Fight the good fight against pressure ulcers
Prevention and treatment starts with staying 'in the know'
By
Linda Childers
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Nurses know pressure ulcers are one of the biggest challenges in caring for patients. Critical care patients are at an especially high risk, because of increased use of medical devices such as catheters and feeding tubes, among others, being bedridden and conditions that restrict flow of blood to the skin such as vascular diseases and diabetes.
Over the years, the treatment of pressure ulcers has evolved, reflecting a growing understanding of the causes and development of pressure injuries. In 2015, the
American College of Physicians released new guidelines
for preventing and treating pressure ulcers  and in 2016, the
National Pressure Ulcer Advisory Panel
announced a new Pressure Injury Staging System as “a clarifying staging system to better address the different  types of skin wounds commonly seen by medical professionals.” New guidelines for pressure ulcer prevention all involve taking a multidisciplinary approach to assessing patients who may be at risk for developing pressure ulcers. The ACP notes risk factors for pressure ulcers include older age, black race or Hispanic ethnicity, lower body weight, cognitive or physical impairments, and other comorbid conditions that affect soft tissue such as incontinence, edema, malnutrition and diabetes.
Jessica Simmons, APN
Jessica Simmons, MSN, APN, FNP-C, CWON, DNC,
a wound care practitioner at Swedish American Hospital’s Wound Care Clinic in Rockford, Ill., and a Wound, Ostomy and Continence Nursing Certification board member, said the Braden Scale for predicting pressure sore risk is still considered an important screening tool in pressure ulcer prevention.

The scale, used to determine if new patients need to be monitored more closely for the possible development of pressure ulcers, uses six areas of observation: sensory perception, moisture, mobility, nutrition, activity and friction/shear. Each category is scored and the total score, ranging from 6-23 indicates the level of pressure ulcer risk.
“The Braden Scale is one tool that we use to assess pressure ulcer risk,” Simmons said. Other strategies Simmons and her colleagues use to prevent pressure ulcers include: •
Evaluating catheters —
Since incontinence can lead to moist skin, it increases the risk of pressure ulcers and medical devices also can cause pressure ulcers. “We also have implemented the American Nurses Association’s prevention tool to reduce catheter associated urinary tract infections on a hospital-wide basis,” Simmons said. “We’ve transitioned from using indwelling catheters to looking for alternative means to manage moisture. Condom catheters have been effective at keeping the patient’s skin dry.” •
Managing friction —
Since friction can cause skin impairment and contribute to pressure ulcers, patients on medical devices are evaluated to determine how to reduce their risk. “We incorporate sacral dressings with silicone foam for usage on patients who may be on devices such as air vents that require them to lay with their head elevated at an angle,” Simmons said. “This protects the patient’s sacrum and reduces friction in the event they slide down their bed.” •
Reducing moisture —
Simmons was part of a special wound care committee that looked at patient bedding and how it can play a role in reducing the risk of pressure ulcers. “We used to double up on the layers of bedding underneath patients,” Simmons said. “We found that eliminating layers, using breathable underpads or briefs, and using antimicrobial, moisture wicking fabrics helps to reduce moisture and friction and prevent pressure ulcers.” •
Dressing changes —
Simmons said dressings have evolved over the years and improved options have helped nurses to better manage pressure ulcers. The ACP also recommends hydrocolloid and foam dressings which are effective at promoting healing. “We now have dressings that are made for multi-day use and are easier on patients who may be in pain,” Simmons said.
Specific concerns for pediatric patients
Roxanna Reyna, BSN, RNC-NIC, WCC, CWOCN,
a wound care coordinator at Driscoll Children’s Hospital in Corpus Christi, Texas, said although basic wound-healing principles apply to all patients, the specific anatomy and physiology of pediatric patients requires detailed wound care. “At DCH, we created a multidisciplinary SKIN (Saving Kids’ Integument Now) team that strives to prevent pressure ulcers in our pediatric patients,” Reyna said. “As part of the program, we look at skin-care regimen, nutritional optimization, appropriate support surfaces, patient repositioning and moisture management. Since implementing the program, our pressure-ulcer incidence has fallen substantially.” • 
Skin care regimen —
After evaluating different products for adverse reactions, Reyna said DCH chose skincare products made for sensitive skin that contain natural oils and botanicals that provide cleansing, nourishment and moisture. The ACP recommends clinicians also use electrical stimulation as adjunctive therapy to accelerate wound healing. •
Evaluating support surfaces —
Looking at mattresses and surfaces of bassinets and cribs throughout the hospital, Reyna said DCH staff conducted a small study to evaluate the pressure redistribution of support surfaces. “We upgraded to pressure-redistribution mattresses and continue to reposition patients every two hours in order to prevent pressure ulcers from developing,” Reyna said. The ACP recommends mattresses made of foam or gel that doesn’t move when a patient lies on it, for those who may be at an increased risk of developing pressure ulcers. •
Remembering nutrition —
One of the overlooked areas of pressure ulcer prevention is nutrition, Reyna said. The ACP also recommends using protein or amino acid supplementation in patients with pressure ulcers to reduce wound size. “Patients at risk of pressure ulcers need adequate nutrition and hydration,” Reyna said. “A deficiency in nutrients can delay wound healing, so patients are evaluated to ensure they are getting protein, vitamin C and zinc, all of which help with wound healing.”

As part of the program, we look at skin-care regimen, nutritional optimization, appropriate support surfaces, patient repositioning and moisture management. Since implementing the program, our pressure-ulcer incidence has fallen substantially.”  
— Roxanna Reyna, RN

A look at chronic wounds
  • In the U.S., chronic wounds affect around
    6.5 million patients
    .
  • According to the Agency for Healthcare Research and Quality, there are
    more than 17,000 pressure ulcer related lawsuits
    filed annually (second only to wrongful death lawsuits).
  • Nearly
    60,000 U.S. hospital patients are estimated to die each year
    from complications due to hospital-acquired pressure ulcers.
  • The
    total annual cost for treating pressure ulcers in the U.S.
    is estimated at $11 billion.
  • 40 million inpatient surgical procedures
    were performed in the U.S. in 2000, followed closely by 31.5 million outpatient surgeries.
  • 29.1 million people or
    9.3% of the U.S. population have diabetes
    .
  • 85% of diabetes-related lower extremity amputations
    are preceded by a foot ulcer. 
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EDITOR'S NOTE:
Linda Childers is a freelance writer.