A pressure ulcer is a serious complication of multimorbidity and immobility. To better understand what a pressure ulcer is, we will review the different stages of pressure ulcer. The following are the different stages :
Stage 1: intact skin with blanchable erythema
Stage 2: open skin with a partial loss of thickness from epidermis to dermis with a pink wound bed
Stage 3: full-thickness loss of skin with extension through the underlying tissue but not to the fascia
Stage 4: full-thickness loss of skin extending to the bone, muscle, tendon or joint capsule, and fascia
Unstageable: full-thickness loss of skin with the base of the ulcer of slough or eschar such that the full depth of the wound cannot be appreciated. The depth of the pressure ulcer can only be evaluated and correctly staged when the slough or eschar is removed. Deeper tissues can manifest a wider area of injury or necrosis that is apparent from the surface, so the “true stage” of a pressure sore may not be evident until the wound is debrided and all necrotic material is removed .
Although pressure ulcer is not always preventable or curable, we should always attempt to prevent and treat using the best available evidence in its treatment and management. Physical, cognitive, and physiological factors such as impaired perfusion increase the risk of pressure ulcer .
7.6.2 Evidence-Based Prevention and Treatment Strategies
Prevention and treatment of pressure ulcer require multifaceted approach and strategies. These strategies include physiological and physical care, optimal nutrition, mobility, psychological and emotional support, and knowledgeable group of practitioners.
From the Cochrane reviews, nutrition is a major contributing factor to wound healing as evidenced by multiple randomized controlled trials from the Cochrane reviews . Studies were done to compare enteral vs. parenteral nutrition, dietary supplement in addition to regular diet vs. regular diet alone, and different types of dietary supplements. Subgroup analyses were done on the characteristics of the setting (e.g., hospital inpatients vs. outpatients), method of feeding (e.g., enteral vs. parenteral feeding), and characteristics of patients (e.g., people with existing malnutrition vs. people without malnutrition).
Among the prevention studies, Delmi in 1990 examined 59 elderly patients in two hospitals who sustained femoral neck fractures after accidental falls. The two groups either received a standard hospital diet alone or one nutritional supplement daily in addition to their hospital diet. The results noted that the number of pressure ulcers (PU) in the control group was 9% (n = 3/32) compared to 7% of the treatment group (n = 2/27) with a statistically nonsignificant relative risk (RR) for pressure ulcers of 0.79 (95% confidence interval (CI) of 0.14–4.39, p = 0.8).
In another hospital wherein the same study was done, the number of PU was 0 in the treatment group (n = 9) and three in the control group (n = 15, 20%) with a not statistically significant RR of 0.23 (CI of 0.01–3.98, p = 0.3). Wound healing had an RR = 0.79 in the control group which is basically the same wound healing number of PU at 6 months.
There was no PU in the treatment group (n = 25) at 6 months compared to a 7.4%, and two PU in the control group with a not statistically significant RR of 0.22 (CI of 95% 0.01–4.28, p = 0.3).
Hartgrink in 1998 followed 140 patients recovering from fractured hip for two weeks. Treatment group received standard hospital diet with nasogastric tube feeding compared to the control group receiving standard hospital diet. The study showed that 52% (25/48) in the treatment group vs. 56% (30/53) in the control group had grade 2 or more PU. There is no significant difference in a per protocol analysis (RR = 0.92, CI of 95% 0.64–1.32, p = 0.6).
After 2 weeks, the treatment group who received one nutritional supplement with the hospital diet had 55% (27.51) of a stage I–II PU whereas the control group who received hospital diet with noncaloric water-based placebo had 59% (39/52), respectively with an RR of 0.92 (95% CI of 0.65–1.3). The incidence of stage II PU was 18% in the treatment group compared to 28% in the control group, which is not statistically significant odds ratio (OR) of 0.6 (95% CI of 0.3–1.6).
In summary, of the three groups who received mixed nutritional supplements, all reported a lower PU incidence in the supplement group; however, the sample is far too small to detect clinical significance.
Several studies were also done on the treatment pressure ulcers. Taylor in 1974 used ascorbic acid 500 mg twice daily on 20 surgical patients with pressure ulcers for a month. The results showed a statistically significant reduction of the size of pressure ulcers by 84% in the intervention group as compared to 42% reduction in the control group.
Complete healing of the pressure ulcers occurred in six patients in the intervention group with a mean healing rate of 2.47 cm2/week vs. three patients with healing rate of 1.45 cm2/week in the control group. Another study was done in 1995 by Riet in multicenter nursing homes using 500 mg ascorbic acid twice daily (healing rate of 0.21 cm2/week) in the treatment group (n = 43) compared with the control group (n = 45) of a healing rate of 0.27 cm2/week.
Chernoff in 1990 used high-protein diet for pressure ulcer size ranging from 1.6 to 63.8 cm2 and very high-protein diet for pressure ulcer size ranging from 1.0 to 46.4 cm2. On both diets, the pressure ulcers decreased in size but more so in the very high-protein diet. Pressure ulcer size decreased by 42% with high-protein diet, while 72% decrease was noted with patients who received very high-protein diet.
As optimal nutrition is undoubtedly extremely important in the prevention and treatment of pressure ulcer, nutritional status should always be evaluated to ensure adequate intake of calories, proteins, and vitamins. Protein intake of one to two grams/kg/day is recommended with supplemental vitamin C and zinc. Malnutrition is one of the few reversible contributing factors to pressure ulcers. Establishing adequate caloric intake has been shown to improve healing of pressure ulcers.
188.8.131.52 Body Surface Mattress
Although pressure ulcers are sometimes unavoidable as announced at the conference in John Hopkins last February 2010 by National Pressure Ulcer Advisory Panel (NPUAP) , it is still an expectation that every prevention strategy should be implemented. One of the strategies is the use of body surface mattress. There are different body surface mattresses available to prevent or heal pressure ulcers.
Foam alternatives to standard hospital foam mattresses reduce the incidence of pressure ulcers in people at risk. Pressure-relieving overlays on the operating table reduce postoperative pressure ulcer incidence, although two studies indicated that foam overlays caused adverse skin changes. Meta-analysis of three trials indicated that Australian standard medical sheepskins prevent pressure ulcers. The relative merits of higher-specification constant, low-pressure, and alternating-pressure support surfaces for preventing pressure ulcers are unclear, but alternating-pressure mattresses may be more cost-effective than alternating-pressure overlays in a UK context. Medical grade sheepskins are associated with a decrease in pressure ulcer development .
184.108.40.206 Psychological/Emotional Support
Pressure ulcer can create an emotional and psychological distress from a distorted body image. A qualitative study was done addressing the health-related quality of life on 30 participants aged 22–94 years old with pressure ulcers from an acute and primary setting in England and Northern Ireland from December 2007 to October 2008. There were four domains on the health-related quality of life (HRQL) such as pressure ulcer (PU) specific symptoms, physical functioning, psychological well-being, and social functioning. PU-specific symptoms include pain and discomfort, exudates and odor; physical functioning included mobility, daily activities, general malaise, and sleep; psychological well-being included mood, anxiety, and worry, self-efficacy and dependence, appearance, and self-consciousness; social functioning included social isolation and participation.
The results revealed that PU has a negative effect on HRQL as it restricts mobility and activities, contributes toward pain and emotional problems leading to social isolation . Pain is less reported by the elderly population, but it needs to be considered prior to dressing changes of PU.
220.127.116.11 Staff Education
Although evidence-based guidelines for pressure ulcer prevention are available and recommended, non-adherence is frequently reported. Lack of knowledge about PU prevention and negative attitudes of nurses are also frequently reported . As clinicians (nurses, physicians, and physical therapists), we should always strive to continue to seek out the best available evidence in the prevention and management of PU. One example of evidence is the clinical care daily project, the translating research into practice (TRIP) was used to support implementation of a care management solution aimed at preventing pressure ulcers.
Initial success was evidenced by 34% reduction in PU rates and an 86% reduction in missed patient turns 3 months post-implementation of the daily intervention. The TRIP is an extension of the Roger’s model, which has proven evidence-based nursing practice intervention for PU. The Roger’s diffusion innovation model provides a framework for identifying expected patterns of human behavior when an innovation or change is introduced .
18.104.22.168 Physical and Physiological Care
In order to prevent pressure ulcers, skin should be kept moist and well hydrated. Pressure ulcers and its surrounding areas should be dry and clean, free from urine and feces. Passive mobility of patient should be done routinely for those who are unable to move or who are very weak to move on their own. For those who have enough strength to move, they should be encouraged to do so.
Although immobility is a contributing factor for developing pressure ulcer, there is no clear evidence that repositioning every 2 h or every 4 h prevents pressure ulcers. However, pressure is reduced to some degree as the patients are moved by turning and positioning. Adequate pain control to ensure pain-free mobility and pain-free wound debridement. Any physiologic deficiency like anemia and dehydration should also be corrected.
22.214.171.124 Wound Debridement
Wound debridement is done for devitalized tissue to prevent bacterial decontamination. Debridement is accomplished either by surgical removal of devitalized tissues or by a chemical enzymatic agent. Chemical enzymatic agent may be applied for stage 1–111 pressure ulcers.