Journal of Gerontological Nursing

Investigating the Problem of Pressure Sores

Marilyn Pajk, MS, RN; Gloria Aubut Craven, MS, RN; Janet Cameron-Barry, MS, RN; Theresa Shipps, MS, RN; Nancy Wiltz Bennum, BSN, RN

Abstract

Despite increasingly sophisticated technology enabling us to diagnose and treat disease, few problems develop so quickly persist so tenaciously and heal so slowly as the pressure sore.

Abstract

Despite increasingly sophisticated technology enabling us to diagnose and treat disease, few problems develop so quickly persist so tenaciously and heal so slowly as the pressure sore.

The problem of pressure sores is timeless. Despite increasingly sophisticated technology enabling us to diagnose and treat disease, few problems develop so quickly, persist so tenaciously, and heal so slowly as the pressure sore. In addition, perhaps no other problem is so directly seen as a reflection of the quality of nursing care the patient has received. Small wonder then that many of me attitudes we as nurses have regarding the prevention and management of pressure sores include guilt, frustration, and confusion. The multiplicity of skin care products and equipment on the market (over 2,500 in the United States alone),1 as well as conflicting recommendations for the prevention and care of pressure sores, adds to the confusion.

Much has been written about the incidence and cost of pressure sores. In a study of 18,000 hospital admissions, Rubin, et al,2 reported that 262 patients (1.5%) were either admitted with pressure sores or developed them after admission. Debilitation was identified as the most common precipitating factor. In another study of patients with spinal cord injuries, El-Toraei3 found that 25% to 85% of these patients developed pressure sores. These lesions were felt to be accountable for 7% to 8% of deaths in spinal cord injury patients.3 Fowler4 estimated the cost of medical and nursing care for patients hospitalized with pressure sores in a community hospital as $6,000 per patient per month. In addition, Bardsley5 demonstrated in an 18-month survey of 30 patients with pressure sores that 4,874 patient days were lost from active rehabilitation therapy.

At our 300-bed teaching community hospital, several members of the nursing department observed that many patients were admitted with pressure sores and other nonpressure-related problems (eg, rashes, excoriations, tape burns) or developed these problems after admission. In response to these observations and a desire to offer a solution to the problem, an interdisciplinary skin care committee was formed. Members of the committee included clinical nurse specialists, an enterostomal therapist, a physical therapist, a nutritionist, a total parenteral nutrition nurse clinician, a nurse epidemiologist, and several staff nurses.

Though there was consensus among members of the committee that skin care problems were a frequent and serious patient care issue, the exact magnitude of the problem remained unknown. One of the primary goals of the committee, therefore, was to conduct a clinical investigation involving all patients in the medical, surgical, and special care areas. Most important, while we were interested in the frequency and stages of skin breakdown, we wanted to identify quantitatively those patients at risk for developing problems. We felt this identification to be essential because of the importance of prevention in the management of pressure sores.

Review of the Literature

Previous studies have been conducted to identify patients at risk for the development of pressure sores.6,7,10,11 In 1962, Norton, et al,7 developed an assessment tool using a simple scoring system for five assessment categories. The five categories included physical condition, mental condition, mobility, activity, and incontinence. Norton's sample consisted of 250 patients with a mean age of 79.9 years. The study revealed a significant correlation between the patient's score on this assessment tool and the risk for tissue breakdown. Within this sample, 24% of patients developed pressure sores. The mean score for those patients who developed pressure sores was 12.

Table

FIGURECRITERIA FOR STAGING PRESSURE SORES

FIGURE

CRITERIA FOR STAGING PRESSURE SORES

Gosnell (1973)6 conducted a study using an assessment tool that was based on Norton's tool. Gosnell, however, eliminated the variable "physical condition" and instead examined nutrition in her assessment of patients. The sample consisted of 30 patients with a mean age of 78.8 years who were admitted to extended care facilities.

Gosnell found that nutrition, activity, mobility, and mental status were influential variables in the development of pressure sores. She found, however, that continence was not a significant variable. Gosnell suggested that the patient at high risk had a total score of 11 or less. Within this sample, gender and age were not differential factors regarding the occurrence of pressure sores.

Study Construction

The study was conducted at a 300bed community teaching hospital in New England. The hospital provides care to all age groups, including a high percentage of elderly. Ten patient care units were involved, including three medical, three surgical, one pediatric, one coronary care, one progressive cardiac care, and one intensive care. All beds in these areas were assigned to auditors involved in the study, and all patients occupying these beds were included in the sample. The audit was carried out over ten consecutive work days. Each bed was audited only once during that period of time. A total of 208 patients were audited. Patient data were collected primarily via physical examination and interviews. Information was also collected from the patients' medical records and from interviews with staff nurses. The data collected consisted of demographic information, assessment of risk factors for skin breakdown, assessment of skin integrity, and the use of preventive products at the time of the survey.

The demographic data in the audit tool included such variables as age, gender, height, and weight. The risk factor component of the tool was derived from the assessment tools developed by Norton7 and Gosnell.6 Five risk factor variables were included: mental status, continence, mobility, activity, and nutrition. Each of these variables was rated either on a four- or five-point scale. This scale resulted in a potential low score of 5 (representing patients at greatest risk) and a high score of 20 (no risk). A rater's guide based on Gosnell's research was used to assist in scoring each patient. One aspect of the guide that was revised for the purpose of this investigation was the operational definition of nutritional status. The criteria developed to rate nutritional status in this study encompassed more than observation of food intake. For example, factors such as loss of appetite for one week and prolonged diarrhea were considered contributive to a borderline nutritional state.

Skin integrity was evaluated by direct observation. Auditors inspected each patient and noted whether the patient had intact skin, pressure sores with or without other skin problems, or other skin problems only. All pressure sores were staged according to standardized criteria, which were developed based on earlier definitions used by Guttman8 and Shea9 (see Figure). Other skin problems included those conditions that were not pressure related, such as tape burns, dry skin, and rashes.

Five nurse auditors participated in the study, each of whom was assigned two patient units. An exercise to enhance interrater reliability was conducted in which auditors assessed the same two patients for both risk factors and skin integrity. There was 100% agreement among auditors; therefore, consensus was reached that the criteria utilized allowed for consistent measurement.

Study Findings

Demographics - Of the 208 patients studied, 114 patients (54.8%) were women and 94 (45.2%) were men. The age range in this sample was 5 to 91 years with a mean age of 61.8 years. Although the age range was broad, the population was primarily elderly. It is notable that 107 (51.4%) of all patients were 65 years or older. In fact, 93 (44.7%) of the patients studied were 70 years or older.

Table

TABLE 1FREQUENCY OF PRESSURE SORES BY LOCATION

TABLE 1

FREQUENCY OF PRESSURE SORES BY LOCATION

Skin Integrity - Within the sample, 105 patients (50.5%) were identified as having intact skin, 41 patients (19.7%) were observed to have pressure sores, with or without other skin problems, and 62 patients (29.8%) had other skin problems. In all. 111 pressure sores were noted and staged: 75 Stage 1, 34 Stage 2, and 4 Stage 3. No Stage 4 pressure sores were noted. These findings imply that a number of patients had two or more pressure sores (as was the case). Data collected concerning location of pressure sores revealed that they were most frequently observed in the sacral and buttock areas (52 sores or 46.8% of all sores identified). AU of these pressure sores were classified as either Stage 1 or Stage 2 (see Table 1).

Risk Factor Score and Variables - The risk factor scores for the total sample ranged from 5 to 20, with a mean of 16.76, representing the entire possible range. By examining each variable of the risk factor score, it became clear that some risk factors were seen with more frequency than others. A ranking of the risk factor variables in order from those seen with greatest frequency to least frequency was as follows: altered nutritional status, impaired activity, impaired mobility, incontinence, and altered mental status. In addition, each variable of the risk factor score was analyzed to determine the strength of the relationship between the variable and the incidence of skin breakdown. All five risk factors were found to be strongly associated with skin breakdown at a significance level of <0.0000.

Risk Factor Score and Skin Breakdown - Though all patients were assessed for total skin integrity, for purposes of comparison with the risk factor score, patients were placed into one of two groups: those with pressure sores, of all stages, and those without pressure sores. The mean risk factor score for patients with pressure sores was 13.07. The mean risk factor score for patients without pressure sores was 17.66. This relationship was significant at <0.001.

The population with pressure sores was further categorized according to the stage of skin breakdown. There were a total of 41 patients with pressure sores. Within the sample, some patients had more than one pressure sore at different stages of skin breakdown. In these cases (n = 11), patients were placed into the category of more severe breakdown. For example, a patient with both a Stage 1 and a Stage 2 pressure sore was placed into the Stage 2 category.

Fourteen patients were categorized as having Stage 1 pressure sores. For these patients, the mean risk factor score was 14.07. Twenty-four percent were categorized as having Stage 2 skin breakdown with a mean risk factor score of 12.91. Within the sample, three patients were categorized as having Stage 3 skin breakdown. The mean risk factor score for these patients was 9.67. The downward trend of the mean risk factor scores with the increasing severity of skin breakdown suggests that the risk factor score may be associated not only with skin breakdown but with the severity of the breakdown as well.

Table

TABLE 2AGE IN RELATION TO SKIN INTEGRITY

TABLE 2

AGE IN RELATION TO SKIN INTEGRITY

Gender and Skin Integrity - Women developed pressure sores more frequently than men. Twenty-five percent (n = 29) of all women had pressure sores in comparison to 12.8% (n = 12) of men. There was no significant relationship between gender and the risk factor score. However, the risk factor score remained correlated to skin integrity for both men and women.

Age and Skin Integrity - There was a clear linear relationship between skin integrity and age. The proportion of subjects less than 55 years of age who had intact skin was 96.9%. The proportion of patients over 84 years of age with intact skin was 18.8% (see Table 2).

Based on the results of a ? test, age was again found to be significantly related to skin integrity (p <0.01, t = - 7.38). The median age for the sample was 65 years. The mean age of the 167 patients with intact skin was 58.3 years. However, the mean age of the 41 patients with pressure sores was 76.1 years.

Table

TABLE 3MEAN RISK FACTOR SCORE IN RELATION TO SKIN INTEGRITY, CONTROLLING FOR AGE

TABLE 3

MEAN RISK FACTOR SCORE IN RELATION TO SKIN INTEGRITY, CONTROLLING FOR AGE

Skin integrity and the risk factor score for those younger than 65 and for those 65 and older were examined by means of a t test (see Table 3). Of 101 patients younger than 65, 94 had intact skin and a mean risk factor score of 18.3. Seven patients with pressure sores had a mean risk factor score of 15.7. Of the 107 patients who were 65 or older, 73 had intact skin with an accompanying mean risk factor score of 16.79. For those 34 patients with pressure sores, the mean risk factor score was 12.52. Therefore, when controlling for the variable age, a significant relationship between skin integrity and the risk factor score remained.

Age by Decade Compared to the Risk Factor Score and Individual Risk Factors - The relationship between age and the risk factor score was significant at a level of < 0.001 (Fearson's Correlation: r = - 0.43). Further breakdown of the data by decade indicates that there is a clear linear relationship between the risk factor score and advancing age. For subjects younger than 55 years of age (n = 64), the mean risk factor score was 18.62. The mean risk factor score for each subsequent decade was as follows: 17.3 for subjects 55 to 64 (n = 37), 16.4 for subjects 65 to 74 (n = 34), 15.56 for subjects 75 to 84 (n = 57), and 12.93 for subjects 85 to 94 (n = 16). This linear relationship was significant at < 0.001. The same linear relationship was upheld for each of the five individual risk factors and all were significant at < 0.001.

Discussion and Recommendations

The findings of the study further validate the relationship between the risk factor score and skin breakdown. This relationship holds true for each component of the risk factor score as well as me total score. In addition, the data suggest significant relationships between patient characteristics such as age, gender, and the incidence of skin breakdown.

In relation to the risk factor score, studies by Norton and Gosnell identified scores of 12 and 1 1 respectively as the critical scores at which pressure sores developed (see Table 4). Our study did not have a longitudinal design; therefore, we were not able to identify the score at the point of skin breakdown. However, based on our data, a critical score would seem to be 14.07. This figure represents the mean score for patients with Stage 1 pressure sores, the earliest skin breakdown.

Implications for Clinical Practice - The study findings substantiate the clinical relevance of using a risk factor assessment tool to identify the patient at high risk for pressure sore development. The tool should be used at the time of patient admission and on a regular basis. The frequency with which the tool is used may vary according to the setting and the patient's level of acuity. For example, a patient who is admitted on an acute basis to a hospital will require more frequent assessments than a patient who is in stable condition at home or in an extended care facility.

Based on me findings of this study, the investigators recommend that a patient be considered high risk if the patient:

1. Has a total risk factor score of 15 or less;

2. Shows a downward trend in risk factor score over time; and

3. Is 65 years or older, or has a low score on any individual risk factor.

When a patient is identified as high risk, preventive measures should be instituted immediately. The risk factor assessment tool serves as a guide for nursing interventions. Individual risk factors can be evaluated and modified when possible. For example, if a patient is rated as having a poor or borderline nutritional status, nursing interventions, such as calorie counts, nutritional supplements, and a nutrition consult, should be carried out to modify this risk factor.

Nursing Interventions - Patients who are incontinent should be gently cleaned using plain water or a minimum of mild soap. All soap residue should be removed and the skin thoroughly dried to prevent maceration and irritation of the at-risk tissue. Disposable plasticlined underpads should not be used directly against the skin as this further promotes tissue maceration. Instead, the plastic-lined underpads, when used, should be placed in pillow cases or beneath the draw sheet. The skin should be protected using a thin layer of a petroleum-based product because this type of product is water resistant and provides a protective barrier against urine and feces. Topical agents such as zinc oxide and aluminum paste should be avoided. While these products are protective, they are messy and difficult to remove gently.

Table

TABLE 4CRITICAL SCORES FOR PATIENTS AT HIGH RISK

TABLE 4

CRITICAL SCORES FOR PATIENTS AT HIGH RISK

For patients with impaired activity level, bed mobility, or mental status, several nursing interventions are recommended. A turning schedule should be instituted and posted at the patient's bedside. The turning schedule should be adapted to the patient's activity level and daily routines. If possible, teach the patient, a family member, or both to make frequent small body shifts while in bed and sitting in a chair. Frequent shifting redistributes body weight and promotes blood flow to the tissues. To prevent shearing of tissue, the head of the bed should not be elevated greater than 30° unless the patient is eating or respiratory problems are an inhibiting factor.

When the patient is in a chair, sitting time should be limited to two hours at a time, as the sitting position creates intense pressure on the ischial tuberos itates. Pressures against bony prominences are even greater when the patient is in a sitting position than when lying supine. As an adjunct to these nursing interventions, an appropriate bed surface should be selected to decrease pressure against bony prominences. The following bed surfaces, listed in the order of increasing protection, are available: convoluted foam (egg crate), alternating air mattress, water mattress, and air-fluidized bed (eg, Clinitron®). A seat cushion is also recommended to decrease pressure when the patient is seated in a chair. The use of rubber rings (ie, donuts) should be avoided as these devices compress the tissue against the ring, thus diminishing blood flow to tissue that is at risk.

The risk factor assessment tool is most helpful when it includes a section for documenting the presence of pressure sores and the stage of skin breakdown when present. This portion of the tool assists in standardizing terminology and can further serve as a guide to nursing interventions. If the healthcare facility has established treatment protocols based on the stages of skin breakdown, these protocols may be readily instituted.

The risk factor assessment tool with its components of risk factors and staging criteria can be used as a monitoring system. When used over time with an individual patient, it allows for monitoring of the risk factor score and identifying the onset of skin breakdown. When this type of tool is adopted for use on a patient care unit or throughout a facility, it can also serve as a quality assurance tool. The staging portion of the tool provides a quick reference to the outcomes of nursing care; that is, the presence or absence of skin breakdown as well as the progression. When used for quality assurance purposes, the data collected will help identify a problem if it exists. Based on problem identification, appropriate strategies can be developed to achieve problem resolution.

Recommendations for Further Study - Though the study confirms the usefulness of the risk factor assessment tool, there are still unanswered questions. Therefore, the investigators recommend:

1. A study using a longitudinal design to help clarify the relationship between the risk factor score and the onset of skin breakdown;

2. A replication study to verify the findings related to age and skin integrity;

3. Further study of the relationship between the risk factor of incontinence and skin integrity; and

4. Further study of the relationship between gender and skin integrity.

The problem of pressure sores is a problem that "won't go away." Only through a systematic approach to the problem and careful evaluation can progress can be made toward solving this problem. Meeting this challenge is worthwhile when one considers the time, money, and effort expended in correcting the problem of pressure sores once they have occurred.

References

  • 1. Meers R: Lecture. Center for Decubitus Ulcer Research, presented in Boston. June 1982.
  • 2. Rubin C, Dietz R, Abruzzese R, et ai: Auditing the Decubitus Ulcer Problem. Am J Nurs 1974; 74:1820-1821.
  • 3. El Toraei, cited by Reuler JB, Cooney TG: The pressure sore: Pathophysiology and principles of management. Ann Intern Med 1981;94:661-666.
  • 4. Fowler E: Timely information for improving patient comfort. Et Cetera 1979; 1:1-3.
  • 5. Bardsley, cited by Berecek K: Etiology of decubitus ulcers. Nurs Clin North Am 1975; 10:157-170.
  • 6. Gosnell D: An assessment tool to identify pressure sores. Nurs Res 1973; 22:55-59.
  • 7. Norton D: An Investigation of Geriatric Problems in Hospitals. London. National Corporation for Care of Old People, 1962.
  • 8. Guttman L: The problem of treatment of pressure sores in spinal paraplegics. Br J Plast Surg 1955; 8:196-213.
  • 9. Sbea J; Pressure sores: Classification and management. Clinical Orthop 1975; 112:89-100.
  • 10. Williams A: A study of factors contributing to skin breakdown. Nurs Res 1972; 21:238-243.
  • 11. Verohnick PJ: Decubitus ulcer observations measured objectively. Nurs Res 1961; 10:211-214.

FIGURE

CRITERIA FOR STAGING PRESSURE SORES

TABLE 1

FREQUENCY OF PRESSURE SORES BY LOCATION

TABLE 2

AGE IN RELATION TO SKIN INTEGRITY

TABLE 3

MEAN RISK FACTOR SCORE IN RELATION TO SKIN INTEGRITY, CONTROLLING FOR AGE

TABLE 4

CRITICAL SCORES FOR PATIENTS AT HIGH RISK

10.3928/0098-9134-19860701-06

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