Prevention and Treatment of Pressure Ulcers: An Evidence-Based Approach
Robert E. Pieroni
CLINICAL PEARLS
The prevention of pressure ulcers is considered a marker for quality of care.
Patients with pressure ulcers often suffer the psychosocial effects of pain, depression, social isolation, and decreased quality of life.
Patients should not be allowed to lie on skin that has been reddened by pressure.
Of the numerous pressure ulcer risk factors, the two major ones that can be influenced by clinicians are nutrition and tissue loading.
Turning schedules need to be individualized; some patients may need to be turned more frequently than every 2 hours.
Studies have demonstrated decreased pressure ulcer incidence in health care facilities that have instituted the recommendations of the federal agency formerly known as the Agency for Health Care Policy and Research (AHCPR), and now known as the Agency for Healthcare Research and Quality (AHRQ), including pressure ulcer risk assessment and care protocols.
Because muscle and subcutaneous tissue are more susceptible to pressure than the epidermis, pressure ulcers are often worse than they appear and are often understaged.
The AHCPR/AHRQ pressure ulcer guidelines continue to represent the standard for comprehensive pressure ulcer management used by regulating and accrediting bodies.
The process of healing is by granulation, contraction, and re-ephithelialization and scar tissue formation; open ulcers never return to Stage I.
Excess weight can mask nutritional deficiencies; even morbidly obese patients can be severely malnourished, placing them at further risk for the development of pressure ulcer.
A static support surface may be effective in patients who can spontaneously reposition themselves; otherwise, a dynamic surface is preferable.
Patients should be placed on a dynamic support surface if there are limited positioning options or if the patient bottoms out on a static surface.
Patients with large Stage III or IV pressure ulcers should be strongly considered for a dynamic support surface.
Use of dynamic support surfaces in high-risk patients with pressure ulcers has resulted in both improved outcomes and cost savings.
Hospitalized patients placed on air-fluidized beds have demonstrated significant decreases in pressure ulcer size.
Electrotherapy may be considered for clean Stages III and IV pressure ulcers when there is no improvement after a month of otherwise optimal treatment.
Surgical debridement is the most rapid and efficient method to remove necrotic debris; with ongoing infection, sharp debridement is required.
With eschars, penetration of enzymatic agents is decreased; before enzyme application, softening by autolysis or cross-hatching by sharp incision is needed.
Open pressure ulcers can lose considerable fluid and protein, contributing to dehydration and malnutrition; increased catabolism, especially with infected pressure ulcers, can further deplete nutrients.
When a pressure ulcer does not heal, always consider a possible infection, including osteomyelitis.
Pressure ulcers, although affecting all age-groups, are more common in the elderly and can result in considerable pain, suffering, expense, litigation, morbidity, and possibly, death. The purpose of this chapter is to provide the reader with an overview of the widely accepted, evidence-based guidelines, Pressure Ulcers in Adults: Prediction and Prevention (Clinical Practice Guideline No. 3)1 and Treatment of Pressure Ulcers (Clinical Practice Guideline No. 15),2 both prepared by the federal agency formerly known as the Agency for Health Care Policy and Research (AHCPR). (AHCPR has since become the Agency for Healthcare Research and Quality [AHRQ]. While the guidelines may still sometimes be referred to as AHCPR guidelines, we use the current agency name, AHRQ, here.)
The following case study underscores several important aspects in the prevention of pressure ulcers in at-risk patients.
CASE ONE
Mrs. R., a 78-year-old, was admitted to our medical center with respiratory failure requiring ventilation. Additionally, she had breast cancer that had metastasized to her spine, resulting in paraplegia. Other problems included type 2 diabetes mellitus and hypertensive arteriosclerotic cardiovascular disease. She was on numerous medications at home, several of which were found to be inappropriate for her age and medical conditions and were discontinued. On admission, nutritional parameters, including serum prealbumin and red blood cell count, were found to be low. Her blood urea nitrogen (BUN) and serum glucose levels were high. Her food and fluid intake were optimized, pain was controlled, and diabetes and hypertension were better regulated. The nursing staff closely followed hospital and national guidelines including skin inspection, turning, repositioning, surface support, and infection control, among other measures. She was also closely followed up by the dietary and physical therapy departments. Several
pulmonary infections and urinary tract infections (UTIs) were promptly diagnosed and treated. Physicians frequently complimented the nursing staff on their excellent care of the patient.
pulmonary infections and urinary tract infections (UTIs) were promptly diagnosed and treated. Physicians frequently complimented the nursing staff on their excellent care of the patient.
Despite her metastasic cancer and other comorbid conditions, the patient survived for several more years. Although she was at extremely high risk for the development of pressure ulcers, as noted on her initial pressure ulcer assessment, the patient died peacefully with completely intact skin.
All members of a multidisciplinary medical team worked closely to ensure Mrs. R.’s comfort and to prevent complications. In addition to her initial suboptimal nutrition, hydration, and diabetic control, Mrs. R. had other risk factors for developing pressure ulcers, including immobility from her paralysis, frequent infections, and the need for continued ventilator support, among other medical problems. Close collaborative efforts on a continuous basis prevented the development of any pressure ulcers.
OVERVIEW
Terminology
Although the terms pressure ulcer and decubitus ulcer have been used interchangeably, technically the latter (from the Latin decumbere, meaning “to lie down”) refers to ulcers over bony prominences while the patient is supine (e.g., over the occupit, sacrum, or heels). A pressure ulcer that results from excess pressure while a patient is seated would not be classified as a decubitus ulcer. Pressure ulcer is therefore the preferred terminology because it applies to all wounds caused by excessive pressure over bony prominences.
Many sites may be involved in pressure ulcers. Almost 95% form on the lower portion of the body, with approximately 65% in the pelvic area and 30% in the lower extremities. Common sites include sacrum, coccyx, ischium, ilial crest, trochanter, lateral malleolus, lateral foot, and heel.
TABLE 37.1 DIFFERENTIAL DIAGNOSIS OF SKIN ULCERS | ||||||||||||||||||
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Epidemiology
It has been estimated that from l to 3 million adults in the United States may be affected by pressure ulcers. The elderly, because of possible skin changes with aging, as well as increased likelihood of comorbid states, have a higher incidence of pressure ulcer development, with as many as 70% of pressure ulcers developing in patients older than 70.3,4
Estimates of pressure ulcer management costs in the United States have ranged from $1.3 to $6.8 billion dollars annually. Treating a severe pressure ulcer and its sequelae can cost in excess of $250,000. The cost in human suffering is incalculable. Pressure ulcer prevention guidelines can significantly decrease such costs and may considerably increase ulcer-free days at minimal cost.4, 5, 6
DIFFERENTIAL DIAGNOSIS
In addition to pressure ulcers, the main type of dermal ulcers (e.g., ischemic, venous, and neuropathic), as well as some clinical features and modes of treatment, are shown in Table 37.1.
RISK FACTORS
Scores of risk factors and comorbid states that may enhance susceptibility to pressure ulcers have been described. The extrinsic risk factors (e.g., pressure, friction, and shear) often act in combination. Both intensity and duration of pressure are important in the development of pressure ulcer. Table 37.2 summarizes the conditions associated with pressure ulcers.
Braden Scale
The Braden Scale (see Fig. 37.1) is an assessment tool to determine a patient’s risk level for developing skin breakdown.7 It has been tested in both acute-care and long-term care settings and has demonstrated high inter-rater reliability.8,9 The Braden score may range from 6 (highest pressure ulcer risk) to 23 (lowest risk). Patients with scores <18 are considered at risk.10 Factors included in the Braden Scale are sensory perception, moisture, activity, mobility, nutrition, friction, and shear.
 Figure 37.1 Braden Scale. NPO, no oral intake; TPN, total parenteral nutrition. (Copyright (c) Barbara Braden and Nancy Bergstrom, 1988. All rights reserved). |
TABLE 37.2 INTRINSIC RISK FACTORS AND COMORBID STATES ASSOCIATED WITH PRESSURE ULCER DEVELOPMENT | ||||||||||||||||||||||||||||||||||||||||
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STAGING
Saucerization of Pressure Damage
At pressures above the capillary filling pressure of 32 mm Hg, arteriolar perfusion is jeopardized. Pressure at the skin surface has a cone-shaped radiation, resulting in much greater internal distribution. The skin is actually less susceptible to damage than the subcutaneous tissue is. Subcutaneous tissue, in turn, is better protected than muscle, which is most vulnerable to pressure damage. Therefore, on examining the skin we frequently see just the tip of the iceberg as far as tissue damage.11
The multidisciplinary National Pressure Ulcer Advisory Panel (NPUAP), formed in 1987, is an independent, nonprofit organization established to evaluate areas of concern in pressure ulcer management. NPUAP’s pressure ulcer staging system,12 the most frequently used, has been adopted by the AHRQ guideline panels. The NPUAP staging system is:
Stage I:
Pressure ulcers are observable pressure-related alterations of intact skin whose indicators, as compared to adjacent or opposite body areas, may include changes in skin temperature (i.e., warmth or coolness), tissue consistency (i.e., firmness or bogginess), and/or sensation (i.e., pain, itching). The pressure ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the pressure ulcer may have persistent red, blue, or purple hues.
Stage II:
Pressure ulcers are associated with partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
Stage III:
Pressure ulcers are associated with full-thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, the underlying fascia. The pressure ulcer presents clinically as a deep crater, with or without undermining of the adjacent tissue.
Stage IV:
Pressure ulcers are associated with full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint, or capsule). Undermining and sinus tracts may also be associated with Stage IV pressure ulcers. (The above is adapted from National Pressure Ulcer Advisory Panel (NPUAP). NPUAP position on reverse staging of pressure ulcers, in Advanced Wound Care, Vol. 8. 1998:32).
Because skin is a not a uniform organ, its appearance or thickness varies according to anatomic site. On average, a pressure ulcer that is approximately 2 mm or deeper and is
located on the trunk, pelvic girdle, ankle, or heel is usually classified at least as a Stage III. This depth approximates that of a US nickel or a house key. Initial pressure ulcer staging is important because the ulcer is not restaged as it heals.
located on the trunk, pelvic girdle, ankle, or heel is usually classified at least as a Stage III. This depth approximates that of a US nickel or a house key. Initial pressure ulcer staging is important because the ulcer is not restaged as it heals.
Reverse (Healing) Staging
The NPUAP has issued a position statement12 against using back staging or reverse staging. For example, a healing Stage IV pressure ulcer would not be progressively downstaged to III, II, and so on, as it heals. A healing pressure ulcer is replaced with scar tissue because dermis, subcutaneous fat, and muscle cannot be regenerated. Therefore, restaging as an ulcer heals does not describe the physiologic changes that occur. If a previously healed pressure ulcer reopens, the prior staging diagnosis should be used (i.e., once an ulcer is Stage IV, it will always remain Stage IV).
INCIDENCE/PREVALENCE
Values for pressure ulcer incidence, (i.e., new cases occurring over a specified period) and prevalence (a cross-sectional count of cases at a specific time point) may vary considerably among different patient populations, among treatment facilities, and with differences in methodology used for calculating pressure ulcers. Some high-risk populations, such as quadriplegics, are obviously more prone to develop pressure ulcers. AHRQ and NPUAP panels have compiled statistics for pressure ulcer incidence and prevalence in different care settings, as shown in Table 37.3.
COMPLICATIONS
Clinicians often surrender to a defeatist attitude about pressure ulcers because of the oversimplified conception that ulcers reflect a patient’s age and/or disease process. The presence of pressure ulcers may compromise the care for other medical needs. Coexistent malnutrition and dehydration contribute to further development of pressure ulcer and result in a lethal vicious cycle. Complications of pressure ulcers include the following: Protein loss, malnutrition, anemia, dehydration, electrolyte disturbances, pain, suffering, disfigurement, psychological distress, suicide, social isolation and stigmatization, increased lengths of stay, decreased quality of life, squamous cell carcinoma, susceptibility to future pressure ulcers, maggot infestation, multiorgan failure, risk to others (e.g., from infection by methicillin-resistant Staphylococcus aureus [MRSA] or vancomycin-resistant enterococci [VRE]), delay in treating other disorders, infections (e.g., bacteremia, cellulitis, fasciitis, endocarditis, osteomyelitis, septic arthritis, sinus tract infections, abscesses, tetanus, meningitis), and death.
TABLE 37.3 INCIDENCE (I) AND PREVALENCE (P) OF PRESSURE ULCERS | |||||||||||||||
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Bed-bound patients who develop pressure ulcers are almost twice as likely to die. Twenty years ago it was estimated that >60,000 deaths occur yearly from pressure ulcers and their complications. Once a pressure ulcer develops, the patient may have a twofold to sixfold increase in chance of dying.13,14
PREVENTION
Prevention of pressure ulcers is an area of growing concern to all physicians, but especially to geriatricians. Pressure ulcers are largely preventable. Some clinicians feel that pressure ulcers are completely preventable with appropriate care.15, 16, 17 Should a pressure ulcer develop, after early recognition and treatment with a comprehensive regimen, nearly all Stage IV pressure ulcers can be avoided.18
Injury Prevention
When evaluating potentially preventable medical injuries in the hospitalized aged, Rothschild et al.19 reviewed the literature on six preventable injury categories: Pressure ulcers, nosocomial infections, falls, adverse drug reactions, delirium, and surgical complications. The authors found that treatment variables that predispose to the development of pressure ulcer include nurse staffing ratios, repositioning frequency, medication selection, and type of surface support. They recommend quality management programs with multidisciplinary approaches to prevent injuries. Physicians and other health care workers with specialized training in fall prevention can help reduce injuries and ulcers by up to one third. Staff education can decrease pressure ulcers by 50%.19 They further noted that physical restraints are associated with the development of pressure ulcer.
 Figure 37.2 Pressure Ulcer Scale for Healing (PUSH) tool. |
 Figure 37.2 (continued) |
TABLE 37.4 FACTORS AFFECTING A HEALTH CARE FACILITY’S RISKS RELATING TO PRESSURE ULCERS | ||||||||||||||||||||||||||||||||||||||||||||||||
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Long-term Care Prevention
Horn et al.20 reported results of the National Pressure Ulcer Long-Term Care Study, in which >1,500 residents from 95 US long-term care facilities were evaluated. Findings indicated that numerous patient, treatment, and facility factors were associated with higher incidence of pressure ulcer. These factors included higher initial disease severity, history of a recent pressure ulcer, significant weight loss, eating difficulties, and urinary catheter use. Factors associated with diminished likelihood of developing pressure ulcers included nutritional intervention, use of antidepressants, use of disposable briefs, increased nurse and aide time devoted to patient care, and lower Licensed Practical Nurses (LPNs) turnover rates. This study underscores the decreased quality of life and increased morbidity and mortality associated with pressure ulcers. Long-term care facilities can lower pressure ulcer incidence by implementing comprehensive prevention protocols.20
Over the years, hundreds of empiric remedies have been used to treat pressure ulcers, some with untoward results. Parish et al.21 listed several of these including sugar, egg whites, dried blood, castor and cod liver oils, mutton tallow, and vegetable poultices made from carrots, turnips, and charcoal. Unfortunately, even today some publications have recommended outmoded remedies such as drying and massage of pressure ulcers.
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