Preventive Measures For Pressure Ulcers

Encourage Seniors To Maintain A Healthy Diet

The benefits of a well-functioning circulatory system are only as good as the nutrients it delivers. Seniors should strive to eat a well-balanced, healthy diet, explains Medscape. In fact, optimizing the nutritional status of a senior living with a pressure sore is key to ensuring successful treatment. For seniors living with metabolic disorders, such as diabetes, a healthy diet can go much further than simply preventing or encouraging the healing of pressure sores.

Eat Healthily And Drink Plenty Of Fluids

Eating a healthy and nutritious diet and preventing dehydration by drinking enough liquid is important in preventing pressure sores. Being obese or having severe weight loss can increase the risk of getting pressure sores. A poor diet can affect the health of your skin and your immune system. Likewise, hydration plays a vital role in your skin’s health and helps to repair injured skin. Adequate fluid intake is necessary for wound healing, to support the blood flow to wounded areas and to prevent breakdown of your skin.

Where To Get Help

• Domiciliary care staff

• Ricci JA, Bayer LR, Orgill DP. Evidence-Based Medicine: The Evaluation and Treatment of Pressure Injuries, Plast Reconstr Surg. 2017 Jan 139:275e-286e
• Walia GS, Wong AL, Lo AY, Mackert GA, Carl HM, Pedreira RA, et al. Efficacy of Monitoring Devices in Support of Prevention of Pressure Injuries: Systematic Review and Meta-analysis. Adv Skin Wound Care, 2016 Dec 29:567-574
• Wound, Ostomy and Continence Nurses Society-Wound Guidelines Task Force, WOCN 2016 Guideline for Prevention and Management of Pressure Injuries : An Executive Summary. J Wound Ostomy Continence Nurs. 2017 May/Jun 44:241-246
• Scafide KN, Narayan MC, Arundel L. Bedside Technologies to Enhance the Early Detection of Pressure Injuries: A Systematic Review, J Wound Ostomy Continence Nurs. 2020 Feb 13.
• Munoz N, Posthauer ME, Cereda E, Schols JMGA, Haesler E. The Role of Nutrition for Pressure Injury Prevention and Healing: The 2019 International Clinical Practice Guideline Recommendations. Adv Skin Wound Care, 2020 Mar 33:123-136.
• Qigui X, Qinling Y, Huapeng L. Meta-analysis of effect of foam dressing and hydrocolloid dressing on bedsore management. Chinese Nurs Res. 2017 31:3397-3400.
• Westby MJ, Dumville JC, Soares MO, Stubbs N, Norman G. Dressings and topical agents for treating pressure ulcers. Cochrane Database Syst Rev. 2017 6.

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Who Is Most Likely To Get A Pressure Ulcer

Anyone living in a care home can develop a pressure ulcer, but some factors make it more likely.

Risk factors include:

• Limited mobility or being unable to change position without help.
• A loss of feeling in part of the body.
• Having had a pressure ulcer before, or having one now.
• Not having eaten well for a period of time.
• Thin, dry or weak skin.
• A significant cognitive impairment.

Symptoms Of Stage 3 And Stage 4 Pressure Ulcers

Stages 3 and 4 pressure ulcers have deeper involvement of underlying tissue with more extensive destruction. Stage 3 involves the full thickness of the skin and may extend into the subcutaneous tissue layer granulation tissue and epibole are often present. At this stage, there may be undermining and/or tunneling that makes the wound much larger than it may seem on the surface. Stage 4 pressure ulcers are the deepest, extending into the muscle, tendon, ligament, cartilage or even bone.

Figure 1: Stage 4 sacral pressure ulcerFigure 2: Stage 3 pressure ulcer on hip

Dr. Simon Palfreyman examines the impact of pressure ulcer interventions

Simon Palfreyman and Brendan Mulhern 28 January 2016

Pressure ulcers are wounds that result when people are immobile or have reduced mobility. They tend to occur over bony prominences. Pressure ulcers can range from superficial skin damage to deep, extensive wounds that extend through to the bone. The prevention and treatment of pressure ulcers have been identified as major costs for health-care providers.

The purpose of the study was to explore the feasibility of using generic PROMs in patients with pressure ulcers or at risk of developing pressure ulcers.

Approach

Highlights of the findings

The presence of an ulcer had a negative impact on quality of life and also led to a perceived lower level of dignity. The PROM questionnaires were able to measure the difference between those who had an ulcer and those who did not have an ulcer.

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Responsibility Of Line Managers:

• Implement these guidelines in their clinical area.
• Ensure that staff understand their accountability and responsibility and comply with these guidelines.
• Ensure that staff have the knowledge, skills and competence appropriate for their role and responsibilities to manage the risk of new / existing pressure ulcers as part of the assessment and equipment provision through the healthcare facility.
• Ensure that all staff have access to copies of references and resources referred to within this guidelines.
• Monitor the occurrence of new pressure ulcers classified as Grade 3 or Grade 4 and investigate possible reasons and outcomes.

Which Interventions Are The Most Important

Pressure ulcers usually heal very slowly, and may come back. That’s why it’s so important to make sure they don’t develop in the first place. People who are confined to a wheelchair or have to stay in bed for a long time often say that they can feel parts of their body becoming sore. It’s important to pay attention to what they say, to quickly reduce pressure on their skin, and regularly change the position they sit or lie in.

Observing which parts of the body are most susceptible to pressure, as well as the positions that put the most pressure on them, can help you get an idea of what sort of relief might be helpful. For example, lying down puts much less pressure on your backside than sitting in a chair. If you use a wheelchair, you can find out what helps to reduce the pressure and then make that your routine.

It’s also important to try to move if possible even if you have to lie in bed or sit in a wheelchair. If you are able to sit up, leave the bed, or even walk a few steps with a bit of help, its a good idea to do that as often as possible.

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Sample Size And Sampling Procedure

The sample size was determined by using single population proportion formula with the assumption of: 50 % proportion, 95 % confidence level and 5 % margin of error. Given that the source population was less than 10,000 correction formula was used and 5 % non-response was added, making the final sample size 201. Since the total number of nurses working in the hospital was 255, the study involved all of them to increase the power of the study.

Procedure And Data Analysis

Demographic and clinical data to describe the population were collected. This included the American Spinal Injury Association Impairment Scale and neurological level of injury according to the International Standards for Neurological Classification of Spinal Cord Injury. In addition, each pressure ulcer was scored on the Pressure Ulcer Scale for Healing version 3.0. The PUSH tool version 3.0 rates pressure ulcers according to the surface area of the pressure ulcer, amount of exudate and type of tissue damage. The total scores range from 0 to 17 points, with higher scores indicating a severe pressure ulcer and a score of zero representing no pressure ulcer. The original plan was to correlate the undermining scores with the PUSH to provide some evidence about the validity of the undermining measurements. However, this aspect of the study was subsequently abandoned when it became clear that the PUSH was not a reasonable gold standard for undermining. We, however, report the PUSH data and its correlation with the undermining scores.

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Who’s Most At Risk Of Getting Pressure Ulcers

Anyone can get a pressure ulcer, but the following things can make them more likely to form:

• being over 70 older people are more likely to have mobility problems and skin that’s more easily damaged through dehydration and other factors
• being confined to bed with illness or after surgery
• inability to move some or all of the body
• medical conditions that affect blood supply, make skin more fragile or cause movement problems such as diabetes, peripheral arterial disease, kidney failure, heart failure, multiple sclerosis and Parkinson’s disease

Measuring Key Processes Of Care

5.2.1 Why measure key processes of care?

While measuring pressure ulcer rates is the ultimate test of how your facility or unit is performing, pressure ulcer rates are limited in that they do not tell you how to improve care. If your pressure ulcer rate is high, on what specific areas should you focus? To know where to focus improvement efforts, it is important to measure key processes of care. Many important processes of care could be measured in assessing pressure ulcer prevention. We recommend initially looking at no more than three:

• Performance of comprehensive skin assessment within 24 hours of admission.
• Performance of standardized risk assessment within 24 hours of admission.
• Performance of care planning that addresses each deficit on standardized risk assessment.

5.2.2 What data sources should be used in measuring key processes of care?

Much pressure ulcer preventive care may not be documented. Nonetheless, we recommend medical record reviews as the source of data on the performance of key processes of care. While rates may initially be low because of poor documentation, this finding will encourage improved documentation of the care actually being provided.

Tools

Use this tool developed by the Quality Improvement Organization program for abstracting medical record data .

5.2.3 How do we ensure performance of comprehensive skin assessment within 24 hours of admission?

Tools

A sample protocol for checking skin assessments is available in Tools and Resources .

Tools

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Braden Scale For Predicting Pressure Ulcer Risk

The Braden Scale for Predicting Pressure Ulcer Risk, is a tool that was developed in 1987 by Barbara Braden and Nancy Bergstrom. The purpose of the scale is to help health professionals, especially nurses, assess a patients risk of developing a pressure ulcer.

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Use Specialty Bedding Or Materials To Reduce Pressure

Depending on the needs of each senior, specialty beds, such as water or air mattress toppers, or special, cushioned padding, such as heel protectors, may be needed to reduce the amount of pressure placed on sensitive areas of the body. These additional materials should not be limited to mattresses or modifications to footwear. Instead, keep the options open for what may and may not be the most comfortable and beneficial to the needs of seniors.

For example, a memory-foam pillow is great, but it does little good if it is always placed in the same position. Furthermore, soft, pillow-like wedges may be used to help seniors remain on their sides while lying in bed between repositioning times.

Some newer beds may suggest automatic turning is available for use. However, these systems do not completely reposition a person. As a result, it is best to use these systems in conjunction with manually reposition of a person.

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When To Get Medical Advice

If you’re in hospital or a care home, tell your healthcare team as soon as possible if you develop symptoms of a pressure ulcer. It’ll probably continue to get worse if nothing is done about it.

You should be regularly monitored and offered advice and treatment to reduce the risk of pressure ulcers, but sometimes they can develop even with the highest standards of care.

If you’re recovering from illness or surgery at home, or you’re caring for someone confined to bed or who is a wheelchair user, contact your GP surgery if you think you or the person you’re caring for might have a pressure ulcer.

Get medical advice immediately if there is:

• red, swollen skin
• pus coming from the pressure ulcer or wound
• cold skin and a fast heartbeat
• severe or worsening pain
• a high temperature

These symptoms could be a sign of a serious infection that needs to be treated as soon as possible.

What Are The Stages Of A Pressure Injury

There are four stages that describe the severity of the wound. These stages include:

• Stage 1: This stage is discolored skin. The skin appears red in those with lighter skin tones and blue/purple in those with darker skin tones. The skin does not blanch when pressed with a finger.
• Stage 2: This stage involves superficial damage of the skin. The top layer of skin is lost. It may also look like a blister. At this stage, the top layer of skin can repair itself.
• Stage 3: This stage is a deeper wound. The wound is open, extending to the fatty layer of the skin, though muscles and bone are not showing.
• Stage 4: This stage is the most severe. The wound extends down to the bone. The muscles and bone are prone to infection, which can be life-threatening.

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Those Most At Risk Of Getting Pressure Ulcers

Anyone can get a pressure ulcer, but you are more at risk if you:

• have to stay in bed after surgery or because of illness
• are unable to move some or all of your body
• have urinary incontinence and bowel incontinence
• have a poor diet
• have a medical condition that affects blood supply or makes your skin more fragile

How Should A Standardized Pressure Ulcer Risk Assessment Be Conducted

As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development. However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers. This can best be accomplished through a standardized pressure ulcer risk assessment.

3.3.1 What is a standardized pressure ulcer risk assessment?

After a comprehensive skin examination, pressure ulcer risk assessment is the next step in pressure ulcer prevention. Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented. This process is multifaceted and includes many components, one of which is a validated risk assessment tool or scale.

Other risk factors not quantified in the assessment tools must be considered. Risk assessment does not identify who will develop a pressure ulcer. Instead, it determines which patients are more likely to develop a pressure ulcer, particularly if no special preventive interventions are introduced. In addition, risk assessment may be used to identify different levels of risk. More intensive interventions may be directed to patients at greater risk.

Action Steps

Ask yourself and your team:

3.3.2 Why is a pressure ulcer risk assessment necessary?

Action Steps

Ask yourself and your team:

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What Role Do Diet And Skin Care Play

Some people who are hardly able to move don’t get very hungry or thirsty. In order for them to stay in good physical condition, though, it’s important to make sure they get enough to eat and drink. Eating too little or a very unbalanced diet and hardly having anything to drink may weaken their skin even more. Some people take dietary supplements, but there’s hardly any research on whether these products can help prevent pressure ulcers.

It’s important to keep the skin from getting too dry, but also to prevent it from being exposed to constant moisture either one increases the likelihood of damage to the skin. There’s not yet enough good research to be able to say whether regular use of creams or lotions can prevent pressure ulcers.

What Causes Pressure Injuries

• Continuous pressure builds when you sit or lie on a bony area for too long. Pressure slows or stops the blood from flowing to the skin. This may hurt the skin and cause tissue damage. Pressure can start to cause damage to your skin and tissue about 2 hours after staying in the same position.
• Shearing or friction happens when delicate skin is dragged across a surface, such as sheets. This may cause your skin to tear or a blister to form. Sliding up or down in bed or moving from the bed to a chair may tear your skin. Muscle spasms may cause your arms or legs to jerk and rub the sheets, causing tears in your skin.

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What Is A Pressure Injury

A pressure injury is an area of injured skin. A pressure injury happens when force is applied on the surface of the skin. This force can be a constant pressure on an area of skin or a dragging force between the skin and another surface. These injuries usually happen over bony parts of the body . A pressure injury can become life-threatening if it advances to a deep wound or becomes infected.

Who Is At Risk For Developing Pressure Injuries

• People with a limited amount of mobility or a total inability to move. Those in wheelchairs or bedridden are at particular risk and need to be moved or turned regularly.
• Those with prosthetic limbs. If the device does not fit properly, the skin can be irritated and a pressure injury can develop.
• People with a loss of sensation. They are at risk because they may not feel the pressure being applied to the skin. As a result, they may not move, which could worsen the damage.
• Those with malnutrition. Wound healing is slowed when nutritional needs are not met.
• The elderly. As people age, the skin naturally becomes thinner and more easily damaged.

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