pressure ulcers - lippincott williams &...

Fighting back against

pressure ulcers

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins

PPressure ulcers are a complexhealthcare problem that affectquality of life and often con-tribute to sepsis and death.Preventing and treating pressureulcers in the United States is esti-mated to be a $1.3 million indus-try; the Centers for Medicareand Medicaid Services (CMS)reports that the average cost oftreating a pressure ulcer is about$43,180.1,2

Although there are wide varia-tions, the national incidence ofpressure ulcers in acute care hasbeen reported to be 7% to 9%;prevalence (the total number ofpressure ulcers at a specific pointin time) averages 14% to 17%.1

In CCUs, the incidence andprevalence vary from 8% to 40%,according to data collected by theNational Pressure Ulcer AdvisoryPanel from 1990 to 2000.3

Critically ill patients are atincreased risk for developingpressure ulcers, which greatlyincreases their morbidity andmortality. Factors that increasepressure ulcer risk for criticalcare patients, compared withmedical-surgical patients, includemultisystem organ failure, mul-tiple comorbidities, hemody-namic instability, vasoactivedrugs, sensory impairment,mechanical ventilation, immo-

bility, and incontinence.4 Otherrisk factors for critically illpatients include malnutrition,multiple surgical interventions,emergency admission, transferfrom outside facilities, and pro-longed hospitalization.5 Someresearch suggests that patientswith diabetes, sepsis, stroke, car-diovascular disease, or hypoten-sion are at higher risk becauseof the resultant microcirculatorydysfunction.6 For more on pres-sure ulcer development, seeGetting into pressure ulcers.

Various studies have lookedat the costs associated withincreased length of stay, debride-ment, wound care supplies, andnursing time, but these costs don’tbegin to measure the enormityof the problem. Indirect costssuch as the pain and suffering ofthe patient and family, increasedpotential for infection, sepsis, anddeath can’t be measured.

Can pressure ulcers beprevented?Pressure ulcers are considered pre-ventable, despite a long-standingdebate as to whether some areunavoidable. Even with the bestprevention strategies in place,some experts believe that pressureulcers may be unavoidable insome critically ill patients in mul-

tisystem organ failure. The skin,like other bodily systems, can fail.2

Healthcare facilities mustdevelop standards of care andimplement measures to reducethe incidence of healthcare-associated pressure ulcers. TheAgency for Healthcare Policyand Research (now the Agencyfor Healthcare Research andQuality) released clinical practiceguidelines for prevention in 1992.The CMS has identified pressureulcers as one of eight diagnosesthat are reasonably preventable,and no longer reimburses facili-ties if patients acquire pressureulcers in acute care. The Institutefor Healthcare Improvement(IHI) has named pressure ulcerprevention as one of five goals inits 5 Million Lives Campaign. TheAmerican Nurses Association hasidentified maintenance of skinintegrity and decreasing pressureulcer incidence as a nursing quali-ty indicator.

Key elements of pressure ulcerprevention programs includeidentifying at-risk patients;implementing prevention proto-cols; educating patients, families,and healthcare providers; anddeveloping strategies to enhancecommunication among healthcareproviders. Nurses continue to beleaders in developing standards

www.nursing2009criticalcare.com September l Nursing2009CriticalCare l 35

Up to 40% of critical care patients have these wounds.Find out how one facility took steps to reduce that rate.

By Rosemary Jones Kates, RN, APN-BC, CRNP, CWOCN, MSN, andAmy Callahan, RN, APN-BC, CRNP, CNE, MSN

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Fighting back against pressure ulcers

36 l Nursing2009CriticalCare l Volume 4, Number 5 www.nursing2009criticalcare.com

for preventing pressure ulcersand managing them when theyoccur. A successful preventionprogram requires commitmentacross the organization, involv-ing all disciplines.

Patients with darkly pigment-ed skin are at higher risk forpressure ulcer development andmay be more likely to die frompressure ulcers.7 Because thesepatients don’t have persistentredness or nonblanchable ery-thema, Stage I pressure ulcersmay be difficult to detect. Lookfor skin discoloration or othersubtle changes such as changesin skin temperature (warmeror cooler), firmness, bogginess,or pain, compared with otherareas. The National PressureUlcer Advisory Panel has revisedthe definition of Stage I pressureulcers to reflect these differences.8

Although nurses often are thefirst healthcare providers to rec-ognize subtle changes in a patient’sskin, pressure ulcers aren’t just a

nursing problem. Because the eti-ology of pressure ulcers is multi-faceted, prevention needs toinclude the entire medical team(nurses, physicians, nutritionist,physical therapists, and social ser-vice workers) as well as the patientand family members.

Assessing riskStart with pressure ulcer riskassessment and develop an indi-vidualized plan of care to reduceyour patient’s risk of developinga pressure ulcer. The BradenScale and the Norton Scale areboth validated and reliable assess-ment tools in predicting patientsat risk (see Braden Scale for predict-

ing pressure ulcer risk). Perform arisk assessment, as well as a skinassessment to detect existingpressure ulcers or changes inskin integrity.2 All patients shouldbe assessed on admission andreassessed at least every 24 hours,and with any change in their clin-ical status.

The Braden Scale, the mostwidely used assessment toolin the United States, assessespatient risk in six subsets.Mobility, activity, and sensory per-

ception evaluate the effects ofpressure intensity and duration;moisture, nutrition, and friction

and shear evaluate the tissue’sability to tolerate pressure.3,9

Each subscale contains a numer-ical range of scores. A total scoreof 23 is possible and indicates norisk. Older patients and thosewith darkly pigmented skin areat risk for pressure ulcer devel-opment if they score 18 or less;other adults are at risk if theyscore 16 or less, and a score of 9or less indicates very high risk.

Evaluate the patient’s subsetscores and intervene in the areaswith the lowest scores (seeProtocols by risk level from the

Braden Scale). For instance if thepatient is identified as at riskin nutrition, your plan of careshould include monitoring calories,increasing protein, administeringdietary supplements, and consult-ing a nutritionist. For a patient witha low score in activity, implement aturning schedule, place the patienton a pressure-reducing supportsurface, and protect his heels byelevating them off the bed.

Although highly reliable, theBraden Scale may not capture all ofthe patient’s risk factors, especiallyin a critically ill patient. Be sure totake a complete patient history andconsider other risk factors (such asdiabetes, hypotension, age, andmedications) in your care planning.

Assessing skin regularlyThe next step is to perform acomprehensive skin assessmenton patient admission and atperiodic intervals. The IHI

Getting into pressure ulcersPressure ulcers are defined as a localized injury to the skin and underlyingstructures as a result of pressure, sometimes in combination with shearand or friction. They usually occur over a bony prominence. A number ofcontributing factors are also associated with pressure ulcers; the signifi-cance of these factors has yet to be elucidated.

Factors contributing to pressure ulcer development include:• Immobility. Patients diagnosed with recent fractures, stroke, sensory

impairment secondary to sedation, or an underlying abnormality causingthem to be immobile for any length of time are at greatest risk.

• Duration and intensity of pressure. Low pressure for a long time can be asdamaging as high pressure for a short time.

• Tissue tolerance (the ability of the tissues to tolerate the pressure).For example, muscle is more sensitive to pressure damage than skin.3

• Collagen production. Collagen is important in maintaining skin integrity,and production can be decreased by age, malnutrition, and use of steroids.

• Tissue perfusion, which can be affected by serum protein, anemia,hypotension, extracorporeal circulation, diabetes, and use of vasoactivedrugs.3

• Extrinsic factors such as friction, shear, and moisture and irritants (suchas from incontinence), which are disruptive to the epidermis.


suggests that skin inspectionsshould be done at least every 24hours in acute care. Critically illpatients will need more frequentassessments. Under new CMSregulations, the admission skinassessment must be completednot only by the nurse in acutecare but also by the physician,so the facility can be reimbursedappropriately if the patient hasan existing Stage III or Stage IVpressure ulcer. Perform a compre-hensive head-to-toe skin assess-ment with particular emphasison pressure points and areas atgreatest risk usually over pres-sure points such as the heels,sacrum, occiput, malleolus, andischium. Assess the patient’s skintemperature, turgor, moisture,and integrity.2

One facility’s experienceIn an effort to decrease the inci-dence of pressure ulcers in ourmedical ICU (MICU), we formedan interdisciplinary team consist-ing of the wound, ostomy, andcontinence nurse (WOCN) special-ist; the clinical nurse specialist; theMICU staff nurses; physicians;nutritionists; physical therapists;and occupational therapists. Ourprogram included an educationplan, a designated day for woundcare rounds, and collaborationbetween all disciplines involvedin the prevention and manage-ment of pressure ulcers in criti-cally ill patients.

We developed a tool to ensurethat the Braden Scale was com-pleted according to protocol andproper interventions were initiat-ed. In addition to the regulardaily rounding, we do formalrounding as a team on “WoundCare Wednesday.” The team con-sists of the clinical specialist, the

WOCN specialist, and nursingstaff. All patients in the unit areassessed for potential or actualskin breakdown, and the team col-laborates and develops a plan forprevention and treatment. Thistime provides the WOCN special-ist an opportunity to talk to edu-cate the staff at the bedside. Forall patients with skin breakdown,the WOCN specialist is consultedto ensure that the patient is receiv-ing appropriate treatment.

On a daily basis, the physicianteam rounds on the MICU anddiscusses any patient skin integri-ty issues with the nursing staffand nutritionist. Physician in-volvement in skin assessment ispart of our initiative; all patientsare assessed by the physiciansfor alterations in skin integrityon admission and in collaborationwith the nursing staff when aneed is identified. The WOCNspecialist is available to the teamand to support education for thenurses and the medical team.

Because patients and familiesare critical to these efforts, they’reinvited to participate in woundcare rounds if they’re able, andare always kept abreast of anyskin integrity issues and preven-tion measures.

Educating clinical staff was akey component to the success ofthis program. The clinical nursespecialist, WOCN specialist,nutritionist, and physical therapistprovided education, includingdemonstrations, on identifyingat-risk patients, skin assessment,staging pressure ulcers, woundinterventions, nutritional support,and documentation. In 2008, apatient lift system was includedin the education program to rein-force proper techniques for liftingpatients during transfer and posi-tioning them to decrease frictionand shear.

The nutritionist reviewsenteral feeding solutions andsupplements used in criticalcare patients, including high-protein supplements that helpmaintain skin integrity andfacilitate skin healing. At MICUadmission, all patients undergoa complete skin assessment andBraden Scale risk assessment.These assessments are repeatedevery 12 hours. Patients identi-fied as at risk for pressure ulcersreceive additional preventiveinterventions and pressure ulcertreatments as appropriate andaccording to the hospital’s skinand pressure ulcer protocol.

Most patients in the MICUare immobile and require regu-lar turning, proper positioning,and pressure-relieving devices.We consult physical and occupa-tional therapists to mobilizepatients as soon as possibleand help with positioning issues


Because patients andfamilies are criticalto pressure ulcer

prevention efforts,they’re invited to

participate in woundcare rounds if they’re able.


Braden Scale for predicting pressure ulcer risk



Sensory

perception—abilityto respond meaning-fully to pressure-related discomfort

Moisture—degree towhich skin isexposed to moisture

Activity—degree ofphysical activity

Mobility—ability tochange and controlbody position

Nutrition—usualfood intake pattern

1. Completely limit-

ed—unresponsive(doesn’t moan, flinch,or grasp) to painfulstimuli, due todiminished level ofconsciousness orsedation ORlimited ability to feelpain over most ofbody

1. Constantly

moist—skin is keptmoist almost con-stantly by perspira-tion, urine, etc.Dampness is detect-ed every time patientis moved or turned.

1. Bedfast—confinedto bed

1. Completely

immobile—doesn’tmake even slightchanges in body orextremity positionwithout assistance

1.Very poor—nevereats a complete meal.Rarely eats morethan one-third of anyfood offered. Eats 2servings or less ofprotein (meat or dairyproducts) per day.Takes fluids poorly.Doesn’t take a liquid

2.Very limited—responds only topainful stimuli.Can’t communicatediscomfort except bymoaning or restless-nessORhas some sensoryimpairment that lim-its the ability to feelpain or discomfortover half of body

2.Very moist—skinis often, but notalways, moist. Linenmust be changed atleast once a shift.

2. Chairfast—abilityto walk severely lim-ited or nonexistent.Can’t bear ownweight and/or mustbe assisted into chairor wheelchair.

2.Very limited—makes occasionalslight changes inbody or extremityposition but unableto make frequent orsignificant changesindependently

2. Probably inade-

quate—rarely eats acomplete meal andgenerally eats onlyabout half of anyfood offered. Proteinintake includes only3 servings of meat ordairy products perday. Occasionally

3. Slightly limited—responds to verbalcommands, but can’talways communicatediscomfort or theneed to be turnedORhas some sensoryimpairment thatlimits ability to feelpain or discomfortin 1 or 2 extremities

3. Occasionally

moist—skin isoccasionally moist,requiring an extralinen change aboutonce a day

3.Walks

occasionally—walksoccasionally duringday, but for veryshort distances, withor without assis-tance. Spendsmajority of each shiftin bed or chair.

3. Slightly limited—makes frequentthough slightchanges in bodyor extremity positionindependently

3. Adequate—eatsover half of mostmeals. Eats a total of4 servings of protein(meat or dairy prod-ucts) per day.Occasionally willrefuse a meal, butwill usually take asupplement when

4. No impairment—responds to verbalcommands. Has nosensory deficit thatwould limit ability tofeel or voice pain ordiscomfort

4. Rarely moist—skin is usually dry,linen only requireschanging atroutine intervals

4.Walks frequently–

walks outside roomat least twice a dayand inside room atleast once every twohours during wakinghours

4. No limitation—makes major andfrequent changesin position withoutassistance

4. Excellent—eatsmost of every meal.Never refusesa meal. Usuallyeats a total of 4or more servingsof meat and dairyproducts.Occasionally eatsbetween meals.

(continued)



Braden Scale for predicting pressure ulcer risk (continued)

Friction and shear

dietary supplementORis N.P.O. and/or main-tained on clear liquidsor I.V.s for more than5 days

1. Problem—requiresmoderate to maxi-mum assistance inmoving. Completelifting without slidingagainst sheets isimpossible.Frequently slidesdown in bed or chair,requiring frequentrepositioning withmaximum assistance.Spasticity, contrac-tures, or agitationleads to almost con-stant friction.

will take a dietarysupplementORreceives less thanoptimum amount ofliquid diet or tubefeeding

2. Potential problem—moves feebly orrequires minimumassistance. During amove, skin probablyslides to some extentagainst sheets, chair,restraints, or otherdevices. Maintainsrelatively good posi-tion in chair or bedmost of the time butoccasionally slidesdown.

offeredORis on a tube feedingor total parenteralnutrition regimen thatprobably meets mostof nutritional needs

3. No apparent prob-

lem—moves in bedand in chair indepen-dently and has suffi-cient muscle strengthto lift up completelyduring move.Maintains good posi-tion in bed or chair.

Doesn’t requiresupplementation.

Used with permission of Barbara Braden and Nancy Bergstrom.

on patients with special needs.For example, if a patient ishemodynamically unstable andcan’t tolerate complete turns, thephysical therapist may devise aplan that uses wedges and smallweight shifts to relieve pressure.The MICU nutritionist roundswith the interdisciplinary teamdaily. Nutrition assessments andnutrition goals are evaluated bythe nutritionist.

Maintaining skin integrity inincontinent patients is always achallenge. The hospital has astandard protocol for protectingskin integrity in incontinentpatients, but needed somethingmore advanced to prevent andtreat pressure ulcers in patientswith diarrhea. After carefulconsideration and a review ofthe literature to identify best

practices, we recently initiateduse of a fecal management systemto divert stool from critically illpatients’ skin. The system reducesskin contamination and helps tomaintain a clean and dry environ-ment that reduces the risk of skinbreakdown and supports healing.

In developing guidelines for theuse of this product, we recognizedthat other measures should beused before resorting to a rectaltube. First, nurses needed to workwith the medical team and nutri-tionist to identify and treat theunderlying cause of diarrhea.Measures such as skin cleaning,skin barriers, and a fecal inconti-nence pouch should be tried first.The fecal management system,which requires a written orderand a digital rectal exam by thephysician to assess sphincter con-

trol, should be used only after allother measures fail.

The process to implementthe use of this device was multi-disciplinary. Nursing drove theinitiative to improve and maintainskin integrity. As part of our Pro-fessional Practice Council, nursesfrom the MICU and the medicalcoronary care unit were involvedin product selection, trial, andevaluation. The clinical nurse spe-cialists from both units and theWOCN specialist provided sup-port in protocol development andeducation, which included nurs-ing and medical staff. Gastroen-terologists reviewed the protocols.

We perform pressure ulcer prev-alence studies monthly to measurethe success of our efforts. A com-plete skin assessment is done onall patients in the unit on the day




Protocols by risk level from the Braden Scale

At risk (15-18)*

• Frequent turning• Maximal remobilization• Protect heels• Manage moisture, nutrition, and friction and shear• Pressure-reduction support surface if bed- or chairbound

Moderate risk (13-14)*

• Turning schedule• Use foam wedges for 30-degree lateral positioning• Pressure-reduction support surface• Maximal remobilization• Protect heels• Manage moisture, nutrition, and friction and shear

High risk (10-12)

• Increase frequency of turning• Supplement with small shifts• Use foam wedges for 30-degree lateral positioning• Pressure-reduction support surface• Maximal remobilization• Protect heels• Manage moisture, nutrition, and friction and shear

Very high risk (9 or below)

• All of the above plus• Use pressure-relieving surface if the patient has

intractable pain, severe pain exacerbated by turning,or additional risk factors

Manage moisture

• Use commercial moisture barrier• Use absorbent pads or diapers that wick and hold

moisture• Address cause if possible• Offer bedpan or urinal and glass of water in

conjunction with turning schedules

Manage nutrition

• Increase protein intake• Increase calorie intake to spare proteins• Supplement with multivitamin (should have

vitamins A, C, and E)• Act quickly to alleviate deficits• Consult nutritionist

Manage friction and shear

• Elevate head of bed no more than 30 degrees• Use trapeze when indicated• Use lift sheet to move patient• Protect elbows and heels if being exposed to

friction

Other general care issues

• No massage of reddened bony prominences• No doughnut-type devices• Maintain good hydration• Avoid drying the skin

of the study. Patients with pressureulcers are identified and medicalrecords are reviewed to determineif the pressure ulcers were presenton admission or developed duringthe hospitalization. The MICUaverages a 7% incidence forhospital-acquired pressure ulcersand continues to strive to improve.Meeting the challenges to preventpressure ulcers is ongoing andincludes reevaluating protocolsand continuing to educate staffmembers, patients, and families.Constant communication amongteam members is key. ❖

REFERENCES

1. Kring D. Reliability and validity of theBraden Scale for predicting pressure ulcerrisk. J Wound Ostomy Continence Nurs.2007;34(4):399–406.

2. Armstrong DG, Ayello E, Capitulo K, etal. New opportunities to improve pressureulcer prevention and treatment: implica-tions of the CMS inpatient hospital carepresent on admission indicators/hospital-acquired conditions policy: a consensus pa-per from the International Expert WoundCare Advisory Panel. Adv Skin Wound Care.2008;21(10):469–478.

3. Baranoski S, Ayello E. Wound Care Essen-tials: Practice Principles. Lippincott Williams &Wilkins; 2008.

4. Elliott R, McKinley S, Fox V. Qualityimprovement program to reduce the preva-lence of pressure ulcer in an intensive careunit. Am J Crit Care. 2008:17(4):328–334.

5. Padula C, Osborne E, Williams J. Preven-

tion and early detection of pressure ulcersin hospitalized patients. J Wound OstomyContinence Nurs. 2008;35(1):65–75.

6. Lyder C. Pressure ulcer prevention andmanagement. JAMA. 2003;289(2):223–226.

7. Lyder C. Closing the skin assessmentdisparity gap between patients with lightand darkly pigmented skin. J WoundOstomy Continence Nurs. 2009;36(3):285.

8. National Pressure Ulcer Advisory Panel.http://www.npuap.org.

9. Magnan M, Maklebust J. The nursingprocess and pressure ulcer prevention:making the connection. Adv Skin WoundCare. 2009;22(2):83–92.

Rosemary Jones Kates is a wound, ostomy, andcontinence nurse at Jefferson UniversityPhysicians in Cherry Hill, N.J. Amy Callahan is acritical care clinical nurse specialist in the medicalintensive care unit at Jefferson UniversityHospital in Philadelphia, Pa.

* If other major risk factors are present, advance to the next level of risk. Major risk factors are: advanced age, fever, poor dietary intake of protein,diastolic BP below 60, or hemodynamic instability.

Used with permission of Barbara Braden.


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