Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Lyder ; Elizabeth A. Lyder ; 1 Elizabeth A. Pressure ulcers remain a major health problem affecting vitamin d3 and graves diesease 3 million adults.
Preventing pressure ulcers has been a nursing concern for many years. Although the prevention of pressure ulcers is a multidisciplinary responsibility, nurses play a major role. Insolutions program and skin care ahrq, the U.
Although the AHRQ document was published 15 years ago, it still serves as the foundation for providing preventive pressure ulcer care and a model for other pressure ulcer guidelines developed afterward. Nurses are encouraged to review these comprehensive guidelines. The document identifies specific processes e, solutions program and skin care ahrq. Solutions program and skin care ahrq also suggests that when the health care providers are functioning as a team, the incidence rates of pressure ulcers can decrease.
The incidence rates of pressure ulcers vary greatly with the solutions program and skin care ahrq care settings. For patients in the hospital, they can occur within the first 2 weeks. Mortality is also associated with pressure ulcers. Several studies noted mortality rates as high as 60 percent for older persons with pressure ulcers within 1 year of hospital discharge.
Thus, solutions program and skin care ahrq, the development of pressure ulcers can be a predictor of mortality. Studies further suggested that the solutions program and skin care ahrq of skin breakdown postsurgery can lead elders to have major functional impairment post surgical procedure.
It has been estimated that the cost of treating pressure ulcers is 2. Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis.
Sincewe have understood that normal blood pressure within capillaries ranges from 20 to 40mm Hg; 32mm Hg is considered the average. However, capillary blood pressure may be less than 32 mm Hg in critically ill patients due to hemodynamic instability and comorbid conditions; thus, even lower applied pressures may be sufficient to induce ulceration in this group of patients.
Pressure ulcers can develop within 2 to 6 hours. More than risk factors of pressure ulcers have been identified solutions program and skin care ahrq the literature. Some physiological solutions program and skin care ahrq and nonphysiological extrinsic risk factors that may place adults at risk solutions program and skin care ahrq pressure ulcer development include diabetes mellitus, solutions program and skin care ahrq, peripheral vascular disease, cerebral vascular accident, sepsis, and hypotension.
Microcirculation is controlled in part by sympathetic vasoconstrictor impulses from the brain and secretions from localized endothelial cells. Since neural and endothelial control of blood flow is impaired during an illness state, the patient may be more susceptible to ischemic organ damage e.
Additional risk factors that have solutions program and skin care ahrq correlated with pressure ulcer development are age of 70 years and older, current smoking history, solutions program and skin care ahrq, dry skin, low body mass index, impaired mobility, altered mental status i. The few studies that have included sufficient numbers of black people for analysis purposes have found that blacks suffer more severe pressure ulcers than nonblacks.
What tool and how often a pressure ulcer risk assessment should be done are key questions in preventing pressure ulcers. Due to the number of risk factors identified in the literature, nurses have found the use of risk assessment tools helpful adjuncts to aid in the identification of patients who may be at high risk.
Most health care institutions that use pressure ulcer risk assessment tools use either the Braden Scale or Norton Scale, with the Braden scale being the most widely used in the United States. The Braden Scale is designed for use with adults and consists of 6 subscales: The scores on this scale range from 6 high risk to 23 low riskwith 18 being the cut score for onset of pressure ulcer risk.
Research has shown that hospital nurses could accurately determine pressure ulcer risk The Norton Scale was developed in the United Kingdom and consists of five subscales: The Braden Scale and Norton Scale have been shown to have good sensitivity 83 percent to percent, and 73 percent to 92 percent, respectively and specificity 64 percent to 77 percent, and 61 percent to 94 percent, respectivelybut have poor positive predictive value around 40 percent and 20 percent, respectively.
The net effect of poor positive predictive value means that many patients who will not develop pressure ulcers may receive expensive and unnecessary treatment. Moreover, optimal cutoff scores have not been developed for each care setting e.
Thus, nurses still need to use their clinical judgment in employing preventive pressure ulcer care. Centers for Medicare and Medicaid Services CMS recommends that nurses consider all risk factors independent of the scores obtained on any validated pressure ulcer prediction scales because all factors are not found on any one tool.
The usefulness of clinical informatics to assess and prevent pressure ulcers has been explored. Several key characteristics of facilities that were high users emerged:. There is no agreement on how frequently risk assessment should be done. The appropriate interval for routine reassessment remains unclear. Studies by Bergstrom and Braden 4243 found that in a skilled nursing facility, 80 percent of pressure ulcers develop within 2 weeks of admission and 96 percent develop within 3 weeks of admission.
The Institute for Healthcare Improvement has recently recommended that in hospitalized patients, pressure ulcer risk assessment be done every 24 hours 44 rather than the previous suggestion of every 48 hours. Preventing pressure ulcers can be nursing intensive. The challenge is more difficult when there is nursing staff turnover and shortages.
Studies have suggested that pressure ulcer development can be directly affected by the number of registered nurses and time spent at the bedside. Given that the cost of treatment has been estimated as 2. A growing level of evidence suggests that pressure ulcer prevention can be effective in all health care settings.
One study examined the efficacy of an intensive pressure ulcer prevention protocol to decrease the incidence of ulcers in a bed long-term care facility. The sample included residents 69 prior to prevention intervention and 63 after prevention intervention.
The 6-month incidence rate of pressure ulcers prior to the intensive prevention intervention was 23 percent. For the 6-months after intensive prevention intervention, the pressure ulcer incidence rate was 5 percent. This study demonstrated that significant reductions in the incidence of pressure ulcers are possible to achieve within a animal cancer specialists short period of time 6 months when facility-specific intensive prevention interventions are used.
A subsequent study by the same researchers was undertaken to evaluate the cost effectiveness of the pressure ulcer prevention protocol after a 3-year period, solutions program and skin care ahrq.
The implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in pressure ulcer incidence were lost over time. However, clinical results of ulcer treatment improved and treatment costs fell during the 3 years. A more recent nursing study examined the effects of implementing the SOLUTIONS program, which focuses pressure ulcer prevention measures on alleviating risk factors identified by the Braden Scale, in two long-term care facilities.
Facility B beds experienced a corresponding 76 percent reduction from 15 percent to 3. Gunningberg and colleagues 52 investigated the incidence of pressure ulcers in and among patients with hip fractures and found significant reductions in incidence rates 55 percent in to 29 percent in The researchers attributed these reductions in pressure ulcer incidence rates to performing systematic risk assessment upon admission, accurately staging pressure ulcers, using pressure-reducing mattresses, and continuing education of staff.
Thus, the use of comprehensive prevention programs can significantly reduce the incidence of pressure ulcers in long-term care. The use of quality improvement models, where systematic processes of care have been implemented have also been shown to reduce overall pressure ulcer incidence.
In one study involving 29 nursing homes in three States, representatives of the 29 nursing homes attended a series of workshops, shared best practices, and worked with one-on-one quality improvement mentors over 2 years. Another study using similar methods involving 22 nursing homes found 8 out of 12 processes of care significantly improved.
In the acute care setting, several studies have attempted to demonstrate that the implementation of comprehensive pressure ulcer prevention programs can decrease the incidence rates. However, no studies could be found that eliminated pressure ulcers. One large study evaluated the processes of care for hospitalized Medicare patients at risk for pressure ulcer development.
Charts were evaluated for the presence of six recommended pressure ulcer prevention processes of care. This study found that at-risk patients who used pressure-reducing devices, were repositioned every 2 hours, and received nutritional consults were more likely to develop pressure ulcers than those patients who did not receive the preventive interventions.
One explanation for this finding may be the amount of time 48 hours before the preventive measures were implemented. Given the acuity of patients entering hospitals, waiting 48 hours may be too late to begin pressure ulcer prevention interventions.
Thus, despite this one study, there is significant research to support that implementing comprehensive pressure ulcer prevention programs reduces the incidence of pressure ulcers. A key component of research studies that have reported reduction of pressure ulcers is how to sustain the momentum over time, especially when the facility champion leaves the institution.
It is clear from the evidence that maintaining a culture of pressure ulcer prevention in a care setting is an important challenge, one that requires the support of administration and the attention of clinicians. Although expert opinion maintains that there is a relationship between skin care and pressure ulcer development, there is a paucity of research to support that.
How the skin is cleansed may make a difference. One study found that the incidence of Stages I and II pressure ulcers could be reduced by educating the staff and using a body wash and skin protection products. The majority of skin care recommendations are based on expert opinion and consensus.
Intuitively nurses understand that keeping the skin clean and dry will prevent irritants on the skin or excessive moisture that may increase frictional forces leading to skin breakdown.
Individualized bathing schedules and use of nondrying products on the skin are also recommended. Moreover, by performing frequent skin assessments, nurses will be able to identify skin breakdown at an early stage, leading to early interventions. Although there is a lack of consensus as to what constitutes a minimal skin assessment, CMS recommends the following five parameters be included: The search for the ideal intervention to maintain skin health continues.
One study compared hyperoxygenated fatty acid compound versus placebo compound triisotearin in acute care and long-term care patients. Pressure ulcer incidence was lower in an intervention group of acute care patients when topical nicotinate was applied 7.
There are several key recommendations to minimize the occurrence of pressure ulcers. Avoid using hot water, and use only mild cleansing agents that minimize irritation and dryness of the skin.
Skin care should focus on minimizing exposure of moisture on the skin. One of the most important preventive measures is decreasing mechanical load. If patients cannot adequately turn or reposition themselves, solutions program and skin care ahrq, this may lead to pressure ulcer development.
It is critical for nurses to help reduce the mechanical load for patients. This includes frequent turning and repositioning of patients, solutions program and skin care ahrq. Very little research has been published related to optimal turning schedules. This landmark nursing study created the gold standard of turning patients at least every 2 hours.