Pressure ulcer prevention

Risk factors

By: Mölnlycke Health Care, December 8 2011Posted in: Pressure ulcer prevention

Both intrinsic and extrinsic factors must be considered. General health, nutritional status, skin moisture, age and history of previous pressure ulcers are some of the key components that affect the risk for a patient developing pressure ulcers.
Consider extrinsic factors like pressure, friction, shear, and microclimate
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Learn more about the aietiology of pressure ulcers

  • Intrinsic and extrinsic factors must be considered
  • A structured risk assessment should be undertaken – reassessment must not be forgotten
  • Accurate documentation of each assessment is critical
  • A prevention plan should be implemented based on risk assessment
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Intrinsic Risk Factors include an assessment of the following

General health status – Does the patient present multiple health issues? Conditions such as diabetes mellitus and respiratory conditions may increase a patient's risk for the development of pressure ulcers.
Mobility status – Reduced mobility affects the ability to relieve pressure on vulnerable tissues.
Nutritional status – Poor nutrition may have multiple effects. Nutritional status can be assessed though simple weight monitoring and the assessment of specific indicators such as haemoglobin or serum albumin.
Skin moisture – The effects of incontinence and body temperature should be considered when assessing skin's condition.
Age – The effects of age may increase risk. However, if a mix of risk factors are present, pressure ulcers can occur at any age.
History of previous pressure ulcers – Healed ulcer sites represent a high risk as scar tissue may only be 80% as strong as original tissue.
Drug history – Steroids are an example of a drug that may affect skin integrity.
Perfusion / oxygenation related issues – CVS instability, inotrope support, and oxygen requirements are all reported to increase the risk of pressure ulcers.
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Extrinsic Risk Factors

Four extrinsic factors1, 24 are most commonly reported to pose a risk of tissue damage:

  1. Pressure1, 24
  2. Shear1, 24, 25, 26
  3. Skin microclimate1, 27 – heat and humidity
  4. Friction1 – this force has historically been included in this list but is now discussed separately and the wounds described as friction wounds

It is often the combination of forces that create the highest risk for a vulnerable patient. Tissue deformation happens in soft tissue, adipose tissue, connective tissue and muscle when these forces occur. This stress and strain affect the perfusion and cellular mechanisms essential for normal functioning. In the clinical setting, non uniform forces are usually witnessed and shear forces are often present. Age, lifestyle, and chronic illnesses can affect the ability to respond to these forces.

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Pressure



Definition- a force applied perpendicular to tissue.

Fast facts

  • Affected by stiffness of surface, load, tissue composition, and geometry
  • Usually expressed in lb/in2 (psi) or mmHg
  • Bony prominences can be exposed to higher stresses/strains and therefore may be reflected in deep tissue injury
  • Combination of pressure with other forces may exacerbate issues
  • Pressure wounds tend to be uniform or circular in shape and tend to present with a neat appearance
  • Influence of time – high loads experienced for short periods of time can be as damaging as smaller loads experienced for long periods of time
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Shear



Definition - “an action or stress resulting from applied forces which causes or tends to cause two contiguous internal parts of the body to deform in the transverse plane”.


Fast Facts

  • Occurs when the patient is lying flat and increases with lateral movement
  • Tissue deformation may increase when constant pressure and shear forces are present
  • Increased shear forces can exacerbate tissue damage
  • Shear inflicted ulcers often present with a shallow area that progresses to a depth represented by bruising. Skin edges may also be ragged
  • Shear forces tend to cause deeper tissue damage which may not be immediately visible
  • Changes in position are likely to cause shear – for example when the head of bed is raised or lowered
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Microclimate



Definition - the local tissue temperature and moisture
at the body/support surface interface.

Fast Facts

  • Moisture is known to impact on ability of the skin to function
  • Reduces stiffness, softens skin, may cause maceration
  • May reduce strength of skin by up to 96% and may lead to erosion
  • Increase the co-efficient of friction
  • Increases adhesion to contact surface and may increase the risk of shear
  • Promote abrasion, slough and ulceration
  • Shifts skin pH from acidic to alkaline
  • Elevated temperature increases metabolic rate
  • Elevated temperature leads to increased sweating
  • At the interface point with the support surface, body heat becomes trapped, the skin's temperature increases, and moisture accumulatesAnimal studies have demonstrated a link between higher temperatures and ulcer formation14
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Friction



Definition - “the contact force parallel to the skin surface in case of sliding – i.e. sliding of the surfaces along each other”.

Fast Facts

  • Friction results in the disturbance of the skin.  Its ability to act as a barrier may be impaired. This poses and increased risk of infection or the underlying structures may be exposed
  • Friction often presents as a shallow, denuded and painful area
  • The buttocks, sacrum, back elbow, and heels are the most common areas for friction wounds
  • Friction wounds may be characterized by being very untidy wounds with ragged edges

References

  1. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline. Washington DC: National Pressure Ulcer Advisory Panel; 2009
  2. Bibliometric Analysis of Pressure Ulcer research. JWOCN; 37(6); 627-632; Hong-Lin Chen et al; 2010
  3. Medical Device related pressure ulcers in hospitalised patients. International Wound Journal; 7(5); 358-365; Black J M et al; 2010
  4. WOCN Society. Professional Practice Manual 3rd Edition, Appendix D Prevalence and Incidence: A Toolkit for Clinicians, Mt. Laurel NJ; 2005 3. Dressing related pain in patients with chronic wounds: an international patient perspective. Price P et al. International Wound Journal; 2008
  5. International Guidelines: Pressure ulcer prevention: prevalence and incidence in context. A consensus document. London: MEP Ltd, 2009
  6. Pressure Ulcer Prevalence Monitoring Project: Summary report on the Prevalence of Pressure Ulcers. EPUAP Review; Volume 4, Issue 2, 2002
  7. Results of nine international pressure ulcer surveys: 1989-2005. Ostomy Wound Management; 54(2). Vangilder C et al; 2008
  8. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy/Wound Management. 50(10):22-38. Woodbury MG, Houghton PE; 2004
  9. Prentice JL, Stacey MC. Pressure ulcers: the case for improving prevention and management in Australian health care settings. Primary Intention 2001; 9: 111-12027
  10. A Cross-sectional Descriptive Study of Pressure Ulcer Prevalence in a Teaching Hospital in China Zhao G, Ostomy Wound Manage. 2010 Feb;56(2):38-42
  11. Factors affecting healing of Pressure ulcers in Korean Acute Hospital. Sung Y.H et al. WOCN January 2011
  12. Description of pressure ulcers pain at rest and at dressing change. Szor JK. JWOCN. 26(3):115–120; 1999
  13. Pressure ulcer pain suffering; issues in a multi centre pain prevalence, Nixon J et al. Oral presentation at EPUAP Annual Conference, Birmingham, UK. 2010
  14. Reaching for the moon: achieving zero pressure ulcer prevalence. J Wound Care 18(4): 137–44 Bales I, Padwojski A ;2009
  15. The cost of pressure ulcers in the UK: Age and Ageing; 33: 230–235; Bennett G et al; 2004
  16. Legal Issues in the Care of Pressure Ulcer Patients: Ket Concepts for Healthcare Providers – A Consensus Paper from the International Expert Wound Care Advisory Panel. 23(11):493-507, November; Fife C et al; 2010
  17. Centers for Medicare & Medicaid Services. Proposed Fiscal Year 2009 Payment, Policy Changes for Inpatient Stays in General Acute Care Hospitals. Available at: http://www.cms.hhs.gov/apps/media/press/factsheet.asp?Counter=3045&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500. Accessed May 13, 2008.
  18. Centers for Medicare & Medicaid Services. Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2009 Rates; Proposed Changes to Disclosure of Physician Ownership in Hospitals and Physician Self-Referral Rules; Proposed Collection of Information Regarding Financial Relationships Between Hospitals and Physicians; Proposed Rule. Federal Register. 2008;73(84):23550. Available at: http://edocket.access.gpo.gov/2008/pdf/08-1135.pdf
  19. Hospitalisation related to pressure ulcers among adults 18 years and over. Agency for Healthcare Research and Quality; Statistical Brief #64. 2006
  20. Interprofessional Management of Complex Continuing Care Patient Admitted with 18 Pressure Ulcers. Baker T et al. Ostomy Wound Management; Feb 2011
  21. Pressure Ulcer Classification; Differentiation between pressure ulcers and moisture lesions. EPUAP Review 6(3); Defloor T., et al ;2005
  22. Wound Dressing Shear Test Method (Bench) Providing Results Equivalent to Humans.Bill B et al. Poster Presentation at the EPUAP Congress, Oporto, 2011
  23. Wound Dressings, Measuring the Microclimate They Create, Call E. Oral Presentationat the EPUAP Congress, Oporto, 2011
  24. Dressings can prevent pressure ulcers :fact or fallacy? The problem of pressure ulcer prevention. Wounds UK;5(4) pg 61-64; Butcher M et al; 2009
  25. Journal of Wound, Ostomy and Continence Nursing: May/June 2007 - Volume 34 - Issue 3S - p S67 doi: 10.1097/01.WON.0000271036.00057.f8 Scientific and Clinical Abstracts From the 39th Annual Wound, Ostomy and Continence Nurses Annual Conference, Salt Lake City, Utah, June 9-13, 2007:Research Abstracts: Wound-Evidence-Based Interventions
  26. Shear A contributory factor in pressure ulceration. A presentation aimed at clinicians and associated professional. www.npuap.org; accessed 14/12/09
  27. Temperature-modulated pressure ulcers: a porcine model. Arch Phys Med Rehabil. 76(7):666-73; Kokate J.Y et al; 1995
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