With the paradigm shift toward health promotion and disease prevention, much emphasis is focused on chronic diseases. Undoubtedly, most people do not think about pressure ulcers as a chronic condition. In fact, the number of individuals developing or being hospitalized with pressure ulcers is growing.
Age alone is not the only contributing factor to pressure ulcer development. It is also about the inconveniences of old age such as impaired mobility, poor nutrition, changes in mental status or chronic diseases. High blood pressure, heart disease and diabetes affect blood flow to organs including the skin, increasing the risk of pressure ulcers. Quality of life and increased costs to patients, families and healthcare organizations can be correlated to pressure ulcer management.
Pressure ulcers are the fourth leading preventable medical error in the United States.1 Each year, 60,000 individuals die from pressure ulcers as a secondary diagnosis. The hospital stay for pressure ulcer treatment is three times longer compared to other chronic diseases. In 2010, pressure ulcer care averaged between $10.5–17.8 billion.
The Joint Commission listed pressure ulcers as a National Patient Safety Goal for long-term care in 2006.1 The Centers for Medicare & Medicaid Services (CMS) list stage III and stage IV pressure ulcers as “never events.” The Institute of Healthcare Improvement included the prevention of pressure ulcers in its “5 Million Lives Campaign.” The widely recognized complications from this preventable event have stirred awareness toward prevention.
A MULTIDISCIPLINARY APPROACH
The skin is the first line of defense against infections. Healthy skin requires the correct pH and moisture balance to protect it from bacterial invasion. Moisturized skin prevents dryness which causes cracks in the skin. Skin that is too wet increases the risk of shear and friction. These basics are often forgotten in lieu of the many tasks that nurses perform; however, the responsibility of pressure ulcer prevention extends beyond the nursing staff.
In long-term care, best practices involve a multidisciplinary approach in pressure ulcer prevention.2 A pressure ulcer prevention (PUP) program provides a proactive approach to skin care. The main goal of a PUP program is to create a systematic method of assessing risk factors, developing strategies to eliminate risk factors, providing ongoing education and evaluating strategies. This approach provides standardized guidelines for all staff to follow. Second, a team process communicates an “all eyes” on the skin approach. To remove the hurdle of staff’s commitment to early identification of risk factors, they need to comprehend the lethality of pressure ulcers.
The key to any successful PUP Program is the early identification of risk factors, so appropriate strategies can be implemented. A pressure ulcer risk scale should always be used as part of a comprehensive clinical assessment. The Braden Scale for Predicting Pressure Sore Risk is the most widely used evidence-based risk tool. Six subscales (sensory perception, skin moisture, activity, mobility, nutrition and friction/shear) are used to score patients’ risk of developing pressure ulcers. The range of scoring rated 6 to 23 provides variation for risk based on the total sum of the subscales. For example, a score of 13-14 indicates the patient is at moderate risk for developing a pressure ulcer.
Each risk level is matched with researched strategies which provide specific guidelines for that patient. In long-term care, it is recommended that risk assessments be completed on admission, weekly for one month and then quarterly, or if a resident’s condition changes significantly. It is important for staff to understand risk factors and appropriate interventions to promote healing. Although nurses can communicate interventions, they do not always follow clinical practice guidelines due to staffing or focusing on other priorities. Comprehensive education for everyone involved in care of the patient is needed to improve knowledge and competency.
PUP programs must target the four leading contributors to pressure ulcers: pressure, moisture, friction/shear and nutrition. Pressure can be easily managed by frequent moving, the use of assistive devices for positioning, application of heel floaters, repositioning chair-bound patients and using pressure reduction surface devices for at-risk patients and pressure-relieving surfaces for those identified as very high risks or patients with existing pressure ulcers.
With frequent repositioning and moving, checking for moisture should occur. A good barrier cream is needed for patients who are incontinent. The skin should be washed as soon as soiling occurs with warm water, mild soap and gentle cleansing. Absorbent pads that wick moisture are best. Many organizations are going diaper-free for bed-bound patients. When two-hour rounds are implemented, staff has the opportunity to provide good incontinence care. A bedpan and urinal should also be offered as well. Moving patients tend to result in skin tears from lack of attention, or hurried or inexperienced staff.