THE SILENT KILLER
Pressure Ulcers pressure ulcer is a part of the skin, which breaks down from body weight (Berman 2007, Ferguson 2000). This often occurs when the patient or person stays in one position for a long time, such as after surgery or injury. The persistent pressure on that area of the skin reduces the blood supply and the affected tissue can die. First, it turns up as a reddened skin, then a blister, an open sore and, finally, a crater. It is most commonly found in areas where the bones are prominent. These are often the elbow, heels, hips, ankles, shoulders, back and the back of the head. Causes of pressure ulcers are being bedridden or in a wheelchair, skin fragility, chronic medical conditions, limited body movements, malnourishment, mental disability, older age, and urinary or bowel incontinence. Other causes can be decreased weight, impaired nutritional intake, dehydration, and low serum albumin, which are considered risk factors (Fergusson).
There are four stages of severity. In Stage I, the skin becomes red and the pressure ulcer begins. In Stage II, the blister becomes an open sore. In Stage III, the skin breaks down and looks like a crate. The tissue under the skin becomes damaged. And in Stage IV, the damage becomes deep and extensive. The muscle, bone, tendons or joints are often affected (Berman, Ferguson).
Statistics say that more than a million persons develop pressure ulcers every year (Fergusson et al. 2000). Of this total, approximately 11% are found in skilled-care and nursing homes, 10% in acute care, and 4.4% in home care. Hospital cases account for 2.7% to 29.5%. Pressure ulcers seriously reduce the patient’s quality of life. Medical conditions, infections and even death are associated with pressure ulcers. Records show that about 60,000 persons die of complications from pressure ulcers. Court suits have been filed in connection with the prevalence by the patient, his or her family, government agencies or the media. Courts have found many facilities liable for poor pressure ulcer management. Between 68% and 78% of these court suits have ended up with a verdict or a settlement at an average of $250,000. Studies found that those who were granted monetary recovery caused by poor nutrition were five times more than that caused by pressure ulcer management alone (Fergusson).
Complications of pressure ulcers include sepsis, localized infection, cellulites and osteomyelitis (Allman 1995). Sepsis is the most serious. A pressure ulcer most often accounts for aerobic or anaerobic bacteremia. A pressure ulcer that does not heal can imply osteomyelitis. Many studies have identified pressure ulcers as the cause of 60% of deaths in hospitals and nursing homes at 60%, especially for older persons who develop them within a year from hospital discharge. Other complications are pain and depression, which are both connected with decreased healing of the ulcers (Allman).
Marjolin’s ulcer is seen as another and major complication of pressure ulcers (Tutela et al. 2004). Although rare, Marjolin’s ulcer is a malignant degeneration, which develops from a chronic wound, such as pressure ulcer. It has also been reported to develop from radiotherapy, hidradenitis suppurativa and diabetes. It was first observed by Roman physician Aurelius Celsus in abnormal tissue growth in burns in the first century AD. It was again encountered in the early 19th century by Hawkins and Dupuytren in a chronic wound. But French surgeon Jean Nicolas Marjolin was credited with its first accepted description. The latency of Marjolin ulcers has been observed in persons aged 20 to 50. In 1965, Arons attributed the linear degeneration from chronic irritation to atypia to carcinoma. Marjolin’s ulcer has a much faster metastatic rate than squamous cell carcinoma, not due to inflammation. Metastatis has been observed and documented in 30% of Marjolin’s ulcers as compared to only.5% to 6% of squamous cell carcinomas. It most commonly occurs from osteomyelitis and less frequently from burns, trauma, hidradeinitis suppurativa, radiotherapy, venous ulcers and diabetes foot ulcers (Tutela et al.).
Prevention and treatment of pressure ulcers require identifying high-risk patients, preventive interventions and the best therapies (Cuddigan 2001). Determining the actual incidence and prevalence of pressure ulcers on a national level, in turn, requires accurate measurement of these data. Yet these data are difficult to obtain because of a lack of good sources, inconsistent use of major terms, and difficulty in conducting incidence and prevalence studies. The best practices, which must be translated into effective clinical practice, are themselves difficult especially with pressure ulcer care. This care is largely multidisciplinary. A lot of the work is performed by unlicensed staff. These best care practices also need to be integrated with a workable reimbursement scheme (Cuddigan).
Prevention and treatment of pressure ulcers cover all the aspects of patient care (Ferguson 2000). These include nutritional intervention, pressure relief and management, incontinence management, and wound care. The first step in planning prevention strategies is to determine pressure ulcer risk. This is the responsibility of nurses. Two of the most commonly used risk assessment scales are the Norton Scale and the Braden Scale. The Norton Scale consists of physical condition, mental status, activity, mobility and incontinence dimensions. It has been criticized for not containing a nutrition dimension. The Braden Scale consists of sensory perception, moisture, mobility, activity, nutrition and friction or shear components. The nutrition component covers feeding route, feeding status, dietary intake and nutritional supplement use (Ferguson).
Nutritional status has been strongly correlated with the risk of pressure ulcers (Fergusson 2000). Calories, protein, fluid, vitamins and minerals are considered valuable in wound healing. Nutritional intervention is, thus, a major component in preventing and treating pressure ulcers. This covers assessment of nutrition status, estimate of nutrition needs, and implementation of intervention strategies. These strategies range from optimizing the feeding environment to enteral tube feeding. Nurses play a critical role in the patient’s nutrition situation. In cooperation with other clinicians, they can provide the best and appropriate nutrition care for patient with pressure ulcers (Ferguson).
A study of 330 patients over 65 years old in hospitals and long-term facilities in Canada investigated risk assessment scores, prevention strategies and pressure ulcer incidence (Thompson 2000). It found that an accurate prediction was difficult to make among all the patients. Only half of the respondents actually developed pressure ulcers. The study concluded that comprehensive assessments have to done on admission and with health status change in order to make the prediction. Medical practitioners must also evaluate the patients’ medical status, nutritional status, quality of care, social support and the environment to support the prediction and prevention effort (Thompson).
Health experts believe that patients with pressure ulcers should be given high-potency vitamin and mineral supplements on a daily basis (Collins 2002). Vitamin C helps in collagen formation. Patients with pressure ulcers necessarily suffer from a vitamin deficiency as they are under stress. Supplementation should range from 500 to 1,000 mg of Vitamin C per day and adjusted to gender and nutritional conditions and interventions. Most authorities agree on 750 mg daily for women and 900 mg for men. These doses are high enough to supply patients with pressure ulcers with sufficient supply of Vitamin C for their condition (Collins).
Over and above, knowledge on the best practices for the prevention and treatment of pressure ulcers has remained wanting (Cuddigan et al. 2001). Appropriate clinical trials are not performed as often as needed and the funding is not readily available. Furthermore, the methods of translating research findings into clinical practice are not adequately developed for use. Interventions must be developed in order to detect nationwide decreases in the incidence of pressure ulcers (Cuddigan et al.).
The situation of pressure ulcer care has also been problematic (Cuddigan et al. 2001). Many facilities, which extend this type of care, have been encountering financial shortages, requiring reorganizations. Those who are experienced in pressure ulcer care are being terminated. Otherwise, the resources are either short or unavailable. These situations tend to make gains in pressure ulcer care quickly vanish (Cuddigan et al.).
Lastly, national records on pressure ulcer rates have remained incomplete and unreliable (Cuddigan et al. 2001). Hospital discharge records do not all reflect or include pressure ulcer cases even if the patients reach Stage III or IV. In addition, these records are unable to recognize and tally the difference between pressure ulcers at different stages and complications already present on admission. It is still a fact that pressure ulcer rates in these databases remain lower than those gathered in clinical studies, indicating the inaccuracy of the databases. Yet valid and complete information from these national databases is needed to provide accurate feedback to providers. They form the basis for sound clinical, educational and public policy decisions for the future (Cuddigan et al.).
Allman R.M. et al. (1995). Pressure Ulcer Risk Factors Among Hospitalized Patients with Activity Limitation. 5 pages. Hopkins Medicine. Retrieved on January 5, 2008 at http://www.hopkinsmedicine.org/geriatrics/education/MedStudent/Geriatrics/SummerScholarsProgram/Section8.pdf
Berman, K (2007). Pressure Ulcer. 1 web page. MedlinePlus: National Institute of Health
Collins, N (2002). Vitamin C and Pressure Ulcers. 4 pages. Advances in Skin and Wound Care: Springhouse Corporation
Cuddigan, J. et al. (2001). Pressure Ulcers in America: Prevalence, Incidence and Implications for the Future. 9 pages. Advances in Skin and Wound Care: Springhouse Corporation
Ferguson, M., et al. (2000). Peptic Ulcer Management: the Importance of Nutrition. MedSurg Nursing: Jannetti Publications, Inc.
Thompson, P.A. (2000). Pressure Ulcers. 2 pages. Advances in Skin and Wound Care: Springhouse Corporation
Tutela, R. Jr., et al. (2004). Marjolin’s Ulcer Arising in a Pressure Ulcer. 3 pages. Advances in Skin and Wound Care: Springhouse Corporation
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