Risk Assessment and Prevention Techniques for Pressure Ulcers in Elderly Hospitalized Patients: An A

An annotated bibliography on whether risk assessment prevents the risk of pressure ulcers in the elderly hospitalized patients is presented in this essay after researching and reviewing the existing literature from six sources. Pressure ulcers, commonly called bed sores, are certain types of skin injuries caused from pressure over the skin for a long period of time. These tend to develop on tender skin covering bony parts of the body like hips, ankles, heels and tailbones. This type of skin injury also affects the underlying tissue. It is a common disease occurring in the elderly who have restricted mobility due to their health conditions. As their skin becomes dry, thin or weak due to ageing, pressure ulcers are more likely to occur. These ulcers are highly painful and cause infection and complications and require immediate attention. Other factors like dementia, confinement to bed, paralysis or inability to move and obesity may also cause these ulcers. So, risk assessment must be done to identify patients who are vulnerable to pressure ulcers. Risk assessments are done by judging a patient’s condition and health status by using various risk assessment tools. This helps the healthcare experts to determine and map out the preventive measures that need to be administered to the patient. This essay provides a detailed study on the benefits of these techniques. A concise evaluative summary of the six articles, at the end of the essay, provides a concise view of the research topic. From the stated evidence, a research question has also been formulated which may be used in future research.

The study examines the effectiveness of using pressure ulcer tools to determine the level of its risk among patients at high risk, such as the elderly, in different healthcare settings. Several risk assessment tools, like the Braden tool, the Waterlow tool, the Norton scale and the Ramstadius tool, are in practice in different clinical environments but the most effective tool is still unknown. So, this study is aimed at comparing the accuracy of these tools in determination of risk of pressure ulcers in patients. It was found that these tools did not make any difference in its prevention as compared to clinical judgement by nurses.

As different patients have different requirements, thus, one tool is not enough to measure the risk of incidence of the disease in all patients. The authors examined that these tools can even give false positive results. If these results are followed by nurses, then, they may use preventive techniques unnecessarily on patients who are not at risk. Another study proved this fact where 80% of the patients received preventive measures unnecessarily due to such inaccurate results. The authors argued that risk assessment is only beneficial if it is followed by methods to combat the ramifications of risk factors. Thus, risk assessment alone is not adequate in the prevention of pressure ulcers.

Pressure ulcers have been a major concern to the nursing community since ages. This book studies the various aspects of the disease, its diagnosis and intervention procedures in detail. Two common questions that arise before framing the preventive measure plan of pressure ulcers is which tool is the most effective in assessing risks and how frequently should risk assessment be done in patients.

The Norton scale, widely used in the United Kingdom, has 5 sub-scales of assessing risks like mental condition, physical condition, mobility, activity and incontinence while the Braden Scale, widely used in the United States, has 6 sub-scales of assessing risks like moisture, mobility, activity, sensory perception, friction and shear and nutrition. Although these two scales have shown good sensitivity and specificity, their prediction of risk is very poor and their predictive power may highly differ from each other, even under the same circumstances, for instance, the Norton scale may identify a person as at risk of developing ulcer, while the Braden scale may identify him/her as not at risk. These limitations of risk assessment tools may come in the way of providing treatment and care to patients by nurses. Therefore, risk assessment from beforehand is not always helpful.

The paper delves deep into examining the prevalence of pressure ulcers among the population and implementation of suitable strategies for its prevention accordingly. The authors found that this disease is the most prevalent among hospitalized patients, especially among those in intensive care units, and it ranges from 5-15%. Prevalence of the disease among the elderly is almost same in both sexes. Ageing poses more threat of the disease as most of the elder people have impaired mobility and they are generally wheelchair or bed-bound. Ageing also changes the texture of natural skin and it becomes more prone to shear and tear, increasing the risk of ulcers. People are more inclined towards its prevention as prevention strategies are more cost effective than treatment strategies.

A study showed the range of cost of pressure ulcer treatment in the UK to be from $1500 to $18,000. Therefore, prevention strategies are beneficial and can only be implemented after risk assessment. The Norton, Waterlow and Braden scales are commonly used for this purpose but it was found that they have their own advantages and downsides. Inaccuracy of results of these tools does not have any effect on the reduction of incidence of the disease. Thus, it can be concluded that improper risk assessment means implementation of inappropriate preventive measures.

he study aims at exploring the ability of nurses’ visual skin assessment and its relationship with widely used risk assessment tools in assessing risk of developing pressure ulcers among hospitalized people. The earlier assessment of risk, the earlier will be the implementation of interventions in managing risks. This disease can be avoided if the risk factors are detected accurately. The elderly are more likely to be affected as their skin undergoes several pathological changes with ageing. The reduction in the content of collagen and elastin of their skin reduce its protective actions, which enhances the risk of pressure ulcers.

Visual Skin Assessment (VSA) by nurses requires their proper knowledge and grip on this subject. The author argues that VSA is not always an appropriate tool as the underlying skin problems are not visible to the nurses and hence, they cannot detect the threats early. Although the score of sensitivity and specificity of VSA are found to be higher than Norton scale and Waterlow scale respectively, the authors argue that this method is not completely reliable. A newly developed technique of sub epidermal moisture (SEM) measurement, which is mainly applied to detect the incidence of the disease in insensate or immobile patients, is found to be effective in determining risks.

Its sensitivity and specificity scores were found to be 100% and 83.33% respectively. It is built upon biophysical and physiological principles which make it extremely effective in detection of the disease at an early stage. The SEM scanner tests the bio-capacitance of the tested tissues for producing accurate results. It is highly sensitive to the moisture content within the tissue and can pinpoint any change precisely. This technological advancement may help in detection of pressure ulcers at an early stage, thus, exposing a scope of providing appropriate interventions on time. No other technological advancement is currently available to detect tissue inflammation. The major difference between VSA and SEM is that VSA is not effective until the underlying problems are visible on the skin while SEM measurement is able to detect the problems at an early stage. So, SEM is an effective measurement tool in preventing pressure ulcers in elderly as well as other demographics of the population as it can detect the disease almost 4 days earlier as compared to VSA. This can definitely help in making subject specific prevention strategies at an early stage.

The authors observed pressure ulcers to be the most common phenomena occurring in aged care facilities and hospitals. Several conventional screening tools are used in these healthcare organizations but none of them are found to be reliable. The international pressure ulcer guidelines recommend screening of patients within 8 hours of their admission to prevent risks of the disease. But this time recommendation has no specific evidence. The authors argue that 30 minutes to 6 hours is enough for the development of ulcers. Thus, proper screening of the patients is essential in taking preventive measures.

They state that the inefficiency of the screening tools is often due to measurement of the contained items in them which are not clinically significant. Risk assessment tools are often found to show false positive results. This deters the process of risk prevention as patients may be detected falsely at high risk while the patients actually at high risk of getting affected may be neglected. So, the effort of risk assessment goes to an absolute waste. According to the authors, if people are positively detected with high risk of developing pressure ulcers, then, they must be re-positioned once in every two hours, throughout the day. Alternating mattresses with air mattresses have also shown declining incidence rates of the disease.

Pressure ulcers are a major concern these days in healthcare organizations. It is quite common among the hospitalized patients, who do not have the ability to move frequently or are restrained from moving due to their clinical conditions. Each of the articles reviewed above focuses on the risk assessment techniques and preventive measures of pressure ulcers. Moore and Patton (2019) observed that the conventional pressure ulcer risk assessment tools are not always helpful as they do not give accurate results in some cases. These tools cannot estimate the risk effectively and they are not better than clinical judgement done by nurses. This results in wrong identification of at-risk patients. Lyder and Ayello (2008) have noted that though Braden and Norton scales can measure the risk effectively, they have their own limitations, which prevent the implementation of intervention techniques. Mervis and Phillips (2019) stated that pressure ulcers are most prevalent among hospitalized patients.

Treatment of pressure ulcers costs more than its prevention, so prevention measures are more in demand as compared to its treatment. But improper risk assessment causes implementation of inappropriate preventive measures. They also note that aging is an important cause of this disease. O'Brien et al (2018) noted that SEM measurement technique is more effective than nurses’ VSA method as it can detect the physiological changes and tissue damages under the skin at an early stage. Sharp, Schulz Moore and McLaws (2019) noted the causes of ineffectiveness of risk assessment tools and its consequences.

From the 6 articles reviewed above, the main theme includes the efficiency of risk management and the risk management tools. A research question has been formulated below using the PICO (Patients, Intervention, Comparison, Outcome) framework-

Patients- Elderly hospitalized patients

Intervention- Risk assessment tools and tests

Comparison- Between light-skinned and dark-skinned patients

Outcome- Pain reduction

Thus, the research question would be-

Are darker-skinned elderly hospitalized patients more at risk of developing pressure ulcers than their light-skinned counterparts?

Conclusion

From the 5 articles reviewed above, it can be concluded that this assignment has critically analysed the risk assessment techniques which are generally in practice in most healthcare institutions and also their effectiveness in preventing pressure ulcers in patients, especially those who are elderly and hospitalized. This essay demonstrated the importance of risk assessment and how certain techniques and technologies can be used to detect the risks. Risk assessment is important as it helps the nurses to make informed decisions and to make plans in advance for combating the disease. While erroneous results can have negative implications, positive results may save lives of the elderly. Negative results may classify patients not at risk as at-risk and unnecessary treatments are administered on them. But positive results may help administer interventions even earlier than the visibility of symptoms. SEM management technique is one of the best tools available to the healthcare sector which detects risk of pressure ulcers precisely and accurately.

References

Lyder, C.H. and Ayello, E.A., 2008. Pressure ulcers: a patient safety issue. Patient safety and quality: An evidence-based handbook for nurses.

Mervis, J.S. and Phillips, T.J., 2019. Pressure ulcers: Pathophysiology, epidemiology, risk factors, and presentation. Journal of the American Academy of Dermatology, 81(4), pp.881-890.

Moore, Z.E. and Patton, D., 2019. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews, (1).

O'Brien, G., Moore, Z., Patton, D. and O'Connor, T., 2018. The relationship between nurses assessment of early pressure ulcer damage and sub epidermal moisture measurement: a prospective explorative study. Journal of tissue viability, 27(4), pp.232-237.

Sharp, C.A., Schulz Moore, J.S. and McLaws, M.L., 2019. Two-hourly repositioning for prevention of pressure ulcers in the elderly: patient safety or elder abuse?. Journal of bioethical inquiry, 16(1), pp.17-34.

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