January 10th, 2018
Predicting Pressure Ulcer Risk – overview of the clinical problem
Pressure ulcers present a significant challenge in the provision of effective care to older adults. By definition, “a pressure ulcer is any injury caused by unrelieved pressure that damages the skin and underlying tissue, usually over a bony prominence” (Franz, 2004, p. 4). Its prevalence has been observed in different settings particularly those involving care provision to the older adults. For instance, in older population under home-care assistance programs, pressure ulcers prevalence has been approximated at 12.7 % and 15.1% in different surveys (e.g. Bours et al., 1999; Woodbury & Houghton, 2004 as cited in Capon, Pavoni, Mastromattei & Di Lallo, 2007, p. 264). In acute care settings, observed prevalence has varied from 7% to 38 % (e.g. Melotti et al. 2003 as cited in Capon, et al. 2007, p. 264; Franz, 2004, p. 4), with high prevalence values being observed in units providing long term care – e.g. 29.9% in Canada (Woodbury & Houghton, 2004, as cited in Capon, et al. 2007, p. 264) and 28% and 33.2 % in America (Horn et al., 2002; Zulkowski, 1999 as cited in Capon, et al. 2007, p. 264). The incidence of the condition hasis estimated to range from “0.4-38% in acute care, 0-17% in home care, and 2.2-23.9% in institutional” long term care (Ayello, 2007, par 1).
In terms of development, pressure ulcers result from “pathologic changes in the blood supply to dermal tissues” (Thomas, 2001, p. 704). Such changes mainly involve heightened pressure being applied to susceptible tissues, mainly in cases where there exist contact between surfaces and weight bearing points, which mainly occur over bony prominences (Thomas, 2001). since there may exist differences in resistance to pressure between such tissues over bony prominences and soft tissues located far away from the bone, pressure ulcers predominate in body parts characterized by the former e.g. sacrum, ischial tuberosities and coccyx (Thomas, 2001).
For susceptibility, older patients have been observed to be more vulnerable to pressure ulcers across different care settings (Frantz, 2004). For instance, Papantinio, Wallop and Kolodner (1994) found out that the risk of pressure ulcers for patients more than 70 years old who had undergone surgery, was as much as five times that of individuals aged less than 60 years (as cited in Frantz, 2004, p. 4). Such risk of pressure ulcers is heightened by co-occurrence of other determinant factors, which are common in old age (Frantz, 2004). Such other risk factors include decreased sensory perception, poor nutrition, and excessive exposure to moisture (Frantz, 2004).
Pressure ulcers are staged according to the severity and extent of tissue involvement. Stage 1 is the “non-blanchable erythema of intact skin, heralding lesion of skin ulceration” (Frantz, 2004, p. 5). This may involve skin discoloration, edema and hardness in dark-skinned individuals. Stage 2 involves the “partial thickness skin loss”, which may occur in the epidermis, dermis or in both tissues (Frantz, 2004, p. 5). The third stage is characterized by “full thickness skin loss” that includes necrosis of subcutaneous tissue, at times, such tissue damage, extending to the fibrous tissue underlying the subcutaneous tissue, but not spanning such fibrous tissue (Frantz, 2004, p. 5). In stage four, the full thickness skin loss involves “extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures” (Frantz, 2004, p. 5).
Decreasing the risk of pressure ulcers is important since their high prevalence and incidence, presents a challenge to effective provision of care, not only as a result of the cost associated with treatment but also its contribution to morbidity and mortality of the elderly (Defloor & Grypdonck, 2005; Vap & Dunaye, 2000). Early detection in this respect is critical in avoiding escalation of the condition and minimizing the cost of treatment. Vap and Dunaye, (2000) for instance note that the cost of treatment and healing of pressure ulcers id determined by severity, with chronic wounds taking as much as six months to respond fully to treatment (p. 39). Management of the condition however may rest in identifying at-risk individuals so as to target preventative initiatives to such individuals. Accordingly, by encompassing core risk factors in its assessment, Braden scale may prove effective at delineating at risk populations thus help care givers to initiate appropriate response to avert the onset of pressure ulcers (Ayello, 2007). Go to part 3 here.