Our Aging Skin, Term Paper Example

Our Aging Skin: Prevention of Pressure Ulcers in the Older Adult

Introduction to the Topic

Many older adults who experience limited mobility and other health concerns may face a higher risk of pressure ulcers, particularly during lengthy periods of confinement to a bed or a wheelchair. These conditions require patients to be moved or turned on a periodic basis so that their skin is able to breathe and they are able to alleviate the risks associated with pressure that could contribute to skin breakdown and other complications, while also improving their quality of life. These factors require expert knowledge and guidance in addressing the prevention of pressure ulcers in a comprehensive manner that will encourage healthcare providers to be proactive in reducing the risk of pressure ulcers. In the United States, an average of one to three million people develop pressure ulcers on an annual basis, and 2.5 million people in acute care facilities develop pressure ulcers (Dorner et.al, 2009) In addition, there are approximately 60,000 deaths per year as a result of pressure ulcers and related complications (Dorner et.al, 2009). From 1993-2006, the incidence of pressure ulcers increased by 80 percent and contributed to $11 billion in healthcare costs (Cox, 2011). In the intensive care unit (ICU), the risk of pressure ulcers ranges from 14-42 percent (Cox, 2011). The significance of pressure ulcers is so high that this condition has been classified by the federal government as a prominent public health concern; however, the Centers for Medicare and Medicaid Services will not provide coverage for preventable, hospital-acquired pressure ulcers at Stages III and IV (Lyder et.al, 2012). Therefore, the development of strategies to alleviate pressure ulcers is required that will be effective in managing patient needs associated with pressure ulcers as best as possible to prevent further complications, using existing clinical knowledge and resources as a guide in advancing patient care objectives to improve their overall health and wellbeing as best as possible (Lyder et.al, 2012).

History of Pressure Ulcers in the Older Adult

Pressure ulcers were first discussed back in the 1850s, when Florence Nightingale noted that “If he has a bedsore, it’s generally not the fault of the disease, but of the nursing” (Lyder & Ayello, 2008). In this context, nurses have demonstrated concern regarding pressure ulcers as part of a nurse’s responsibility to be proactive in treating patients effectively without placing patients at risk during hospitalization (Lyder & Avello, 2008). It is believed by some experts that “pressure ulcer development is not simply the fault of the nursing care, but rather a failure of the entire heath care system⁷—hence, a breakdown in the cooperation and skill of the entire health care team (nurses, physicians, physical therapists, dietitians, etc.)” (Lyder & Avello, 2008). In this context, it is important to identify the areas where breakdowns persist and how to overcome these conditions to place patients out of harm’s way as best as possible to prevent pressure ulcer formation (Lyder & Avello, 2008). This practice requires an evaluation of the conditions under which nurses, physicians, and other clinicians work so that pressure ulcer prevention is a critical priority for a hospital or other healthcare organization (Lyder & Avello, 2008).

In 1992, national pressure ulcer prevention guidelines were established by the Agency for Healthcare Research and Quality and remain the standard for nurses to follow, including specific processes such as skin care, mechanical loading and education for staff members and patients (Lyder & Avello, 2008). These guidelines are significant because they support nurses’ ability to be proactive in treating patients who are at a high risk of developing pressure ulcers in order to prevent these complications from taking place as best as possible (Lyder & Avello, 2008). Furthermore, a team-based approach must be implemented in order to provide patients with the best possible care and treatment in an effort to prevent pressure ulcers from forming, particularly in patients who are at the highest level of risk (Lyder & Avello, 2008).

Incidence of the Problem and Related Statistics

According to the National Pressure Ulcer Advisory Panel, there is an incidence rate of 0.4 percent to 38 percent in hospital environments, between 2.2 percent and 23.9 percent in long-term skilled nursing facilities, and 0 to 17 percent for patients who receive care from home health agencies (Lyder & Avello, 2008). For many hospitalized patients, pressure ulcers may develop within the first two weeks from the time of admission, but elderly persons who are hospitalized may develop these ulcers within the first week, which was reported in 15 percent of cases (Lyder & Avello, 2008). For some patients, it is likely that up to 60 percent of patients with pressure ulcers will die within one year of discharge (Lyder & Avello, 2008). To clarify, “pressure ulcers do not cause death; rather the pressure ulcer develops after a sequential decline in health status. Thus, the development of pressure ulcers can be a predictor of mortality” (Lyder & Avello, 2008). These rates must be considered because they require nurses to examine their practices with respect to at-risk patients and in their ability to be proactive in supporting effective patient care that will contribute to a reduction in pressure ulcers and related costs, which average $37,800 per patient (Lyder & Avello, 2008).

Patients develop pressure ulcers when capillaries create perfusion in the skin layers, thereby contributing to tissue necrosis (Lyder & Avello, 2008). Average blood pressure within the capillaries is 32 mm Hg; however, when this number is higher or other comorbid issues exist, there is a high risk of formation of a pressure ulcer within two to six hours (Lyder & Avello, 2008). Therefore, it is important to identify those patients who face the highest level of risk and aim to be effective in administering preventative measures to ensure that pressure ulcers do not develop during this at risk period (Lyder & Avello, 2008). Since there are over 100 risk factors associated with pressure ulcers, these must be carefully considered, such as diabetes, hypertension, peripheral vascular disease, and cerebral vascular accident (Lyder & Avello, 2008). These contributing risk factors must be closely monitored and patients should receive the best possible treatment in order to prevent ulcer formation (Lyder & Avello, 2008).

Current Issues and Predictions for the Future

In 2008, the Centers for Medicare & Medicaid Services modified their policies with respect to high volume and high cost health conditions, thereby requiring higher payments when the condition was deemed preventable under evidence-based guidelines, and were identified as a secondary diagnosis; therefore stage III and IV pressure ulcers no longer qualified for reimbursement when the ulcer had occurred during hospitalization (Rogers, 2013). This is a critical reminder of the need to adhere to established guidelines and recommendations regarding pressure ulcers to prevent their occurrence because they are not covered by insurance under specific conditions where they would not occurred had the guidelines been met (Rogers, 2013). This is a significant reminder that nurses and other healthcare providers must use specific guidelines and demonstrate expert knowledge in identifying and treating patients who are at high risk for pressure ulcers, particularly if they possess other comorbid conditions that may impact their risk (Rogers, 2013).

Another critical area that must be addressed is the importance of terminology regarding pressure ulcers so that nurses and physicians are on the same page regarding these terms and how they impact treatment objectives (Rogers, 2013). To be specific, wound descriptors must be consistent and appropriate so that all clinicians involved in a patient’s care across shifts are able to understand the terminology and the descriptions that have been provided (Rogers, 2013). This practice will ensure that the treatment regimen is also consistent from one shift to the next without posing a risk to the patient in any way (Rogers, 2013). As a result, there is a strong need to develop a strategy that will encompass effective patient care and treatment, while also considering other methods that will encourage nurses and other clinicians to be proactive in the treatment of pressure ulcers to promote timely healing and recovery as best as possible, given the limitations that might exist for each patient (Rogers, 2013).

It is also important for nurses to gain familiarity with the Braden scale for patient risk assessment, a tool which provides subscales to address different areas that may impact pressure ulcer development (Rogers, 2013). It should be noted that “From individual to unit-based activities, executive to physician, each staff member involved in the care of patients can provide support and consistency in helping with identification and prevention of PrUs. No one individual item created the accuracy; it is the succession of each step that built this process” (Rogers, 2013). This information supports the development of a framework to accommodate patient needs and to demonstrate the importance of assessment tools and methods to improve outcomes associated with pressure ulcers as best as possible (Rogers, 2013). This practice requires an understanding of the different contributing factors regarding pressure ulcers and how to best approach ulcers with the tools that are available to positively impact patient care and treatment on a continuous basis (Rogers, 2013).

In recent years, there has been a significant trend towards bundled interventions as a means of treating pressure ulcers, given the options that are available to improve patient outcomes using these interventions (Gray-Siracusa & Schrier, 2011). For example, a number of support surfaces offer patients some relief in the event that they face a high risk of pressure ulcers, depending on factors such as weight and overall health status (McInnes et.al, 2011). For example, constant low-pressure devices (CLP) include mattresses, overlays, and replacement beds, while some devices promote different pressure points in a mechanical fashion, known as alternating-pressure devices (AP) (McInnes et.al, 2011). From this perspective, it may be argued that there are different options for different types of people, and this requires a high level determination of the type of intervention that is most appropriate for a given patient, based upon his or her specific risk factors (McInnes et.al, 2011). It is known that “The aim of pressure ulcer prevention strategies is to reduce either the magnitude, or duration, of pressure between a patient and his (or her) support surface (i.e. the interface pressure), or both. This may be achieved by regular manual repositioning (e.g. two-hourly turning), or by using pressure-relieving support surfaces such as cushions, mattress overlays, replacement mattresses or whole bed replacements, which are widely used in both institutional and non-institutional settings. Often a combination of repositioning and support surface enhancement may be used” (McInnes et.al, 2011, p. 3). In this context, it is likely that patients will be provided with an intervention that is most appropriate for their specific health status; furthermore, nurses must be cognizant of the belief that not all pressure ulcer interventions are applicable to all patients and that other factors must also be considered that have an impact on these patients and whether or not they develop pressure ulcers, as well as the degree to which the chosen surface is effective in advancing patient health, rather than contributing to negative outcomes for patients (McInnes et.al, 2011).

Pressure ulcers also contribute to significant challenges that go beyond their physical characteristics, and nurses must be available as support systems so that patients are able to experience some degree of recovery and understanding of the condition and how it impacts their lives (McInnes et.al, 2011). Patients must be provided with nurse-led assessments and interventions that will have a positive and lasting impact, along with an opportunity to examine the different constructs of care and treatment that will positively impact their lives in a significant manner (McInnes et.al, 2011). In examining a systematic review of pressure ulcer interventions, a number of considerations were made, including an understanding of the different types of studies available, including randomized controlled trials and quasi-randomized trials that were used to identify new pressure ulcers (McInnes et.al, 2011). Specific interventions were considered, such as the following: 1) low-tech CLP surfaces, including foam, gel-filled, air-filled, water-filled, fiber-filled and bead-filled mattresses and overlays; 2) high-tech support surfaces, such as mattresses and overlays with deflating and inflating air-filled sacs; low-air-loss beds, and air-fluidized beds; and 3) other types of surfaces, such as turning beds and frames, limb protectors, and specific types of wheelchair cushions (McInnes et.al, 2011). These factors contribute to the overall direction and focus of pressure ulcer interventions that are likely to have some degree of impact on patients who require these surfaces as a widespread prevention tool (McInnes et.al, 2011).

Using a database search including CINAHL, MEDLINE, and EMBASE, a number of important studies were identified that provided information regarding the incidence of pressure ulcers, in accordance with specific criteria (McInnes et.al, 2011). Some of the most prominent studies compared different types of high-tech and low-tech surface tools in order to determine their effectiveness in alleviating the risk and frequency of pressure ulcers (McInnes et.al, 2011). The authors indicated that for patients who face a very high risk of pressure ulcers, specific types of higher quality foam mattresses should be used as a starting point in alleviating pressure ulcers, along with specific pressure relief tools for some patients who require surgery (McInnes et.al, 2011). However, there are differing perspectives regarding the use of high-tech and low-tech devices, but those that deliver alternating pressure may be a cost effective measure to consider (McInnes et.al, 2011). This systematic review supports the belief that in examining the options for patients who face a high risk of pressure ulcers, all options should be on the table to begin with, thereby creating an environment in which there are options for nurses to provide adequate input regarding these devices so that patients receive the level of care and treatment that is necessary to treat pressure ulcers to begin with (McInnes et.al, 2011).

A study by Vanderwee et.al (2011) addresses the significance of pressure ulcer prevention in the hospital setting and provides a basis for examining how some hospitals develop their own strategies to address this problem in an effort to alleviate some of these risks. To be specific, 84 hospitals in Belgium were included in the cross-sectional, multi-prevalence study, using patients over the age of 18 and an evaluation of pressure ulcer risk in patients within this category (Vanderwee et.al, 2011). Upon review of the statistics, it was determined that approximately 10.8 percent of the patients who were considered to be high risk received the level of prevention that was required to alleviate this risk effectively, with 73.5 percent receiving “partly adequate prevention” (Vanderwee et.al, 2011). In addition, it was determined that those patients in an armchair were more likely to receive adequate intervention tools than those who were in bed; however, those seated did not have adequate cushioning and repositioning to offload pressure (Vanderwee et.al, 2011).

For many patients, there is also a risk of pressure ulcer development in the heel area; therefore, this requires an understanding of the different elements that may be used to alleviate pressure in the heel area to reduce this risk, such as elevating heels with a cushion or pad to reduce prevalence (Vanderwee et.al, 2011). Perhaps most significant is that there are obvious barriers to achieving at least an adequate level of pressure ulcer prevention, such as lack of knowledge, poor attitudes, the costs associated with intervention tools, and unclear responsibilities regarding these practices for nurses and other healthcare providers, among others (Vanderwee et.al, 2011). These factors demonstrate that many hospitals throughout the world still have a long way to go with respect to pressure ulcer prevention and that in an effort to alleviate some of these issues, there must be a greater focus on the development of knowledge-based strategies to minimize gaps in information and to open the lines of communication so that all patients receive adequate care and treatment when they face a higher risk of pressure ulcers (Vanderwee et.al, 2011).

In addition to padding and other tools to alleviate pressure ulcers, other factors must also be carefully considered in this practice, such as the use of wound cleansers for patients who have already been diagnosed with pressure ulcers as a means of promoting healing in these patients (Levine et.al, 2013). Other criteria to consider include the following: 1) repositioning, for which established protocols are not available, yet is a viable technique in support of alleviating high pressure areas; 2) negative pressure therapy, which is a means of alleviating wound edema and expanding the blood supply to the affected area, even though this practice is not fully proven in research studies; 3) debridement, which is available in different forms, such as biologic (sterile larvae or maggots applied to the surface to remove dead tissue), autolytic (the use of enzymes to remove dead tissue), chemical (the use of sodium hypochlorite to remove tissue), mechanical (wet/dry dressings, whirlpools, and wound cleasing), and enzymatic (urea, collagenase, or papain to remove dead tissue) (Levine et.al, 2013). Furthermore, enteral and parental feeding may be used as a form of supplemental nutrition to stimulate healing in pressure ulcers; vitamins and minerals may be used to promote healing, such as vitamin C and zinc; specialized mattresses to promote pressure alleviation; ultrasound therapy, which may or may not stimulate healing; honey to promote healing; cellular therapy to alleviate heel pressure ulcers; musculocutaneous and fasciocutaneous flap closure to close pressure ulcers and alleviate the loss of function; and other alternatives that may include ostectomy (Levine et.al, 2013). Therefore, each of these alternatives must be examined more closely and must provide a basis for determining how to best treat existing pressure ulcers, using the body of evidence that is available to improve the understanding of these ulcers, including why they formed and how to best treat them to promote healing (Levine et.al, 2013).

For practicing nurses, there must be effective protocols in place that will provide a basis for examining the different constructs of care and treatment that support the pressure ulcer patient population more effectively. A systematic review conducted by Soban et.al (2011) and published by The Joint Commission represents a means of determining how to best approach pressure ulcers in order to accommodate patient needs and to alleviate some of the risks associated with these ulcers to improve quality of care and quality of life. Through an examination of databases such as CINAHL, PubMed, CENTRAL, and DARE, articles were extracted that were associated with key words such as staff education, performance monitoring, and risk assessment, among others (Soban et.al, 2011). Upon conducting the study and analyzing the results, the authors noted that “the use of the core [Quality Improvement] QI techniques was often inconsistent with QI methodology. The usefulness of audit and feedback, for example, as a means to change provider behavior is empirically documented. Among the studies in our sample, we noted a frequent disconnect between performance monitoring and the provision of feedback to nurse managers/staff. The reason for this disconnect is unclear” (Soban et.al, 2011, p. 250). Therefore, these conditions represent a challenge to the practices that currently exist with respect to nurse-led interventions regarding pressure ulcers, particularly since there are significant issues that must be addressed and that must provide a framework to address quality improvement as best as possible, considering that there are significant factors in how nurses communicate and share ideas regarding pressure ulcer prevention, and how they often lack critical knowledge that may make all the difference in promoting quality improvement strategies throughout the nursing unit (Soban et.al, 2011). In this context, it is believed that nurse-led interventions regarding pressure ulcers remain a difficult area where there must be additional information in place to accommodate patients and to provide them with the tools and resources that are required to accomplish patient care and treatment objectives in a successful manner to improve outcomes and quality of life for patients who face a significant risk of developing pressure ulcers (Soban et.al, 2011).

The identification of pressure ulcers requires a high level of support and guidance in order to prevent these ulcers in patients through quality improvement programs and other resources. A study conducted by Dahlstrom et.al (2011) examined some of these alternatives and sought to better understand the impact of pressure ulcer identification and documentation so that patients might receive the best possible level of care and treatment for this condition. The study examined a two-year program aimed at quality improvement as promoted by the Centers for Medicare & Medicaid Services, thereby increasing the potential to develop systems that might alleviate some of the risks associated with pressure ulcers in patients (Dahlstrom et.al, 2011). Specifically, “the Centers for Medicare & Medicaid Services (CMS) has deemed the most severe hospital-acquired PUs (Stage III and Stage IV) “never events” indicating that they should not occur if a hospital follows adequate performance standards and thus should not be reimbursed…In response to the pilot study’s results and the CMS reimbursement change, in June 2007, our institution launched a multi-component campaign to encourage full documentation of PUs as a first step towards reducing hospital-acquired PU prevalence” (Dahlstrom et.al, 2011). This study sought to examine the potential success of the campaign and if it was useful in supporting the aims of improving pressure ulcer prevention and treatment in patient who are at risk of this condition for any number of reasons (Dahlstrom et.al, 2011).

Based upon the results of the multifaceted intervention, it was determined that there are significant factors related to the development of high quality documentation for pressure ulcers, including the use of electronic medical records, specific education and training for residents regarding pressure ulcers, and other factors to improve documentation efforts (Dahlstrom et.al, 2011). Unfortunately, these factors were ineffective over the long term and did not provide the desired level of support and guidance that is necessary for nurses to be effective in meeting patient needs and in alleviating the risk of pressure ulcers on a continuous basis (Dahlstrom et.al, 2011). Nonetheless, the use of chart abstraction to monitor specific events may be a useful tool in addressing the challenges of pressure ulcer formation in patients (Dahlstrom et.al, 2011). Quality improvement strategies must be addressed on a continuous basis and provide a framework for achieving successful outcomes in order to accomplish the desired level of assessment and treatment that nurses must provide in order to support this high-risk patient population (Dahlstrom et.al, 2011).

To expand further, the development of protocols to support patients who are at risk of pressure ulcers requires a comprehensive effort from many different areas in order to accomplish the desired objectives in care and treatment for this patient population. This program should not only include nurses, as nursing assistants also play a significant role in these practices and in aiming to better understand the different areas where patient care and treatment quality are self-limiting or are limited by the surrounding environment. Therefore, an effort known as The On-Time Quality Improvement for Long-Term Care Program (On-Time) was established to meet the following objectives: 1) to improve the knowledge base and documentation skills of certified nursing assistants (CNAs) who work with long-term care patients; 2) to improve clinical decision-making through decision support tools to improve documentation quality; and 3) to improve risk identification and early intervention in an effort to produce viable and practical outcomes for patients (Sharkey et.al, 2011). With this type of program, it is believed that there will be significant factors related to the growth of the CNA knowledge base through education and direct experience in documenting information that supports patient health and wellbeing for those at risk of developing pressure ulcers (Sharkey et.al, 2011). Within this context, the On-Time program includes the following tools: 1) CNA documentation elements designed to standardize the information that is reported; 2) the development of On-Time reports to evaluate CNA-related data; 3) the development of process improvements to support on-time reporting tools; and 4) evaluating progress of the On-Time program through tracking tools (Sharkey et.al, 2011). These factors contribute to the overall development of the practice environment and in enabling CNAs to have a more significant role in shaping the nursing work environment in a long-term care facility, particularly when there is a high risk to patients in the development of pressure ulcers under specific conditions that involve risk factors (Sharkey et.al, 2011).

With the implementation and utilization of the On-Time program, it is evident that there is an overall reduction in the incidence of pressure ulcers in the designated facilities where implementation is high (Sharkey et.al, 2011). This is a visible reminder of the ability of programs to be effective indicators of change in alleviating some of the risks of pressure ulcers and in enabling CNAs to play a critical role in this process, rather than relying upon nurses to assume the burden of this responsibility and in turn, potentially contribute to errors in this practice area due to high levels of stress and excessive responsibilities (Sharkey et.al, 2011). In this context, it is important for nurses to be provided with a framework that supports successful outcomes and that aims to bring the responsibility of pressure ulcer prevention to a wide variety of individuals who work in the healthcare profession (Sharkey et.al, 2011). These practices will provide a basis for examining the different constructs of care and treatment that patients receive in healthcare facilities and to determine the best possible course of action with respect to patient needs that will also have the greatest possible impact on patient health and wellbeing (Sharkey et.al, 2011).

Overview

The prevalence of pressure ulcers throughout the healthcare system continues to be very high in many vulnerable populations, thereby contributing to the need to determine the level of risk associated with pressure ulcers for the affected populations. Clinicians from a variety of environments and specialties must be involved in providing preventative care and treatment to patients who are at the highest risk of pressure ulcers at all times. This also requires expert knowledge and guidance in supporting patient care needs effectively and in alleviating some of the challenges that exist with respect to patient care and treatment regarding pressure ulcers. It is important to demonstrate the value of knowledge, tools, and other resources as necessary in order to prevent pressure ulcer formation as best as possible, while also considering the factors that contribute to this condition in some patients. The treatment of existing pressure ulcers in the appropriate manner using existing guidelines is also critical to a patient’s level of and response to recovery. Therefore, these practices must be considered as part of a larger framework that has a significant impact on patient care outcomes for those persons who are deemed at high risk.

It is important for nurses and other healthcare providers to recognize the importance of pressure ulcer prevention as part of a larger framework to achieve success in the practice environment, while also considering other factors that play a role in shaping patient outcomes and in supporting the growth of knowledge and the administration of care in the practice environment. Pressure ulcers cause significant burden to patients in many ways; therefore, these factors must be considered as part of a larger approach to care and treatment that will have a positive impact on patient outcomes over time. It is believed that when communication is active and clarity is achieved regarding pressure ulcer prevention and treatment, there is a greater potential to be effective in treating the condition and in supporting the needs of patients who face the greatest risk of this condition. Therefore, an organized and detailed approach to prevention, care, and treatment must be in place in order to accommodate patients and to provide them with the resources that are required to improve their quality of life and overall health status.

Conclusion

Patients who face a high risk of pressure ulcers must obtain high quality care and treatment in the healthcare environment in order to prevent formation of these ulcers and the development of other factors that may pose an even greater risk to this patient population. These efforts require a comprehensive framework of nurse-led interventions that will identify possible risks associated with pressure ulcers, along with other challenges that may have a significant impact on patient outcomes. This knowledge must be used in conjunction with existing tools that are designed to alleviate some of the risks of pressure ulcers, along with a framework to achieve success and support improvements in patient care quality that will have a positive impact on quality of life. This framework is also of critical importance in reducing some of the risks that are related to the cost of treating pressure ulcers and in enabling the quality of patient care to improve in order to prevent ulcer formation over the long term. This process also requires a collaborative effort from nurses and other healthcare providers in order to achieve the desired results in prevention, care, and treatment and to minimize the risk of pressure ulcers in patients over time.

References

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McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E., Dumville, J. C., & Cullum, N. (2011). Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev, 4.

Rogers, C. (2013). Improving processes to capture present-on-admission pressure ulcers. Advances in Skin & Wound Care: The Journal for Prevention and Healing, 26(12), 566-572.

Sharkey, S., Hudak, S., Horn, S. D., & Spector, W. (2011). Leveraging certified nursing assistant documentation and knowledge to improve clinical decision making: the on-time quality improvement program to prevent pressure ulcers. Advances in skin & wound care, 24(4), 182-188.

Soban, L. M., Hempel, S., Munjas, B. A., Miles, J., & Rubenstein, L. V. (2011). Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Joint Commission Journal on Quality and Patient Safety, 37(6), 245.

Vanderwee, K., Defloor, T., Beeckman, D., Demarré, L., Verhaeghe, S., Van Durme, T., & Gobert, M. (2011). Assessing the adequacy of pressure ulcer prevention in hospitals: a nationwide prevalence survey. BMJ quality & safety. Retrieved from https://biblio.ugent.be/input/download?func=downloadFile&recordOId=1234940&fileOId=1246800