Pressure ulcers


Pressure ulcersresult from tissue damage caused by unrelieved, focal pressure (Dealey 1994). When body tissues are compressed against a hard surface (such as a bony prominence), capillaries are closed off, and the consequent reduction in blood flow causes hypoxia in the area then Pressure ulcers will develop. If the pressure is not relieved, the capillaries rupture and leak, resulting in non-blanching erythema.

Non-blanching erythema is an ominous sign of tissue damage.
Ongoing, unrelieved Pressure ulcers results in a cycle of inflammation, hypoxia, oedema, ischaemia, and necrosis that extends the area of tissue damage.

Eventually, tissue breakdown occurs. Because muscle and fat are more susceptible to the effects of pressure than is skin, damage to the internal tissues can be more extensive than what is apparent on the skin.

An persons susceptibility to pressure-related tissue damage varies.

It is dependent on:
-the intensity and duration of pressure;
-and the tolerance of the tissues to pressure.

Strategies for prevention of pressure-related damage

Effective skin care is vital to the prevention of pressure ulcers. When assisting elderly people in their care with daily hygiene, nurses have an excellent opportunity to inspect skin condition carefully. At this time it is easy to observe skin turgor, moisture level, colour, and texture. Ensuring that wounds and skin conditions are not overlooked does require some training, and a program of training in skin assessment is recommended for all nurses working with older persons. With sound assessment skills, potential pressure areas can be identified early and action taken to avoid skin breakdown.

Risk assessment

It is vital to determine which individuals are at risk of developing pressure ulcers.
The factors that place an individual at greater risk of developing a pressure ulcer have been incorporated into various risk-assessment scales. These scales rate various factors that can contribute to pressure ulcer development and express this rating as a numerical score.

The most important factors are:

-immobility: the inability to change position voluntarily; and
? decreased sensory perception: a reduced ability to sense discomfort and pain.

Other factors that can contribute to pressure-related damage include:

-shear and/or friction;
-age greater than 65 years;
-poor nutrition; and
-poor circulation.

The most commonly used risk-assessment scales are the Norton scale (1989), the Waterlow scale (1985), and the Braden scale (1987). An effective scale should indicate whether an individual is at low, moderate, high, or very high risk of developing pressure ulcers. Pressure ulcer risk-assessment scales have received some criticism for over-predicting risk and for a lack of valid research studies to support their use (Banks 1998). However, the use of risk-assessment tools has many benefits including effective use of resources, facilitation of auditing, improvement in standards, minimization of risk, and protection against litigation.

Prevention of pressure ulcers
In addition to the systematic, regular assessment of risk, it is vital to ensure that evidence-based strategies are used that translate the risk score into practical nursing interventions (Maklebust & Sieggreen 2001). After all, practical interventions, not the completion of a risk-assessment score, prevent the development of a pressure ulcer. The introduction of any pressure ulcer risk- assessment scale must be undertaken in association with a comprehensive education strategy and implementation plan to ensure that effective use is made of the information gained from using the scale.

Table 4.1 (below) presents some useful strategies and the rationale for each.

Control of excess moisture:

Excess moisture can cause maceration of the
(incontinence, perspiration, skin wound exudate)

Avoid dry skin Dry skin can crack: A cleanser with a pH close to that of th
skin should be used.

Good nutritional status and Supplementation needs to be considered
fluid balance (vitamins, high-energy and high-protein drinks, enteral feeding)

Avoid use of doughnut-shaped: These are not effective devices.

Avoid massaging of bony: This can cause deep tissue damage prominences

Avoid raising the bed head higher: A bed head raised more than 30 degrees than 30 degrees results in increased shear forces because

Raise the foot end of the bed: This can help prevent sliding down the bed slightly by providing counter-traction the person slides down the bed