Pressure ulcers are a serious patient safety problem. They are also recognised as a clinical indicator of a patient’s standard of care.

The incidence of pressure ulcers in residents of Australian health care facilities, particularly within aged care, has been reported to range between 13% and 35% in any given year. The clinical, financial and personal costs of pressure ulcers have a detrimental effect on patients, families and the community.

Pressure ulcers result in significant deterioration of quality of life for patients, as well as high costs to health care facilities in terms of high potential for morbidity and general care and facility costs. 

Most pressure ulcers are preventable and many hospitals and residential aged care facilities (RACFs) already implement programs for the prevention and management of pressure ulcers.

The first stage in both prevention and management is risk assessment. As outlined in the Queensland Health Pressure Ulcer Prevention and Management Resource Guidelines, www.health.qld.gov.au, all patients must have a risk assessment completed within 24 hours of admission.

A risk assessment involves examination of the skin, nutritional and a general medical assessment to identify risk factors. Major risk factors include; immobility, sensory loss, impaired cognitive state, urinary and faecal incontinence, age over 65 years, chronic illness, poor nutritional status, impaired oxygen delivery to tissues, raised skin temperature, skin dryness and the presence of pressure.

Preventative strategies to reduce risk factors can be incorporated into care plans for residents identified as ‘at risk’. Some important strategies are outlined below:

•  Pressure elimination Relieving pressure on the skin is cited as one of the main factors in reducing the risk of pressure induced tissue injury. This can be achieved by altering patient’s position as little as 10-20 degrees.
• Skin protection Skin folds can be sites of atypical pressure ulcers as small items, tubes and clothing can be caught and act as a focus for pressure ulcer development.
• Lifestyle assessment Facilitation of appropriate and timed physical activity can minimise immobility.
• Skin assessment Keeping skin at the correct moisture level is essential, as damage is more likely to occur if skin is either too dry or too moist.
• Nutrition assessment Inappropriate restrictions may lead to protein energy malnutrition further increasing the risk of pressure ulcers, poor healing and increased infection risk. Optimisation of nutrition and hydration is vital.
• Equipment assessment Special equipment such as pressure reduction mattresses and cushions can be used to reduce pressure in particular places.

For managing existing cases of pressure ulcers, treatment principles are dependant on the level of pressure ulcer severity.

Stage 1 - Ulcer appears as a defined area of persistent redness if skin is lightly pigmented. Treatment: protect and cover with transparent films, barrier creams or skin sealants.

Stage 2 - Partial thickness skin loss involving epidermis and/or dermis.

Treatment: hydrate, insulate and absorb. Consider transparent films, occlusive wafers and hydrogels, foams.

Stage 3 - Full thickness skin loss involving damage or necrosis of subcutaneous tissue.

Treatment: cleanse, prevent infection and promote granulation. Consider calcium alginate, hypertonic saline, cavity foams or vacuum assisted closure.

Stage 4 - Full thickness skin loss with extensive destruction, tissue necrosis or damage to supporting structures.

Treatment: as for stage 3 plus pack dead space.

Ultimately, all prevention management and treatment principles come down to relieving pressure, promoting ulcer healing, reducing risk factors and optimising general health.

References

• Department of Health and Aging - Trial of a System for Prevention and Management of Pressure Ulcers www.health.gov.au
• The Victorian quality council. Pressure ulcers – a cause for concern
• Queensland health - Pressure ulcer prevention and management guidelines
• The Royal Australian College of General Practitioners – Medical care of older Australians in residential aged care facilities