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Senior Editor: Ilese J. Chatman Senior Project Manager: Cheryl Firestone Manager, Publications: Helen M. Fry, M.A. Associate Director, Production: Johanna Harris Executive Director: Catherine Chopp Hinckley, Ph.D. The Joint Commission/Joint Commission Resources Reviewers: Mary Brockway, Suzanne Delaney, Nanne Finis, Roberta Fruth, Helen Fry, Catherine Chopp Hinckley, Claudia Jorgenson, Carol Mooney, Susan Yendro Hill-Rom Reviewers: Melissa Fitzpatrick, Karen Janoff Additional Reviewers: Virginia Maripolsky, Ali Nashat Shaar, Cecilia Zamarripa Joint Commission Resources/Hill-Rom Nurse Safety Scholars-in-Residence: Irene Jankowski, Diane Whitworth, Cecilia Zamarripa Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services. Joint Commission International A division of Joint Commission Resources, Inc. The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the international community through the provision of education, publications, consultation, and evaluation services. JCR educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at JCR educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a JCR publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval. JCR is solely responsible for the development and contents of this toolkit, with funding support provided by Hill-Rom. 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[email protected] ISBN: 978-1-59940-615-2 Library of Congress Control Number: 2001933656 For more information about Joint Commission Resources, please visit http://www.jcrinc.com. For more information about Joint Commission International, please visit http://www.jointcommissioninternational.org. 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 iii 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 iviv 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