Pressure ulcers occur when you remain in one position for too long – and “too long” may be as little as a couple of hours, although it can take a week before the damage is visible.
Under normal circumstances, a healthy person with unimpaired mobility automatically moves about, whether awake or asleep, in order to relieve discomfort and prevent pressure damage occurring, so those at risk of developing an ulcer are people who are not able to move at will, because of illness, pain, surgery or disability.
In addition to pressure, other factors that can contribute to tissue damage include friction and shear (where the skin is rubbed or stretched); poor nutrition and hydration; skin maceration (where incontinence or excessive sweating leaves the skin damp). Both very obese (bariatric) individuals and those who are underweight/malnourished are at an additional risk of developing pressure ulcers.
The injuries have been known by various names, including bedsores, pressure sores and decubitus. Pressure ulcer is now the term preferred by healthcare professionals, and it is defined as “a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction”.
The mechanism by which the damage occurs is that compression prevents efficient blood flow to the area, so the tissues are deprived of oxygen, leading to damage and death. A pressure ulcer has been likened to an iceberg, in that what is visible at the surface is just a small proportion of the injury that lies beneath.
The most common places to develop pressure damage are the heels and sacrum, followed by buttocks, elbows, ankles and hips: generally, areas where bone is close to the surface, with less padding for protection. It is the tissue nearest to the bone that is damaged first, with the surface of the skin being the last to be affected.
Pressure ulcers are categorised from I to IV, according to severity.
The cost of pressure damage is enormous. First and most importantly, these are extremely painful wounds, which bring a great deal of suffering to the individual concerned.
The financial cost to the NHS has been estimated to be between £1,760 million and £2,640 million each year – approximately 4% of its total budget – making pressure ulcers the single most costly chronic wound to the Health Service. These figures have been arrived at based on typical costs for treating pressure ulcers, which are £1064, £4402, rising to £7313 and £10,551 for wounds of Category I through to IV.
It is widely believed that the prevalence and cost of pressure ulcers is understated, as the majority of studies have been based on hospital populations, where just 11% of cases are found. In fact, it is likely that some 20% of care home residents and 30% of people cared for in the community will develop pressure ulcers.
Slow and difficult to heal, these costly and damaging wounds are almost entirely preventable, with good nursing care. It is important to identify those who are at risk and to intervene early with strategies for prevention, in the bed, wheelchair or chair, in the bath and on the commode.
There is no universal agreement on a single approach to prevention or treatment of pressure damage. A review of 174 studies of treatment strategies, carried out in 2013, found no evidence that nutritional support; local wound applications; support surfaces; or adjunctive therapies had any greater effect than standard care, placebo or sham interventions.
There was evidence that air-fluidised beds, protein-containing nutritional supplements, electrical stimulation and application of radiant heat helped to reduce wound size.
A review of 26 studies, undertaken in the same year, suggested that preventive strategies with a number of elements, known as “skin bundles” could be effective. The common features of the effective strategies were: staff training, revision of protocols for assessing and documenting ulcers; audit and feedback; redesigning documentation and reporting processes; and use of risk prediction scores.
NICE (the National Institute for Health and Clinical Excellence) has guidance on pressure ulcers. You can read their recommendations on their website (it will open in a new browser window).
The first requirement is to carry out and document an assessment of pressure ulcer risk:
• when a person is admitted to hospital or care home
• when a person is receiving care in a GP’s surgery, emergency department or community care setting, if they have a risk factor for pressure ulcers, such as:
* significantly limited mobility or ability to reposition themselves (for example, people with a spinal cord injury); * a previous or current pressure ulcer; * significant loss of sensation; * nutritional deficiency; * significant cognitive impairment.
Those assessed as being at high risk should be given a skin assessment, for:
• skin integrity in areas of pressure
• colour changes or discolouration
• variations in heat, firmness and moisture (for example, because of incontinence, oedema, dry or inflamed skin).
Repositioning is a key intervention for individuals assessed as being at risk. If they are able to move themselves, they should be encouraged to do so frequently, and at least every six hours. If they are unable to manage independently, they should be assisted with repositioning, using appropriate equipment if necessary.
Surfaces that provide good support for people at risk of pressure damage include high specification foam, and systems that provide alternating pressure, continuous low pressure, air floatation or viscous fluid.
“Stop the Pressure” is an initiative from NHS Midlands and East, which has been rolled out across the NHS. The campaign used data collected by NHS Safety Thermometer and worked to raise awareness and improve monitoring and management of patients at risk of damage.
They found that the number of new pressure ulcers was reduced by 50% in one year.
A key part of the success of the campaign was attributed to a preventive strategy with a number of elements, referred to as the SSKIN bundle, which was communicated with great clarity.
The acronym SSKIN contains five key steps:
• Surface – make sure patients have the right support
• Skin inspection – early inspection means early detection
• Keep patients moving
• Incontinence/moisture – patients need to be kept clean and dry
• Nutrition/hydration – make sure patients have the right diet and plenty of fluids
As part of a worldwide effort to reduce the prevalence of pressure damage, November sees the international Stop Pressure Ulcer Day, which this year is 16th November 2017.
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