Prevention of pressure ulcers in elderly patients – adapted from the Journal of the American Geriatrics Society 1995;43:919-6 – Tips from Other Journals
The prevalence of pressure ulcers ranges from 3 to 11 percent in hospitalized patients and from 11 to 35 percent in nursing home patients. In a review article, Patterson and Bennett emphasize that prevention remains the main goal.
Pressure is the most important external factor that may cause the development of a pressure sore. Evidence of tissue damage can be identified after even one to two hours of as little as 60 mm Hg pressure. Friction, shear, moisture and chemical irritants, such as urine, are other important factors.
The standard way to relieve pressure in bed-bound patients is sequential turning from the back to the left side and then to the right side every two hours. Direct pressure on the greater trochanters and lateral malleoli should be avoided by positioning the patient’s back at a 30-degree angle to the bed. Pillows placed between the knees and lower legs help relieve pressure. When the patient is supine, the heels must be elevated from the support surface to prevent heel decubiti, a common and serious complication in patients with hip fracture or stroke. Strict adherence to a turning and positioning regimen may be difficult for staff and inconvenient for patients during nighttime hours. Pressure-relieving pads, mattresses and beds may be beneficial. Unfortunately, few studies have evaluated their efficacy and cost-effectiveness.
It is important to remember that tissue damage begins in the muscle and subcutaneous tissues, before any skin damage is observed. Regular assessment of the skin and objective documentation of the location, size, stage (or depth) and number of ulcers are important for both early detection and effective treatment. Pressure sores occur most commonly on the sacrum, hips, buttocks, lateral malleoli and heels, but can occur wherever contact occurs between body parts.
Clinical staging or grading of the pressure sore helps guide clinical management (see accompanying table). Based on the clinical stage and underlying risk factors, six basic strategies can be used to treat pressure sores: (1) relieve pressure; (2) remove necrotic debris; (3) control local infection; (4) promote granulation; (5) protect healthy tissue, and (6) address the patient’s condition. (Patterson JA, et al. Prevention and treatment of pressure sores. J Am Geriatr Soc 1995;43:919-6.)
Stages of Pressure Sores as Defined by AHCPR
I Nonblanchable erythema of intact skin; must be differentiated from
reactive hyperemia that resolves once pressure is relieved. II Partial-thickness skin loss involving epidermis and/or dermis the
lesion is superficial (e.g., abrasion, opened blister or shallow crater). III Full-thickness skin loss into the subcutaneous tissue; necrosis and
undermining may be present. IV Full-thickness skin loss with extension beyond the deep fascia and
involvement of muscle, bone, tendon or joint space; necrosis,
undermining and sinus tracts may be present.
AHCPR = Agency for Health Care Policy and Research.
COPYRIGHT 1996 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group