U N DERSTAN DI NG RISK FACTORSin Pressure Ulcer Development and Wound Healing

Educoting your staff

lressure ulcers affect hundreds of millions of people world-pwide. complicate the delivery of patient care, and contributeI to patient deaths and disability. In fact, nearly 60,000 U.S.

hospital patients are estimated to die from complications due to hos-pital-acquired pressure ulcers each year. It is estimated that2.5 m11-lion patients are treated each year in U.S. acute-care facilities forpressure ulcers. Incidence rates vary by clinical settings, ranging from0.4 percent to 38 percent in acute care and 2.2 percent to 23 .9 percentin long-term care.

The impact of pressure ulcers on healthcare cost is tremendous.The total cost of treatment of pressure ulcers in the United States isestimated at $11 billion per year. According to CMS, 257,412 pre-ventable pressure ulcers were reported as secondary diagnoses in hos-pitals in 2007 . The average cost of each of those pressure ulcers isestimated to be $43,180 per hospital stay.

Based on the risk for pressure ulcers, a holistic care plan shouldbe developed to help prevent pressure ulcers. There is no cookie-cut-ter skincare plan that would be right for every patient. True, there arecertain components that apply to every skincare plan (cleansing,moisturizing, positioning, nutrition and so on) but the specifics willvary depending on the individual's risk factors and circumstances.However, avoiding or taking steps to counteract known risk factorsfor pressure ulcers can go a long way toward preventing them.

Here are 11 contributing factors for pressure ulcers. These do notnecessarily "cause" pressure ulcers, but they can contribute to a pres-sure ulcer developing. Some of them are beyond our control; somecannot be eliminated, but we can implement strategies to decreasethem. The good news is that some of these factors are things that wedefinitely can control.

1. CirculationPressure ulcers can occur when skin breaks down because of

decreased circulation. Blood supplies our tissues with oxygen andother nutrients needed to survive. When blood flow is blocked orreduced, the tissue can literally "starve" for oxygen and nutrients. Theresult is that the tissue dies. Poor circulation allows a pressure ulcerto develop.

2. Mechanical stressThe skin is the body's largest organ and it can be stressed when-

ever we rub, scratch, or cut it, put pressure on it or create friction. Forexample, sliding a patient along a bed sheet can create friction on theskrn. While this friction would not necessarily cause a pressure ulcer,it can weaken aheady-stressed skin and set the stage for further damage.

Connie Yuska, RN, M5, C0RLN

3. TemperatureScience is just beginning to appreciate the

role temperature plays in the wound healingprocess. If a patient has a wound, it will heal bestif the wound temperature is kept as close to nor-mal (homeostasis) as possible. The wound tem-perature should be the same as the temperature ofthe tissue around it. Changing the dressing canaffect wound temperature. For example, it can takeup to four hours for the wound temperature toreturn to homeostasis after one dressing change.

4. Too wet/too dryHealthy skin cells divide and thrive when they

live in an optimal moist environment. Keeping theskin's moisture balance just right can help preventa pressure ulcer. Skin that is too wet (maceration)or too dry (desiccation) makes it easier for theskin to break down or for a wound to not heal.

5. InfectionMicroscopic bacteria are one of the biggest

enemies for any patient and they are all around uswhile we try to keep the skin and wounds free ofbacteria. When it comes to pressure ulcers, infectioncan unnecessarily prolong inflammation, the firstphase of wound healing.

6. Chemical stress on woundsIn an effort to clean the wound and kill bacte-

ria, it is often recommended that chemical prod-ucts be applied to the wound. Such chemicalsmight include povidone-iodine, hydrogen perox-ide, hypochlorite (Dakin's), alcohol, acetic acid,iodophors and Tripsin ("Balsam of Peru"). It istrue that these solutions will kill bacteria, but theycan also kill healthy tissue as well. The chemicalscan do more harm than good, so choosing anappropriate cleanser is important. Bacteria mustbe reduced in the wound, but in a way that doesnot destroy the optimal healing environment.

7. MedicationsPatients with pressure ulcers typically take

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medications, and many common medications can actually slow or affectwound healing. The best known of these drugs are anticoagulants (war-farin and other so-called "blood thinners,'), anti-inflammatory drugs(such as NSAIDs like ibuprofen), chemotherapeutic agents and antibi-otics. The need for such drugs must be balanced against the potential riskto the patient in terms of slowing the healing of pressure ulcers.Medications that alter alertness, activity and mobility might also make aperson less able to respond to pressure.

8. DiseaseThe better a person's overall health, the less risk he or she has for

pressure ulcers. Many diseases, such as diabetes and vascular disease, arerisk factors for developing a pressure ulcer and can also make it muchharder for the body to heal a pressure ulcer that might occur. This is ofparticular concern for patients with diabetes or any disease that suppressesthe immune system.

9. NutritionGood nutrition is essential to healthy skin. patients who are well

nourished and continue to get good nutrition in the hospital are at lessrisk for pressure ulcers than patients with nutritional deficits. when eval-uating nutrition, be sure that you get laboratory values. Do not depend onjust asking the patient about eating habits or observing what the patienteats from his or her hospital trav.

10. AgeAdvanced age is a risk factor in pressure ulcer development because

older skin tends to be drier, breaks down more easily and forms new cellsmore slowly. This is obviously not a controllable risk factor, but one thatneeds to be taken into account.

11. Body buildIn particular, two body types are at increased risk for pressure ulcer

development. obese patients and extremely thin patients are both athigher risk for pressure ulcers.

obese patients are at higher risk because circulation to fatty tissue isnot as good as circulation to leaner muscular tissue. poor circulationmeans less oxygen, less nutrition and more risk for pressure ulcers. verythin patients run a risk as well because there is less fatty tissue to "cushion,'them. "Thin skin" over bony prominences around knees, heels and hipsare high-risk zones for pressure ulcers.

Areas at Riskcertain parts of the body are at greater risk for pressure ulcers than

others. In general, the areas with the "thinnest skin" are most at risk,places where there is a bony prominence and not much "cushion" to protectit. These areas include:. The backs of the heels;. The back ofthe head (occiput);. Knees;. Elbows;. Buttocks and tailbone (coccyx, sacrum);. Hipbone when lying on side (Greater Trochanter).

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Any area of the body that is covered (by acast, boot, restraint, tubing, collar, etc.) is alsovulnerable to a pressure ulcer.

The StagesIf a pressure ulcer is forming (Stage I), it

will likely show up first as a darkened area ofskin. On patients with light skin tones, it mayshow up as brown, reddish-brown, red or purple.On patients with dark skin tones, it is morelikely to appear purple or black. This discoloredarea will have a distinct (but not necessarilyregular) boundary. If you put a little manualpressure on the discolored area, it does not turrrlighter (non-blanchable). This discolored areais usually surrounded by reddened, discoloredor swollen skin. The skin around the discoloredarea may feel hardened.

In a deep tissue injury (DTI), the upperlayer of skin is intact but there is an area of darkred, purple or blue-black that indicates that thetissue underneath the epidermis has been dam-aged. A DTI can also be present if there is ablood-filled blister on the skin's surface, A DTImay progress to a full-thickness Stage 3 orStage 4 pressure ulcer.

When you do see pressure ulcers, you willprobably be asked to describe them. TheNational Pressure Ulcer Advisory Panel(NPUAP) has set up a system to help definepressure ulcers by stages.

Deep Tissue Injury (DTI) May appear inone of two ways, either a reddish, purplish, ordark area of discolored skin that is still intactand may be hard to the touch or a blood-filledblister.

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Educatrol &JrainLng

Stage I Stage I Redness or discoloration (may show up as a darkenedarea in patients with dark skin tones) on an area of otherwiseintact skin. If you press it, it does not lighten in color. Thediscolored area has a distinct (but possibly inegular) boundaryand the area around it can be swollen, red or hardened.

Stage II Shallow but open wound with a pink wound bed or anopen or ruptured pus-filled blister.

Stage III A deep open wound in which you may be able to seethe subcutaneous tissue.

Stage IV Full thickness tissue loss with exposed bone, tendon ormuscle. Slough or eschar might be present on some parts of thewound bed. Undermining and tunneling are often present.

Unstageable Full thickness or tissue loss in which the base ofthe ulcer is covered by slough and/or eschar in the wound bed.

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Risk Factors that Prevent HealingThe risk factors associated with developing pressure ulcers are

similar to the risk factors that can prevent an existing pressure ulcer fromhealing properly. To understand these risk factors, we should review howthe body heals itself when the skin is wounded.

Skin is the body's largest organ. It covers and protects our entirebody and regenerates itself constantly. It must be strong enough toprotect us, yet flexible enough to move with us. Damage to the skin cantake many forms.

There are three distinct lavers of the skin:

1. EpidermisThe outer layer of skin is called the epidermis. The epidermis does

not contain any blood vessels. The epidermis itself is made up of fivesub-layers (sometimes called substrata). Those layers (from most to leastsuperficial) are called:

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1. Stratum corneum2. Stratum lucidum3. Stratum granulosum4. Stratum spinosum5. Stratum basale

The body builds epidermal cells from the bottom up. They start outin the basale layer. As they work their way to the top, they change a bitin composition (adding keratin) and they change shape. When they final-ly reach the upper layer (stratum corneum), they die and get sloughedoff. This "shedding" of old skin cells is called desquamation. Thisprocess of new cell growth, cell migration and desquamation goes onthroughout the lifetime.

2. DermisBelow the epidermis is a thick layer of skin that includes blood cap-

illaries and connective tissue called the dermis. The dermis acts like acushion to protect the body from normal stress and strain. Nerve endingsthat respond to pressure and heat are found in this skin layer, which alsocontains hair follicles and sweat slands. The dermis is further dividecinto two layers:1. Papillary region (closest to the epidermis)2. Reticular region (contains a lot of collagen and elastic fibers)

3. SubcutaneousThe innermost layer of skin is the hypodermis, which is sometimes

also called the subcutis. When a wound occurs, the body has the abilityto regenerate or recreate epidermal and dermal tissue (skin at both theouter and middle layer). A cascade of biochemical events takes place inthree phases:1 Inflammatory2. Proliferative3. Remodeling

Risk factors for pressure ulcers are actually the same things thatwould impede or interfere with the body's cascade of repair responses. Inother words, the risks for getting a pressure ulcer are the same things thatmake it hard for a pressure ulcer, once developed, to heal.

The frst phase in wound healing involves inflammation. The woundand surrounding area may change color, increase in temperature andswell as the body mobilizes to destroy bacteria in and around the woundand to try to neutralize any debris in the wound. The inflammatory stageis the body's acute response to a wound and is typically of short duration.Anything that prolongs or interferes with the inflammatory stage (med-ication, infection) can interfere with healing.

The inflammatory phase sets the body up for the proliferative phase.In this phase, new blood capillaries are formed (angiogenesis), collagenis replaced and new skin cells grow and move into place (epithelization).In epithelization, specialized cells called myofibroblasts grow along thewound edges and spread out over the surface of the wound, contractingthemselves to helo close the wound.

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Fducation-& Training

In the final phase of remodeling, the bodyadjusts collagen in the dermis layer and cellsthat are no longer needed die off in a processcalled apoptosis.

The best way to deal with the 11 risk fac-tors in wound development and wound healingis to provide the body's healing cascade withthe most optimal environment in which to "doits thing."

It is estimated that 2.5 millionpatients are treated each yearin U.S. acute-care facilities forpressure ulcers.

Here are 11 tips for creating a healing skinenvironment:1. Do whatever is possible to improve the

patient's circulation.2. Do not drag or slide the patient when

moving him; reduce mechanical stress tothe skin.

3. Keep the wound temperature constant andbe alert to temperature changes, which canbe warning signals.

4. Keep the moisture balance stable and don'tlet the skin get too wet or too dry. This isgood advice for all pats of the body, notjust the wound area.

5. Help fight the bacterial invasion withappropriate weapons.Don't go overboard with chemical weapons,since some of them (including old standbyslike povidone-iodine, hydrogen peroxide,alcohol and others) kill healthy cells aswell and may do more harm than good.Consider the role medications can play inslowing healing; the physician may haveto weigh the risks and benefits of certaindrugs, such as blood thinners and antibiotics.

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Education & Training

The patient's underlying and co morbid conditionsplay a part in healing. We can't necessarily controlthese factors, but we should account for them in thehealing process. Pain may be a factor in delayedwound healing.Make sure the patient is adequately nourished bychecking lab reports (don't rely on the patient,sself-reports of what they are eating).Older patients heal more slowly than younger ones;we can't do anything about it, but we need to adjustour expectations appropriately. Give extra effort toprotect elderly patients from getting a pressureulcer in the flrst place, since they are much lessresilient and heal more slowly.Obese patients and the very thin are most at risk forpressure ulcers. Be extra diligent with such patientsto prevent pressure ulcers from developing.

The development ofpressure ulcers presents a diffi-cult challenge to the healthcare provider who must staywell versed on how to prevent pressure ulcers as well ashow to effectively treat them once they do develop.Education of your staff is key and understanding the riskfactors for developing pressure ulcers is an excellentplace to start. +

Connie Yuska, RN, MS, CORLN is vice presidentof Clinical Services for Medline Industries Inc. andhosts a series offree educational webinars on pressureulcer prevention for both acute and. long-te:rm careprofe ssiormls ( wvvw.medlinecoml pressureulc erpreventionlwebinar. A graduate of the J&J/Whnrton Nurse ExecutiveProgram, she is a member of the Board of the lllinoisOrganization of Nurse Leaders and a member of theAmerican Organization of Nurse Executives. Mostrecently, she served as the Chief Nursing Officer of a largecommunity hospital in Chicago and as a consultant forJoint Commission Resources in the Quality and patientSafety Solutions division.

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The development 0f pressure ulcers presents a difficultchallenge to the healthcare prlvider who must stay well

versed 0n hlw to prevent pressure ulcers as well as howto effectively treat them lnce they d0 develop.

What's the Difference Between Incidenceand Prevalence of Pressure Ulcers?

Two words you commonly hear and read about withreference to pressure ulcers and other medical conditionsare prevalence and incidence. They are often usedtogether. You might see the terms used interchangeably,which is incorrect.

What is Prevalence?Prevalence is defined as a cross-sectional count

of the number of cases of a medical condition at aspecific point in time. Prevalence measures all cases ofa condition (e.9., pressure ulcers) among those at risk fordeveloping the condition. Measures of prevalence aremade at one point in time (e.g., a specific day). This num-ber includes all residents that have a pressure ulcer, nomatter when it occurred"

What is Incidence?lncidence is the number of new cases of pressure

ulcers in a specific period of time (e.g., 3 months, 6months or I year) in relation to the total number ofpersons in the population who are ,,at risk,' at thebeginning of the time period. This number reflects thenew pressure ulcers that have occurred after admission toa facility and before discharge.

A prevalence and incidence study is a combination oftwo studies that, when done consecutively, provides afacility with key statistics on patients with existing pressureulcers and on those who acquire them during their stay.

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