Pressure ulcer (PU) is a serious healthcare issue among the residents in an aged care facility resulting from unrelieved pressure over bones that are exposed to the compressing surfaces. It results in lesions in soft tissue and eventually, damages the underlying tissues. The frail elderly residents are at risk for developing PU if incontinent, immobile or cognitively impaired (Theisen, Drabik & Stock, 2012). PU risk assessment, prevention and management are the important parameters that need to be undertaken by a nurse in reducing the prevalence of PU among the elderly population in residential aged care homes.
Risk assessment is the first and foremost step in the prevention of PUs that is undertaken by nurses. For PU risk assessment, various scales like Braden, Waterloo and Norton scales are used. Various risk factors or predictors contribute to the progression of PUs like skin integrity, sensory perception, skin moisture, physical activity, mobility, nutritional status, friction and tear. The scores obtained by risk assessment scales provide an estimate for the PU risk development in a patient.
In a quantitative retrospective cohort study conducted by Tescher et al., (2012) showed that Braden scale and subscales is highly used for the PU risk assessment by nurses superior in specificity and sensitivity. Assessment of skin integrity is also important to check for the impairment, weakness and complete deterioration of the skin to assess for the progress of PU in the aged people. The strength of the article is that the effectiveness of Braden sub scores were found to be highly predictive in assessing the PU development risk apart from Braden scale alone. Risk alert was also explained in the study where nurses must consider both Braden scale and sub scores for the highest PU risk assessment. However, the study has a limitation where the presented data is active clinical practice and impact of Braden scale is studied in high-risk population, however, it may be different in any other population. The exact factors are not mentioned for the PU development as many contributing factors play a role for its development and progression.
Once the patient is identified with risk, nurses manage them by assisting them and maintaining regular and thorough skin inspection, Skin care is also done by keeping the skin clean using emollient soap or pH balanced cleanser to keep the skin hydrated and moisturized.
Prevention of PU is done by controlling friction, and pressure duration is decreased by using pressure-relieving devices like mattresses and air pillows, cushioning between thighs and between skin surfaces that are likely to be subjected to friction in the bony prominences.
Moore, Cowman & Posnett, (2013) conducted a randomised controlled trail (RCT) for evaluating effectiveness of repositioning done every 3 hours (using 30° tilt) and ambulation is encouraged by nurses at stage I so that it increases their mobility and enhancement of blood circulation. It is effective in terms of nurse time as compared to standard care. The strength of this study is that it showed the effectiveness of repositioning in preventing PUs and is highly economical in the clinical setting. The study also supported the National Pressure Ulcer Advisory Panel (NPUAP) guidelines providing economic support. The main limitation of this study is that there is limited information available on the true healthcare system and resource cost of PUs in the actual clinical settings as elderly population demographics are changing straining health budget. In this study, frequent repositioning done every 3 hours is effective; however, a detailed economic analysis is required to understand the repositioning aid and equipment costs.
LeBlanc et al., (2013) conducted a cross-sectional, quantitative study to assess the prevalence of skin tears and associated PU risk. The residents in a long-term care facility were assessed for skin tear and care based on number and location. Elderly population in long-term care are at high risk for skin tears according to the skin tear results. The strength of the study is that it highlighted the research gap prevailing among nurses regarding skin tears and requirement of additional epidemiological studies for clear definition of skin tear for PU risk assessment. The main limitation of the study is that the sample size was small and requires multisite study in healthcare facilities determining the skin tears and contributing factors to skin tear development and PU risk.
Skin care is also done through the assessment of tolerance level and condition of skin and prevents dryness of skin. The skin is inspected daily for the areas of warmth and redness as it is early sign of a beginning of pressure sore like blisters or craters (Markova & Mostow, 2012). The skin is kept dry and moisture free as dry skin has less chances for forming friction and PU development.
The nutritional intake is assessed and hence improvement is done by suggesting diet that promotes pressure tolerance level according to the patient’s body weight (Yatabe et al., 2013).
The articles are useful for the discussion as the information provided by the authors provide relevant information about the PU prevalence, prevention and management strategies adopted by nurses among elderly population in residential aged care homes.
LeBlanc, K., Christensen, D., Cook, J., Culhane, B., & Gutierrez, O. (2013). Prevalence of skin tears in a long-term care facility. Journal of Wound Ostomy & Continence Nursing, 40(6), 580-584.
Markova, A., & Mostow, E. N. (2012). US skin disease assessment: ulcer and wound care. Dermatologic clinics, 30(1), 107-111.
Moore, Z., Cowman, S., & Posnett, J. (2013). An economic analysis of repositioning for the prevention of pressure ulcers. Journal of clinical nursing, 22(15-16), 2354-2360.
Tescher, A. N., Branda, M. E., Byrne, T. O., & Naessens, J. M. (2012). All at-risk patients are not created equal: analysis of Braden pressure ulcer risk scores to identify specific risks. Journal of Wound Ostomy & Continence Nursing, 39(3), 282-291.
Theisen, S., Drabik, A., & Stock, S. (2012). Pressure ulcers in older hospitalised patients and its impact on length of stay: a retrospective observational study. Journal of Clinical Nursing, 21(3?4), 380-387.
Yatabe, M. S., Taguchi, F., Ishida, I., Sato, A., Kameda, T., Ueno, S., ... & Yatabe, J. (2013). Mini nutritional assessment as a useful method of predicting the development of pressure ulcers in elderly inpatients. Journal of the American Geriatrics Society, 61(10), 1698-1704.