Complications from the nursing diagnosis impaired skin integrity; pressure ulcers claim thè lives of 60,000 people each year.1 The prevalence of pressure ulcers is estimated to range from 4% to 14% among hospitalized persons, 8.7% to 19%. among those cared for in their homes with the supervision of health-care professionals, and 12% to .23.% among persons cared for in long-term care facilities. Fifty pst cent of persons with pressure ulcers are over the age of 70
Costs Doth in human and financial terms* are often overwhelming. In a survey of 23 patients in an acute care facility who were referred for pressure ulcer treatment, Aïterescu found the total cost for treatment per person with a pressure ulcer ranged from $47.52 to $10,105.99, with an average cost of $1,300.37.A Costs were incurred from dressings, ointments and solutions, pressure relief devices, room rates, enterostomal therapy, and nurse services* In addition, four patients required the services of: a surgeon, costing between $52.39 arid $349.25. Estimates of total institutional costs for treatment of a person with pressure ulcers in a long-term care facility ranged from $4,255 to $23,301 7
Nursing time was singled out and included as nursing personnel. Other costs included pressure relieving devices, pharmaceutical and nonpharmaceutical supplies, laboratory, and physiotherapy services. Treatment of pressure ulcers was found to be 2.5 times more costly than prevention.8
Although the direct cause of pressure ulcers is pressure that narrows blood vessels with resultant cellular ischemia and tissue death, there are a number of factors that contribute to pressure ulcer formation in older persons. These risk factors include immobility and inactivity, age, malnutrition, fecal and urinary incontinence, and a decreased level of consciousness.913 These risk factors, such as age and decreased level of consciousness, are not often readily eliminated. However, the development of pressure ulcers may be halted through ongoing nursing management of the older person who presents with these risk factors. Older persons are often partially, if not completely, dependent on the care provided by nurses to prevent pressure ulcer formation. If the risk factors noted above are not managed, they become iatrogenie causes of pressure ulcers.
Because of die prevalence and adverse consequences, gerontological nurses must understand the iatrogenic causes and means of preventive treatment for pressure ulcers. This article discusses risk factors/iatrogenic causes associated with impaired skin integrity: pressure ulcers in the aging population and sets forth recommendations for preventive health-care management.
IMPAIRED SKIN INTEGRITY: PRESSURE ULCERS
The skin serves the body in several ways: it protects the internal environment of the body; regulates body temperature; stores sodium chloride, glucose, and water; eliminates waste products; produces vitamin D; and provides sensory feedback for equilibrium, pleasure, and injury protection. The skin consists of three layers: the epidermis, dermis, and subcutaneous tissue. The epidermis is the outer layer of the skin and is composed of cells that are constantly being shed and replaced. The dermis is made up of dense connective tissue and contains blood vessels, nerves, nerve receptors, hair follicles, and sweat and oil glands. The subcutaneous tissue lies beneath the dermis and connects the skin to the outermost muscles. The subcutaneous layer is composed of elastic and fibrous connective tissue and contains fat globules, blood vessels, lymphatic vessels, and nerves.
Impaired skin integrity is defined as a state in which an individual's skin is adversely altered.14 "Pressure ulcer;" "decubitus ulcer," and "bedsore" are terms often used interchangeably to describe an area of impaired skin integrity in which cellular necrosis has occurred. With pressure, blood flow decreases, nutrients to the site are diminished, and removal of cellular waste products is ineffective. In supine patients, the areas most susceptible to pressure ulcers are over the bony prominences of the sacrum, heels, spine, hip, knees, costal margins, and occiput. 1S"17 The ischial tuberosities are particularly vulnerable pressure areas if the elderly person is placed in a sitting position.18
CLASSIFICATION SCHEME FOR GRADING DECUBITUS ULCERS20
The defining characteristics of the nursing diagnosis of impaired skin integrity related to pressure ulcers include a disruption of skin surface, destruction of skin layers, and invasion of body structures.14 The process whereby cellular destruction occurs and the pressure ulcer develops has been used as a means by which to stage the impairment of skin integrity. The classification schema developed by Shea19 and modified to an assessment tool by Frantz20 is provided in Table 1 .
RISK FACTORS AND NURSING MANAGEMENT
Preventive care of a client's skin is within the independent role of the professional nurse. Nursing must decrease the incidence and prevalence of pressure ulcers by identifying those persons who are at risk and instituting preventive treatment measures. Among the pressure ulcer risk assessment scales found in the literature are the Norton scale,12·21 the Gosnell scale,11·22 and the Braden scale.10·23 These scales identify common risk factors for pressure ulcers, which include the aging process, immobility and inactivity, malnutrition, fecal and urinary incontinence, and a decrease in a person's level of consciousness.
Normal physiological changes in the skin make the older person more prone to impaired skin integrity. The epidermis shows a generalized thinning and the skin may appear thinner, paler, and more translucent. Collagen fibers of the dermis undergo changes that decrease the strength and elasticity of the skin. A reduction in the number of epithelial cells and blood vessels produces a decreased vascularity of the dermis. With the thinning of the epidermis, the skin is more easily injured and healing is delayed if blood flow to the dermis is impaired.
The most visible changes may include wrinkling of the skin and a subnormal skin temperature due to a loss of subcutaneous fat and water. Skin turgor will also be reduced, with an increase in skin fragility because of a loss of elastic fiber. The older person then experiences an increase in dryness, scaliness, and itchiness because the sebaceous glands produce less oil to lubricate the skin. Sweat glands (eccrine glands) become uneven in size and accumulate lipofuscin in the cytoplasm, and in the very old, many of these glands are replaced with fibrous tissue. Because of the decreased ability to produce sweat, the threshold for sweating is raised and the elderly person's ability to maintain body temperature homeostasis is impaired. Pain perception is diminished due to a reduction of the cutaneous end organs responsible for pressure and light touch sensation (Pacini's and Meissner's corpuscles).24
Nursing measures to protect the skin include a routine assessment of the older person's skin condition. The older person or care providers should be taught that daily bathing, hot water, and the use of drying powders lead to skin breakdown. A complete bath every day is not recommended. The essential areas of the body that must be bathed daily are the face, axilla, and genital areas. Tepid instead of hot bath water should be used. If soap is used, superfatted brands, such as Dove, Caress, and Basis, are less drying than deodorant or alkaline soaps. Mineral oil, applied immediately after the bath while the skin in still hydrated, helps to moisturize the skin.25 Care providers must also recognize that the older person is not as agile and may need assistance in assessing, cleaning, and drying lower extremities, such as die feet. Because of diminished pain perception, which may be compounded by other chronic health conditions such as diabetes, the older person may not recognize the early perception oí" pain. Consequently, a denial of discomfort is not a sufficient assessment indicator of intact skin.
Immobility and Inactivity
Although pressure is the major etiology of pressure ulcers, immobility and inactivity are important risk factors.1516·26"29 Immobility is identified as an alteration in the amount and control of movement a person has, whereas inactivity relates to an alteration in independent ambulation. The elderly, especially those over age 70, are more prone to develop pressure ulcers when immobilized.3,12·30"32 Even a small amount of pressure over time can result in tissue changes.15 Great amounts of pressure over short periods are tolerated better than small amounts of pressure over longer periods, and equal pressure over the body is better tolerated than pressure concentrated over one area.26·29·33 The location of the pressure ulcer is related to positioning of the older person.17 Since the older person is often confined to a wheelchair or bed because of safety concerns and availability of staff, it is not surprising that 69% of pressure ulcers occur on the hips and buttocks and 29% are located on the lower extremities.5,34 Other areas in which pressure ulcers are seen include the ischial tuberosities, vertebrae, sacrum, underside of the scrotum, greater trochanter of the femur, lateral malleolus, heels, scalp, and ears.
Nursing management of immobility and inactivity includes assessing all areas prone to breakdown at least every 2 hours.12 Healthy yet vulnerable areas of skin may be massaged to facilitate circulation. Areas of skin that are erythematous should not be massaged because massage may further damage the skin and capillaries. Persons must be repositioned to relieve pressure and facilitate blood supply to dependent pressure areas. The older person may be positioned in the 30° oblique right and left side positions and supine. The 90° lateral positions are not used because of the weight this position places on the skin over the trochanter, and die prone position places too much strain on the older person's cervical column.35
Planning and posting an assessment and positioning schedule may prove especially helpful. The schedule is planned so that the person is in the position needed for other treatments throughout the day (eg, gastrostomy feedings, meals, wheelchair activities, toileting). Posting and keeping the schedule with the persons as they participate in other activities help all staff members ensure that skin assessment and position changes are completed as necessary (Table 2). Educating and planning with competent older persons is important so that they can participate in frequent small shifts in body weight to reduce the number of pressure ulcers.36
Friction and shearing forces further potentiate impaired skin integrity in the immobilized older person.10,37,38 Friction removes the protective epithelial layer, whereas shearing forces cause tissue layers to move against each other and alter blood flow by stretching or kinking blood vessels located in the subcutaneous tissue. To help prevent these forces from occurring, older persons who are able to move themselves or assist in position changes may benefit from the use of an overhead trapeze bar. Fowler's position should be limited to 30 minutes to prevent undue pressure on the coccyx. Tum sheets, foot boards, Hoyer lifts, and side rails also help to raise and reposition the person without putting undue pressure, shearing, or friction on the skin.
The use of foam, air, and super-soft mattresses works together with repositioning to decrease pressure on sensitive areas of the immobile person.9,35,39 For effective use of these devices, it is essential that manufacturers' instructions are followed (eg, number and tightness of fit of bedcovers). Electrical muscle stimulation units and transcutaneous electrical nerve stimulation units are also being studied as means to increase skin and muscle blood flow for prevention and treatment of pressure sores.20-40"42
Nursing must also collaborate with the other disciplines in designing a preventive plan of care. Physical therapy should be consulted to determine the types and frequency of range of motion and other strengthening exercises. These exercises, done regularly, promote circulation to the skin and facilitate joint flexibility, consequently helping to prevent further loss of mobility. Occupational therapy is helpful in designing activities that keep the older person physically and intellectually active, with appropriate rest periods throughout the day.
A positive correlation between the presence of pressure ulcers and nutritional deficiencies was identified by Pinchocofsky-Devon and Kaminski.43 Malnutrition, especially vitamin C deficiency and hypoalbuminemia, have been related to pressure ulcer formation.26·44"46 Vitamin C aids in the absorption and use of iron and is essential for protein collagen formation. A sufficient intake of protein is necessary to maintain a positive nitrogen balance for normal tissue growth and replacement. Anemia is related to hypoalbuminemia and is a contributing factor to pressure ulcer formation because of edema, which decreases skin elasticity, and the decreased oxygen carrying capacity of the blood.47 Other nutrients required for healthy skin include zinc, sulfur, riboflavin, niacin, linoleic acid, and vitamin A. An adequate intake of carbohydrates is necessary to maintain normal levels of blood glucose and prevent breakdown of tissue proteins. For the older person with decreased physical activity, the metabolic processes slow down and there is a reduced caloric need. However, the need for a proper balance of carbohydrates, proteins, vitamins, and minerals remains.
ASSESSMENT AND POSITIONING SCHEDULE
The older person who is at risk for impaired skin integrity: pressure ulcers because of malnutrition may benefit from an ongoing assessment of nutrient intake through accurate calorie counts (what was eaten, not what was provided). Food preferences and dislikes need to be identified with the older person or the person's significant other. Gerontological nurses should work with a dietitian to assess and identify appropriate nutritional parameters within the older person's preferences. Small, frequent meals may be better accepted and digested in the older person. If the diet allows, family members can be encouraged to supplement the older person's diet with special foods from home. In consultation with the physician, supplemental vitamins and minerals may be recommended. These supplements should be given at meal times so as to not only decrease gastric upset, but also to aid in nutrient absorption and use.
Hydration status needs to be monitored and an adequate amount of fluids provided and offered at frequent intervals. Although research on changes in taste sensation with aging is inconclusive,48·49 it has been found that regular oral hygiene increases taste perception for the older person.50 Oral care should be provided after meals and at bedtime. In collaboration with the physician, blood chemistries (eg, blood urea nitrogen, albumin, hematocrit/hemoglobin, uric acid, and bilirubin) should be assessed as needed to monitor the client's nutritional outcomes.
Fecal and Urinary Incontinence
Approximately 10% of older persons who live in the community and 20% of those who live in institutions suffer from urinary incontinence, and 10% to 23% of older institutionalized persons suffer from bowel incontinence.5153 Incontinence of bowel and bladder is frequently cited as an important risk factor for pressure ulcer development.3·21"23 The moisture from incontinence is believed to promote skin maceration and make the skin more susceptible to injury. Fecal incontinence may cause skin excoriation because of the digestive enzymes contained in the stool.
Degenerative changes that occur in the bladder include an increase in fibrous connective tissue, weakening of die bladder muscles, incomplete emptying, a decrease in the force of urinary stream, a decrease in the capacity of the bladder; and an increase in urinary frequency. Although the large intestine may have compromised blood flow because of an increased twisting of blood vessels, bowel elimination habits are not altered. Consequently, urinary or bowel incontinence is not to be considered a normal change associated with aging. Many factors, such as drugs, physical disorders (urinary infection, prostate enlargement), psychological disorders (anxiety, dementia), and environment, affect the continency status of the older person.
If incontinence does occur, a thorough assessment must be conducted in collaboration with the physician. The causes and type of incontinence must be identified and interventions established to treat die specific problem and facilitate continency. To prevent maceration, the urine and stool should have as little contact with the skin as possible. Scheduled regular toileting, ensuring adequate privacy, external urinary continency devices (eg, condom catheters), and adult disposable briefs may prove helpful. Adaptive devices must be examined to ensure that they are applied and fit correctly. The skin must be assessed regularly (every 2 hours for the adult wearing disposable briefs and more often when other risk factors are present) and gently cleansed with nonirritating soap and water, rinsed, and gently patted dry. Clean intermittent catheterization may also be an alternative for overflow incontinency.54 It may also help to decrease the amount of perineal moisture by allowing time during the day in which adult disposable briefs are removed and the genital area exposed to the air for drying. With frequent diarrhea, a protective emollient or lubricant may be needed.
Decrease in Level of Consciousness
A decrease in level of consciousness (awareness of self or environment) is not synonymous with the normal aging process. However, the elderly are more prone to chronic health conditions (eg, Alzheimer's disease, cerebral vascular accidents) and medication use (eg, psychotropics) that may alter their level of consciousness. Older persons who experience a decrease in their level of consciousness are at risk for pressure ulcers because of an altered ability to recognize and respond to the pain associated with pressure ulcer formation.
In collaboration with the physician, the causes of the altered level of consciousness must be identified and treated. Preventive treatment includes monitoring the person's health condition and medications. For persons with dementia, the nurse must recognize that although they may state that they feel okay and are not in pain, assessment of the skin must be carried out regularly. Monitoring is especially important for the client in the more advanced stages of Alzheimer's disease because that person is likely to be emaciated. Essentially, the gerontological nurse must act on behalf of older persons who present with decreased levels of consciousness because uiey are unable to protect themselves.
Within all of the interventions stated, the gerontological nurse must continue to recognize the importance of teaching older persons how to provide self-care as they are able. Significant others, such as family members, also need to be knowledgeable of the risk factors associated with impaired skin integrity: pressure ulcers. In this way they can understand why particular treatment measures are carried out and become more actively involved in the care of their loved one.
Gerontological nurses must continue the development and refinement of tools with which to predict the degree of risk for impaired skin integrity: pressure ulcers and to study the effectiveness of preventive pressure relief measures. A consistent method of grading pressure ulcers (Table 1) needs to be applied by all nurses. With continued research, iatrogenic and other risk factors, grading of pressure ulcers, and cost-effective treatment will be delineated for potential impaired skin integrity: pressure ulcers.
Although pressure ulcers have afflicted persons for centuries, the iatrogenic causes of pressure ulcers are not acceptable. By understanding the factors that put the older person at risk, the gerontological nurse can more readily identify those in need of preventive measures and institute nursing treatments before any change in skin integrity occurs.
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CLASSIFICATION SCHEME FOR GRADING DECUBITUS ULCERS20
ASSESSMENT AND POSITIONING SCHEDULE