Pressure ulcers Know How to Stop the Pain

To the untrained eye, a pressure ulcer may appear to be an open scab; although a pressure ulcer is more serious. According to Black and Hawks (2005), a pressure ulcer is, “any lesion on the skin caused by unrelieved pressure and resulting in damage to the underlying tissue” (p. 1403).

People who most commonly get pressure ulcers are those that are immobile or paralyzed. The reason for this is because sitting or laying down for extended periods of time increases pressure points by collapsing blood vessels and restricting the flow of blood to these areas. This may eventually lead to the death of the cells in these areas. By studying the causes of pressure ulcers and knowing the proper treatment procedures, nurses should be able to reduce the number of pressure ulcer cases in high risk groups.
Educating patients and nurses is one of the most important strategies to prevent and reduce pressure ulcer occurrences. Continuing education programs should be periodically conducted for nurses to reinforce and update their training. This will help to make sure the patient teaching that the nurses are doing is accurate and reliable. Pressure ulcers can affect anyone who is either paralyzed or immobile for an extended period of time, although these types of ulcers are most commonly seen in elderly people. Pressure ulcers develop when soft tissues are compressed between a bony prominence and a firm surface for a long period of time. Elderly people have the highest occurrences due to their limited mobility in conjunction with their thinner fragile skin. Given that this group has the greatest risk for pressure ulcers evaluating what causes them to appear and how to prevent them is the next step.
There is a scale that can be used in order to determine risk for pressure ulcers called a Braden or Norton tool. This tool gives a numerical score to six different areas in order to better determine risk factors for skin breakdown. According to Frantz (2004), “a patient in any setting with a score of eighteen or below should be considered at risk” (p. 5).Using this tool while doing daily skin checks could dramatically influence the number and severity of cases seen. Risk assessments should be completed on admission and 48 hours later. One cause, which could affect how fast a pressure ulcer is detected, is the lack of pain perception related to a loss of sensation. The Mayo Clinic staff state that , “in some cases, the pressure that cuts off circulation comes from unlikely sources: the rivets and thick seams in jeans, wrinkled clothing or sheets, a chair whose tilt is slightly off- even perspiration, which can soften skin making it more vulnerable to injury”(2007, para. 3). This is usually due to spinal cord injuries or disease. Smoking, malnutrition, incontinence, and medical conditions such as diabetes or cardiovascular disease can also affect the chances of getting pressure ulcers.
Once the patient is admitted with pressure ulcers the focus needs to shift to treatment and to prevent them from getting worse. One way to reduce the ulcers is to change the patient’s support surfaces, such as switching to an air mattress or water mattress, in order to limit the number of pressure points and increase movement. Another very important part of the treatment plan is turning the patients. The outdated recommendation for moving a patient to help with relieving pressure used to be every two hours. The new recommendation is dependent on the patient and their illness. When caring for a client who already has a pressure ulcer it is essential to know the different stages involved in order to give the proper treatment depending on the stage.
Stage 1- Skin has redness that does not turn white with pressure. It may hurt, itch or fell warm and spongy. If pressure is relieved quickly stage 1 will go away shortly after.
Stage 2- The top layer of the skin and the skin just below it are damaged. The ulcer can look like a shallow blister or abrasion. The surrounding tissue may have a red or purple discoloration.
Stage 3- This stage can have damage down to the muscle by causing damage or necrosis of the subcutaneous tissue.
Stage 4- A deep crater with extensive destruction or damage to muscle, bone or supporting structures. It is very difficult to heal and can lead to deadly infections.
It is crucial to identify pressure ulcers as early as possible to increase the chance of saving the skin from any further damage.
The skin can be protected using several methods; movement is the most effective for patients that are in bed. Movement at least every two hours is very important because it relieves pressure on the blood vessels and allows unrestricted blood to flow to those areas. Frantz (2004) states, “when patients are sitting in chairs and are unable to reposition themselves, their weight should be shifted every fifteen minutes to relieve pressure on the ischial tuberosities” (p. 7). Another method is to inspect the skin at least once a day, looking for warm reddened areas mostly around bony prominences, for example: the hips, heels, shoulders and back of the head. As detailed by the figure below from, Aging in the Know (2007).
Using pillows can help to avoid reddened areas or areas of increased pressure. Using a systematic schedule for turning and repositioning will help to ensure repositioning is being done consistently and in the right time frame. When repositioning a patient, lifting devices such as a trapeze or lifting sheet are helpful to make turning and repositioning easier. An important thing to remember is to be careful not to cause shearing or breaking of dry cracked skin. Dry cracked skin can be avoided by washing with warm water and a mild cleaning agent and treated with moisturizers to minimize irritation and dryness. It is also imperative to protect the skin from excess dampness, caused by sweat, wound drainage, and urinary or fecal incontinence.
Knowing the causes of pressure ulcers and who is at the greatest risk will make it easier for nurses to reduce the number of cases in high risk groups. As stated by, Courtney, Ruppman, and Cooper (2006), ”nearly 60,000 U.S. hospital patients are estimated to die each year from complications due to hospital acquired pressure ulcers” (p. 36). That is a very high number for a condition that is so preventable with daily skin checks and regular repositioning.
a. Intervention 1 Education and Prevention
i. Disadvantage 1 Anxiety and Interpretation of the material.
The material may be misinterpreted because English may not be the patient’s primary language which may cause the important issues and points to not be communicated properly. The patient may also not understand everything the nurse is saying due to an increased anxiety level from being in the hospital. According to (Quinn, 2007, p. 451). Some disadvantages are that the patient may feel under the spotlight. They may also miss the support of other patients. Along with the fact the patient may feel embarrassed they are not learning the information quickly and the teaching is going to fast.
ii. Disadvantage 2 Nurses misconception of the patient and patient’s reluctance.
The nurse may be taking for granted that the patient understands everything the nurse is saying due to the patient’s not wanting to ask questions. The nurse also knows the information much more than the patient and it comes easy to them so the nurse may skip over something they feel is not as crucial to cover. The nurse may go too fast thinking the patient can keep up also which may make the patient more apprehensive to asking questions. Because of this the patient may feel rushed and unimportant.
b. Intervention 2 Treatments
i. Disadvantage 1 Support surfaces
Disadvantages to having an air mattress can be that it may be punctured. Without proper inflation the bed is easier to puncture which is not beneficial to the patient. A water mattress may also be used but some disadvantages to this are that it must have a heater for the water to keep the patient’s body temperature at a comfortable level. Maintenance of a water mattress is difficult because the water has to be conditioned to prevent bacteria from growing. Procedures may also be more complicated when trying to perform them on a water mattress, such as a thoracentesis. Getting out of bed or changing a patient’s dressings may be more difficult for the patient as well. There are other support surfaces available to patients all having their own disadvantages. According to (Popescu and Salcido, 2006, section 8). The other available options are gel, foam, low air loss, dynamic overlays and air fluidized. Nurses should include this as part of the risk assessment that is performed when patients arrive at their facility to ensure patients are getting the proper support surfaces.
ii. Disadvantage 2 Dressings and Nutrition
Dressings are a very important part of the treatment process. Although dressings are not effective unless the wound is kept moist while the skin around it is dry. If the wound is not cleaned and the dressing not changed daily the wound will not heal. The disadvantage to this is the fact the patient may not be able to change the dressing on the wound by without assistance. Nutrition also plays a vital role in wound healing because if proper nutrition is not maintained the wound will heal slower. When discussing nutrition the nurse must make sure the patient does not have any GI dysfunction or can not swallow without aspirating. As stated in Black and Hawks (2005). Nutritionally compromised clients need to have a plan for nutritional support or supplementation implemented. Implementing a plan could be difficult for older patients that have definite food preferences and expectations. If adequate nutrition is not met alternative methods are put into action such as enteral or parenteral feedings.






References

American Geriatric Society, (2005). Pressure sores (bed sores). In Aging in the Know (ch 30). Retrieved January 31, 2007, from
http://www.healthinaging.org/aging intheknow/chapters_ch_trial.asp?ch=30
Black, J.M., & Hawks, J.H. (2005). Pressure Sores. Medical Surgical Nursing Clinical Management for Positive Outcomes, 7, 1403-1411.
Courtney, B.A., Ruppman, J.B., & Cooper, H.M. (2006). Initiative cuts pressure ulcer incidence in half. Nursing Management, 37, 36-45.
Frantz, R.A., (2004). Prevention of Pressure Ulcers. Journal of Gerontological Nursing For Nursing Care of Older Adults. 30, 4-9
Mayo Clinic Staff, (2007). Bed sores. Retrieved January 31, 2007, from http://mayoclinic.com/health/bedsores/DS00570
The Medical Journal of Australia, (2004). Preventing Pressure Ulcers. Retrieved October 28, 2007, from http://www.mja.com.au/public/issues/180_07_050404/sta10029_fm.html
NSW Department of Health, (2003). Prevention of Pressure Ulcers Rehabilitation and Residential Settings. Retrieved October 20, 2007, from http://www.health.nsw.gov.au/quality/pdf/pressure_ulcers_rehab.pdf
Propescu, A., Salcido, R. (2006) Pressure Ulcers and Wound Care Retrieved October 15, 2007, from http://www.emedicine.com/pmr/topic179.htm
Quinn, F. (ND). The Principles and Practice of Nurse Education. Retrieved October 15, 2007, from http://books.google.com/books?id=r0bqU8lgSXgC&pg=RA1-PA451&lpg=RA1-PA451&dq=patient+teaching+disadvantages&source=web&ots=5jGbU94u21&sig=OjBf02Rpm6fI1h54EPkxkd-5oDE#PRA1-PA451,M1