Pressure ulcers

30

Pressure ulcers

Objectives

Upon completion of this chapter, the reader will be able to:

• Define the stages of pressure ulcers.

• Identify the risk factors that place a patient at risk for pressure ulcer development.

• Recognize and implement appropriate pressure redistribution strategies for the prevention of pressure ulcers.

• Develop and implement a care plan for pressure ulcer management.

CASE 1   Kevin Maloney (Part 1)

Kevin Maloney, an 89-year-old man, comes to the emergency room with altered mental status. He lives alone in his own home and his children check on him daily. The daughter reports that he has become incontinent over the last few days and that she found many wet undergarments throughout the house. When she went to see him today, she found him confused and lying on the floor in his room. She saw no evidence of trauma, and the patient stated he “was tired and lay down on the floor.” She is not sure how long he was there. On evaluation, the patient is oriented to name only. His vital signs are as follows: temperature 99.1° F, blood pressure 125/82, respiration rate 18, pulse 82.

On physical examination, Mr. Maloney is found to have skin breakdown on the left buttock. The wound measures 6 cm × 5 cm × 0.1 cm. The wound bed is in the dermis and is pink without necrotic tissue visible. It appears to have minimal serous drainage, and no odor.

CASE 2   Meryl Curry (Part 1)

You are seeing Meryl Curry, a 75-year-old woman who resides in an assisted living facility, for an initial evaluation. She has diabetes, hypertension, chronic obstructive pulmonary disease (COPD), and a history of a stroke with left-sided hemiparesis. She is on 2 L per minute of home oxygen for the COPD. She is incontinent of bladder and wears protective undergarments. She is continent of bowel and is able to toilet herself. Mrs. Curry recently lost her husband and has been depressed. She does not like to leave her apartment and sits in an easy chair most of the day. Since the loss of her husband, her appetite has diminished. The patient has had two admissions in the past 6 months for COPD exacerbation. She is a thin, frail-appearing woman with a flat affect.

On physical examination, the patient has very pronounced bony prominences. She is found to have skin breakdown on the sacral/buttocks area measuring 8 cm × 9 cm which is covered with 100% necrotic tissue. There is erythema surrounding the site and foul-smelling drainage.

Epidemiology and differential diagnosis

With an aging population and a trend to provide more health care services in the home, primary care providers find themselves increasingly providing care for patients with pressure ulcers. Incidence rates of pressure ulcers vary widely. In previous studies, pressure ulcers were noted to occur most frequently in acute care settings, with incidence rates as high as 38% in older persons. Efforts have reduced these rates considerably—in the past 10 years hospital incidence rates among older persons have dropped to between 2.8% and 9%. Long-term care and home care settings, in comparison, have incidences that range from 3.6% to 59% and 4.5% to 6.3% respectively.1

The primary care provider, when taking care of a patient with a pressure ulcer, must be mindful of the litigious nature surrounding this geriatric syndrome. Often these ulcers are seen by family and patients as a sign of neglect. Careful assessment, documentation, and multidisciplinary care planning are therefore important both to educate patients and to optimize healing and prevent litigation.2

Pressure ulcers are devastating to the patient and the health care system. The Centers for Medicare and Medicaid Services estimate that the cost per stay for hospitalized beneficiaries with a secondary diagnosis of pressure ulcer is $40,381.3 Annual costs as high as $129,000 have been estimated for the treatment of stage IV pressure ulcers.4 In the Netherlands, where the proportion of elderly persons in the population equals that projected for the United States in 25 to 30 years, one report identified pressure ulcers as that country’s most costly condition, surpassing cancer and cardiovascular disease.5

As of October 2008, the Centers for Medicare and Medicaid Services have stopped reimbursing acute care facilities for treatment of pressure ulcers that developed in-house. In 2011 the National Quality Forum considered recommending an expansion of this legislation to include post-acute and long-term care.6 This legislation was based on the belief that pressure ulcers are largely preventable. Although these efforts to improve quality are to be applauded, it continues to be unclear how this decision will impact pressure ulcer prevention and treatment.

Pressure ulcers develop when pressure forces exceed capillary blood flow, causing ischemia, and subsequent tissue necrosis occurs. This most readily happens over bony prominences such as the coccyx, sacrum, heels, hips, and elbows. Depending on the overall health and mobility of the patient, and on the hardness of the surface on which the patient is sitting or lying, tissue ischemia and necrosis can occur in as little time as 2 hours. Pressure ulcers can also occur wherever skin is damaged by excessive friction or shear and moisture. Pressure ulcers are the only wound type that should be staged (i.e., venous leg ulcers and other wound types are not staged).

When an open ulcer is seen on a geriatric patient, the clinician needs to consider not just pressure ulcer but other potential sources of skin breakdown.

When an open ulcer is seen on a geriatric patient, pressure ulcer should be at the top of the differential diagnosis. However, there are other causes of skin breakdown, including moisture-associated skin damage, an open abscess, comorbid illness, and malignancy. Table 30-1 reviews the differential diagnoses of ulcerations that are commonly misdiagnosed as pressure ulcers. Of these, several merit note:

• Moisture associated skin damage (MASD) and abrasions are the most common misdiagnosis. Although MASD and friction put the patient at risk of pressure ulcers, a discrete ulceration needs to form to delineate pressure ulcer from these conditions.7

• A diabetic foot or arterial foot ulcer can be difficult to distinguish from a pressure ulcer; however, it is important therapeutically to determine the primary underlying cause. In the case of a diabetic foot ulcer, this would be neuropathy. For an arterial foot ulcer, the cause would be poor arterial flow, with weak or absent pulses a corroborating sign.

• Skin changes at life’s end—also known as skin failure—is another increasingly recognized syndrome.8 Thus far it has been challenging to diagnose this condition as distinct from pressure ulcers.

The National Pressure Ulcer Advisory Panel states that some pressure ulcers are unavoidable. The panel also recognizes pressure ulcers as being separate from skin failure, but that the two diagnoses can coexist. For patients who have an illness that has caused poor tissue perfusion and thus low tissue tolerance to any pressure, the provider should consider documenting the pressure ulcer as “unavoidable” and that skin failure may be occurring.9

Risk factors and prevention

Prevention efforts in every care setting should be used to limit the development of pressure ulcers.

Aggressive, 24-hour-a-day prevention efforts in every care setting are critical to limit the development of pressure ulcers. The first step is to be aware of the factors that place patients at high risk. Risk factors are numerous and can be separated between intrinsic and extrinsic risk factors (Table 30-2).

Clinical tools to estimate pressure ulcer risk

For pressure ulcers, there are two validated and widely used risk assessment tools: the Braden scale and the Norton scale.10 Neither has undergone randomized trials to look at their impact on pressure ulcer incidence.11 Risk assessment should be done on a regular basis and whenever the patient’s condition changes, and the score provided by the tool should be considered supplemental to clinical judgment.

The Braden scale has six domains: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The first five domains are rated on a scale from 1 to 4, with 1 being worst and 4 being best; friction/shear is rated from 1 (problematic) to 3 (not a problem). The maximum score is 23. Typically, patients are considered at risk of pressure ulcer development if their Braden score is 18 or lower. Therefore, scores at or below 18 should trigger nursing and other support staff to put in place more aggressive preventive measures, such as frequent turning, a specialized mattress, and perhaps a nutrition consult.

The other tool that is often used to assess pressure sore risk is the Norton scale. This uses a 1-to-4 scoring system in rating five domains: physical condition, mental condition, activity, mobility, and incontinence. A score of less than 14 usually indicates a high risk of pressure ulcer development. The Norton scale tends to identify more patients at high risk than the Braden scale.12

For both of these tools, individual item scores are important in planning care. For instance, a patient may score high in nutrition and have no sensory impairments but also be very immobile with poor activity and friction/shear forces at work. By looking at the items that engender risk, the provider can target interventions to the most important risk factors for that individual patient. However, when a patient “rules in,” every risk factor identified by the Braden or Norton scale should have an action plan prepared and implemented.

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Jun 8, 2016 | Posted by in GERIATRICS | Comments Off on Pressure ulcers

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