Pressure ulcers or otherwise known as bed sores or decubitus ulcers are skin injuries in the underlying tissue that result from long periods of pressure on the skin. In most cases, ulcers develop on those sections of the skin that cover bony areas such as ankles, heels, or hips (Mayo Clinic Staff, 2017). This issue is a pervasive quality problem in healthcare because ulcers develop quickly, with some skin sores healing with treatment and others never disappearing completely. The research paper will synthesize the relevant literature on the topic of ulcer management and prevention to identify ways of eliminating this quality problem in healthcare and improve patient satisfaction.
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Pressure Ulcers Symptoms, Causes, and Pathophysiology
According to the NHS (2017), early symptoms that may point to the development of ulcers include discoloration of the skin (people with light skin usually get red patches while those with dark skin get either purple or blue patches). Usually, those patches of discolored skin feel “warm, hard, or spongy”; patients can experience itchiness or pain of the affected area, with that area not changing color (NHS, 2017, para.1). Later symptoms of pressure ulcers indicate that the condition has progressed into a severe skin injury. Such symptoms include “open blisters or wounds (category two), deep injuries that reach deeper skin layers (category three), and severe injuries that can even reach bones and muscles (category four)” (NHS, 2017, para. 2).
The primary cause of pressure ulcers is associated with the tissue being placed in the same position for a prolonged time, which is common among paralyzed patients and those with fractured bones. The tissue’s distortion takes place because of the following two reasons:
An object may be pressing on the tissue and thus causing damage to it through preventing adequate blood circulation from occurring;
The tissue experiences pressure from being compressed between the skeleton and the support of the body (in most cases, such support includes chairs and beds).
Because of the compression and distortion of the skin tissue, blood vessels can become distorted compared to their usual shape and thus are ineffective in delivering blood to the skin (Gebhardt, 2002). Although the specific nature of changes occurring in the ischemic skin is not understood completely, such changes can lead to necrosis and further skin damage that is complicated to manage. Subsequently, necrosis leads to the development of pressure ulcers; most importantly, among patients that are particularly susceptible to the problem, the condition can develop within several hours. However, it is crucial to understand that the mere application of pressure on soft tissue cannot cause damage to it. In the case of ulcers, it is only when pressure is non-uniform that the risk of experiencing damage increases. This means that high levels of pressure that are uniform cannot cause pressure ulcers, as, for example, in divers or underwater organisms that are exposed to a uniform pressure of high levels.
The development of ulcers can be associated with either one or a combination of several causes, which include a patient’s loss of movement or sensation or the failure of reactive hyperemia (Gebhardt, 2002). Healthcare providers should take appropriate measures to prevent pressure ulcers from developing due to reactive hyperemia’s failure. Immobility has to be profound to cause ulcers independently, which suggests that only those individuals with severe and debilitating spinal conditions can develop pressure ulcers from not being able to move. Therefore, immobility alone is the cause of pressure ulcers only in rare cases. It is important to mention that even small movements of the body such as leaning in different directions are enough to get some pressure relief. It is noteworthy that patients that are in a state of extreme immobility but still can communicate will not develop pressure ulcers; they can ask their healthcare providers to help them change their position and re-adjust the pressure. Patients with poorly fitted plaster casts can be included in this category because they can ask for help but cannot reduce the pressure themselves. Because of this, nurses encourage patients with orthopedic casts to report any pain or discomfort when being positioned in the same state for a prolonged period.
With regards to patients that have developed ulcers due to the failure of reactive hyperemia, it is crucial to note that their tissue cannot be restored due to ischemic episodes. Pathophysiologically, pressure ulcers manifest as white skin patches that do not change color with pressure. According to Gebhardt (2002), reactive hyperemia is a contributor to pressure ulcers that occur in dying or very sick patients that cannot refill capillary beds due to intense compression (Gebhardt, 2002).
Patients affected by ulcers do not feel any pain or discomfort resulted from the prolonged distortion of the tissue and thus cannot report it or move to relieve it because of the loss of sensation, which can occur in two ways. First, the damage to the nervous system can prevent patients from feeling pain or discomfort; such damage can be traumatic (e.g., spinal injury), congenital (e.g., spina bifida), or maybe a result of a disease (e.g., aortic aneurysm or metastatic disease) or iatrogenic causes (e.g., local nerve blocks) (Gebhardt, 2002).
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Pressure Ulcers Significance
For different patients, the implications of sustaining pressure ulcers can vary from minor discomfort to a significant reduction in their quality of life due to painful and uncomfortable injuries of large size (Gebhardt, 2002). Importantly, pressure ulcers can even lead to death in the most severe cases. The quality problem of managing or preventing pressure ulcers is significant because it causes significant harm to patients that suffer from them, which subsequently increases health care budgets. Also, when health care providers and facilities fail to manage or prevent pressure ulcers, they automatically increase the chances of further litigation.
While the exact costs of pressure ulcers remain debatable, it has been concluded that expenditures are on the high level regarding both management and prevention. Despite this, healthcare professionals are required to provide the highest levels of care regardless of costs. Therefore, it is fundamental to discuss cost-effective and efficient means of ulcer prevention to reduce healthcare spending and improve patient outcomes.
Interventions for Preventing and Managing Pressure Ulcers
According to the guidelines developed by the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance, nutrition plays a large role in ulcer prevention and management (Haesler, 2014). Because of this, it is recommended to perform a nutritional screening for every patient at risk (or those that have already developed ulcers) at the initial admission to the healthcare facility and with each dramatic change in condition. Also, it is essential to conduct nutritional assessments and weight statuses of patients to evaluate their weight history, determine whether they can consume food independently, and assess the overall adequacy of nutrients’ intake (Haesler, 2014).
After conducting successful screenings and assessments, it is recommended to develop a care plan to address patients’ nutritional needs. The care plan should include recommendations on energy intake, protein intake, hydration, vitamins, and minerals. Important suggestions to take into account when developing the nutritional care plan are the following:
Provide an individualized energy intake plan based on a patient’s medical condition and the likelihood of developing pressure ulcers;
Adjust the intake of energy based on changes in weight;
Prescribe high protein nutritional supplements for minimizing the risks associated with pressure ulcers development;
Encourage appropriate daily fluid intake and monitor dehydration symptoms;
Develop a healthy diet plan to include more vitamins for achieving a nutritional balance (Haesler, 2014).
Skin massage has been a traditional tool for preventing the development of pressure ulcers among bed-ridden patients; it is based on the suggestion that massaging a patient’s skin can boost the local flow of blood to the tissue subjected to extreme pressure (Zhang, Sun, & Yue, 2015). Nurses can perform massages using creams to reduce the level of friction on the skin and improve its overall condition. While there is a lack of certainty whether massages can prevent pressure ulcers, a patient’s repositioning during the procedure can help.
Because the risk of pressure ulcer development ranges from patient to patient, the assistance of support surfaces is essential for catering to the needs of each person separately. Manufacturers of support services recommend following the guidelines for use and maintenance of equipment. When using support surfaces to reposition or mobilize patients at risk of pressure ulcers, it is crucial to assess their levels of inactivity, the risk for development of new pressure ulcers, as well as severity, number, and location of the existing skin damage (Haesler, 2014).
Low-technology support surfaces with continuous low pressure on patients’ skin include foam mattresses, alternative mattresses, and overlays, gel-filled, fiber-filled, air-filled, water-filled, or bead-filled surfaces, as well as sheepskins (National Clinical Guideline Center, 2014). High-technology support surfaces include the following:
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Low-air-loss beds, in which body support is provided by several integrated air sacs made for passing warmed air;
Air-fluidized beds, in which warmed air goes in circles passing small ceramic beads that are covered with a permeable sheet (National Clinical Guideline Center, 2014);
Alternating-pressure overlays or mattresses, which have sacs filled with air that either deflate or inflate for relieving pressure on the skin.
This means that healthcare providers should choose support surfaces that fit their practice setting, assess different kinds of available equipment (both high and low technology), prevent possible complications, and choose other positioning devices (e.g., bed linen, incontinence pads, etc.) by the support surfaces that can aid their patients in avoiding developing pressure ulcers (Haesler, 2014).
It has been proven that inconveniently or improperly placed medical devices can lead to pressure ulcers in hospitalized patients (Black et al., 2010). Therefore, it is essential to review and choose medical devices based on the least amount of harm they can cause to patients. To do so, health care providers should make sure that those devices are sized correctly, that manufacturers’ specifications are followed, and that medical devices that have been used on patients are secured sufficiently to avoid unexpected dislodgement that leads to additional pressure (Haesler, 2014).
To prevent medical devices from causing pressure on patients’ skin, nurses should be held accountable for removing the devices that can cause pressure as soon as allowed clinically, keeping skin that is close to medical devices clean, repositioning the devices to redistribute the pressure, and supporting medical devices to decrease pressure or shear forces (Haesler, 2014). Also, patients should be provided with prophylactic clothing that allows them to feel less pressure from medical devices. When selecting suitable protective dressing for patients, healthcare providers should consider the ability of the dressing to sustain an appropriate microclimate, the ease of removal or application, thickness of the material and tightness, the location on the body where the medical device will be placed, as well as the intended purpose of that device (Haesler, 2014).
Early Mobilization and Repositioning
According to Bhattacharya and Mishra (2015), repositioning patients who are at risk of developing (or have already developed) bedsores is performed for minimizing the pressure on the skin. The frequency of repositioning should be determined based on patients’ needs and risks. It is important to take into consideration the pressure that support services can cause, issues with tissue tolerance, levels of mobility, and key objectives of the ulcer intervention. About cost-effectiveness, repositioning is one of the sufficient tools for ulcer prevention; however, health care providers should be trained on the most beneficial practices and techniques. For instance, a nurse should be able to reposition a patient in a way that will help relieve the pain and redistribute the pressure. Also, nurses should be instructed not to leave patients at risk of pressure ulcers in bed longer than required. Patients at bed rest should be assisted to progress to at least sitting as quickly as possible. It is recommended to develop a schedule for mobilization activities by assessing patients’ overall health and tolerance to movement.
Pressure ulcers are a significant quality issue that prevents patients from receiving appropriate care. The problem not only affects individuals’ health but also increases governmental spending. Because of this, it is essential to educate healthcare professionals on cost-effective ways of managing and preventing the condition. Ranging from appropriate diet planning to an adequate use of tools and devices, there is an array of cost-effective methods healthcare providers can introduce to deal with the quality issue of pressure ulcers. Assessment, management, and prevention of pressure ulcers are impossible without educating and training healthcare professionals on how to use their knowledge and skills for improving patient outcomes. Because the rates of pressure ulcers grow with the increasing population of elderly patients and people with disabilities, staff training on this matter is essential. Education needs to address the needs of at-risk patients (that range from neonates to the elderly) and help healthcare providers to determine changes that occur in the patient’s risk statuses. It is important to note that in general, roles and responsibilities of preventing and managing pressure ulcers are placed on nurses; however, it is recommended to provide training to professionals across different areas of expertise to ensure a multidisciplinary approach towards managing the quality problem of pressure ulcers.
Bhattacharya, S., & Mishra, R. (2015). Pressure ulcers: Current understanding and newer modalities of treatment. Indian Journal of Plastic Surgery: Official Publication of the Association of Plastic Surgeons of India, 48(1), 4-16.
Black, J., Cuddigan, J., Walko, A., Didier, L., Lander, M., & Keple, M. (2010). Medical device related pressure ulcers in hospitalized patients. International Wound Journal, 7(5), 358-365.
Gebhardt, K. (2002). Part 1: Causes of pressure ulcers. Nursing Times, 11(41), 41-52.
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Haesler, E. (2014). Prevention and treatment of pressure ulcers: Quick reference guide. Web.
Mayo Clinic Staff. (2017). Bedsores (pressure ulcers). Web.
National Clinical Guideline Center. (2014). The prevention and management of pressure ulcers in primary and secondary care. Web.
NHS. (2017). Pressure ulcers (pressure sores). Web.
Zhang, Q., Sun, Z., & Yue, J. (2015). Massage therapy for preventing pressure ulcers. Web.