The Prevention And Management Of Pressure Sores

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Pressure sores are also called 'pressure ulcers', 'bed sores' and 'decubitusulcers'. A pressure sore can be described as localised damage to the skin caused by disruption of the blood supply to the area, usually caused by pressure, shear or friction, or a combination of any of these. There has not been a national survey of pressure sore prevalence in the UK; however, a survey by O'Dea (1995) of over 8000 patients found that 18.6% of hospital patients had pressure sores. A national survey in the USA found a pressure sore prevalence of 10.1% in acute hospital patients (Barczak et al., 1997). Barrois et al. (1998) reviewed the epidemiology of pressure sores in countries across Europe and found that the prevalence was between 6% and 9% in France, Spain, Greece and Sweden.

For many years pressure sores were seen as a failure of care, in particular, the result of bad nursing. Florence Nightingale (1861) considered that good nursing could prevent them, whereas a very influential French doctor called Jean-Martin Charcot (1825-1893) believed that doctors could do nothing about pressure sores. As a result, pressure sores became a very emotive issue and were referred to by doctors as 'a nursing problem' and by nurses with comments such as 'we do not have pressure sores here'.

This attitude is changing. A document published by the Department of Health stated that pressure sores should be considered a key indicator of the quality of care provided by a hospital (DoH, 1993). There is a much greater awareness that all healthcare professionals need to be involved in pressure sore prevention (Culley, 1998). A number of multidisciplinary societies have been formed such as the Tissue Viability Society and the European Pressure Ulcer Advisory Panel with the intent of expanding knowledge and supporting good practice.

5.2.1 The aetiology of pressure sores

Pressure sores are caused by a combination of factors both outside and inside the patient.

External factors

There are three external factors which can cause pressure sores either on their own or in any combination of the three. They are pressure, shear and friction.

Pressure is the most important factor in pressure sore development. When the soft tissue of the body is compressed between a bony prominence and a hard surface causing pressures greater than capillary pressure, localised ischaemia occurs. The normal body response to such pressure is to shift position so the pressure is redistributed. When pressure is relieved a red area appears over the bony prominence. This is called reactive hyperaemia and is the result of a temporarily increased blood supply to the area, removing waste products and bringing oxygen and nutrients. It is a normal physiological response.

Capillary pressure is generally described as being approximately 32mmHg, based on the research of Landis (1931). His research was carried out on young, healthy students. He found the average arteriolar pressure was 32 mmHg, but the average pressure in the venules was 12 mmHg. There is also a certain amount of tissue tension which resists deformation. It is not uncommon for interface pressures of around 30-40mmHg to be seen as 'safe'. This is not always correct. Ageing causes a reduction in the numbers of elastic fibres in the tissues, resulting in reduced tissue tension. In situations where the blood pressure is artificially lowered, such as during some types of surgery, capillary pressure is also likely to be lower. In these circumstances, very little pressure is required to cause capillary occlusion. Ek et al. (1987) found that a pressure of only 11 mmHg was necessary to cause capillary occlusion in some hemiplegic patients.

If unrelieved pressure persists for a long period of time, tissue necrosis will follow. Prolonged pressure causes distortion of the soft tissues and results in destruction of tissue close to the bone. A cone-shaped sore is created, with the widest part of the cone close to the bone and the narrowest on the body surface. Thus, the visible sore fails to reveal the true extent of tissue damage.

The bony prominences which are most vulnerable to pressure sore development are sometimes referred to as the pressure areas. They include: the sacrum, ischial tuberosities, trochanters, heels and elbows (see Fig. 5.1).

Shear forces can deform and disrupt tissue and so damage the blood vessels.

Fig. 5.1 The bony prominences or pressure areas.

Gebhardt (1995) argues that pressure is rarely applied uniformly and that the subsequent distortion leads to shearing. Shearing may occur if the patient slides down the bed. The skeleton and tissues nearest to it move, but the skin on the buttocks remains still. One of the main culprits of shearing is the back-rest of the bed which encourages sliding. Chairs which fail to maintain a good posture may also cause shearing.

Friction occurs when two surfaces rub together. The commonest cause is when the patient is dragged rather than lifted across the bed. It causes the top layers of epithelial cells to be scraped off. Moisture exacerbates the effect of friction. Moisture may be found on a patient's skin as a result of excessive sweating or urinary incontinence.

Internal factors

The human body is frequently subjected to some or all of the external factors, but does not automatically develop pressure sores. The determining factor(s) come from within the patient.

General health is important as the body can withstand greater external pressure in health than when sick. Bliss (1990) suggests that the acutely ill are particularly vulnerable. Although the reasons for this are not certain, Bliss suggests some precipitating factors including pain, low blood pressure, heart failure, the use of sedatives, vasomotor failure, peripheral vasoconstriction due to shock and others.

Age has been shown to be a major factor in the development of pressure sores. David et al. (1983) carried out a pressure sore prevalence survey of 20 health districts from within four health regions. They found that 85% of the patients with pressure sores were over 65 years old. A survey by Nyquist and Hawthorn (1987) found that within one health authority 47% of patients with pressure sores were on wards for the elderly.

As people age, their skin becomes thinner and less elastic. In part, this is because the collagen in the dermis reduces in quantity and quality. Collagen provides a buffer which helps to prevent disruption of the microcirculation (Krouskop, 1983). There may be wasting of the overall body mass, resulting in loose folds of skin. There is also an increased likelihood of chronic illnesses or diseases developing, many of which may also predispose to pressure sore development. Once a sore occurs it is much harder to heat in an older person than a young one (see Chapter 2).

Reduced mobility can affect the ability to relieve pressure effectively, if at all. It also predisposes to shearing and friction if the patient is confined to a bed or chair. General prevalence surveys such as those of David et al. (1983) and Nyquist and Hawthorn (1987) found reduced mobility to be a factor for many patients with pressure sores. Versluysen (1986) studied 100 patients over 60 years old with a fractured femur and found a prevalence of 66%. This study was replicated by Nyquist and Hawthorn (1988) who found a prevalence of 42.3%.

Exton-Smith and Sherwin (1961) studied the number of movements made by 50 elderly patients during the night. A strong relationship was found between those with reduced movement and the development of pressure sores. Reduced movement during sleep may be associated with a variety of drugs such as hypnotics, anxiolytics, antidepressants, opioid analgesics and antihistamines. Berlowitz and Wilking (1989) studied a variety of factors in patients with pressure sores, and patients developing pressure sores, and found that reduced mobility was significantly associated with pressure sores in both groups. Brandeis et al. (1994) also found reduced mobility to be a significant factor in a study involving nursing home patients.

Another aspect of reduced mobility is that of the patient undergoing major surgery. Operations may last many hours while the patient lies immobile on the hard operating table. Mobility may also be reduced in the immediate postoperative period because of the effects of the anaesthetic, pain, analgesia, infusions or drains. Today, very sophisticated surgery is carried out, often on older patients as well. The risks of pressure sore development associated with such surgery are consequently increased.

Reduced mobility may also be associated with neurological deficit, such as a patient with paraplegia, but this is not always so. A diabetic patient may suffer from neuropathy without loss of mobility. Neurological deficit may be associated with strokes, multiple sclerosis, diabetes, and spinal cord injury or degeneration. Loss of sensation means the patient is unaware of the need to relieve pressure, even if able to do so. Dealey (1991a) found that neurological deficit was a common factor in those patients with pressure sores found in a survey of a teaching hospital. Kaba-gambe et al. (1994) took 10 patients with spinal cord injury and compared them with 11 healthy subjects. They found an impaired reactive hyperaemia response in those with spinal cord injury.

Reduced nutritional status impairs the elasticity of the skin. Long term it will lead to anaemia and a reduction of oxygen to the tissues. Pinchkofsky-Devin and Kaminski (1986) assessed the nutritional status of 232 patients in a nursing home; of these, 117 patients had mild-to-moderate malnutrition and 17 had severe malnutrition. Although none of the other patients had pressure sores, they were present in all the 17 severely malnourished patients. Cullum and Clark (1992)

carried out a study of intrinsic factors associated with pressure sores in elderly people. They found that serum protein concentrations were significantly lower in those patients admitted with pressure sores and those who developed sores when compared with patients who did not have pressure sores. Berlowitz and Wilking (1989) and Brandeis et al. (1994) also found impaired nutritional intake a factor in pressure sore development. The factors which may lead to malnutrition are discussed in Chapter 2.

Body weight should also be considered. Very emaciated patients have no 'padding' over bony prominences. They have less protection against pressure. On the other hand, very obese patients are difficult to move. Unless great care is taken, they may be dragged rather than lifted in the bed. Another problem of the obese patient is that moisture from sweating may become trapped between the rolls of fat causing maceration. Both of these types of patient may also have a poor nutritional status.

Incontinence of urine can contribute to maceration of the skin and thus increase the risk of friction. Constant washing removes natural body oils, drying the skin. In a pressure sore prevalence survey of Greater Glasgow, Jordan and Clark (1977) found 15.5% of patients with pressure sores to be incontinent of urine and 39.7% to have faecal incontinence. Schnelle et al. (1997) found incontinence to be related to blanching erythema, an early indicator of pressure damage. Factors that may be associated with urinary incontinence include the use of diuretics or sedatives. Diarrhoea may cause incontinence in the elderly or immobile patient. It is a side-effect found with the use of some antibiotics.

Poor blood supply to the periphery lowers the local capillary pressure and causes malnutrition in the tissues. It may be caused by disease, such as heart disease, peripheral vascular disease or diabetes. Drugs, such as beta-blockers and inotropic sympathomimetics, may cause peripheral vasoconstriction. These drugs may be used following cardiac surgery when the patient is already suffering from reduced mobility. Blood flow may also be affected during surgery. Sanada et al. (1997) measured blood flow during surgery in the skin over the iliac crest and sacrum. They found a 500% increase in flow in those patients who did not develop pressure sores, but a drop in flow in those who later developed pressure sores.

Dealey (1997) cited a number of external factors which can exacerbate the internal factors discussed above. They include:

• inappropriate positioning, which may increase pressure or shear;

• restrictions to movement such as lying for long periods on a trolley;

• lying for long periods in one position on hard surfaces such as the X-ray table;

• poor lifting and handling techniques increase the risk of friction and shear;

• poor hygiene which leaves the skin surface moist from urine, faeces or sweat;

• drugs such as sedatives which make the patient drowsy and less likely to move.

5.2.2 The cost of pressure sores

The true cost of pressure sores is impossible to calculate. There is the untold cost in terms of pain and suffering to the patient as well as the cost to the health service.

There are few official data in the UK. The Department of Health commissioned a report into the costs of pressure sores by Touche Ross & Co. (1993). Their work produced estimates rather than precise figures using a mythical 600-bed hospital. They worked on high and low costs for both prevention and treatment (see Table 5.1). It can be argued that their costings were flawed as they included the cost of a clinical nurse specialist in tissue viability in the cost of prevention but not for treatment costs. They also suggested that staff spent more time on preventing a patient from developing a pressure sore than treating a patient with a sore. Most nurses would take issue with this conclusion.

Table 5.1 The costs of pressure sores.

Prevention

Treatment

Low cost

£644797

£644661

High cost

£2 709878

£1153498

Several others have looked at some aspect of costings, one of the most often quoted is a study by Hibbs. Hibbs (1988) calculated that the cost of treating one patient with a deep sacral pressure sore was £25 905.58. This patient was in hospital for 180 days. A further calculation looked at the 'opportunity costs'. Opportunity costs describe what has been foregone because of specific circumstances. For example, because of the extended stay in hospital of this patient, the opportunity to carry out 16 routine hip or knee replacements was lost. Similar calculations can also be made looking at standard days and standard costs. A critique of this work was published by two economists nine years later (Brooks & Thompson, 1997). They support Hibbs's approach and regret that there have been few economic appraisals in relation to pressure sore prevention. Dealey (1993) noted the cost of treating one patient to be just over £22 000. The cost of a suitable mattress to prevent further breakdown after discharge was £450 - indicating that prevention is cheaper than cure. Clough (1994) drew a similar conclusion in his study. He found that it cost £320 per patient to treat patients in an intensive care unit with pressure sores whereas it cost £150 per patient for prevention.

Some studies have looked at length of stay as a way of assessing pressure sore costs. Lapsley and Vogels (1996) looked at the cost of pressure sores in patients who had undergone surgery either for hip replacement or coronary artery bypass graft. They found a significantly longer stay for those patients who developed pressure sores compared with those who did not. Stordeur et al. (1998) also studied patients undergoing cardiovascular surgery. They found that the total length of stay was longer by a mean of six days for those who developed pressure sores.

Another cost that has to be taken into consideration is that of litigation. Tingle (1997) describes a number of legal cases where the patient or their families were awarded damages ranging from £3500 to £12 500. In all of these cases there is a chronicle of incompetence and negligent care. In some instances the pressure sore directly contributed to the patient's death. Allied to this there is often inadequate assessment and poor documentation.

5.2.3 The prevention of pressure sores

Although it is a truism, as far as pressure sores are concerned, prevention is better than cure. Waterlow (1988) suggests that 95% of all pressure sores could be prevented. The document Health of the Nation (DoH, 1992) calls for an annual reduction of 5-10%. in the incidence of pressure sores. To this end most trusts now have pressure sore prevention policies. There is also a move towards the development of evidence-based guidelines to provide a framework from which local policies may be developed. European pressure sore prevention guidelines have recently been published and will provide a useful framework for discussing prevention (European Pressure Ulcer Advisory Panel, 1998). The guidelines can be divided into sections on risk assessment, improving tissue tolerance, pressure relief and education. Each section is cited in full in Tables 5.2-5.5.

Table 5.2 European Pressure Ulcer Advisory Panel guidelines on pressure ulcer prevention.

(1) Identify 'at risk' individuals needing prevention and the specific factors placing them at risk

• We believe that there are a number of issues associated with risk assessment tools. Risk assessment should be as an adjunct to clinical judgement and not as a tool in isolation from other clinical features (C).

• There should be clarification of a full risk assessment of patients to include: general medical condition, skin assessment, mobility, moistness and incontinence, nutrition and pain (C).

• All strategies related to pressure damage should always be based on the best available evidence.

• Assessment of risk should be more than just the use of an appropriate risk assessment tool and should not lead to a prescriptive and inflexible approach to patient care (C). While risk assessment should be performed immediately on entry into a care episode, this assessment may take time to fully complete if information is not readily available (C). Assessment should be ongoing and frequency of reassessment should be dependent on change in the patient's condition.

The letters A-C in Tables 5.2-5.5 refer to the grading recommendations of the European Pressure Ulcer Advisory Panel (1998). For definitions of each grade, see Table 8.3.

(1) Identify 'at risk' individuals needing prevention and the specific factors placing them at risk.

Too often, risk assessment is just seen as using a risk calculator to determine the patient's score and then following a 'recipe' of care. Risk calculators should be part of the assessment process. However, assessment should also include: general medical condition, a nutritional assessment, skin assessment, identification of any incontinence and the effect that this may have on the skin and also the level of mobility.

There are a number of risk calculators available. The earliest that was developed was the Norton Score (Norton et a/., 1975). Subsequently other scores have been

Table 5.3 European Pressure Ulcer Advisory Panel guidelines on pressure ulcer prevention.

(2) Maintain and improve tissue tolerance to pressure in order to prevent injury

• Skin condition should be documented daily and any changes should be recorded as soon as they are observed. Inspection must be documented. Initial skin assessment should take into account the following:

I. Bony prominences (sacrum, heels, hips, ankles, elbows, occiput) to identify early signs of pressure damage.

II. Identify the condition of the skin: dryness, cracking, erythema, maceration, fragility, heat and induration (C).

Every effort should be made to optimise the condition of the patient's skin. Assessment of patients with dark or tanned skin is especially difficult (C).

• Avoid excessive rubbing over bony prominences as this does not prevent pressure damage and may cause additional damage (C).

• Find the sources of excess moisture due to incontinence, perspiration or wound drainage and eliminate this, where possible. When moisture cannot be controlled interventions that can assist in preventing skin damage should be used (C).

• Skin injury due to friction and shear forces should be minimised through correct positioning, transferring and repositioning techniques.

• Following assessment, nutritionally compromised individuals should have a plan of appropriate support and/or supplementation that meets individual needs and is consistent with overall goals of therapy (C).

• As the patient's condition improves the potential for improving mobility and activity status exists, rehabilitation efforts may be instituted if consistent with overall goals of therapy. Maintaining activity level, mobility and range of movement is an appropriate goal for most individuals (C).

• All interventions and outcomes should be documented (C).

developed. Probably the most widely used within UK hospitals is the Waterlow Score (see Fig. 5.2 (Waterlow, 1985)). This calculator considers a wider range of variables than Norton. The scoring is also reversed so that the higher the score, the higher the risk. It has the advantage of dividing the degree of risk into categories; 'at risk', 'high risk' and 'very high risk'. These can be useful when considering the use of appropriate support systems. Waterlow included suggestions for preventive measures on the reverse of the card. The Braden Score (Bergstrom etai, 1985) is widely used in the USA. It has been demonstrated to have greater sensitivity and specificity than other scales, but only if used by registered nurses (Bergstrom et a!., 1987).

Risk calculators have been judged according to their sensitivity and specificity. Sensitivity relates to the percentage of patients predicted to develop pressure sores who have gone on to develop them. Specificity is defined as the percentage of patients deemed not to be at risk who do not develop pressure sores (Anthony, 1996). Bridel (1993a) found that the Waterlow Score had a high sensitivity but a lower specificity whereas the reverse was true for the Braden Score. However, the effect of nursing care needs to be taken into account, as it may affect the success of the calculator. Deeks (1996) suggests that where sensitivity and specificity appear to be poor it is often in settings where effective prevention methods are being used.

Despite the criticisms that can be made of the risk calculators, there is benefit in

Table 5.4 European Pressure Ulcer Advisory Panel guidelines on pressure ulcer prevention.

(3) Protect against the adverse effects of external mechanical forces: pressure, friction and shear

• Any individual who is assessed to be at risk of developing pressure ulcers should be repositioned if it is medically safe to do so (B).

• Frequency of repositioning should be consistent with overall goals (C).

• Documentation to record repositioning should be completed. Correct positioning and support is important to minimise friction and shear in both bed and chair (C).

• Correct positioning or devices such as pillows or foam wedges should be used to keep bony prominences (e.g. knees, heels or ankles) from direct contact with one another in accordance with a written plan (C). Care should be taken to ensure that these do not interfere with the action of any other pressure relieving support systems in use (C).

• When repositioning patients, do so in such a way as to minimise the impact on bony prominences (C).

• Devices to assist manual handling should be used during transfer and positioning of patients to minimise shear forces for those patients who require assistance in movement, in accordance with EU manual handling regulations.

• In all care settings, individuals considered to be at risk of developing pressure ulcers should have a personalised written prevention plan which may include a pressure redistributing device (A).

• Patients at risk of developing pressure ulcers because of the time spent sitting in a chair should be allocated a chair of the correct height in addition to a pressure relieving device (B).

• Any person who is acutely ill and at risk of developing a pressure ulcer should avoid uninterrupted sitting out of bed (B). The period of time should be defined in the individualised care plan, but generally not more than two hours (B). Individuals, where appropriate, should be encouraged to reposition themselves if this is possible (B).

• Individuals at risk from pressure ulcers who are likely to spend substantial periods of time in a chair or wheelchair should generally be provided with a pressure redistributing device (B). Individuals who are able should be taught to redistribute weight every 15 minutes (C).

using a systematic method of identifying and assessing patients at risk of pressure sore development. Flanagan (1997) stresses the importance of assessing patients regularly rather than just at an initial assessment. It should also be noted that once a patient is identified as being at risk appropriate preventive action must follow. Failure to do so would be a failure in the duty of care that each nurse has to her patients.

(2) Maintain and improve tissue tolerance to pressure in order to prevent injury.

There is a natural resilience in skin which enables the healthy individual to overcome many of the problems of friction or shear met in everyday life. It makes sense to utilise these properties and to enhance them where possible. Skin assessment should be undertaken daily for the at-risk patient. Where possible the patient and/or carer should be involved in this process. Any alterations in skin status should be recorded immediately; unqualified staff should be alerted to the need to inform the qualified nurses should this arise, as a change in the plan of care may be required.

Skin assessment is important in two ways: it provides baseline data of the initial

Table 5.5 European Pressure Ulcer Advisory Panel guidelines on pressure ulcer prevention.

(4) To improve the outcomes for patients at risk of pressure damage through educational programmes

• Educational programmes for the prevention of pressure damage should be structured, organised and comprehensive, and made available to all levels of healthcare providers, patients and family or caregivers (C).

• The educational programmes for prevention of pressure damage should include the following items:

Pathophysiology and risk factors for pressure damage. Risk assessment tools and their application. Skin assessment.

Selection and instruction in the use of pressure-redistributing and other devices. Development and implementation of individualised programmes of care. Principles of positioning to decrease risk of pressure damage. Documentation of processes and patient outcome data. Clarification of responsibilities for all concerned with this problem. Health promotion.

Development and implementation of guidelines.

• The educational programme should be updated on a regular basis based on the best available evidence. The content of the programme should be modified according to the audience (C).

WATERLOW RISK ASSESSMENT CARD

RING SCORES IN TABLE, ADD TOTAL

SEVERAL SCORES PER CATEGORY CAN BE USED

RING SCORES IN TABLE, ADD TOTAL

SEVERAL SCORES PER CATEGORY CAN BE USED

BUILD/WEIGHT FOR HEIGHT

RISK AREAS VISUAL SKIN TYPE

SEX AGE

SPECIAL RISKS

*

AVERAGE

0

HEALTHY

0

MALE

1

TISSUE MALNUTRITION:

*

ABOVE AVERAGE

1

TISSUE PAPER

1

FEMALE

2

eg. TERMINAL CACHEXIA

e

OBESE

2

DRY

1

14-49

1

CARDIAC FAILURE

5

BELOW AVERAGE

3

OEDEMATOUS CLAMMY "T ^ DISCOLOURED

1

50-64

2

PERIPHERAL VASCULAR DISEASE

5

CONTINENCE

1

65-74

3

ANAEMIA

2

COMPLETE/ CATHETERISED

75-80

SMOKING

1

U

2

4

NEUROLOGICAL DEFICIT:

OCCASION INCONT.

1

BROKEN/SPOT

3

81 +

5

eg DIABETES, CVA

CATH/INCONTINENT OF

MOBILITY

*

APPETITE

M.S., PARAPLEGIA;

4-6

FAECES

2

FULLY

0

AVERAGE

0

MOTOR/SENSORY

DOUBLY INCONT.

3

RESTLESS/FIDGETY

1

POOR

1

MAJOR SURGERY/TRAUMA

ORTHOPAEDIC-BELOW WAIST. SPINAL ON TABLE > 2 HRS

APATHETIC RESTRICTED

2 3

N.G. TUBE/ FLUIDS ONLY

2

5 5

INERT/TRACTION

4

NBM/ANOREXIC

3

MEDICATION

*

CHAIRBOUND

5

STEROIDS, CYTOTOXICS, ANTI-INFLAMMATORY

4

SCORE: 10+AT RISK 15+HIGH RISK 20+VERY HIGH RISK

SCORE: 10+AT RISK 15+HIGH RISK 20+VERY HIGH RISK

6 J WATERLOW

Fig. 5.2 The Waterlow Score. Reproduced with permission.

skin status at the beginning of a care episode; and it provides ongoing information on the effectiveness of the prevention plan. Skin assessment involves:

• assessment of the bony prominences, remembering that emaciated patients may develop sores in uncommon areas, e.g. ribs;

• skin status should be identified - dryness, fragility, erythema, areas of maceration are all vulnerable to tissue damage;

• skin colour - dark skin is more difficult to assess for early signs of tissue damage; watch for dryness, cracking or induration.

Traditionally, skin care was provided by rubbing patients' pressure areas, particularly sacrum, buttocks and heels, at regular intervals. A variety of lotions and potions were used. However, this practice has been discredited. Dyson (1978) compared two groups of 100 elderly patients over a six-month period. The control group had their buttocks and sacrum rubbed with soap and water. The other group had their buttocks washed as required only. There was a 38% reduction in pressure sore incidence in the experimental group compared with the control group. A recent review of the literature by Buss et al. (1997) considered the effects of massage or rubbing on pressure sore prevention. They concluded that this practice could not be recommended.

When the practice of rubbing was discontinued most nurses developed a reluctance to use any type of cream over the pressure areas. Whilst this is generally appropriate, there may be exceptions in the case of very dry or very moist skin. Emollients should be considered when caring for patients with very dry skin. This can be in the form of emollients in the bath or an emollient cream. Creams should be applied gently to the affected area. If the skin is moist, the source of the moisture should be identified and dealt with if possible. A barrier cream may be needed to protect the skin from the harmful effects of moisture. Frequent cleansing using soap and water for incontinent patients can cause excessive drying of the skin. Dealey and Keogh (1998) found a significant improvement in skin status using a cleanser and barrier cream compared with soap and water in elderly incontinent patients at risk of pressure sore development.

Friction and shear can be reduced by correct positioning, transferring and repositioning techniques. Incorrect positions in either bed or chair can cause patients to slide. Regular moving of patients puts nurses at risk of back injury. One study showed that two nurses on a geriatric ward lifted the equivalent of 2.5 tons in weight in one hour (General, Municipal and Boilermakers Union, 1985). Lifting regulations have been established by a European Community directive indicating the necessity for a policy on manual lifting. In the UK, the Health and Safety Executive produced such a document (1992). All healthcare institutions must have a policy for manual handling and staff should have regular training on correct methods of moving patients. Hoists, slides and other aids for moving patients should be available. The Royal College of Nursing (1996) produced a code of practice which suggests that manual handling should be eliminated in all but exceptional or life-threatening situations. All nurses have a responsibility to take reasonable care for their own safety and for that of patients and colleagues.

If nutritional assessment identifies a patient as having a reduced nutritional status then an appropriate plan of care must be developed. Chapter 2 discusses this in more detail.

As has already been noted, pressure sores may be associated with acute illness. As the general condition of patients improves so their levels of mobility and activity should increase. Some patients may require considerable rehabilitation to optimise their mobility levels. It is important that patients achieve as great a level of mobility and activity as is practical for each individual as immobility has far reaching consequences (see Fig. 2.3, page 31).

(3) Protect against the adverse effects of external mechanical forces: pressure, friction and shear.

Relief of pressure is the main method used in the prevention of pressure sores. This may be achieved by regular repositioning of the patient and the use of pressure-relieving equipment (support systems) when necessary. Patients should be given care appropriate to their specific needs.

For many patients regular repositioning is all that is necessary for pressure sore prevention. Patients should be moved every 2-4 hours depending upon need. The standard method is to turn patients from side to side. Lowthian (1979) designed a 'turning clock' to establish effective positioning. Figure 5.3 shows how it can be used so that a patient can be sitting up at mealtimes and side-lying at others.

TURNING CHART

MIDNIGHT

TURNING CHART

MIDNIGHT

Repositioning Clocks For Pressure Ulcers

NOON INSTRUCTION LIST

Fig. 5.3 Lothian Turning Clock (from Lothian, 1979).

NOON INSTRUCTION LIST

MN - 1

7 - 8

2 - 3

9 - 10

1 - 2

8 - 9

3 - 4

10 - 11

2 - 3

9 - 10

4 - 5

11 - MN

3 - 4

10-11

5 - 6

4 - 5

11 - MD

6 - 7

5 - 6

12 - 1

7 - 8

6 - 7

1 - 2

8 - 9

Oertwich et al. (1995) found that even small movements can reduce pressure and increase blood flow over bony prominences. Regular assessment of the pressure areas must be made in order to detect any evidence of excessive pressure; if this occurs other means of pressure relief may be needed.

An alternative to traditional 'turning' of patients is the 30° tilt. This method of positioning patients was developed in a younger disabled unit (Preston, 1988). The patient is placed into a tilted position by the use of pillows (see Fig. 5.4). Once in position, there is no pressure on the sacrum or heels. The interface pressure on the buttock is around 25mmHg. Colin et al. (1996) compared the effect of the 90° lateral position with the 30° tilt and found significant hypoxaemia over the trochanter in the former position but none in the latter.

Degree Tilt Pressure Care Pictures

5.4c

Fig. 5.4 The 30 degree tilt. This is a useful method of positioning patients who are difficult to turn or are not able to lie on their side. Patients may be safely left for long periods in this position, but the pressure areas should be carefully monitored to establish an appropriate time for each patient, (a) Place the patient in the centre of the bed with sufficient pillows to support the head and neck, (b) Place a pillow at an angle under one buttock thus tilting the pelvis by 30 degrees. Check with a flattened hand that the sacrum is just clear of the mattress, (c) Place a pillow lengthways under each leg so that the heels are lifted clear of the bed. Reproduced by kind permission of Medical Support Systems Ltd.

5.4c

Fig. 5.4 The 30 degree tilt. This is a useful method of positioning patients who are difficult to turn or are not able to lie on their side. Patients may be safely left for long periods in this position, but the pressure areas should be carefully monitored to establish an appropriate time for each patient, (a) Place the patient in the centre of the bed with sufficient pillows to support the head and neck, (b) Place a pillow at an angle under one buttock thus tilting the pelvis by 30 degrees. Check with a flattened hand that the sacrum is just clear of the mattress, (c) Place a pillow lengthways under each leg so that the heels are lifted clear of the bed. Reproduced by kind permission of Medical Support Systems Ltd.

Patients can be left for increasingly longer periods without turning, again careful observation must be made of all vulnerable areas. Once patients have become accustomed to using the 30° tilt, they may be left for up to eight hours without turning; not only does this allow an undisturbed night's sleep, but it is of great benefit for use in the community. This method of positioning is not suitable for all patients, but is a useful addition to the skills available for preventing pressure sores.

The standard hospital mattress

Much has been written in recent years about the use of various support systems. Far less time has been spent considering the standard mattress, despite the fact that this is what most patients use. O'Dea (1993) found that 33% of patients with pressure damage were being nursed on a standard hospital mattress. Foam has a finite lifespan. The Department of Health recommends that the standard mattress has a lifespan of four years. The foam in the mattresses should be at least 130 mm in depth, or it will collapse in a much shorter time. The use of two-way stretch covers gives improved pressure relief, in contrast to Staph Chek covers which increase pressure (Podmore, 1993). The water resistance of the cover can be damaged by the use of alcohol sprays for cleaning, which can also reduce the life of the mattress; cleaning with soap and water is the best method to use.

All hospitals should establish a replacement programme. Mattresses need to be tested annually for grounding and the effectiveness of the cover. Worn out mattresses can then be replaced. The Effective Health Care Bulletin (1995) recommends that pressure-relieving foam mattresses should be used for at-risk patients rather than the standard mattress. Many hospitals are replacing worn out standard mattresses with this type of mattress.

Pressure-relieving beds and mattresses

There is an ever increasing range of equipment available for use. They range from overlays to highly sophisticated beds. Some reduce pressure by 'spreading the load' and reducing pressures over bony prominences; others actually relieve pressure, in a variety of ways.

Caution is needed in the purchase of pressure-relieving equipment. Clark and Cullum (1992) found that, despite an increase in the availability of equipment, the prevalence of pressure sores increased over a four-year period. Young (1992) and Bliss and Thomas (1993) have discussed the lack of research into the various pressure-relieving systems available. The Effective Health Care Bulletin has examined the evidence regarding the range of product types available and considered that it is not possible to recommend any one product as a 'best buy'. However, they do suggest that high-risk patients are best nursed on a large cell alternating air mattress, a low air loss bed or an air fluidised bed.

Until more conclusive evidence is produced, selection of a support system must depend upon the degree of risk of the patient and individual choice. Dealey (1997) has reviewed the range of support systems and identified their potential use. In many areas, choice is limited according to the availability of equipment. Figure 5.5

Release The Pressure Sore With Equipment
Fig. 5.5 Selecting pressure-relieving equipment.

suggests how equipment can be selected according to the degree of risk of the patient.

Jay (1997) suggested that cost, patient comfort, clinician satisfaction, safety and reliability and logistical considerations need to be taken into consideration as well as efficacy. Some of these factors can be illustrated by considering the water bed. The water bed was widely used during the 1970s. It provided effective pressure reduction. However, it was very unpopular with both nurses and patients. It was extremely heavy and it was sometimes pushed into corners of a ward because of its weight, thus isolating the patient. It was very difficult for individuals to move in the bed or for nurses to move patients. There were also logistical problems with filling and emptying the water and a potential infection hazard if the water was not treated with long-life antimicrobials.

Additions to the bed

Pressure relief can be enhanced by the use of simple measures. The use of bed cradles can lift the weight of the bedclothes off the patient. Back-rests are widely used, but it should be remembered that they cause the patient to slide down the bed, risking damage to the skin by shearing. Strategic placing of pillows can relieve pressure from bony prominences such as heels, the malleoli of the ankles, and the knees. Pads can be applied to the heels or elbows for extra pressure relief. If the patient is out of bed during the day, these pads can be applied at night. Zernikem (1994) compared several devices for heels and found that eggshell foam and foam splints were the most effective.

Chairs

Once ill patients start to be seated out of bed, they are perceived to be 'mobile' and so may be left in the chair for long periods of time without being moved. Many hospital armchairs are in a poor state and fail to give any pressure relief or maintain a good posture (Dealey et ai, 1991). Chairs should be checked and replaced or repaired in the same way as mattresses. Many chairs have a reclining back of between 15° and 40° which puts the patient in a semi-reclining posture. This may make it more difficult for the patient to stand. Ideally, a chair should have a recline of not more than 10°, enabling the patient to move more freely. Although cushions may be added to chairs to improve pressure relief, the cushion should not make the chair so high that the patient's feet do not touch the floor. Conventional seating is not suitable for everyone. Some patients have severe seating problems due to contractures, deformity or infirmity; specialised seating must be considered for these people.

Cushions

Most of the research on cushions has been on those for use in wheelchairs. Wheelchairs have a canvas base which Rithalia (1989) found exerted pressures in the region of 226mmHg. It is essential that a cushion should always be used in a wheelchair. For those people who become wheelchair bound because of disability, special assessment should be made to identify the cushion most suited to the specific needs of the patient. Many physiotherapists and occupational therapists have developed specialist skills in assessment. A wide range of cushions is available, made from similar materials to mattresses and overlays.

Other hospital equipment

Vulnerable patients may spend time lying or sitting on very hard surfaces such as operating tables, X-ray tables, trolleys and some types of wheelchair. Very little consideration has been given to the need to provide some sort of pressure relief in these circumstances. Versluysen (1986) undertook a study of 100 consecutive elderly patients admitted with a fractured femur. The interface pressures were measured on the casualty trolleys and operating tables. The casualty trolleys with a 5 cm deep foam mattress showed pressures ranging from 56-60 mmHg at the sacrum and 150-160 mmHg at the heels. The fracture operating table had interface pressures ranging from 75-80 mmHg at the sacrum and 60-120 mmHg at the heels. Bridel (1993b) conducted a small pilot study of 24 patients undergoing surgery. She found an incidence of 12.5% of pressure sores that occurred as a result of damage on the operating table. Hawkins (1997) compared the standard operating table with an air-filled pad and a foam pad for patients undergoing cardiothoracic or major vascular surgery. The results showed a significant reduction in pressure sore incidence in both of the groups using the pads compared with the group lying directly on the operating table.

Every patient at risk of pressure sore development should have an individualised written plan of care. It is important to document all assessments and the care given. This will enable staff to monitor the effectiveness of the plan and to identify any early signs of tissue damage. It should also ensure effective use of equipment as patients may be moved to less sophisticated equipment when they no longer have need of the 'high tech' equipment, or vice versa.

(4) Improve the outcome for patients at risk of pressure damage through educational programmes.

There is little point in developing a policy for pressure sore prevention if no attempt is made to provide relevant education for healthcare professionals and assistants, patients and carers. A number of authors have described the beneficial outcomes of educational programmes. O'Brien et al. (1998) found a reduction in the biannual prevalence rate following an educational programme. Danchaivijitr et al. (1995) and Regan et al. (1995) found a reduction in pressure sore incidence following the introduction of a prevention programme supported by staff education.

Summary

The various aspects of pressure sore prevention can be summarised as follows:

• Assessment: identify those at risk, assess and monitor the skin, especially bony prominences, identify continence problems.

• Plan appropriate preventive measures.

• Evaluate outcomes by maintaining vigilant skin assessment.

• Monitor all support systems, establishing replacement or maintenance programmes where appropriate.

• Ensure staff have an adequate knowledge of causes and prevention of pressure sores.

• Establish a teaching programme for long-term at-risk patients and their carers.

• Monitor outcomes of overall prevention strategies by measuring the prevalence and incidence of pressure sores.

5.2.4 The management of pressure sores

If a pressure sore occurs, preventive measures should still be continued. The precise cause of the sore and the effectiveness of the prevention programme need to be evaluated. Any necessary changes must be made, such as using a different support system or increasing proteins and vitamins in the diet. There are several other factors which need to be considered in the management of pressure sores. They include position of the sore, grading of the sore and its appearance and appropriate selection of wound management products.

The position of pressure sores

Some bony prominences are more prone to pressure sores than others. Lockett (1983) reported on the position of pressure sores found in the survey by David et al. (1983). Figure 5.6 shows the range of positions with the percentages found in each. There are some specific aspects of care that need to be considered.

Fig. 5.6 The common position of pressure sores (after Lockett, 1983},

Fig. 5.6 The common position of pressure sores (after Lockett, 1983},

Heels 20%

Sacrum 31%

Lower limbs 5%

Upper limbs 3%

Trunk 4%

Buttock 27%

Trochanters 10%

Heels 20%

Sacrum 31%

Lower limbs 5%

Upper limbs 3%

Trunk 4%

Buttock 27%

Trochanters 10%

Sacrum: Dressings must be chosen with care, as many tend to ruckle up as the patient moves. Chair sitting must be strictly regulated as to type of chair and length of time seated in it. Buttocks: As for sacrum.

Heels: Ideally dressings must not be too bulky as this may impede mobility. Dressings may need to be 'tailored' in order to fit correctly around the heel. If footware is being worn, care must be taken to ensure that it is not too tight, or this will exert pressure on the heel. Ensure there is adequate pressure relief when in bed. Trochanters: Some dressings may ruckle up, so select carefully. Elbows: Pressure sores are usually caused by friction from moving about the bed. Consider ways of reducing friction - e.g. use of a monkey pole, use of pads or semipermeable film dressings.

Trunk: Sores here are uncommon; try and identify source of pressure and remove or modify it.

Grading of pressure sores

Use of a recognised system of grading pressure sores can be helpful by providing an objective description of a pressure sore. It gives a more accurate picture of the amount of tissue damage than comments such as 'a deep sore'. It should be used in conjunction with other descriptive tools such as measuring or tracing the sore and describing its appearance.

Several methods of grading pressure sores have been put forward. In a review of the relevant literature, Hitch (1995) found ten different grading methods. These systems varied slightly, but in all cases the higher the grade, the deeper the sore. Ideally there should be one recognised grading system. The American National Pressure Ulcer Advisory Panel produced a Consensus Development Statement (National Pressure Ulcer Advisory Panel, 1989) which proposed a grading system that was an amalgam of several commonly used methods of grading. They proposed it should be the start of developing a universally accepted grading system. It is as follows:

Grade I: Non-blanchable erythema of intact skin, heralding skin ulceration.

Grade II: Partial-thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and may be seen as a blister, abrasion or crater.

Grade III: Full-thickness wound involving epidermis, dermis and subcuticular layer. The ulcer presents as a crater with or without undermining.

Grade IV: Extensive destruction involving other tissues such as muscle, tendon or bone.

Figure 5.7 a-d and Plates 15-22 show examples of each of these grades of pressure sore.

Pressure sore appearance

Wound appearance has been discussed in detail in Chapter 3. The same principles can be applied to pressure sores. A pressure sore should be assessed for its appearance as well as its grade. For example, Grades III and IV sores can be necrotic, infected, sloughy or granulating in appearance. Accurate assessment is necessary in order to select a suitable wound management product.

Selection of wound management products

A variety of wound management products can be used when treating pressure sores. The range of wound management products available is discussed in Chapter 4. At present, there is insufficient evidence to determine which dressing is the most appropriate for each grade of pressure sore. It is, of course, entirely possible that such prescriptive wound care would never be appropriate and that a range of products are needed in order to address individual patient need. Many of the studies compare two products and find little or no difference in performance. This may be because there truly is no difference or because the sample size is too small to detect any differences.

Colin et al. (1997) compared a film dressing with a thin hydrocolloid dressing for the management of Grade I and II pressure sores (n = 40). They found no difference in healing rates, but there was a significantly greater reduction in wound size in the film group compared with the thin hydrocolloid group. Teot et al. (1998) compared two thin hydrocolloids on Grade I and II pressure sores and found no differences in outcome (n = 41). Both film and thin hydrocolloid dressings would seem to be suitable for these grades of sore.

Several studies have considered appropriate products for Grade II—IV pressure sores. Teot et al. (1998a,b) compared a second generation hydrocolloid - a hydrofibre dressing - with a traditional tulle dressing (n = 62). The hydrofibre dressing produced a greater healing rate and a greater reduction in wound size. However, these results were not significant. Sopata (1997) compared a gel dressing with an adhesive foam dressing and found no differences in performance between the two (n = 34). Seeley et al. (1998) found no difference in healing rates in a comparison of a hydrocolloid and an adhesive hydrocellular foam dressing {n = 40). A similar study in the UK of the same dressings produced the same results (n = 61) (Bale et al., 1997). However, the researchers found a high drop-out rate (26%), unrelated to the dressings, mainly due to patient discharge or death. They proposed that future study designs should include larger patient numbers. Thomas et al. (1997) compared a hydropolymer foam dressing with a hydrocolloid dressing (n = 99) and found no differences in outcome.

Several researchers have investigated the management of sloughy or necrotic pressure sores. Colin et al. (1996) compared a hydrogel with a dextranomer paste (n = 135). They found a significant reduction in wound size at 21 days in the hydrogel group. The hydrogel treatment costs were also significantly lower than those of the dextranomer paste. The other studies compared two different hydro-gels and found no difference in healing rates (Young et al., 1997; Bale & Crook, 1998; Bale et al., 1998). Hydrogels are effective products for managing sloughy pressure sores, however, there is no evidence to indicate which one out-performs the others.

Fig. 5.7 Pressure sore grades; (a) Grade I - non-blanchable erythema of intact skin. (b) Grade II - partial-thickness skin loss, (c) Grade III - full-thickness skin loss, (d) Grade IV - full-thickness skin loss with extensive destruction. Reproduced with kind permission of Huntleigh Healthcare Ltd.

Fig. 5.7 Coritd

The use of plastic surgery

The healing time of a large-cavity pressure sore can be considerably reduced by plastic surgery. However, it is not appropriate for all patients. Their condition may be too poor or the sore may be healing rapidly. Traditionally, reconstructive plastic surgery is most commonly used on patients with spinal cord injury. Khoo and Bailey (1990) have described the principles of reconstructive surgery. They see it to be a series of steps - removal of all necrotic tissue, repeated debridement until healthy granulation tissue is obtained and then closure of the wound using a skin graft or flap. However, there have been reports of recurrence rates of up to 80%. Kierney et al. (1998) found that such rates could be reduced by working collaboratively with colleagues in the Department of Physical Medicine and Rehabilitation. In a longitudinal study of 158 patients they found a recurrence rate of 25%. They considered their success was related to improved patient selection combined with a protocol for rehabilitation following surgical repair.

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