P

ressure ulcers (PUs) negatively affect a resident’s health and quality of life and also place a tremendous strain upon the healthcare system. PUs affect approximately 1 million people and cost 1.6 billion dollars annually.¹ Xakellis and Frantz² examined 45 PUs for a total of 5,200 days to calculate the cost of a PU from the time of development to the time of healing. They determined the average cost per PU to be $2,731. Another study estimated the cost to heal a complex, full-thickness PU to be as much as $70,000, while a less serious PU ranged from $2,000 to $30,000.³ Certainly, no one in the extended care industry needs to be told of the publicity and advertising campaigns surrounding PUs found in all forms of media. There are thousands of lawsuits filed annually, and settlements have been in the millions of dollars. The good news? Preventing a PU costs less than treating one.⁴
       To be cost and clinically effective, facilities should provide preventive care according to national guidelines, which are written by experts from across the country and based on scientific evidence. These experts rely on and identify the research studies that support their recommendations. These guidelines are available at http://www.guideline.gov.

Identifying a Resident’s Risk Factors

       The national guidelines suggest assessing residents upon admission/re-admission, when the medical condition changes, and quarterly thereafter to determine extrinsic and intrinsic risk factors. Pressure and shearing are considered extrinsic factors. Pressure is the most important factor in PU development. When the soft tissue covering a bony prominence is compressed, the blood supply is disrupted and ischemia results. A healthy individual’s response to such pressure is to change positions. As a result of relieving pressure, a temporary red area occurs, which indicates increased blood supply that removes waste products and brings oxygen and nutrients to the tissue. This normal response is called reactive hyperemia. However, if unrelieved pressure persists, tissue necrosis (i.e., tissue death) will occur. Tissue necrosis takes place in a cone shape with the widest part at the bone and the narrowest on the skin surface.⁵ Thus, the injury apparent on the skin surface is literally the tip of the iceberg.
       Shearing and friction forces also disrupt the microcirculation by displacing and distorting blood vessels as the skin layers move relative to one another. An example of this is when a resident slides down in bed—the skeleton and deep fascia slide downward, while the skin and upper fascia remain in the original position.^5,6

       All individuals are continuously subjected to extrinsic factors; yet, not everyone develops PUs. The determining causes, referred to as intrinsic factors, vary according to the individual. Intrinsic factors include immobility, sensory impairment, advanced age, poor blood supply, severe/terminal illness, significant weight loss, and incontinence. Immobility is considered to be the most significant intrinsic risk factor. Immobility can occur in residents with neurological disease, fractures, pain, and use of restraints. Immobility not only impairs a resident’s ability to relieve pressure, it also predisposes the resident to insult by shearing and friction forces.^5,6
       Sensory impairment results in reduced sensation and insensitivity to painful stimulus to relieve pressure. Impaired sensory awareness occurs in residents with reduced level of consciousness (e.g., comatose), reduced level of awareness (e.g., dementia, delirium, depression, drugs that affect alertness), and/or sensory neuropathy (e.g., diabetes, spinal injuries, degenerative neurological conditions).^5,6
       Studies have discovered the prevalence of PUs in residents younger than 70 years is only six percent, whereas in residents older than 70 years, the incidence doubles to 11.6 percent. With normal aging, skin changes occur. For example, regeneration of the epidermis is delayed, dermis thins, blood supply is reduced, collagen production is decreased, and there is decreased subcutaneous tissue. Further, the number of nerve endings are decreased, resulting in a 20-percent increase in cutaneous pain threshold; therefore, elderly residents may not sense the need to shift weight, leading to skin breakdown.^5,7
       The effects of severe chronic or terminal illness are multiorgan failure, poor perfusion, and immobility. Poor blood supply lowers capillary pressure and causes malnutrition in the tissues. Diseases (e.g., heart disease, peripheral vascular disease, diabetes), drugs (e.g., beta-blockers, inotropes), and smoking can deprive tissue of oxygen.^5,6
       The National Pressure Ulcer Long-Term Care Study (NPULS) followed 2,420 residents at 109 long-term care facilities across the United States for 21 months and discovered that PU risk increased by 74 percent with involuntary weight loss (i.e., > 5% in 30 days, > 7.5% in 90 days, or > 10% in 180 days) and by 42 percent with dehydration. Obesity, especially in residents with limited mobility, tends to make transfers, ambulation, and bed mobility more difficult and increases risk for PU development.⁸
       Use of an indwelling catheter for 14 days or longer has been associated with an increased likelihood of developing a PU. This finding conflicts with traditional views that catheter use to manage urinary incontinence reduces exposure to moisture and therefore reduces PU development. A plausible explanation is that residents with catheters are at risk of developing bladder infections, and the physiological stress of these infections may predispose these individuals to developing a PU. In addition, residents with catheters may be turned and repositioned less frequently than recommended, which can lead to pressure injury and increased risk of developing PUs. In contrast, the use of disposable briefs for 14 days or longer has been associated with a lower incidence of PU development, perhaps because these residents were more likely to be turned and repositioned frequently because their briefs had to be changed regularly.⁹
       Finally, a history of previous pressure ulceration increases the risk of future skin breakdown. As a PU closes, the edges taper, and the wound bed becomes shallower; however, it is not replaced with new muscle, subcutaneous fat, or dermis. Instead, the ulcer is filled with granulation (scar) tissue composed primarily of endothelial cells, fibroblasts, collagen, and extracellular matrix. Because this new tissue does not possess the strength of the lost tissue, this affected area will always be prone to subsequent PUs.⁷
       One tool to help identify and document residents at risk of PU development is the Braden Scale (available at http://www.bradenscale.com/ braden.PDF).

Identifying a Facility’s Risk Factors

       Evidence from the NPULS observed that residents in facilities with care time by registered nurses of more than 15 minutes per resident per day and by nurse aides of more than two hours per resident per day were less likely to develop a PU. These staffing ratios are similar to those proposed by the National Citizens’ Coalition for Nursing Home Reform of 0.53 registered nursing hours per resident day and a minimum level of total direct nursing staff care of 1.6 hours per resident day. In addition, a licensed practical nurse turnover rate of less than 25 percent was associated with decreased likelihood of developing a PU. The more time that registered nurses and nurse aides are able to spend with a resident and the less licensed practical nurse turnover, the more likely the resident will receive adequate and appropriate care, including PU prevention interventions.⁹

Interventions to Prevent Pressure Ulcers

       An interdisciplinary preventive care plan must be developed and interventions must be initiated if the Braden Scale score is less than 18 for elderly and persons with darkly pigmented skin or less than 16 for other adults. Table 1 provides preventive strategies.¹⁰

Education and Training

       All levels of healthcare professionals should be educated in PU risk assessment and prevention. Training and education programs should include risk factors for PU development; pathophysiology of PU development; skin inspection; incontinence and skin care; selection of pressure reduction devices; positioning techniques to minimize pressure, shear, and friction; importance of hydration and nutrition; and reporting procedures should signs of skin breakdown occur.
       Residents who are able and willing should be informed and educated about prevention strategies. This education, where appropriate, should be given to caregivers. Education should provide information on the following: their individual risk factors that place them at risk for developing PUs; the sites that are at greatest risk for PUs; how to inspect skin and recognize skin changes; how to care for skin; methods for pressure reduction; and the importance of reporting signs of damage immediately.

Conclusion

       Pressure ulcers are significant burdens to residents, caregivers, and the healthcare system. Historically, preventive strategies have varied across the United States. To rectify this problem, national guidelines were developed and are invaluable resources, as we continuously strive to provide cost and clinically effective care for the residents we serve.