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Treatment at Wound Site
Once a pressure ulcer has begun to develop, reducing the pressure on that area is critical to improving the condition. Some patients may be unable to avoid resting on certain parts of their body. They may also be unaware when they shift into a position that worsens a pressure ulcer. Bone protrusions on particularly thin patients can also be difficult to work around. Cullum, Mcinnes, Bell-Syer, and Legood, (2015) discuss the advantages of padded support surfaces for patients who are unable to keep weight of a certain part of the body. The softer surface reduces the pressure in the area and stops the tissue from becoming ischemic. This tool can work as a preventative measure as well, but is a vital tool in reducing the effects of a pressure ulcer once it has developed for patients who struggle with resting in different positions.
Standard treatments at the sight of injury for such wounds should also be administered. Bandaging can help reduce additional damage caused by friction of the wound against surfaces such as clothes and bedding. Topical ointments or antiseptics may be used as prescribed by the patient’s physician to manage the healing process and prevent against infection. In particularly severe pressure ulcers, surgery may be necessary to remove necrotic tissue and promote healthy tissue to regrow in the area (CDC, 2015).
Antiseptic and Antibiotics
Depending on the severity of the pressure ulcer, a physician may order a number of different medications to control for infection. These prescriptions may be merely cautionary, as no infection may have yet developed, or they may be designed to actively fight an already existing infection. The longer a pressure ulcer has existed, the higher the likelihood of pathogens contaminating the site, and thus stage three and stage four ulcers are more likely to be infected than stage one and stage two. Additionally, the use of a topical antiseptic treatment becomes less preferable the deeper a wound has reached due to the possibility of causing damage to tissues. The skin is a much more resilient tissue than the underlying fascia and muscle, and as such, topical antiseptic treatments are more likely in stage one and stage two ulcers than in stage three and stage four (Chou et al., 2013).
Antibiotics are most likely to be used in conjunction with topical antiseptic treatment or in its absence. Like topical antiseptic, antibiotics can be used as a preventative measure or as a response to an existing infection. Unlike topical antiseptic, antibiotics can treat infections that may be developing throughout the body in places other than the wound site. Due to the risk of secondary infections and sepsis, antibiotics are the most important line of infection control associated with pressure ulcers. Additionally, they do not damage tissue and can be used in the case of stage three and stage four ulcers where they wound has gone deep enough to expose tissue that may be too sensitive for topical treatment. Two routes of administration exist for antibiotics: oral and intravenous (IV). Due to the high risk of infection associated with having an open wound that is resistant to healing, a physician is likely to prescribe IV antibiotics which are a more aggressive and expedient form of treatment than orally administered ones.
According to research done by Llano et al. (2013) nutrition plays an important role in the development of pressure ulcers. Not all people’s bodily tissue is the same in regards to risk of ulcer development. If a person is malnourished, that person’s tissue is more susceptible to damage and infection and is less resilient and capable of healing than someone whose body is being given the nutrients it needs. The body requires a daily influx of certain chemicals to promote immune system health and to use as building blocks to promote cell reproduction and repair damaged tissue. If tissue becomes damaged and cannot repair right away, this acts as a foothold for bacteria which in turn prevent tissue healing further, thus creating a cycle of damage and leading to an open wound. If two people were to lay in the same position for an extended period of time, and one of them was malnourished while the other one was not, then the malnourished patient would be more likely to develop a pressure ulcer.
The body is constantly being damaged and repairing itself in a way that is not normally noticeable. Often times, a pressure ulcer is not as simple as ischemia caused by laying on an area too long and cutting off the blood supply, but is rather due to that factor combined with an inability for the body to heal due to malnutrition. This complex issue is described by Fossum, Alexander, Ehnfors, and Ehrenberg (2011) as being something that is very difficult for medical and nursing staff to manage. Nutrition is an unseen factor in the body, often complicated by patients conditions. Often a well fed patient can still be malnourished due to the way their body processes food. Additionally, nurses cannot force their patients to eat or to eat healthy foods. And finally, nutrition is something in which nurses have limited training. Due to the complexity of the topic, it is an entirely different field from what nurses are used to handling.
While treatments can be highly effective at minimizing the damage caused by pressure ulcers and often reversing some of their effects on tissue, the best method to approach this condition is complete prevention. As has been mentioned earlier in this paper, pressure ulcers at stage three or stage four are considered never events by the UDHHS (2016), and many hospitals have in their policies regulations against the development of any pressure ulcers. Since the mechanisms that cause this condition always the same, all health care organizations working with at risk populations have protocols in place to minimize the incidence of pressure ulcers. This section will review common practices as well as emerging research in the area of pressure ulcer prevention.
According to Pham et al. (2011), nursing staff are the first line of defense against pressure ulcers. Nurses must be able to identify risks for these conditions early. This does not necessarily imply the identification of a pressure ulcer wound, since one it has begun to develop the nurses have already failed at their job of prevention. Instead, nursing staff must be trained on identifying risk factors commonly associated with pressure ulcer development. For the purposes of this paper, one of the most common risk factors is age and immobility. Pham et al. (2011) discuss the high level of risk associated with elderly patients admitting directly from the emergency room. Due to the recency of whatever condition caused them to require emergency services, these patients have not yet recovered to their normal level of functions. In fact, they may never fully recover to their previous level of functioning, but unlike other patients in nursing care, recent admits from emergency services do not have a known baseline for functioning and mobility. Nurses cannot know what is “normal” for this population and must instead treat them with heightened supervision and insure that they are shifting positions regularly.
In order to be able to accurately supervise high risk patients, nursing staff must have appropriate ratios. Nurses working with elderly patients often require higher ratios than other populations due to the large number of things for which to be monitoring. As Bradford (2016), physical repositioning of a patient by staff is sometimes the only way to prevent pressure ulcer development since some patients are entirely unable to move. This is a strenuous activity that requires multiple staff to be able to accomplish for an entire unit throughout a shift. The nursing shortage cannot be used as an excuse for hospitals having low ratios due to the fact that nursing aides and CNAs can count as nursing staff, though they are not nurses. Much of pressure ulcer prevention, such as monitoring for wound development and routine position changes, does not require a nursing license to accomplish and can be a delegated task.
Sullivan and Schoelles (2013) identify low activity engagement as a risk factor for pressure ulcers. The logic is easy to follow: if patients never leave their beds, then the likelihood of pressure ulcers increases. Often times, patients are capable of leaving their beds but have little or no motivation to do so. Many patients cannot engage in the activities that they once could, and if they left their beds, would be restricted to a wheelchair or a walker. Still, it is important for pressure ulcer prevention for patients to get up and move about, and it falls to nursing staff to find ways to motivate them. Nursing administration can make accommodations and plan activities which patients in which patients would be able to engage. There is a reason that low intensity group activities such as card games are often associated with elderly care. In addition to being mentally and socially stimulating, these act as an excuse for patients to leave their beds and change positions, which in turn reduces the risk of pressure ulcer development
More bodily changes while in a resting position can also be useful for reducing the risk of pressure ulcers. As Bradford (2016) acknowledges, many patients are not capable of leaving their beds, even if they wanted. In these instances, special accommodations must be made to stimulate these patients into wanting to shift positions. A patient who is capable of moving, but still cannot get out of bed, should not be forcibly shifted to a different position by staff, if at all possible. Instead, staff should try to facilitate activities that would encourage such patients to change their resting posture. Even sitting up in bed can help take pressure off of one area and shift it to another, thus reducing the risk for developing injury.
Nutrition is not only a treatment option for patients who have developed pressure ulcers, but is also a prevention tool. As has been mentioned earlier in this paper, poor nutrition can weaken bodily tissues and compromise their ability to heal, thus making a patient more susceptible to pressure ulcers. Though a nutritionist may not be available on staff and the nursing staff at any given facility may not be highly educated on nutrition, hospital administrators can consult relevant literature on the topic or hire an outside consultant to devise an appropriate nutrition plan for people at risk of developing pressure ulcers. In addition to implementing nutritional standards that specifically target tissue strength and resilience, the importance of nutrition can be explained to the patients themselves. The have a right to understand their risk for ulceration and to be an active part of their preventative care (Llano et al., 2013).
As has been discussed in this paper, nutrition is often a difficult facet of patient care to monitor. This is why Fossum et al. (2011) suggest the use of a computerized system designed to monitor patient nutritional status and inform care decisions. In a study spanning two years that involved four hundred and ninety one nursing home residents, Fossum et al. (2011) saw significant reductions in patient malnourishment as a result of the implementation of computerized decision support system (CDSS). Though they do not directly correlate their research to a reduction in pressure ulcer incidence, this study shows promise for the use of this technology. The researchers suggest CDSS be implemented into hospitals’ electronic health records to reduce malnourishment and potentially improve pressure ulcer prevention.
Research by Cullum et al. (2015) indicates that the use of padded surfaces can be beneficial in delaying the onset of pressure ulcers. For patients who have no ability to move or who are too heavy to be easily moved by staff, the use of additional padding as support can greatly reduce the incidence of pressure ulcers by increasing the amount of time it takes for them to develop. Padded surfaces were discussed briefly as a method for treating pressure ulcers after they have developed, but the same principle of spreading a patient’s weight over a greater surface area to reduce the pressure component can be used to prevent the formation of pressure ulcers. Areas that are likely to develop ulcers, such as bony protrusions, can be specifically targeted with padding.
This technique does not in anyway fix the problem. Ulceration will still occur in patients using padded support surfaces. As such, nursing staff must still follow other protocols in place to monitor for wound formation, encourage patients to leave their beds or to change positions, and physically move patients if necessary. The use of padded support surfaces does increase the time of wound formation and thus assist nursing staff in managing patient care, especially in facilities where nursing staff ratios are not ideal.
Pressure ulcers are a multifaceted health care concern with no one solution capable of significantly improving patient care. Rather, a change must be made throughout the nursing field in how this condition is approached. Additional education is needed for both nursing staff and patients to help identify and address those at risk early on to prevent pressure ulcers from forming or to catch them in their earliest stages. Administrators can push for increased funding for activities that encourage patients to move about, can modify policies and procedures to include standards designed to prevent ulcer formation, and can hire competent staff that increase nursing staff to patient ratios. Nurses and nursing aides working directly with patients can educate themselves on current evidence based practices designed to reduce the risks of pressure ulcers. Through integration of nutritional education, the use of assistive technologies such as support surfaces, the use of information technology designed to track patient risks, and the implementation of programs designed to encourage clients to change posture frequently, nursing staff can greatly reduce the incidence of pressure ulcers and educate patients on the risks involved.
Bradford, N. K. (2016). Repositioning for pressure ulcer prevention in adults-A Cochrane review. International Journal of Nursing Practice, 22(1), 108-109. doi:10.1111/ijn.12426
Centers for Disease Control and Prevention (2015). Pressure ulcers among nursing home residents: United States. Retrieved November 13, 2016 from http://www.cdc.gov/nchs/products/databriefs/db14.htm
Chou, R., Dana, T., Bougatsos, C., Blazina, I., Starmer, A. J., Reitel, K., & Buckley, D. I. (2013). Pressure ulcer risk assessment and prevention. Annals of Internal Medicine, 159(1), 28. doi:10.7326/0003-4819-159-1-201307020-00006
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Fossum, M., Alexander, G. L., Ehnfors, M., & Ehrenberg, A. (2011). Effects of a computerized decision support system on pressure ulcers and malnutrition in nursing homes for the elderly. International Journal of Medical Informatics, 80(9), 607-617. doi:10.1016/j.ijmedinf.2011.06.009
Llano, J. X., Bueno, O., Rodriguez, F. J., Bagües, M. I., & Hidalgo, M. (2013). Prevention & treatment of pressure ulcers and nutritional status in elderly population. International Journal of Integrated Care, 13(7). doi:10.5334/ijic.1406
Pham, B., Teague, L., Mahoney, J., Goodman, L., Paulden, M., Poss, J., . . . Krahn, M. (2011). Early prevention of pressure ulcers among elderly patients admitted through emergency departments: A cost-effectiveness analysis. Annals of Emergency Medicine, 58(5). doi:10.1016/j.annemergmed.2011.04.033
Sullivan, N., & Schoelles, K. M. (2013). Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Annals of Internal Medicine, 158(5), 410-416.
United States Department of Health and Human Services (2016). Never Events. Retrieved October 21, 2016 from https://psnet.ahrq.gov/primers/primer/3/never-events