The practice issues of pressure ulcers

University Degree Subjects allied to Medicine

NU1500 Research, Information Technology & Study Skills

The practice issues of Pressure Ulcers

The aim of this assignment is to define the meaning of pressure ulcers, and to explore the causes, and aims of preventing them.

Pressure sore -“A decubitus ulcer; a bedsore. Ulceration of the skin due to pressure, which causes interference with the blood supply to the area” ( Weller 2005)

Bed sore (decubitus ulcer, pressure sore) -“ An ulcerated area of the skin caused by the continuous pressure on part of the body in a bedridden patient” (Fergusson and Stibbs 2003)

Nurses and physicians use many terms for a pressure ulcer. Allerescu and Allerescu (1992) reported that these terms include decubitus, decubiti, pressure ulcer, pressure sore, bedsore and pressure necrosis. They believe the term pressure ulcer bests describe the aetiology. (Davies 1994). A pressure ulcer can also be described as “damage to the skin and underlying tissue” (Wrightington, Wigan and Leigh NHS Trust 2002). Morison (1989) explains that a pressure ulcer is caused by a prolonged unrelieved pressure, however Hibbs (1988) and Morison (1989) describe that shearing and friction are also known to cause the type of tissue damage associated with pressure sores. (Davies 1994). Wrightington, Wigan and Leigh NHS Trust (2002) advise a patient sliding down a chair or in bed causing slight friction can cause and worsen minor pressure ulcers. They explain that pressure on the skin, when unrelieved, squeezes blood vessels which supply the skin with oxygen and nutrients. If this continues, tissue is damaged, and therefore forms a pressure ulcer.

As these definitions explain, a pressure ulcer is a common but potentially preventable condition, presenting most often in high risk patients such as the elderly and those with physical impairments (Reddy, Sudeep, and Rochon 2006). Pressure ulcers develop in a lot of patients, unless preventative measures are vigorously pursued. These ulcers develop wherever bony prominences are covered by skin, in particular the sacrum, heels, knees, elbows and ankles. (Roland and Merritt 2005). They usually present where bone causes a great force upon the skin, such as pressure against other body parts, chair or mattress. (Wrightington, Wigan and Leigh NHS Trust 2002). The Department of Health (1994) provides guidelines as to who are most at risk of developing these ulcers. Some of these include the elderly and weak, incontinent, and a patient’s body which is not sensitive, such as patients who suffer from diabetes or have had a stroke. Others are patients who are nursed in bed, malnourishment, poor circulation and people who are mentally unaware, for example because of heavy sedation or Alzheimer’s disease. It is common to think that pressure is the pure source of pressure sores, but Gebhardt (1995) argues that “tissue deformation is the direct, mechanical, extrinsic cause of pressure sores.” He goes onto say that there must be more definite factors which make one patient more susceptible to pressure ulcers than another.

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A study was performed using 2,771 patients that had mobility impairment and required a high level of nursing care. The aim was to discover if three risk factors (low serum albumin level, fecal incontinence and confusion) were significant in the development of pressure ulcers. The results concluded that the presence of low albumin levels and confusion were statistically significant risk factors, while fecal incontinence was not. This is argued among nurses as the tool used for determining the risk level of a patient developing a pressure ulcer contains questions about the patients’ continence status. Other known risk factors that were defined were patients being malnourished and patients requiring a urinary catheter. A new pressure ulcer risk factor was identified during this study, which had not been previously been described in literature. This was having a Do Not Resuscitate (DNR) order placed on the patient. (Allman, Goode, Patrick, Burst, and Bartolucci 1995.) This risk factor has not previously been identified, but having a DNR order suggests that the patient in question is extremely poorly and would not be resuscitated if they arrested. Therefore the patient would likely to be nursed in bed, concluding that the risk factor is being in contact with a mattress twenty four hours a day, not having the order in place.

With all of these risk factors to consider, a nurse needs to carefully assess the patient needs and identify the main risk factors of developing a pressure ulcer for that particular patient, providing holistic care. As with all humans, everyone is different and may require different care to prevent this “potentially preventable condition” (Reddy, Sudeep and Rochon 2006). To look from this perspective is to realize that every patient is an individual, with very different requirements, whether this be analgesia, treatment or help with mobility. All of these are very important factors in the management of pressure ulcers. “Many providers of nursing care fail to recognize these needs, relying instead on entrenched nursing routines that prevent individualized care.” (Verner 2006/2007)

Preventing pressure ulcers is very complex, dependant on the requirements of the individual. Mobility of a patient plays a great part in preventing these sores, as we have already identified that they are caused by a “prolonged unrelieved pressure.” (Morison 1989) If a patient is mobile or has a degree of mobility using walking aids, pressure ulcers are much less likely to present themselves. Where a client is bedridden, the nursing and multidisciplinary team must relieve the pressure for the patient. This is very important as the patient is unable to do this for themselves. Nurses can use techniques such as changing body position at least two hourly, using types of elbow, hip and heel protectors, using sheets that are clean, without creases and avoiding synthetic materials which are more likely to make the skin sticky and hot. (Department of Health 1994) A patient presenting a pressure ulcer requires careful nursing care to prevent gangrene and it is essential that the area is kept dry and clean. The position of the patient should be frequently changed to prevent the high risk areas, such as the buttocks, heels and elbows from being affected. (Fergusson and Stibbs 2003)

Using the right equipment is especially important when caring for patients susceptible to pressure ulcers, and a doctor, nurse or occupational therapist can advise on the wide range of support equipment available. The equipment includes mattress covers, special beds, and pressure relieving mattresses and cushions. This equipment is available to every patient, so finding the right people for advice before an ulcer forms is vital. This is essential for patients who are being nursed at home, and being looked after by family and Home Care packages. Some people caring for a patient do not have the knowledge about pressure sores until it is too late. When an ulcer has formed and has been identified the family would then seek help from a district nurse. The patient would then have to suffer the pain of the ulcer and start treatment to help it to heal. If the carer were made aware of the problems beforehand they would have been able to use preventative measures to ensure a patient did not develop the ulcer. A support network of the multidisciplinary team must be in place to help situations of patients being nursed in their own homes.

Confusion is a major risk factor as the patient cannot understand the need for pressure relief and will sometimes refuse to comply with the nursing team. It is crucial that the patient understands that preventing development of a pressure ulcer is very serious, as they can take months to heal and if become infected can kill. (Department of Health 1994)

The condition of a client’s skin upon admission plays a major role in the developmental stages of a pressure ulcer. Patients with skin conditions or “tissue” skin will be more susceptible to these ulcers, as will underweight or malnourished patients. Normally a risk assessment will be performed within two hours of being admitted into hospital to identify the risk of developing a pressure ulcer. This is done using the “Waterlow Pressure Ulcer Prevention/Treatment policy” ( 1985 Revised 2005). This tool is utilized to determine a risk factor of a patient with the groups being divided into; at risk, high risk and very high risk. The waterlow assessment tool takes into account many categories that can affect a patient risk of developing a pressure ulcer. These include patients Body Mass Index, continence status, mobility, skin type, sex and age, malnutrition, tissue malnutrition, neurological deficit and major surgery or trauma. This tool is commonly used as it looks at all of the relevant information about the patient before making a conclusion to a particular patient’s risk of developing a pressure ulcer.

When a patient has been identified to have a pressure ulcer, there needs to be a method in place for assessing ulcer formation. The European Pressure Ulcer Advisory Panel (1998) offer a Pressure ulcer classification, that is widely used in the hospital setting. This particular method is supported by the National Institute for Health and Clinical Excellence and the Royal College of Nursing. This sorts ulcers from Grade 1: non-blanchable erythema of intact skin, to Grade 4: extensive destruction, tissue necrosis. (Robin Richardson 2008) This tool is very effective, but if not used accurately it can be misrepresentative of the ulcer it classifies. The vital part of classifying an ulcer is for the nurse or doctor to be constant in all assessments. One nurse may grade a sore as a 1, while another might grade it as a 2. All assessments should be unvarying and if possible, subject to a second opinion.

To conclude, the pressure ulcer is a condition that can be prevented if we practice as literature has taught. There are many tools and practices nurses can utilize to reduce the number of patients who present an ulcer. This will have to start with all nurses and carers understanding these preventative measures and exactly why they are so important. Our patients come into hospital to be treated and for us to help them recover, they do not wish to leave hospital with a life threatening condition that could have been prevented. Knowledge is the key to giving patients the best care we can provide.

Reference List

Allman, R.M., Goode, P.S., Patrick, M.M., Burst, N and Bartolucci, A.A. (1995) Pressure ulcer risk factors among hospitalized patients with activity limitation. The Journal of the American Medical Association. Vol 273, pages 865-870.

Davies, K. (1994) Pressure sores: aetiology, risk factors and assessment scales. British Journal of Nursing. Vol 3, No.6, pages 256-259.

Department of Health (1994) Your guide to pressure sores. UK: Health Literature

Fergusson, R and Stibbs, A. (2003) Oxford Minidictionary for Nurses. 5th Edition, page 66. Oxford: Oxford University Press.

Gebhardt, K. (1995) Clinical: What causes pressure sores? Nursing Standard. Vol 9, page 31.

Reddy, M., Sudeep,G., and Rochon, P. (2006) Preventing Pressure Sores: A systematic review. Vol 296, pages 974-984.

Richardson, R. (2008) Clinical Skills for Student Nurses. Pages195-213. UK: Reflect Press Ltd.

Roland, L.P. and Merritt, H.H. (2005) Merritts Neurology. 11th Edition. Philadelphia, USA: Lippincott, Williams and Wilkins.

Verner, Y. (Dec 2006/Jan 2007) Building profiles to create individual care. Kai Tiaki Nursing. Vol 12, page 11.

Waterlow, J. (2005) ‘Waterlow pressure ulcer prevention/treatment policy’. Waterlow Score Card, available at Judy-Waterlow.co.uk. Last accessed 14/07/2008. [online at: ]

Weller, B.F. (2005) Bailliere’s Nurses’ Dictionary. 24th Edition, page 315. London: Elsevier.

Wrightington, Wigan and Leigh NHS Trust (2002) Tissue Viability, Pressure Ulcer Prevention. Wigan and Leigh: Clinical Support Services.

Secondary references

Alterescu and Alterescu (1992)

Hibbs (1988) and Morison (1989)

Morison (1989)