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Information for facilities

Are You a Health-care Professional?

Pressure ulcers are a serious health issue for patients in all kinds of settings, even at home. A Canadian Association of Wound Care-supported study in 2004 by Drs. Gail Woodbury and Pamela Houghton indicated that the prevalence of pressure ulcers was 25% in acute care, 30% in non-acute care, 22% in mixed health-care settings, and 15% in community care¹. These figures translate into untold patient suffering, caregiver anguish, extra work for health-care providers, and millions spent in health-care dollars.

The good news is that most pressure ulcers can be prevented. What’s needed is awareness on the part of patients and health-care professionals about how pressure ulcers can be prevented and a commitment to the actions required to do so. As a health-care professional you are a key part of the pressure ulcer prevention team; you need to know four basic steps that can help you reduce the rate of pressure ulcers in patients under your care.

First, some quick facts about pressure ulcers.

Q What is a pressure ulcer?
A A pressure ulcer is a change or break in the skin caused by constant pressure, especially over a bony area such as the ankle, tailbone or elbow. Pressure ulcers are also sometimes referred to as pressure sores, bedsores, or decubitus ulcers.

Q What does a pressure ulcer look like?
A A pressure ulcer can appear simply as a red area on the skin or as a blister or as an open sore.

Q How do pressure ulcers develop?
A Pressure ulcers develop through constant pressure on a body part that causes the skin to be compressed against another surface.

Skin can also be aggravated when the body is rubbed, dragged or slid against a surface such as bed sheets. This is known as friction or shear, depending on the type of injury that results. Pressure ulcers can develop over a long period of time, or a short period, depending on the amount and duration of pressure, the original integrity of the skin, and the presence or absence of friction, shear or moisture.

Q Can pressure ulcers be prevented?
A Yes! Most pressure ulcers can be prevented. By following some simple steps that are based on best practice, the health professional can team up with the patient and other caregivers to create an environment where pressure ulcers are reduced or eliminated.

Step One: Identify who is at risk for developing a pressure ulcer.

Not everyone under your care will be at risk for developing a pressure ulcer. Most people have the ability to shift their weight enough to take the pressure off whenever discomfort sets in. By doing so, they lower their risk of causing tissue damage. However, some patients will have a reduced ability, or no ability at all, to either recognize when ischemia (restricted blood flow to an area) is occurring, or to move themselves to relieve the pressure.

Who are these at-risk patients?

1) Anyone unable to move all or some parts of their body. Patients who are very weak or those with paralysis are among those who are unable to shift their position to relieve pressure.

2) Anyone with impaired cognitive or sensory capabilities. These might be patients with dementia or those under the influence of medications that reduce their ability to sense pain or discomfort. This group would also include paraplegics and quadriplegics, and may also include patients with neuropathy, such as persons with diabetes.

3) Anyone with impaired communication abilities. These patients, such as stroke victims, may be able to sense discomfort caused by pressure, but not be able to tell anyone about it. If they can’t move themselves they may try to communicate their need to someone else, but won’t be able to.

4) Anyone who spends long periods of time sitting or lying down. Patients confined to bed or a chair, for example, are at much higher risk of developing a pressure ulcer than someone who can get up and walk around.

5) Anyone whose nutritional intake is inadequate. Nutrition plays a very important role in a person’s resistance to the development of pressure ulcers.

6) Anyone whose skin is frequently assaulted by moisture caused by urinary or fecal incontinence or perspiration.

7) Anyone undergoing surgery. Patients under general anaesthetic may be immobile for long periods of time, on a hard surface. If your facility does not have pressure-ulcer preventing surfaces in the surgical units, special attention must be paid to patients undergoing surgery.

To determine who is at risk, you must conduct a risk assessment for each patient upon admittance to your facility or care. The Braden Scale for Predicting Pressure Sore Risk is a widely used validated tool for assessing patient risk. It takes into account all of the factors above.

Once you have determined the risk level of your patient, you and your colleagues, along with the patient where possible, can create plan of prevention and care appropriate to their risk level.

Step 2: Put best practice activities into place for each patient based on their risk as identified by the Braden Scale.

Key Practice 1: Educate patients, caregivers and families about the patient’s ability to perceive ischemic pain as a response to pressure.

It is important that patients, caregivers and family members understand that the human body has a built-in method to raise the alarm, through pain, when tissue is being traumatized, but that, in some people, this alarm method may not work properly, or at all. These patients are at risk for the development of pressure ulcers.

Key Practice 2: Take the pressure off!

Taking the pressure off your patients will depend on their own capabilities.

A: For patients who are mobile: Encourage them to move.
Some patients will need help and encouragement to get out of bed, or off the chair, and go for regular walks, swim, or do other activities. Where patients are able to get out of bed, they should be encouraged to do so whenever possible. In addition to reducing the risk for pressure ulcers, regular movement stimulates blood flow and reduces the risk for other problems that arise from long periods of immobility, such as pneumonia.

B: For patients who cannot move themselves or who have difficulty moving themselves: Reposition them.
The schedule you devise should be based on the patient’s level of risk as well as other factors such as the presence of lay caregivers and the availability of pressure redistribution devices.

Repositioning the patient is not always easy. You must remember to take into account the comfort level of patients who are put into positions they do not normally assume. You need to ensure that you are not putting the patient into a position that will put pressure on another body part. You must make sure you use proper repositioning techniques and body mechanics to ensure that both you and the patient are not injured during the process. You also need to ensure pain management is part of the turning schedule.

C: For patients who are at very high risk: Implement a full range of pressure reduction strategies, in addition to repositioning.
The strategies you implement should be based on level of risk and available resources. Here are some suggestions:

• Use pressure-reduction devices such as special mattresses and seating cushions.
• Keep the head of the bed below 30 degrees to reduce pressure on the patient’s sitting bones and to lower the risk of injury from friction and shear.
• Conduct thorough, ongoing assessments of areas where pressure may be a problem; patient status may change quickly.
• Include on the pressure reduction team a seating and positioning specialist such as an Occupational Therapist or Physical Therapist who can evaluate each patient’s situation and contribute to the prevention plan.

Key Practice 3: Ensure the skin is in good shape.

The maintenance of skin integrity is a key component in the prevention of pressure ulcers. Once the skin begins to break down, it is at even higher risk for further damage. Key strategies include:

• Regular skin inspection: Look for reddened areas, or in darker skin, areas that are darker than usual, which may indicate a breakdown is imminent. DO NOT rub reddened areas—many clinicians believe this stimulates blood flow, but in fact it tends to cause further trauma and damage the skin.
• Controlling moisture: Fluid from incontinence can irritate skin and predispose it to breakdown. Keep fluid away from skin through the use of barrier creams, incontinence systems and prompted voiding where possible.
• Keeping skin clean and free from irritation. Use moisturizers where required but ensure that substances within the moisturizer are irritant-free. For skin that is too moist, the use of powders can help keep it dry.

Key Practice 4: Ensure the patient is adequately nourished.

Adequate nutrition is a cornerstone, not only for healing ulcers, but for preventing them as well. As part of a program of pressure ulcer prevention you or one of your colleagues will need to do ongoing nutritional assessments to ensure your patient is receiving enough nutrition—in the form of calories, protein, hydration and vitamins and minerals. If a patient is unable to consume enough nutrients through regular meals and snacks, other methods must be considered, such as supplementation or enteral support. A nutritional consult is recommended for any patient who has ANY difficulty consuming adequate nutrition.

Step 3: Communicate.

To reduce the rates of pressure ulcers for the patients under your care, it is important that you communicate regularly with the other members of the care team. This includes patients and their families, your colleagues, including all staff, and your management team. Reduced rates of pressure ulcers can only occur with a full-on culture change in the facility, not through isolated activities, or changes in one area, or modifications by one group of people. It cannot work effectively if everyone does not get involved and support the process.

Step 4: Continue to learn about pressure ulcer prevention.

Education is ongoing, and the more you and your colleagues know about how to prevent pressure ulcers, as well as how to implement what you know, the more successful you will be at preventing pressure ulcers.

To continue your education, you can appeal to your facility to provide ongoing inservice sessions, take courses, attend conferences, such as the CAWC annual conference, read articles or search the Web. Over time, this Web site will grow and develop with more information, useful links, and even interactive quizzes. Please visit often.

Reference
1. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian health-care settings. Ostomy/Wound Management. 2004;50(10):22-38. [read article - PDF - reprinted with the kind permission of Ostomy/Wound Management])