Pressure Ulcers in the Elderly

Care and Prevention
Nurses working with geriatric patients are aware that they provide care not only for the acute or chronic disease symptoms that bring patients to their facilities, but for other conditions that may detract from quality of life. Elderly patients are vulnerable to pressure ulcers primarily due to decreased mobility and poor nutrition; nurses must be responsible for assessing their elderly patients’ ability to ambulate safely and their risk for decreased nutrition in order to safeguard against this debilitating condition.

A holistic approach to this potential complication may be the best way to medically manage this risk.
For the elderly patient a required initial assessment of the skin is done upon admission. One of the tools used to evaluate the patient's level of risk for skin breakdown is the Braden Scale. It assigns numerical values to levels of sensory perception, moisture, activity, mobility, nutrition and friction/sheer. The lower the assessed number, the higher the risk for impaired skin integrity (Black, Hawks & Keene, 2001, p. 1299). The results of the assessment can identify the interventions that will reduce risk and protect the patient's skin. Some examples include keeping the skin warm and dry, reminding and assisting the patient with frequent position changes, and encouraging safe ambulation and mobility techniques. Physical and occupational therapy may be ordered to evaluate the patient's limits of safety and ability to perform activities of daily living. A dietary evaluation should be made and nutritional supplements may be suggested such as multivitamins with minerals and nutritional supplements. Encouraging a balanced diet with sufficient calories and hydration is also a nursing function (Myles, 2006).
As people get older their ability to move or change positions regularly may decrease due to diminishing muscle strength, joint diseases, loss of sensory perception from chronic disease processes or cerebral vascular accident (CVA), confusion or dementia or various other complications of aging. This reduced mobility can subject skin, stretched over bony prominences such as heels, elbows, the coccyx, the scapula, etc., to experience reduced blood flow (CareNotes, 2006). The decreased circulation to these areas begins a breakdown in the integrity of the skin and unless pressure is relieved, skin ischemia can develop, sometimes in less than two hours. Common interventions to protect the elderly patients skin include using pressure relieving mattresses or air filled overlays, pressure reducing pads in wheelchair seats and special wheelchairs that tilt at different angles to relieve constant pressure from sitting in one position. Specially trained staff work with the therapy departments and provide restorative exercises that are designed to maintain and even improve a patient's mobility, which in turn reduces their risk for skin breakdown. Bed bound patients are placed on turning schedules designed to relieve pressure (Baldwin, 2005).
Skin changes as people age. It becomes thinner and more fragile. Its ability to heal or protect the body from outside forces is reduced. Its vascularity is reduced and the decreased delivery of oxygen and nutrients compromises skin integrity and it's ability to heal. According to Zulkowski (2003), the adhesion between the layers of skin such as the dermis and epidermis declines adding increased risk for friction and sheer injuries. These injuries are not a result of unrelieved pressure but are a breakdown of the skin's integrity when turning or repositioning a patient without properly reducing the pressure on the outer layer of the derma, tearing it from the underlying layers of tissue. These injuries can appear like burns or abrasions. Baldwin (2005) states these injuries can be avoided by using "proper patient lifting and moving techniques.
Nutrition is also an area of concern for the elderly. As people age their ability to taste and smell diminishes and food is not as appealing. They may have an impaired ability to chew their food due to worn or missing teeth or ill-fitting dentures. Some may be cognitively impaired or suffer from dementia and lose the ability to feed themselves. Many may be malnourished, especially in protein, a key nutrient necessary for the healing process and the production of collagen. Collagen is major ingredient of healthy skin and as Zulkowski (2003) states, "is the principal structural body protein." As the body ages, the collagen produced loses it's flexibility and becomes thicker and aging skin has decreased elasticity making it more susceptible to tear type injuries. A dietary consultation is a common intervention that will provide an accurate assessment of the patient's nutritional status (Baldwin, 2005). Protein may be increased with their meals and supplements such as Vitamin C and Zinc can be added to the patient's daily medications. If their appetite is poor, nutritional supplements can be offered (Black, et al, 2001, p. 1297).
If a patient is admitted with a pressure ulcer or one develops during care, the wound should be assessed and staged. The assessment includes documenting the cause, size, location, and dimensions of the wound. It should include a description of exudates or drainage, any local signs of infection, the appearance of the wound and the condition of the surrounding skin, and if there is any undermining or odor. Pain is also documented as to its cause, level, location and management (Benbow, 2006).
Pressure ulcers are staged as follows:
Stage I Non-blanching erythema of intact skin; the initial lesion of skin ulceration.
Stage II Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is
Superficial and presents clinically as an abrasion, blister or shallow crater.
Stage III Full-thickness skin loss involving damage or necrosis of subcutaneous
tissue, which may extend down to, but not through, the underlying fascia.
the ulcer presents clinically as a deep crater with or without undermining
of adjacent tissue.
Stage IV Full-thickness skin loss with extensive destruction, tissue necrosis, or
damage to muscle, bone, or supporting structures.
(Black, et al, 2001, p. 1297).
Wound coverings can range from ointments that promote circulation and provide a moisture barrier to long term wound management. This includes debridement to remove necrotic tissue and encourages increased circulation, which delivers oxygen and nutrients to the site. Irrigation with normal saline may be used to clean the wound and once all the dead tissue is removed, dressings may be applied that keep the wound bed moist and the surrounding tissue dry and healthy. Keeping the patient rested and stress free is also thought to improve the healing process (Myles, 2006).
In short, the prevention of pressure ulcers and the treatment of existing sores requires a holistic approach. It takes a healthcare team to protect our elderly from this health risk, which is a real threat to the quality of their life.




Intervention 1: Encouraging a balanced diet with nutritional supplements, sufficient calories and hydration.
i. Disadvantage 1: Socioeconomic; According to Young (2003) “risks for frailty, besides being old, include ethnicity, poverty, and lower educational attainment, each of which independently predicts poorer health and inferior treatment by the health care system.”
ii. Disadvantage 2: Lack of Insurance; Fixed incomes and costs of medications may force the elderly patient with multiple chronic conditions requiring numerous medications to choose between buying food and buying their medications. An estimated 31% of men and 61% of women over age 65 live on fixed annual incomes under $10,000.00 (Zulkowski, 2003

Intervention 2: Keeping skin warm and dry, frequent position changes, physical and occupational therapy to assist with safe ambulation and mobility techniques.
i. Disadvantage 1: Socioeconomic Income is tied to functional limitations in older adults.
In a study published by the New England Journal of Medicine, community dwelling senior citizens participated in a survey conducted by the National Institute on Aging in collaboration with the University of California, Berkley, and the University of Toronto. According to the survey “nearly one in four respondents reported having a functional limitation, defined as a long-lasting condition that substantially limits one or more basic physical activities, such as walking, climbing stairs, reaching, lifting, or carrying” (Anonymous, 2006)
The researchers report that people living below the poverty line have the most functional limitations but that as the income levels increase, so do the reported limitations and with each increase in educational level as well, a measure that is closely tied to income.
ii. Disadvantage 2: Knowledge Deficit; The Institute of Medicine defined failure to thrive late in life as a syndrome manifested by several identifiable factors including inactivity. According to Robertson & Montagnini, “four syndromes are prevalent and predictive of failure to thrive and they are impaired physical function, malnutrition, depression and cognitive impairment. Elderly patients who are depressed are more likely to complain of physical problems than to mention depressive symptoms such as mood changes. This is a knowledge deficit.














References

Anonymous (2006) Income Tied to Functional Limitations in Older Adults. PT 14(11) 94 Retrieved October 26, 2007 from ProQuest database.
Baldwin, K (2005). How to prevent and treat pressure ulcers. LPN 2005 1(2) 18-25
Benbow, M. (2006). Guidelines for the prevention and treatment of pressure ulcers. Nursing Standard 20(52) 42-44. Retrieved January 20, 2007 from Expanded Academic ASAP database.
Black, J., Hawks, J., & Keene, A., (2001). Medical Surgical Nursing. Management for Positive Outcomes. 6th Ed., Philadelphia: W.B. Saunders Company.
How to prevent pressure sores. (2006, May). CareNotes. Retrieved January 20, 2007 from Expanded Academic ASAP database.
Robertson, R., & Montagnini, M., (2004). Geriatric Failure to Thrive. American Family Physician 70(2) 343. Retrieved October 25, 2007 from ProQuest database.
Myles, J. (2006). Woundcare assessment and principles of healing. Practice Nurse 32(8) Retrieved February 3, 2007 from Proquest database.
Young, K. (2003). Challenges and Solutions for Care of Frail Older Adults. The Online Journal of Issues in Nursing. Retrieved October 25, 2007 from Proquest database.
Zulkowski, K. (2003). Protecting your patient's aging skin. Nursing 33(1) 84. Retrieved February 3, 2007 from Proquest database.
Zulkowski, K. (2003). How nutrition and aging affect would healing. Nursing2003 33(8) Retrieved October 26, 2007 from EBSCO host database.