Bed Sore and Treatment and Nursing Care
Pressure Ulcers as Health Issue
health care system. It has been conservatively estimated that annually 1
million adults develop pressure ulcers. The incidence rates vary greatly
depending on the health care sector.
However, pressure ulcer incidence rates
for hospitals range from 0.4% to 38%, for skilled nursing facilities from 2.2%
to 23.9%, and for home health agencies from 0% to 17% (Cuddigan, Ayello,
Sussman, & Baranoski, 2001) . The annual cost to treat pressure ulcers has been
estimated at $1.335 billion, with an average cost range of $1.190 to $10.185 or
more (Kerstein et al., 2001).
Etiology of Pressure Ulcer
The development of pressure ulcers occurs when there is sufficient
pressure over time to cause capillary destruction, resulting in tissue necrosis.
Although the amount of time and pressure needed to obstruct normal capillary
closure vary (acuity of patient), research has found that capillary pressure
ranges from 20 mm Hg to 40 mm Hg, with 32 mm Hg considered the average.
However, this goal standard is being revisited, since it is possible to develop
pressure ulcers at much lower pressures.
Health Issues of Pressure Ulcer
The development of a pressure ulcer and/ or failure to prevent the
ulcer from progressing to a more severe stage can result in negative
consequences for the health care system. Litigation has significantly increased
related to pressure ulcer development.
More-over, the US Centers of Medicare
and Medicaid Services (formerly, Health Care Financing Administration) consider
the development of pressure ulcers as a failure in delivery of quality
services, since the prevention of these ulcers depends on the cooperation from
the entire health care team.
Ulcer Preventive Nursing Care
Nursing research has remained at the fore-front in building the
knowledge base related to pressure ulcer prevention. The first step in
effective pressure ulcer prevention is identifying those patients at risk for
ulcers. Conservatively, there are over 100 health factors: associated with
pressure ulcer development.
The development of pressure ulcer prediction tools
has made a significant difference in identifying those vulnerable adults and
children at risk for ulcer development. Nursing research has led to the
development of pressure ulcer prediction tools.
Some of the most common
prediction tools are the Braden Scale for Predicting Pressure Ulcer Risk and
the Norton Scale (US Agency for Health Care Policy and Research, 1992).
The
Braden and Norton Scales have good sensitivity (83%-100% and 73%-92%
respectively) and good specificity (64%-77% and 61%-94% respectively), but have
low positive predictive value (approximately 40% and 20% respectively)
(Bergstrom, Braden, Laguzza, & Holzman, 1987; Norton, D., McLaren, &
Exton-Smith, 1975).
Thus, there are patients who are receiving preventive
interventions that are truly not at risk. Moreover, optimal cut off scores may
be different depending on patient population; Thus, continued research in this
area is greatly needed.
Pressure Measuring Tools
The use of pressure ulcer prediction tools in non-White populations
has been questioned,since many of the prediction tools being used have not
been validated in non-White populations.Several nursing research studies examining the predictive validity
of these pressure ulcer prediction tools have emerged in the nursing research
literature.
Lyder and others (1999) examined the predictive validity of the
Beaden Scale in Blacks and Hispanics.
The scale was found to be highly
predictive (p=.01) when an optimal cut-off score of 18 or below was used.
Conversely, Pang and Wong (1998) investigated the predictive validity of the
Braden Scale, the Norton Scale, and the Waterlow Scale (primarily used in the
United Kingdom) in a Chinese population.
These researchers found that the
Braden Scale had the best sensitivity (91%) and specificity (62%) It appears
that the Braden Scale may provide an overall better sensitivity and specificity
in non-White populations; however there remains a paucity of nursing research
examining both risk factors and validation of prediction scales in non-white
populations.
Nursing Guidelines for Pressure Ulcer
The development of the Agency for Health Care Policy and Research
(now the Agency for Health Care Research and Quality) guidelines for pressure
ulcer prevention was a mile stone for both distilling and disseminating current
research knowledge on the most effective methods for preventing these ulcers.
Led by nurse researcher Dr. Bergstrom, these guidelines provided key areas for
clinicians to consider for pressure ulcer prevention (risk assessment,
repositioning, use of support surfaces, etc.).
Because pressure ulcer
development is a multivariate problem, no studies could be found that
successfully implemented the guidelines in its entirety.
Gunningberg, Lindholm,
Carlsson, and Sjoden, (2001), investigating the incidence of pressure ulcers in
1997 and 1999 among patients with hip fractures, found significant reduction in
rates (55% in 1997 to 29% in 1999).
They attributed these reductions in
pressure ulcer incidence rates to performance of systematic risk assessment
upon admission, accurately staging pressure ulcers, using pressure reducing
mattresses, and continuing education of staff.
Similar results have been noted
in other studies when they implement a similar pressure ulcer prevention
program (Xakellis, Frantz, Lewis, & Harvey, 1998; Lyder, Shannon,
Empleo-Frazier, McGehee, & White, 2002).
Although nursing research studies
have identified the principles of pressure ulcer prevention, additional studies
are needed to determine optimal titration levels for preventive strategies
based on the patient pressure ulcer risk levels and cost of interventions to
the health care system (resources, staff burden, Etc.).
Objective of Ulcer Treatment
In 1994, the Agency for Health Care Policy and Research (led by Dr
Nancy Bergstrom) published guidelines on the treatment of pressure ulcers.
Nurse researchers have been quite active in leading the knowledge development
in specific areas of pressure ulcer treatment, in particular, tools to
objectively monitor pressure ulcer healing.
Bates-Jensen, Vredevoe, and Brecht
(1992) developed the Pressure Sore Status Tool (PSST) to assess the healing of
pressure ulcers. The content validity of the PSST was established by a panel of
20 experts. Interrater reliability was established, r = .91 for first
observation and r = .92 for second observation (Bates-Jensen et al., 1992).
Another area in which nurse researchers have made an impact has been the
evaluation of dressings to assist in the healing of pressure ulcers. Studies
have found that, compared to traditional gauze, modern wound dressings heal
pressure ulcers faster, are more economical, and save on caregiver time
(Bolton, van Rijswick, & Shaffer, 1997).
Much research is still needed on examining the outcome (healing
rates, costs, etc.) of standardized protocols for pressure ulcer treatment.
Nursing studies are needed on developing and implementing alternative therapies
for healing pressure ulcers.
Qualitative studies are needed to understand the
“lived experience” of patients with pressure ulcers. Finally, nursing
researchers can take the lead on developing and evaluating appropriate levels
of pressure ulcer care for patients receiving palliative care.