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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
The Purpose of This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
The Origins of This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v
Components of This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Who Should Use This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii
How to Use This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii
Terms Used in This Toolkit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .viii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Chapter 1: Pressure Ulcer Care Challenges and Prevention Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Chapter 1 Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
What Are Pressure Ulcers? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Causes of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Variations of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6
Challenges: Perioperative, Intraoperative, and Postoperative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10
Recommendations: Prevention Methods for Perioperative, Intraoperative, and Postoperative . . . . . . . . . . . . . .14
Challenges: Pressure Ulcers in the Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Recommendations: Prevention Methods for the Intensive Care Unit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Challenges: Pressure Ulcers on Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
Recommendations: Prevention Methods for Infants and Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27
Challenges: Pressure Ulcers in the Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29
Recommendations: Prevention Methods for the Emergency Department . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Challenges: The Electronic Patient Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Recommendations: Automated Orders and Prevention Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30
Chapter 1 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .32
Chapter 2: Why Pressure Ulcer Prevention and Care Are Essential . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35
Chapter 2 Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
The Impact of Pressure Ulcers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
Magnitude of the Problem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37
The Joint Commission and Joint Commission International Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Pressure Ulcers and Health Care–Acquired Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40
Worldwide Implications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44
Where We Are Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48
Chapter 2 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51
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Pressure Ulcer Prevention Toolkit
Chapter 3: Improving Care and Prevention Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53
Chapter 3 Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54
Creating an Individualized Plan of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
What to Look For: Total Skin Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55
Risk-Assessment Scales . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .63
Step-by-Step Approach to Continuous Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74
Infection Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .78
Chapter 3 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .81
Chapter 4: Sustaining Improvements in Pressure Ulcer Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .83
Chapter 4 Learning Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84
Developing Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
The Risk-Assessment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .85
The Skin-Assessment Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87
The Nutrition Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
The Positioning Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .90
Ensuring That Policies and Procedures Are Followed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91
Measuring Progress and Improvements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .94
Family Involvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .96
Effects of Educational and Quality Improvement Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .97
Failure Mode and Effects Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99
Sustaining Improvements with FMEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .100
Chapter 4 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109
Chapter 5: Profiles of Success . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111
Bangkok Hospital Medical Center, Thailand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
Beth Israel Medical Center, New York City . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124
Bon Secours St. Mary’s Hospital, Richmond, Virginia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .127
Hahnemann University Medical Center, Philadelphia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
Rex Healthcare, Raleigh, North Carolina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145
St. Vincent’s Health System, Birmingham, Alabama . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .152
University of Pittsburgh Medical Center, Pittsburgh . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .154
Appendix: Chapter Assessment Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .159
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .165
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .173
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1
CHAPTER
Pressure Ulcer Care
Challenges and
Prevention Methods
Pressure Ulcer Prevention Toolkit
Chapter 1 Learning Objectives
After reading this chapter, you should understand the following:
✓ What pressure ulcers are and which patients and residents are at risk for pressure ulcers
✓ The causes and effects of pressure ulcers on patients and residents
✓ The dangers of pressure ulcers, including the extrinsic and intrinsic factors that contribute to
the condition
✓ The National Pressure Ulcer Advisory Panel’s six categories/stages of pressure ulcers
✓ The risk of pressure ulcer development for surgical patients
✓ The most common body sites for pressure ulcer development on intensive care unit patients
✓ The prevalence of pressure ulcers in the pediatric population
✓ The need for pressure ulcer prevention in the emergency department
✓ The impact of the electronic medical record on reducing the risk of pressure ulcer
development
Staff
Education
Organization
Commitment
Pressure
Ulcer
Prevention
Sustain
Improvements
2
Measure
and
Document
CHAPTER 1: Pressure Ulcer Care Challenges and Prevention Methods
What Are Pressure Ulcers?
Causes of Pressure Ulcers
Pressure ulcers are a source of pain and discomfort to patients and
residents. A pressure ulcer is a skin lesion caused by unrelieved pressure resulting in damage of the underlying tissue. They affect
mobility, nutritional intake, elimination, and the psychological
well-being of patients and residents. Pressure ulcers represent a
major health threat to older patients and residents and to patients
and residents with restricted mobility or a chronic disease. Pressure
ulcers continue to present serious problems in health care organizations throughout the world.
Many different elements can contribute to the development of
pressure ulcers, but they are usually caused by prolonged periods of
uninterrupted pressure on the skin, soft tissue, muscle, and bone
and by the weight of the patient against the surface beneath. In
addition to force, friction, shearing forces, pressure-causing effects,
and impaired mobility, other factors, such as restoration of blood
flow, extrinsic factors, intrinsic factors, and various external factors,
contribute to the development of pressure ulcers.
Pressure ulcers typically occur at bony prominences, such as the
elbows, knees, ankles, scalp, back, tailbone, hips, and other areas
where pressure is applied. Pressure ulcers often occur in the pelvis
in addition to other common locations, such as the sacrum (the
bone at the base of the pelvis) and the heels.1 Pressure ulcers can
develop on these bony sites because body weight is concentrated
on these areas when lying on an unyielding surface.
Question to Consider
Which patients or residents are routinely
considered at risk for pressure ulcers?
Patients and residents who are bedridden or
use wheelchairs are at risk of developing pressure ulcers. Other vulnerable individuals in-
Several terms have been applied to describe a pressure ulcer,
including bedsore, decubitus ulcer, and pressure sore. Pressure ulcer is
the accepted term because it is more accurate and relates to the
actual cause of the problem.1
clude stroke victims, patients and residents
with diabetes, and those with dementia. The
older adult who is malnourished is particularly
at risk for pressure ulcers. Patients who are
sedated for any reason may develop pressure
When pressure ulcers are detected early, they are treatable. If left
untreated, pressure ulcers can develop into the later stages of the
condition, resulting in fatal complications. For example, if the
wound becomes infected, it can lead to a serious septic infection,
making it difficult for patients to recover. Sepsis occurs when bacteria enter the bloodstream through the broken skin and spread
throughout the body. It is a rapid-progression, life-threatening
condition that can cause shock and organ failure. Other common
complications include osteomyelitis (an acute or chronic bone infection), cellulitis (skin infection caused by bacteria), infectious
arthritis (infection in the fluid and tissues of a joint), and renal
failure (acute kidney failure).2
Definition of Pressure Ulcer
The National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel define pressure ulcer as a
localized injury to the skin and/or underlying tissue usually
over a bony prominence, as a result of pressure or pressure in
combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the
significance of these factors is yet to be elucidated.
ulcers. Individuals with spinal cord injuries
who cannot feel their legs are also at risk for
pressure ulcers.
Paralysis, insensibility, and aging lead to atrophy of the skin with
thinning of this protective barrier. A decrease in epidermal
turnover, flattening of the dermal-epidermal junction, and loss of
vascularity are particular problems in older patients.
Poorly fitting prosthetic devices also can cause pressure ulcers to
develop over bony prominences. Increased force and duration of
pressure directly influence risk and severity, but pressure ulcers can
develop in as little as three to four hours in some settings, such as
with trauma patients who are immobilized on rigid spine-immobilization boards. Ulcers worsen when skin is macerated, overly
moist, and soaking in liquid from perspiration or incontinence.
Pressure
Pressure or force occurs when the layers of the skin slide over one
another or over deeper tissues, such as when patients slide down in
3
Pressure Ulcer Prevention Toolkit
the bed or a chair. Continuous pressure results in the skin and
underlying tissue not receiving an adequate blood supply. Areas of
the body that are most susceptible are those not well padded with
flesh and fat (such as the tailbone, shoulder blades, hips, heels,
ankles, and elbows). Excessive pressure on soft tissue can be attributed to three factors: (1) the intensity of the pressure, (2) the
duration of the pressure, and (3) tissue tolerance, or the ability of
the skin and its supporting structures to endure pressure without
adverse effect.
Question to Consider
How does shear occur?
Shear is caused by the interplay of gravity and
friction. It exerts force parallel to the skin and
is the result of gravity pushing down on the
body and resistance (friction) between the
patient or resident and a surface, such as the
bed or a chair. For example, when the head of
Friction and Shear
Friction occurs when the skin is rubbed against an external surface.
Friction is a major factor in the development of pressure ulcers
because it acts in concert with gravity to cause shear. Friction can
be created when turning or moving patients, such as boosting
patients up in bed, which can happen in the emergency department. If the patient has thin and frail skin and poor circulation,
friction may damage the skin. Friction alone has the ability to
cause skin damage that is confined to the epidermal and upper
dermal layers.1
In its mildest form, friction causes a mild burn, and this type of
skin damage is often reported as a “sheet burn.” However, when
friction acts with gravity, the effect is shear. Shear occurs when the
skin moves one way while the underlying bone moves in the opposite direction. For example, if a patient slides down in a bed or on
a chair or raises the top half of a bed too much, there is a risk of
shearing, and cell walls and minute blood vessels may stretch and
tear.3 Shear causes much of the damage often observed with pressure ulcers. Some lesions that may result solely from shear are
misinterpreted to be pressure ulcers.
Pressure-Causing Effects
Pressure-causing effects take place when the bones rub against the
skin and underlying deeper tissue. When this occurs, the capillaries
are compressed, and oxygen and nutrients cannot be supplied to
the tissue, which causes ischemia, or local anemia, due to obstruction of the blood supply, hypoxia, and then necrosis or cell death.
Some causes of circulation loss may seem unlikely. Nevertheless,
they do exist. For example, crumbs in the patient’s or the resident’s
bed, wrinkles in the sheets and clothing, and a slightly tilting chair
can cause pressure and ultimately obstruction of the blood supply.
4
the bed is elevated, the effect of gravity on the
body is to pull the body down toward the foot
of the bed.
Impaired Mobility
Impaired mobility is one common reason patients are exposed to
uninterrupted pressure, and it leads to the development of pressure
ulcers. This immobility is present in patients who are neurologically impaired, heavily sedated or anesthetized, restrained,
demented, or recovering from a traumatic injury, such as a pelvic
or femur fracture. These patients are not able to adequately alter
their positions with enough frequency to relieve pressure. For
example, if immobility is prolonged, muscle and soft tissue
atrophy may develop, decreasing the bulk over which bony
prominences are supported.4
Restoration of Blood Flow
Restoration of blood flow becomes a problem if it leads to
reperfusion injuries, which are thought to occur with high- or lowpressure surfaces. This ischemic area of tissue or reperfusion, which
has recently been suggested as a cause of additional damage to this
area, causes pressure sores to enlarge or become more chronic. This
occurs, for example, when a paraplegic or quadriplegic patient is
turned from one side to the other in an effort to combat prolonged pressure on a given side. Kirman and Molnar note that the
exact mechanism of the ischemia-reperfusion cycle of injury has
yet to be fully understood.3 Continued production of inflammatory mediators and reactive oxygen species during ischemia
reperfusion may contribute to the chronic condition of pressure
ulcers.
Although the essential cause of pressure ulcers is prolonged and
uninterrupted pressure on the skin and soft underlying tissues, the
CHAPTER 1: Pressure Ulcer Care Challenges and Prevention Methods
extent to which each patient or resident can withstand pressure
without experiencing an actual ulcer varies. Every patient’s or
resident’s limits of tissue tolerance to pressure vary, making him or
her more or less susceptible to pressure ulcers.
Internal and external factors can lead to the formation of pressure
ulcers. Externally, direct pressure from infrequent position changes
is a leading cause of pressure ulcers.5 Internally, anyone experiencing a general or local loss of pain and pressure sensation is
considered at high risk. These sensations help prompt a spontaneous shift in position to relieve pressure.
Extrinsic Factors
Extrinsic factors that cause pressure ulcers are those in a patient’s
or resident’s immediate environment that place him or her at risk
for developing pressure ulcers. Shear is an important extrinsic
factor that contributes to the development of pressure ulcers in
patients and residents.
Because a patient’s skin does not move freely, the primary effect of
shear occurs at the deeper fascial level of the tissues overlying the
bony prominence. Blood vessels, which are anchored at the point
of exit through the fascia, are stretched and angulated when
exposed to shear.
Moisture, specifically incontinence, is a predisposing factor with
regard to the development of pressure ulcers. Moisture alters the
resiliency of the epidermis (the outer layer of skin) to external
forces. Shear and friction are increased in the presence of mild
to moderate moisture. However, shear and friction actually
decrease when a large amount of moisture is present. Studies
have shown that the high-moisture environment created by
urinary incontinence is not a major factor in the production of
pressure ulcers.6 Pieper points out that more research about
the role of moisture in the development of pressure ulcers is
needed.1
Direct pressure from infrequent position changes is a leading
cause of pressure ulcers. Patients or residents who cannot move
on their own while in bed or sitting in a chair are at risk of
developing pressure ulcers. Patients or residents who are able
to bear some weight and to get out of bed or out of a chair
from time to time are at less risk for developing pressure
ulcers.
Not only can patients and residents get pressure ulcers from sitting
or lying down in the same position for long periods of time, they
can also get pressure ulcers from medical equipment pressing on
the skin. For example, pressure ulcers have occurred on patients’ or
residents’ lips due to pressure from endotracheal tubes, patients’
ears due to nasal cannula (device to deliver supplemental oxygen or
airflow), or on patients’ or residents’ thighs because of the hard
surfaces of urinary catheters.
Rubbing against sheets, wrinkled bedding or clothing, and poorly
adjusted supports, such as splints and casts, are also common
causes of pressure ulcers. In addition, some medications can
contribute to breakages of skin integrity. Tranquillizers, sedatives,
and opiates decrease sensory perception and mobility. Steroids can
disrupt the normal healing process due to their anti-inflammatory
properties, decreasing the general health of tissues. Patients or residents with mental health conditions, such as severe depression,
have an increased risk of pressure ulcers for a number of reasons,
including the fact that they may neglect their personal hygiene,
making their skin more vulnerable to injury and infection.
Intrinsic Factors
Intrinsic factors relate to an underlying health condition or other
factors that make a patient or resident more vulnerable to developing pressure ulcers. Patients or residents who have mobility
problems are at high risk for the development of pressure ulcers.
Immobility may be caused by a number of different situations,
including the following:
➤ A spinal cord injury that causes some or all of a patient’s or
resident’s limbs to be paralyzed
➤ Brain damage caused by an event, such as a stroke, leading to
coma and prolonged condition of generalized immobility
➤ Coma
➤ Severe pain that makes it difficult to move
➤ The aftereffects of surgery
Malnutrition also is predictive of pressure ulcer development. A
nutritional assessment helps identify the presence of malnutrition,
assess its severity, and determine baseline data to evaluate nutritional interventions. In 2000 a study examined the nutritional
status of newly hospitalized patients with Stages III and IV pressure ulcers. It found that a majority of the patients were below
usual body weight, had low prealbumin levels, and were not
getting enough nutrition to meet their needs.6 Certain vitamin
5
Pressure Ulcer Prevention Toolkit
deficiencies, particularly vitamins A, C, and E, may also contribute
to pressure ulcer development.
Question to Consider
How does low blood pressure contribute to
Dehydration is another determining factor in poor nutritional
status and susceptibility to pressure ulcers. Water is an essential
nutrient and serves as a solvent for minerals, vitamins, and amino
acids. It also helps maintain normal cell function. In addition,
water carries nutrients and waste particles throughout the body
and aids in hydration of wound sites and in oxygen perfusion.7
Posthauer notes that adequate hydration is an essential part of
treating all patients with wounds and provides the following case
study as an illustration of the problem4:
pressure ulcer development?
Systolic blood pressures below 100 mm Hg
and diastolic pressure below 60 mm Hg have
been associated with pressure ulcer development. Hypotension may shunt blood flow
away from the skin to more vital organs,
decreasing the skin tolerance for pressure by
allowing capillaries to close at lower levels of
interface pressure.
Mrs. H, 95, is recovering from a hip fracture in a long term care
organization. Her current medical history includes hypertension,
dementia, and dysphagia. While hospitalized, Mrs. H developed a
Stage II pressure ulcer on her coccyx. The wound has deteriorated to
a Stage IV with heavy exudate [accumulation of fluid in a
wound]. Mrs. H currently weighs only 90 pounds, a decline of 5%
in 30 days. Her appetite is poor, and her daily fluid intake averages only 600 mL or less. She is on a sodium-restricted diet, limited
to 2 g/day of sodium. Her urine is dark with a strong odor. Her
output is minimal.
Mrs. H has become increasingly confused in the past few days and
has a fever. Her medications (a diuretic, a laxative, and pain medications) are contributing to her fluid loss. A dietary consultation
has identified risk factors for dehydration, including elevated temperature, dysphagia, poor fluid intake, and a draining pressure
ulcer. Despite Mrs. H’s signs and symptoms, the caregivers have not
yet recognized that she is dehydrated and has nutritional deficiencies that must be corrected. Failing to address this serious problem
will hinder the wound healing process.
Emotional stress also has been associated with pressure ulcer formation. Hospitalization can be a stressor for patients and residents.
Up to 75% of the elderly experience a decrease in functional
ability from hospital admission to discharge. Cigarette smoking is
another contributing factor. It has been shown to correlate positively with the presence of pressure ulcers in a group of patients
with spinal cord injuries. The incidence and extent of existing
ulcers was greater in those patients with higher pack-per-year histories. In addition, patients who smoke have been reported to have
higher recurrence rates of pressure ulcers.
6
Variations of Pressure Ulcers
The National Pressure Ulcer Advisory Panel (NPUAP) classifies
pressure ulcers into six categories or stages, depending on their
severity. The NPUAP recently updated its classification system for
pressure ulcers. The goal of the update is to clarify each stage and
reduce the number of incorrectly staged ulcers or other types of
wounds and skin lesions. The NPUAP’s revised classification
system includes two new stages: suspected deep tissue injury, which
differentiates between two types of unbroken yet obviously traumatized tissue, and unstageable, which describe ulcers covered with
necrotic tissue whose depth of injury is undetermined.7
The various stages do not imply that all pressure ulcers follow a
standard progression or that healing pressure ulcers follow a standard regression.
The system is designed to describe the degree of tissue damage
observed at the specific time of examination and is meant to facilitate communication among the various disciplines involved in the
care and assessment of patients and residents. Illustrations of
normal skin and the various stages of pressure ulcers are shown in
Figures 1.1 through 1.7, pages 7–13. The stages are described in
the following sections.
Category/Stage I
This is the earliest stage of pressure ulcers. Stage I classification
represents intact skin with nonblanchable redness of a localized
area, usually over a bony prominence (see Figure 1.2, page 8).
When tissue becomes temporarily ischemic, relief of pressure