidelines (2003) risk assessment tools can only be used as an aide-mémoire and should not replace clinical judgment.
Normal supply of oxygen and nutrients are essential for the tissues, to maintain health. (Gottrup 2004). When patients sitting or lying, the pressure form particular part of the body results in the decrease of oxygen causes pressure sore (Defloor 2005). The study conducted by Kaitani et al., 2010, Vanderwee et al., 2007 and Pearson et al., 2010 reveals the importance of changing the position for the bed ridden or immobilize patient in preventing pressure sore occurrence. Their studies evidenced the effectiveness of repositioning in regular intervals among the vulnerable patients. Repositioning is considered as an effective control method against pressure sores (decubitus ulcer). According to Vanderwee et al., (2007) the effectiveness of force of pressure greater in sideway position. He also suggested that supine position is the comfortable position to reduce the effect of pressure on the bony prominence. The experiment conducted by Vanderwee et al. (2007 reveals that more regular repositioning does not actually decrease the occurrence of pressure sore. But he recognizes that turning of patients is an effectual preventive method. The incidence of pressure ulcer is more in patients who are lying down in side way position. The risk has been reduced when the patients are lying down in supine position.
On the other hand the study conducted by Peterson et al. (2010) argues that the effectiveness of repositioning is less or not reliable even though it is done by any experienced nurse. And he found that after maintaining an appropriate pressure below 33 mm of Hg reduce the incidence of pressure ulcer. He states that by doing this there is still chance of occurring pressure sore in the risk areas. While turning the patient they are not unloading the all areas prone to pressure effect with the skin. Even though the standard methods for preventing pressure sores are maintained the skin breakdown happening as the risk areas are not relieved from pressure. The study conducted by Kaitani et al. (2010) evidenced that patients suffering from pressure sore have done only a fewer change of positioning and turning. In their studies they states that they didn’t noticed any patients with pressure sore who has been changed their position frequently in a regular intervals.
From the findings of Hobbs (2004) also reveals that there is no decline of incidence in pressure sore in the hospital due to the routine repositioning on older people. Similarly Peterson et al 2010 found that still the incidence of pressure ulcer are increasing in the clinical settings where standard turning of patients has already been done. In EPUAP guidelines (2009), suggests that repositioning is an effective method which will decrease the extent and occurrence of pressure over susceptible points like sacrum, heels, elbows and back of the head bony prominences. However, there was no research study conducted by any researchers to calculate the time gap needed to turn the patient that means there is no evidence of turning intervals from any previous studies or researches.
It is very important to inspect the support surface while doing repositioning. Patient must be repositioned in regularity after inspecting the tissue viability, mobilising level, medical condition and evaluation of skin integrity. It is also subjected by the supportive surface So repositioning can reduce the incidence of pressure sore to an extent. In hospitals and health care homes it is suggested that repositioning to be done in every 4 hours and by the use of air mattress the incidence of the occurrence of pressure sore can be prevented. Many of the patient’s feels very discomfort while turning frequently, to avoid frequent turning pressure reducing support surfaces can be used to relieve pressure.
Importantly pressure relieving support surface devices has vital role in the prevention of pressure. According to Cullum et al., 2001 it is divided into two, low tech devices and high tech devices. Low tech devices are comforting support surface to dispense the body weight over an area whereas high devices are alternating support surface where inflatable cells consecutively inflate and deflate.
According to Lewis M, et al (2003) if the patients having a moderate to high possibility of developing pressure sore, dynamic support surfaces include a large cell alternating pressure mattress, a low air loss or air fluidized bed, or other pressure redistributing systems can be recommended. In a study conducted by Nixon et al (2006)found that in operating tables, specialized foam mattress overlays are effective to reduce the incidence of postoperative pressure sores while in other settings, specialized foam and overlays were the only surfaces that were constantly better to standard hospital mattresses in reducing incidence of pressure ulcers. To decrease the contact between bony prominences and support surfaces, pillows and foams are used. In addition to that for reducing the friction and shearing damage, lifting devices such as slide sheets, slings or sleeves can be used to move the patients.
On the other hand, it is unclear about the evidence for the advantages of higher-specification constant low-pressure and alternating-pressure support surfaces for preventing pressure sores. However, there is clinical evidence of a difference in risk of developing pressure ulcers when using high-specification foam mattresses, compared to standard hospital mattresses. (NICE 2005) Decisions for pressure relieving device should determine at risk assessment. It must include level of risk, comfort, patient`s preferences, general health and timing of the surgery.
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The studies conducted by Holm et al. (2007) and Ferguson et al. (2000) evidenced the significance of nutrition in pressure ulcer prevention. This study suggests that older people are mostly affected due to pressure ulcer. This is because of their less skin integrity and low nutritional status. The nutritional status of the elderly people is usually related with the level of intake of food and fluids along with various nursing intervention methods (Holm et al., 2007). Management of pressure sore and its treatment closely related with the clients nutritional status. The people with less nutritional status have a high risk of occurrence of pressure ulcer. The nutritional status of the patient has to be assessed by the nurse initially. Adequate quantity of proteins, calories, minerals, vitamins and fluids are necessary to maintain the skin integrity and wound healing promotion (Ferguson et al., 2000).
The advancement and management of pressure sore highly influenced by their nutritional status. For doing an successful preventive measures it is essential to carried out with proper nutritional evaluation techniques and planning (Ferguson et al., 2000).pressure sore and nutritional status are closely related to each other and are directly proportional to each other.patients who are with less nutritional status or malnourished are likely to be more prone to develop pressure sore (Thomas, 1997).To reduce the incidence both dieticians and nurses should work jointly.
To assess the nutritional status of the patient and the level of malnourishment and proper planning and interventions to be done to improve the status if inadequate (Ferguson et al., 2000).According to EPUAP (2009) recommendation every health care system should do screening and evaluation tests of the nutritional level of the vulnerable people who are at risk of pressure sore.
Pressure sore in majority cases are preventable and controllable. A targeted control measure is far better than pointing on treating previously recognized pressure sores. Preventive measures to deceits (pressure) sore saves time and money. By doing an effective preventive techniques can also minimise the loss of energy and reduction in the work load over the health care delivery personnel’s and staffs mainly nurses.
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