Pressure ulcer prevention: Assessing all contributing factors
Dr. James G. Spahn
When analyzing the relationship between soft-tissue injury and support surfaces for pressure ulcer treatment and prevention, caregivers must realize support surfaces deliver unwanted gradient pressure and/or shear mechanical stresses, resulting in soft tissue distortion. This distortion causes endothelial damage and can result in ischemia and possible infarction of the soft tissue at risk. The scientific disciplines of chemistry, physics, and mechanics can help caregivers understand mechanical stresses delivered to the patient at risk for pressure ulcer development. The media from which the support surface is made must be evaluated based upon scientific facts and studied by 3-dimensional, not 2-dimensional means.
It is important for clinicians to understand that there is a time delay between two to seven days for most pressure ulcers to be clinically recognized from the time of the caused event. There are many methods for the prevention of pressure ulcers, including support surface protection, such as a pressure-redistributing device. In many cases, the number of pressure ulcers acquired is decreased from 10 to one with the use of a pressure-redistributing mattress. While the simple and low-cost intervention of static air overlays reduces pressure ulcer occurrences, establishing protocols and increasing staff education helps to elevate caregivers' awareness of skin integrity changes providing them with the tools to diminish the incidence of pressure ulcers.
In order to effectively prevent and treat pressure ulcers, there are many important factors, in addition to support surfaces, that must be addressed. First, complete assessments should be done upon admission and weekly thereafter or as per facility policy. If a pressure ulcer is present and progress in healing has not been made within two weeks of product selection, caregivers should re-evaluate the care plan and consider changing the support surface and others products in use. Also, if at any time it is noted that goals have been met, they should consider moving back to the prior level of care for cost savings. For additional assistance in identifying at-risk patients, the use of accepted risk scales that include a comprehensive physiologic status assessment are suggested as basis for prevention, early intervention and treatment goals relating to staff requirements and product selection. A comprehensive risk assessment should be used for prevention and treatment of pressure ulcers on the ankle, foot and heel, due to the fact that support surfaces alone cannot adequately address this problem, along with foot drop and lateral rotation.
Other methods in preventing pressure ulcers, which primarily rely on action from clinicians, range from increased mobility to particular attention to the skin condition. Educating them on the severity of pressure ulcers will reduce the frequency of pressure ulcers among patients. While static air has proven to be an effective method, other components of the protocol should include proper skin care, turning the patient according to patients' needs, helping with nutrition and fluid intake and frequent documentation of care. Clinicians are encouraged to assess patients for their risk of developing pressure ulcers and develop an appropriate care plan. A standardized protocol should be individualized so that a care plan can be developed and followed for each individual patient. Factors to be considered for developing such a plan might include cognitive impairment, nutrition and hydration, mobilization and ambulation, support and surface selection, lower extremity protection, wound care, medications and other general medical conditions.
To ensure equalized load redistribution is provided at all times, long-term care providers must implement the proper products on all surfaces including wheelchairs, geri-chairs, transportation beds, etc. Addressing outside factors can also prove beneficial in prevention and treatment. These factors include but are not limited to nutrition, incontinence, moisture and the general physiologic state of the patient. Knowing a patient's history is critical when deciding on a proper support surface. When patients have had previous pressure ulcers, caregivers must always consider them moderately or highly at risk for future pressure ulcers.
James G. Spahn, M.D., FACS, is the founder of Indianapolis-based EHOB, Inc., manufacturer of the WAFFLE® Brand Products for the prevention and treatment of pressure ulcers.