Journal of Gerontological Nursing

Skin Problems: EPIDEMIOLOGY OF PRESSURE ULCERS IN A SKILLED CARE FACILITY

Christine Burd, RN, MS, CS; Diane K Langemo, RN, PhD; Bette Olson, RN, MS; Darlene Hanson, RN, MS; Susan Hunter, RN, MSN; Timothy Sauvage, CRNA, MS

Abstract

INTRODUCTION

Advances in medical and health care have contributed to increased longevity among the general population. While an increasing number of people are surviving lifethreatening conditions, a concomitant increase in the need for management of chronic health problems has emerged. Pressure ulcers are a common and serious secondary problem associated with chronic debilitated health states (Cooney, 1983; Shepard, 1987; Slater, 1 985), and pose a significant risk to the welfare of nursing home residents in terms of comfort and health.

Abstract

INTRODUCTION

Advances in medical and health care have contributed to increased longevity among the general population. While an increasing number of people are surviving lifethreatening conditions, a concomitant increase in the need for management of chronic health problems has emerged. Pressure ulcers are a common and serious secondary problem associated with chronic debilitated health states (Cooney, 1983; Shepard, 1987; Slater, 1 985), and pose a significant risk to the welfare of nursing home residents in terms of comfort and health.

The Institute of Medicine Committee Report (1986) identified pressure ulcers as one of the most difficult problems to manage in nursing homes. This problem is accentuated in nursing homes due to the fact that the average resident today is older, has more severe and more advanced chronic conditions, and has a higher prevalence of complications from chronic debilitating conditions. Pressure ulcers will most likely continue as a significant problem; it has been estimated that more than half of women and almost one third of men who turned 65 years old in 1990 will use nursing home services at some point in their lives (Murtaugh, 1990).

PURPOSE

Several research questions were addressed in this two-phase study of pressure ulcers. Phase I sought to identify the prevalence of pressure ulcers in a skilled level nursing home facility. Phase II focused on the following questions:

1. What is the incidence of pressure ulcers acquired in a skilled facility?

2. What is the specificity, sensitivity, and recommended risk cutoff score on a skin assessment tool for this skilled nursing care facility?

3. What factors are associated with the development of pressure ulcers for residents in a skilled nursing care facility?

Advanced age has been cited repeatedly as being associated with the occurrence of pressure ulcers (Braden, 1987; Clark, 1988; Ek, 1982; Gosnell, 1973, 1989; Manley, 1978; Norton, 1962; Pajk, 1986; Peterson, 1971; Roberts, 1979). It has been estimated that two thirds of all patients in geriatric wards and nursing homes have conditions that put them at risk for pressure ulcer formation (Seiler, 1985). Risk factors associated with pressure ulcers include impairments of circulation, sensation, physical condition, nutrition, mobility, and activity (Gosnell, 1989). Residents of longterm care settings routinely present with or develop problems in one or more of these risk categories.

A number of other factors have also been identified as increasing the risk of pressure ulcer formation among elderly people. Any condition that significantly decreases mobility or lowers critical arteriole closing pressure below 32 mm Hg can be considered a risk factor (Gosnell, 1989); for example, hypotension or prolonged pressure. Other risk factors identified with pressure ulcer development in the elderly include infections, fever higher than 39°C, surgery, comatose states, cerebrovascular accidents, depression, contractures, catatonia, anemia, and dehydration (Seiler, 1985). Incontinence has also been cited as a predisposing factor to pressure ulcer development (Blom, 1985; Ek, 1982; Goldstone, 1982; Norton, 1962; Towey, 1988).

The prevention and treatment of pressure ulcers has been cited as a clinical problem of extreme importance to be researched by nurses in long-term care settings (Brower, 1985). Risk of death in hospitals increases fourfold among geriatric patients when a pressure sore develops, and six times when a sore does not heal (Allman, 1986).

In a study of 276 hospitalized patients, it was found that patients older than 70 years were at greater risk to develop pressure ulcers (OotGiromini, 1989). Two other large studies have also noted strong relationships between increased age and the development of pressure ulcers. Gerson (1975), in an incidence study involving more than 5,000 patients, found the average age among those who developed pressure ulcers to be 67.6 years as compared with an average of 49.5 years for patients who did not develop pressure ulcers.

In a study of 800 subjects, Manley (1978) found a linear relationship between increasing age and the development of pressure ulcers. Although the overall incidence in Manley's study was 9.7%, those aged 60 to 70 years had an incidence rate of 17.5%, and those over 70 years of age had an incidence rate of 32%. Considering that the majority of long-term care beds are occupied by elderly people, it can be inferred that pressure ulcers pose a significant risk to the welfare of residents in long-term care institutions.

The annual cost for interventions associated with pressure ulcers in all settings is estimated at $5 to $9 billion (National Action, 1985). Costs of products for pressure ulcer care have been reported at $11.96 per day per hospitalized patient with a pressure ulcer (Oot-Giromini, 1989). Frantz's (1989) retrospective study of a 750bed long-term care facility reported a total monthly cost of pressure ulcer care ranging from $267 to $1,191 per resident.

In terms of these estimates, the financial burden to long-term care institutions in the treatment of pressure ulcers is significant. Prevalence rates for pressure ulcers in longterm care settings range from 30% to 35% (Fowler, 1982; Shepard, 1987). Residents are often admitted to nursing homes with pre-existing pressure ulcers. Brandeis et al (1989) reported a prevalence rate of 17.7% among 3,601 admissions to nursing homes within one corporation. Ek and colleagues (1987) reported 16% of 515 admissions to a long-term medical ward in Sweden had pre-existing pressure ulcers at the time of admission. In addition, 7.6% of these 515 residents developed pressure ulcers during their stay.

Versluysen (1985) studied 283 admissions to a British hospital for hip surgery. Of this number, 17% were admitted with pressure ulcers already present, and 157 were identified by the Norton Scale as being at risk for pressure ulcer development (Norton, 1962). Ninety of the 157 patients developed "ulcerative" pressure ulcers, and 73% of the sample were older than 60 years (75% were women). Significantly, the mortality rate of those with pressure ulcers was reported at 27% in this study. Blom (1985) reported 13 of 43 patients (30.2%) were admitted to a Veterans Administration long-term care facility with pre-existing pressure ulcers. This sample was predominantly men, and 53% were 60 years of age or older.

Attempts have been made to identify those persons at risk of developing pressure ulcers. The goal of early identification is the implementation of early prevention and intervention measures to preclude formation of pressure ulcers. At present, information is needed related to the prevalence and incidence of pressure ulcers in long-term care settings, as well as information about resident characteristics that are associated with greater risk for pressure ulcer development (Abruzzese, 1985; Allman, 1986; NPUAP, 1989; Towey, 1988). The research presented in this article was undertaken to assess prevalence and incidence rates and to explore risk factors for pressure ulcer development among a group of nursing home residents.

THEORETICAL FRAMEWORK

The Four Principles of Conservation (Levine, 1969) served as a theoretical basis for this study, with a specific emphasis on the conservation of structural integrity. Conservation of structural integrity is predicated on the nurse's responsibility for therapeutic nursing interventions for maintenance or restoration of the body structure (Levine, 1969). Levine's theory of supportive intervention supports the goal of prevention or restoration of structural (skin) integrity breakdown to conserve resources of the individual resident.

Definition of Terms

Clinically, little agreement has existed as to the terms "pressure ulcer," "decubitus ulcer," or "pressure sore." The definition of a pressure ulcer as adopted by the National Pressure Ulcer Advisory Panel (NPUAP) in 1989, was used for this study.

Pressure ulcer: "Localized areas of tissue necrosis that tend to develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period. . . ."

Table

TABLE 1Stages of Pressure Ulcers*

TABLE 1

Stages of Pressure Ulcers*

Prevalence: "The number of new and old cases assessed on a crosssectional one-time basis."

Incidence: "The number of new cases occurring over a given. . . period."

Risk cut-off score: The most sensitive and specific score on a rating scale that will predict pressure ulcer occurrence.

METHODOLOGY

Setting and Sample

The setting for this two-phase study was a 160-bed skilled level nursing home facility that is part of a regional medical complex bordering and serving two Midwestern states. The sample for the prevalence study (Phase I) consisted of 159 residents, 18 years of age and older, who were inpatients on the day of the study and from whom permission was obtained.

The sample for the incidence study (Phase II) consisted of 25 residents who were admitted to the skilled level nursing home during a 9month period. All adult residents were invited to participate in the study within 24 to 72 hours following admission if they had been admitted without evidence of a preexisting pressure ulcer of any stage. Study purposes were explained and consents obtained from each resident or guardian. Anonymity and confidentiality were assured, and both phases of the study were approved by the University Institutional Review Board and the Medical Center Human Subjects Review Committee.

Instruments

Three instruments were used to collect data for both the Phase I and Phase II studies: a demographic data form, a skin assessment tool, and the Braden Scale for Predicting Pressure Sore Risk.

The demographic data form was used to collect information on age, gender, diagnosis, weight and height, vital signs, steroid therapy, and smoking history. These demographic variables were used for correlation with, and prediction of, the incidence of pressure ulcers. The skin assessment form included the definition of stages I through IV pressure ulcers and a diagram detailing all body pressure points to be assessed. Each site was assessed and rated on a scale of 0 to 4 (NPUAP, 1989; Shea, 1975) (Table 1). A rating system ensured the systematic and consistent assessment and rating of all residents. The skin assessment form also included type of bed and chair used by the resident, as well as overlays and bladder and bowel continence information.

The Braden Scale for Predicting Pressure Sore Risk is a summative rating scale composed of six mutually exclusive subscales. The Braden Scale addresses "critical determinants of pressure (mobility, activity, and sensory perception) and factors influencing the tolerance of the skin and supporting structures for pressure (skin moisture, nutritional status, and friction and shear)" (Bergstrom, 1987a). The rating scale of 1 (least favorable) to 3 to 4 (most favorable) is used for each subscale; the six subscales combine for a maximum possible score of 23. A low score denotes high risk, and a high score is indicative of low risk. Bergstrom et al (1987b) reported interrater reliability for the scale as 88% among registered nurses (r = .99) and 1 1 % to 38% among licensed practical nurses and aides (r = .83 -2.94).

Educational in-service programs were conducted to develop a team of two RNs and two LPNs who would be familiar with the purpose and protocols of the study, the use of the tool, and who would serve as research assistants. Inter-rater reliability (percent of agreement) for the research assistants in this study was .90.

Studies in two settings were previously done by Bergstrom et al (1987a, 1987b) to establish predictive validity of the Braden Scale and focused on sensitivity and specificity of the scale. Sensitivity is the percentage of subjects who developed pressure ulcers from among those who were predicted to do so (Lilienfeld, 1980). Specificity refers to the percentage of subjects who did not develop pressure ulcers and were predicted not to be at risk (Lilienfeld, 1980). Sensitivity in both studies by Bergstrom and her colleagues was reported to be 100%; specificity was reported at 90% and 64%, respectively. A cut-off risk score of 16 was also recommended for the acute care subjects in these two studies.

PROCEDURES

Phase I

On a designated day, researchers completed a systematic skin assessment on all residents consenting to the study. All researchers had been instructed in the use of the tools. Residents found to have a pressure ulcer at any stage had a demographic data form completed. A Braden Risk Scale was completed by two nurses who were knowledgeable about the resident, but who had no information on the results of the skin assessment. If there was a variation of two or more points on the Braden Scale scores, a third nurse assigned a Braden Risk Scale score. In no circumstances did the third score not concur with one of the two originally assigned scores.

Phase II

All newly admitted residents giving consent were assessed within 24 to 72 hours of admission to ascertain initial pressure ulcer status. Residents free of ulcers on the admission assessment were invited to participate in the study. Those consenting had a skin assessment done and a Braden Risk Scale score assigned to them. A demographic data form was also completed. Skin assessments and Braden Risk Scales were independently completed by two nurses to control for rater bias. Subjects were reassessed weekly for 4 weeks after admission or until death or discharge. Completed Braden Scales were placed in a sealed envelope to ensure score anonymity and to prevent bias affecting sequential skin assessments.

DATA ANALYSIS

The Statistical Package for the Social Sciences was used for data analysis. Descriptive statistics were obtained on all variables. Stepwise forward multiple regression with pairwise deletion for missing data was used to ascertain variables predictive of pressure ulcer development.

RESULTS

Phase I

The sample of 159 subjects included 38 men and 121 women. Thirty-seven of the subjects had pressure ulcers for a 23% prevalence rate (Table 2). The prevalence rate was 21% for women and 32% for men. A total of 64 ulcers were identified and the number of ulcers in each stage was as follows: 1 = 27; 0 = 23; ??= 11; and IV = 3. Studies vary as to stage I ulcer definition. This study defined a stage I ulcer as nonblanchable erythema of intact skin. If stage I ulcers meeting this definition had not been included in the prevalence, the rate would have been 14% for this study. In practice, stage I pressure ulcers frequently may go unrecognized as pressure ulcers, yet their recognition is essential to prevent further damage.

The 64 pressure ulcers were located on a variety of body sites; however, the sacrum was by far the most frequent site of occurrence (31 of 64, 48%). The next most frequent location was the heel (n = 9) and then the lateral malleolus (n = 5) (Table 2). In this sample, 57 of 64 (89%) of the ulcers were located on the lower half of the body.

The age of the subjects with pressure ulcers (PU + ) ranged from 34 to 95 years with a mean of 81.0 (SD = 9.0). The mean age of women who were PU+ was 81.5 years (SD = 9.03) as compared with men, who averaged 77.9 years (SD = 8.8). In this study, 84% of women and 83% of men with ulcers were aged 70 years or older, whereas 60% of women and 58% of men were aged 80 years or more. The subjects' diagnoses varied; however, 32 of the 37 PU + subjects had a diagnosis related to a neurological conditions affecting mobility or level of awareness/consciousness.

Phase Il

The sample included 25 skilled care residents. Seven residents developed a pressure ulcer during the study time frame for a 28% incidence rate (6 women; 1 man). The incidence rate for women was 29%, whereas it was 25% for men. The ages of the PU + subjects ranged from 56 to 94 years, with a mean of 81.14 years (SD = 9.01). The mean age of the total sample followed was 83.12 years (SD = 9.71).

Table

TABLE 2Number and Location of Pressure Ulcers for Prevalence and Incidence

TABLE 2

Number and Location of Pressure Ulcers for Prevalence and Incidence

There were a total of 14 ulcers that developed in the seven PU+ subjects, and the ulcers developed on a variety of body locations (Table 2). However, as in Phase I, the lower half of the body was the site for a large percentage of the pressure ulcers; in this phase, 10 of the 13 ulcers were located below waist level. Pressure ulcers developed from day 3 to day 32 of the subjects' institutionalization, with a mean of 9.9 days (SD = 3.14). Of the 7 PU+ subjects, 5 were incontinent of urine (71%); 1 of these had an indwelling catheter, and the other 4 were diapered. Three of the five incontinent of urine were also incontinent of feces. The other two subjects were not incontinent.

Broden Risk Assessment Score

A Braden Scale cut-off score to predict risk for pressure ulcer development was determined using the formula of Bergstrom et al (1987a). The Braden Scale score immediately prior to skin breakdown was used. A Braden Risk Assessment Scale cutoff score of 18 is recommended for this skilled care setting based on the results of this study. At a cut-off score of 18, the sensitivity was 57% and specificity 61%.

Stepwise Forward Multiple Regression Analysis

This statistical test was used to ascertain which, if any, independent variables were predictive of pressure ulcer development. Independent variables examined included urinary and fecal incontinence, smoking history, current and past steroid use, friction and shear, and nutritional status. Nutritional status data were taken from the ratings of nutritional status from the Braden Scale assessments. Pairwise deletion for missing values was used to compensate for missing data. No specific variables emerged as predictors of pressure ulcer development in this sample of skilled care residents.

DISCUSSION

Phase I

The 23% prevalence rate for the 159 skilled care residents in this sample is low in comparison with previously reported rates of 24% by Young (1989) and 30% to 35% reported by Fowler (1982) and Shepard et al, (1987). Brandeis et al (1989) reported a prevalence rate of 17.7% among admissions to a corporation of nursing homes. It would appear that the 23% prevalence rate for this sample of skilled care residents is indeed comparable to other studies.

The finding that 64 ulcers were identified on 37 residents is perhaps reflective of more complex and debilitated conditions among this sample of PU+ skilled care residents. Additional support for this conclusion is reflected in the findings of 11 stage III and three stage IV ulcers.

The finding of the sacral area as the most frequent site of occurrence is consistent with previous study findings (Peterson, 1971; Vasconez, 1977; Versluysen, 1985), as well as the majority of ulcers being found at or below waist level (Peterson, 1971; Vasconez, 1977). No notable differences were noted between mean ages of men (mean = 77.9, SD =8.8) and women (mean = 79.3, SD = 8.9) PU + subjects. That 27% of the women and 42% of the men had multi-site ulcers is of importance in that the men in this sample may have been more "compromised" in terms of overall health than the women. Versluysen (1985) reported the presence of more than one pressure ulcer in half of the subjects studied. The finding that 95% of the subjects in this study were aged 70 years or older and 60% were aged 80 years or over is close to that of Versluysen's study (1985), where 59% of the subjects were 80 20years and over and 90% were aged 70 20years and over.

The 32% prevalence rate for men in this study is considerably higher than the 23% in the Sternberg et al's (1988) study. The prevalence rates for women were comparable at 21% for this study and 18.5% for the Sternberg et al study. Sternberg et al did report a significantly higher prevalence for men than women, consistent with the findings of this study.

Phasell

The incidence of pressure ulcers for 25 skilled care residents was 28%, which is higher than previous reports of 5% to 26% for nursing home residents (Brandeis, 1989: NPUAP, 1989). This study was conducted prior to implementation of case-mix methods for assigning levels of care. Therefore, the sample consisted totally of "skilled" care residents versus "basic" or "intermediate" care level nursing home subjects. This may have contributed to the higher incidence rate.

Although the sample was not large, there were no appreciable gender differences. The incidence for women and men was 29% and 25%, respectively. Clear data on gender and incidence comparisons in nursing homes is not available.

The mean age of the groups with pressure ulcers and without was similar. However, there was one 56-yearold PU + subject who had been admitted for short-term management of diabetes posthospitalization before returning home.

Seven PU + subjects developed a total of 14 ulcers during this study; 10 were stage I, 3 were stage II, and 1 was a stage ??. All but one of the 14 ulcers (93%) were located at or below umbilicus level, supporting previous findings in other studies (Peterson, 1971; Vasconez, 1977). Three of the seven (43%) subjects had developed their ulcers by 7 days after admission. Versluysen (1985) reported that in a sample of nursing home residents, 34% had developed their ulcers by the end of the first week. This again may reflect the assumed higher acuity of this study's sample of skilled care nursing home subjects. The location of this nursing home, being adjacent to an acute care hospital, may be related to the increased acuity of some people who are admitted to this facility, rather than to some smaller nursing homes in surrounding rural towns.

In this study, the same methodology was used as was used by Bergstrom et al (1987a) in developing the tool. The sensitivity and specificity of the Braden Risk Scale score of 18 was not nearly as precise in this study of nursing home residents as among adult intensive care subjects in the Bergstrom et al (1987a) study, where 16 was recommended as the cut-off score for risk. The emphasis on providing adequate nutritional intake in this particular nursing home may have helped raise the overall Braden Scale scores in this sample. Also, perhaps adaptation mechanisms that compensate for chronic illness over time may not be present in acute episodes of illness. The subjects in the nursing home may not be as significantly affected by the risk items as those who are acutely ill.

Risk Factors

Determinants of Pressure. Although no significant predictors were found in this sample, the nursing home population in general could be said to be greatly influenced by the factors addressed by the Braden Scale. Levels of mobility, activity, and sensory perception, which are determinants of pressure (Bergstrom, 1987b), are frequently compromised among nursing home residents who have been institutionalized as a result of the debilitating effects of chronic disease or an acute episode of illness.

This study also supports the previously reported association between impaired functional status and presence of pressure ulcers (Abruzzese, 1985; Allman, 1986; Seiler, 1985; Sternberg, 1988;Towey, 1988). Mobility and activity deficits are common among the institutionalized elderly. The majority of pressure ulcers that developed during this study could be associated with decreased mobility. Certainly, the location of more than three quarters of the pressure ulcers on the lower half of the body, particularly the sacrum, may be indicative of residents' inability to ambulate or change position independently, resulting in increased amounts of time in beds or chairs.

Sensory perceptual abilities, closely allied with independent mobility, are frequently diminished among elderly people. Unfamiliarity with new environments, particularly soon after admission, may serve to aggravate sensory deficits as well. Six of the seven (86%) subjects who developed ulcers had diagnoses that would be associated with decreased levels of mobility and awareness, such as cerebrovascular accident, I^rkinsons's disease, and "chronic brain syndrome." All seven PU + subjects had primary diagnoses that contribute to debility, as consistent with the findings of Peterson and Bittmann (1971) in their study of the epidemiology of pressure ulcers in Denmark.

Tolerance for Pressure. The skin's tolerance for pressure, which is influenced by moisture, nutritional status, friction, and shear (Bergstrom, 1987b), can be jeopardized both by normal aspects of the older person's aging physiology as well as by the presence of superimposed pathophysiology. The aspect of moisture presents an example of double jeopardy: the older person's skin normally becomes thinner and loses tissue elasticity with age, and thus some of the flexibility and supple texture needed to cushion insults to the skin's surface is absent (Matteson, 1988).

This normal change is then exacerbated by superimposed incontinence and the macerating effects of excessive moisture composed of highly irritating excretory compounds. This study's finding of urinary or fecal incontinence in 5 of the 7 residents (71%) who developed a pressure ulcer is similar to previous study findings (Allman, 1986; Sternberg, 1988; Towey, 1988). In a similar way, friction and sheer can jeopardize skin integrity. The loss of lean muscle mass is a "normal" aging change (Matteson, 1988) that can be complicated by immobility, for example, by the effects of Parkinson's disease, resulting in a further reduction in muscle mass and mobility and an increase in pressure.

The forces exerted by friction and shear are strongly related to levels of mobility and activity and are accentuated in older nursing home residents who are frequently confined to beds, recliners, and wheelchairs. The problem of immobility can become self-perpetuating unless interrupted by therapeutic efforts aimed at maintaining and increasing muscle strength. Ine use of physical therapists and restorative aides in the nursing home setting, as well as appropriate training of nursing assistants in lifting and positioning techniques, are crucial to the maintenance of skin integrity. It is important that residents be placed on lifting schedules to relieve pressure. It is essential to maintain muscle strength and range of motion, even during times of acute illness, to prevent permanent loss of function. To this end, the challenge is to develop staffing formulas in nursing homes that are fluid with the changing needs of residents on a daily basis.

Nutritional status is commonly jeopardized in the elderly institutionalized person. The defense against pressure ulcers afforded by nutritional status is often weakened by the effects of disease on nutritional requirements and the effects of chronic illness on appetite. The condition of teeth or the fit of dentures can also interfere with adequate intake. The demand for adequate time and personnel for the intensive feeding assistance that is needed by many nursing home residents can also pose a significant challenge to meeting nutritional needs in the long-term care setting.

An interdisciplinary approach to nutrition in nursing homes is helpful to meet nutritional needs. Nurses are in pivotal roles to collaborate with dietitians and to make referrals to dentists. Nurses can also initiate creative approaches to the use of nursing home staff from all departments to facilitate timely transport of residents to dining rooms and delivery of meals to residents, as well as making mealtime pleasant.

Interaction of Influences in Pressure Ulcer Development

In terms of the regression model's inability to identify specific significant risk factors in this study, it may be prudent to consider alternative explanations. Anecdotally, it was noted that one man who developed multiple pressure ulcers in Phase ? seemed to be severely debilitated, which had prompted his admission to the skilled care faculty from an intermediate setting. He was quite frail and exhibited a combination of risk factors, such as confusion, poor nutrition, immobility, and incontinence. This man died with multiple stage III pressure ulcers approximately 1 month after his participation in the study. In another case, a 91 -year-old woman who had a sudden loss of nutritional intake, mobility, and consciousness imposed by a brief but severe infection developed stage II ulcers. She was able to recover her skin integrity after the illness resolved and she returned to her usual activity and nutritional levels. Perhaps given a larger sample size, such a combination of losses may prove statistically significant.

It is possible that an alternative explanation for pressure ulcer development may exist that has not been included in the Braden Scale assessment. The 56-year-old resident mentioned earlier who had been admitted for short-term management of diabetes posthospitalization before returning home did not have any risks as identified by the Braden Scale, yet she did develop stage II pressure areas on her feet. However, as it was noted, this woman was a diabetic and may have had related vascular compromise. In a previous study by Langemo and colleagues (1991), pressure ulcers were associated with cardiovascular disease, suggesting that perfusion may be of considerable importance in the evolution of pressure ulcers. Future studies need to further explore the relationship between vascular diagnostic entities and their treatments and the development of pressure ulcers.

Pressure ulcers are multifactorial in origin and necessitate ongoing vigilance by the entire health-care team. Prevention and early intervention measures are needed to decrease the incidence and severity. This study demonstrates that more than one fourth of patients admitted to a skilled care facility may be at risk for developing pressure ulcers. Residents must be closely, carefully, and frequently assessed for the risk and presence of pressure ulcers. Debilitated and frail patients and those with very limited mobility should be diligently monitored. Critical times for assessment are on admission and when the patient's condition and mobility are compromised. Pressure ulcers continue to impose significant risk to patients' health, comfort, and welfare.

Although the subjects in this study can only be representative of those requiring higher levels of skilled care, this limitation for generalizability should not distract from the significance of the 28% incidence rate for pressure ulcer development in this group of residents.

RECOMMENDATIONS

The prevention of pressure ulcers in the long-term care setting is of crucial importance in terms of both financial and human costs. Across the United States, there are more than 1 .62 million nursing home beds, which translates into more than a half million patients with pressure ulcers each year (Strohan, 1987). The magnitude of the prevalence, discomfort, and costs associated with pressure ulcers mandates increased surveillance and intervention on the part of the health-care providers in longterm care. The nurse is well-positioned within this setting to implement assessments and strategies that can affect the incidence of pressure ulcer development. Comprehensive initial assessments at the time of admission are crucial. In addition to having a full assessment of skin integrity, newly admitted individuals can be assigned a "risk score," obtained from the Braden Scale or Norton Risk Scale, for example. Although these scales continue to need further testing, they are extremely useful as signposts for the identification of persons at increased risk for pressure ulcer development.

Having a baseline assessment of the skin and risk factors will allow for easier reassessment through comparisons. The initial assessment procedure is simple and can be completed in several minutes with a reliable history. Reassessments with the Braden Scale require approximately 1 minute to do when carried out by a health-care provider who delivers care on a regular basis to the same person. Changes in a person's skin condition can be more quickly identified and acted on when a baseline assessment is available.

Persons having conditions that identify them as being at risk at the time of admission should have those conditions addressed immediately. If a deficit in nutritional status is identified, a dietary consultation can be initiated immediately to determine the need for supplementation, and perhaps temporary tube feeding may be considered if indicated. If the person has impaired mobility, the initial care conference can explore the need for physical therapy. Also, staffing assignments can be made that address the need for sufficient help for nursing assistants to move immobile residents without friction. For example, a buddy system can be formally arranged among nursing assistants for the care of residents who require substantial assistance with mobility or who require total lifting.

Nursing assistants can be involved immediately at admission in planning ambulation, turning and lifting schedules, and implementing bladder and bowel training programs, as indicated. Some nurses have found that the use of skin barriers and leaving diapers off at night can help prevent skin maceration. Special cushions and mattresses can be applied to beds and wheelchairs on admission rather than waiting to use these appliances only for the treatment of existing ulcers.

Any change in the condition of a resident after admission should signal a need for an immediate reassessment of the risk for pressure ulcer development. Interdisciplinary care conferences can be used to update the status of skin integrity on a routine basis. The formation of a skin care committee is recommended to track pressure ulcers, standardize protocols, and to routinely provide updated information to nursing personnel regarding the prevention and treatment of pressure ulcers. The nursing home that was the setting for this study has since reported positive results from this approach. An educated staff and a quality assurance approach program to integrate problems of skin integrity with associated risk factors will be most effective at reducing the incidence of pressure ulcers in the long-term care setting.

Assessment of prevalence and incidence of pressure ulcers is essential to a long-term care facility's overall quality assurance program. It is also a necessary prerequisite for documenting the efficacy of protocols in addressing pressure ulcer prevention and treatment. Use of a risk assessment tool is necessary for systematic and ongoing assessment. Nursing homes could benefit by testing and establishing a Braden Risk Assessment Scale cut-off score specific to their patient population, or by using one of the other available assessment tools.

Recommendations for Further Study

This study could be replicated in nursing homes facilities and would be very useful in providing baseline data for comparative purposes; estabUshing the status of their pressure ulcer problem; and educating staff on a systematic protocol for assessment of risk and pressure ulcer development. A larger study for identification of factors predictive of pressure ulcer development is needed. It would be particularly valuable to study perfusion and its potential relationship to pressure ulcer development. Identification of medical conditions and regimens that may put a patient at risk need to be studied. Perhaps relationships among drug regimens and pressure ulcers could also be explored; for example, looking at the effects of cardiovascular medications. Also, outcomes of specific interventions would be extremely useful to nurses in practice in long-term care settings. As the population ages, it is likely that more elderly persons will face the possibility of developing pressure ulcers. Development of appropriate nursing knowledge and approaches to their prevention and treatment will help to minimize their risks to the older person's health and comfort.

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TABLE 1

Stages of Pressure Ulcers*

TABLE 2

Number and Location of Pressure Ulcers for Prevalence and Incidence

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