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October 2003

By Sharon Kurfuerst, MEd, OTR/L, ABD

Pressure ulcers, defined as localized areas of tissue damage or necrosis that develop as a result of prolonged pressure over a bony prominence, occur frequently in hospitalized or institutionalized elders and are a common cause of morbidity in this population. A variety of risk factors contributes to pressure ulcer development, including impaired mobility, friction or shear, cognitive impairments, compromised nutritional status, and incontinence, as well as risks associated with disease processes such as diabetes mellitus and peripheral vascular disease.

Despite the presence of these risk factors among a clinically complex population, the incidence of pressure ulcers is often perceived as an indicator of the quality of care delivered in skilled nursing facilities and long-term care centers. In addition, there is increasing concern in the health care community about the annual health care expenditures needed to care for elders with pressure ulcers, and more important, a primary concern exists regarding the suffering this causes patients and their families.

Because advanced age is associated with difficulty in achieving adequate wound healing, prevention remains the key to wound care in the older population.1 There are several factors to consider when assessing the risk for pressure ulcers among the elderly as well as when designing a comprehensive prevention program. One factor worthy of note is that the prevention of pressure ulcers requires a constant approach throughout the daily 24-hour period. This includes consideration of factors that contribute to the development of pressure areas when the patient is lying in bed, seated in a wheelchair or an armchair, or performing functional activities. A variety of methods for reducing pressure and thus the chance for skin compromise, should be employed to achieve optimal clinical outcomes, including optimizing skin integrity, ensuring the ability for participation in functional activities, improving mobility, and preventing secondary medical complications such as sepsis, cellulitis, and osteomyelitis.

COMPREHENSIVE RISK ASSESSMENT

With elderly patients, it is important to complete a comprehensive risk assessment for pressure ulcers to establish appropriate treatment plans that minimize the risk of skin breakdown. Clinical observation of the patient’s skin, the use of a standardized pressure risk prediction tool, and a functional assessment all contribute to ensuring coordinated care delivery.

Clinical assessment of skin integrity should include close examination of those sites that are most commonly prone to pressure. These include the occiput, acromion process, scapula, thoracic and lumbar vertebrae, olecranon process, sacrum, coccyx, trochanter, ischial tuberosity, lateral aspect of the knee, medial and lateral malleolus, metatarsals, and calcaneus.2 Any signs of redness, moistness, or fragility should be documented and rechecked frequently to prevent further compromise.

The use of standardized pressure risk prediction tools is another component of the comprehensive risk assessment process. Commonly used scales include the Braden Scale for Predicting Pressure Sore Risk and the Norton Scale for Predicting Risk of Pressure Ulcer. The Braden Scale is the most widely used tool and looks at six risk factors related to the development of pressure ulcers: sensory perception, skin moisture, activity, mobility, nutrition, and friction/shear. Numeric scores are assigned to each area, and then a composite risk score is obtained and correlated to specific degrees of risk. The Norton Scale examines five areas of risk: physical and mental condition, activity, mobility, and incontinence. Areas are again scored, and a composite risk score is obtained. In addition, there are less frequently used prediction tools, including the Gosnell Scale, the Waterlow Pressure Sore Risk Scale, and the Trial Pressure Score Risk Assessment Scale.

Finally, when assessing patient risk for pressure ulcer development, one should note the patient’s overall functional status. This includes continence, functional mobility including the ability for repositioning, cognitive status, nutrition/hydration status, and communication abilities. By combining multiple methods of assessment, one can take a proactive approach to reduce the risk of pressure ulcer development and make sure specific areas of concern are targeted.

PRESSURE ULCER RISK FACTORS

Incontinence: Loss of bowel or bladder control is a primary contributing factor to skin compromise in the institutionalized elderly. Moisture reduction should be the primary goal of managing this risk factor. The patient’s skin should be kept clean and dry, and a variety of strategies is available based on the patient’s needs, including the use of moisture barriers such as a petroleum-based product applied to the skin, plastic bed pads covered with a sheet to decrease moisture contact with the skin, and in some cases where incontinence is difficult to manage, absorbent briefs and catheters.

Compromised nutritional status: Nutritional deficits should be monitored via frequent weight checks as well as the use of laboratory values including serum albumin and lymphocyte count. Patients should be encouraged to eat a balanced diet, with supplements for nutritional support used as appropriate.

Immobility: For those patients with impaired mobility or complete immobility, frequent skin inspections are crucial for early identification of pressure sites. Skin should be inspected at least daily by either the patients themselves or caregivers. The patient’s position should be changed at least every 2 hours; however, hourly is optimal, especially for those patients seated in chairs. If patients are able to shift their own body weight, they should be encouraged to do so every 15 minutes, the normal frequency of weight changes for those with intact mobility.

Pressure relief over bony prominences must be a primary focus of care delivery to the elderly. In addition to repositioning, the use of pressure support surfaces may also contribute to a reduction in the development of pressure ulcers. Pressure support surfaces are designed to lower the surface pressure on the body and include thick foam mattresses, water mattresses, pressure air mattresses, air-fluidized beds, low-air-loss beds, and a variety of wheelchair cushions, including honeycomb, fluid-filled, and foam. Advantages and limitations of each support surface should be considered prior to selection and matched to the patient’s functional abilities and individual goals so that the optimal solution is selected. Items to be avoided for pressure relief include pillows and donut-shaped rings, as they are known to cause compression, resulting in decreased blood supply and thus increased risk for skin compromise.

Friction and shear should be avoided when moving the immobilized patient. Friction occurs when the skin rubs against another surface, such as a sheet. Caregivers should use caution when repositioning a patient and avoid sliding them up in bed as their skin rubs against the sheet, or grabbing the patient under the arms from behind to prevent sliding out of a wheelchair. Shearing occurs when two layers of skin slide on each other or when skin sticks to a surface. Minimization of both friction and shearing can be accomplished by ensuring that the patient has an appropriately designed seating system and that caregivers are trained in proper ways of moving patients who are unable to move themselves.

Cognitive impairment: Patients with cognitive impairments warrant extra attention to skin care. Due to their decreased ability for automatic repositioning, the potential lack of attention to the status of their own skin condition, and possible communication deficits that make it difficult to express pain or discomfort, caregivers need to be acutely aware of the need for frequent repositioning and at least daily skin checks. Caregiver training: a final essential area for consideration in the prevention of pressure ulcers in the elderly is the need for proper education of caregivers, including professional caregivers, family, and the patients themselves. This training should include ensuring an understanding of the risk factors and prevention strategies described above, the rationale supporting selection of support surfaces and their appropriate use, the need for a comprehensive skin care program individualized to the patient’s clinical needs, appropriate methods of positioning and repositioning, facilitation of optimal nutrition, and methods for routine skin inspection.3

Patients and their caregivers, in conjunction with an interdisciplinary team that includes rehabilitation professionals, can then work collaboratively to maintain skin integrity, overall comfort, and quality of life.

Sharon Kurfuerst, MEd, OTR/L, ABD, is director, clinical services, for Genesis Rehabilitation Services in Kennett Square, Pa.

References

Reed MJ. Wound repair in older patients: preventing problems and managing the healing. Geriatrics. 1998;53(5):88-94.
Sussman C. Wound Care: Patient Education Resource Manual. Gaithersburg, Md: Aspen Publishers Inc; 1999.
Pajk M. Pressure sores. In: Beers MH, Berkow R, eds. The Merck Manual of Geriatrics. Whitehouse Station, NJ: Merck & Co; 2003.

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October 2003