Despite their prevalence, pressure ulcers are complicated to treat. Regardless of multiple updates to the terminology and classification systems used to characterize these wounds, there are still problems with understanding. An accurate diagnosis and treatment plan can only be made when the notion of pressure ulcers has been clarified (Kottner et al., 2019). This review focuses on pressure ulcers and tries to identify diagnostic challenges, treatment options, and clinical practice uncertainties. Pressure ulcers, also known as decubitus ulcers or bedsores, are anywhere from a superficial reddening of the skin to a deep crater with exposed bone or muscle. Patients with poor mobility are particularly vulnerable to developing pressure ulcers. Most ulcers affect people over 65 years; however, those with a neurologic disability or a severe disease are also at risk.
Importance of the Issue and Relevance to the Healthcare Environment
Each year, over 2.5 million individuals in the US suffer from pressure ulcers. Pressing on the skin over a long period causes the capillary network to be disrupted, restricting blood flow, and stripping tissues of oxygenated blood and nutrients, resulting in pressure ulcers. As a result, tissue injury and local ischemia will result from this external pressure exceeding the artery capillary pressure. The most prevalent sites for pressure ulcers are the sacrum, soles, ischial tuberosities, major trochanters, and lateral malleolus (Rae et al., 2018). In hospitals, the prevalence ranges from 4.7% to 32.1%, whereas in nursing homes, the prevalence ranges from 8.5% to 22.5%.
Identification of risk variables and skin examination are the first steps in the risk assessment process. There are two types of risk variables for pressure ulcers: intrinsic and extrinsic. Caregivers should be well-versed in risk assessment and prevention to avoid pressure ulcers or detect them early on. However, risk assessment tools may help raise awareness, but they lack predictive power and have no established effect on preventing pressure ulcers. Prescribing pressure ulcer risk is most typically done using the Braden Scale.
When it comes to pressure ulcers, systemic infections outnumber noninfectious consequences by a wide margin. More than a third of infected ulcers may be infected with osteomyelitis, resulting in nonhealing ulcers and systemic symptoms. Plain X-rays and bone scans might be misleading. MR imaging is 98% sensitive and 89% specific for osteomyelitis in individuals with pressure ulcers; however, a bone sample (performed by an orthopedic consultant) is advised and can help guide antibiotic treatment (Wong et al., 2019). The symptoms of bacteremia, including fever, tachycardia, hypotension, and impaired mental status, can develop with or without osteomyelitis. Methicillin-resistant Staphylococcus aureus (MRSA), anaerobes (including enterococci), and gram-negative bacteria (such as pseudomonas, proteus, and Providencia species) should all be treated with empirical antibiotics until the findings of the culture are known.
Several reasons contribute to the development of pressure ulcers, including immobility, diminished or no sensibility, and nutritional deficiency. Long-term immobilization on a spinal block, table, or bed and improperly fitted medical equipment in touch with the patient’s tissues are examples of extrinsic risk factors. Pressure ulcers are more likely to occur in diabetes, malnutrition, and smoking patients. Because of their inability to move and experience pain, patients with spinal cord injuries have the highest pressure ulcer development (between 25 and 66 percent). In nursing homes, pressure ulcers affect 11% of residents, most occurring on the sacrum or soles (Rae et al., 2018). One in every five nursing home residents was discovered to have contractures. Tissue around major joints becomes less elastic, leading to contractures. Pressure ulcers can arise because of the inability of the affected limbs to move freely. In light of these findings, knowing the patient’s physical, ecological, and medical risk factors for developing pressure ulcers is imperative. Patients who have developed a pressure ulcer while in the care of a hospital are no longer eligible for supplemental reimbursement from the Centers for Medicare and Medicaid Services (CMS). Consequently, the prevention of pressure ulcers is a major concern in acute care hospitals.
The Terrace at Crystal LLC’s Vision
The Terrace at Crystal LLC is a registered healthcare provider with the National Plan and Provider Enumeration System (NPPES) and the Centers for Medicare & Medicaid Services (CMS). Its goal is to be known for its expertise and be regarded as a leading provider of high-quality care. Its mission is to be devoted to helping others. The nursing home’s core principles are quality care, community health, access to care, decency, service to others, and justice. This hospital’s staff knows that no two patients are exactly alike regarding medical care. To provide the best care possible, the team at The Terrace at Crystal takes the time to get to know all patients and their specific requirements. It is unnecessary to be away from loved ones to be away from home.
A single doctor working alone cannot prevent all pressure ulcers, no matter how good they are. A multi-disciplinary approach to preventing pressure ulcers is needed, as are the various teams involved in instituting and implementing a care plan (Atkinson & Cullum, 2018). Organizational customs and operational methods that encourage coordination and collaboration, as well as individual skills, are necessary for high-quality prevention.
Aspects of the Facility
The Terrace at Crystal LLC is a for-profit nursing skilled facility. About half of the 115 beds are being used daily, with an overall occupancy rate of 52%. Pressure ulcers affect 13% of long-term, high-risk residents; the national average is 8%, and the Minnesota average is 7%. Medicare and Medicaid are accepted at Terrace at Crystal LLC, which is not housed in a hospital. In 1984, the hospital began offering nursing home care. CMS established that the facility is a leading provider of high-quality skilled nursing services that help people stay healthy and live happier lives. In Crystal, the Terrace at Crystal LLC can be found at 3245 Vera Cruz Avenue.
Owners, managers, directors, licensed practical nurses, nurse aides, physical therapists, and registered nurses make up the Terrace at Crystal LLC staff. If a nursing home fails to address a health or safety issue for an extended period or receives a serious health or safety citation, Medicare may levy fines on the facility. Staffing patterns and standard operating procedures vary widely between hospitals and the departments that make up each. Everyone should be able to tell whether and how their jobs will change if they are well-defined in the organization. For the institution to successfully execute the preventative bundle with its current employees, it will need to consider its abilities and talents when assigning duties. In addition, it will be necessary to think about what each person’s function entails, how those roles interact, and how much communication and reporting should be done regularly.
Solution Related to Pressure Ulcers
A regular assessment of a patient’s medical condition includes a thorough examination of the patient. Detailed information on the origin and persistence of ulcers, as well as past wound treatment and risk factors, is included in the comprehensive history. Additionally, aspects including mental well-being, behavioral and cognitive state, and access to nurses are crucial in determining treatment strategies in the early stages of an evaluation. If a patient has a pressure ulcer, it could be a sign that they cannot get the care they need. Caregivers may require additional training, respite, or help to lift and reposition the patient if the patient requires more extensive support services (Rae et al., 2018). Pressure ulcers are more likely to develop in patients with speech or sensory impairments because they may not be able to express their discomfort in the usual ways.
A physician should keep track of the number of ulcers, their locations, and their dimensions (length, width, and depth). Additionally, nurses should look for any signs of infection, necrosis, or eschar formation and any signs of healing (granulation and epithelialization). The doctor must, above all, establish the stage of the ulcers they are treating. A phase I ulcer can appear as a persisting red, blue, or purple coloring in those with dark skin coloring. Slough or eschar must be removed to expose the wound’s base to determine the ulcer’s stage. Neither the formation of an ulcer nor its recovery can be tracked through stages. Measurement of healing progress can be tracked using the Pressure Ulcer Index for Healing tool.
Nurses’ Implementation of the Solution
At-risk patients should be protected with preventive interventions. Preventive treatment relies heavily on pressure reduction to maintain microcirculation. The programs may have to be determined empirically to find the best patient repositioning schedule based on evidence. Every two hours, patients confined to their beds should be moved. Aspiration and deteriorating congestive heart failure indications can occur if the head of the couch is elevated above 30 degrees; thus, it should be maintained at the lowest possible elevation. Repositioning of patients using physical assistance, for instance, a trapeze bar, can help some people alleviate pressure.
Static (stationary) and dynamic (moving) pressure-reducing gadgets can decrease or alleviate pressure (lower tissue tension to below the capillary closure threshold of 32 mm Hg). There are many different types of static devices, including air mattresses, water mattresses, gel-filled mattresses, foam mattresses, and even mattress overlays. A power source transfers localized pressure in dynamic devices, including switching pressure gadgets and low–air loss and air-fluidized surfaces (Atkinson & Cullum, 2018). Stationary devices are quieter, but they are also more expensive. Compared to regular hospital mattresses, pressure-reducing surfaces reduce ulcer incidence by 60%; however, there is no discernible distinction among pressure-lessening technologies.
The advantages of dynamic against static surfaces are ambiguous. Patients who cannot move or have an ulcer that is not healing correctly should have dynamic surfaces evaluated. If nurses feel beneath the static surface and there is less than an inch of stuff between the bed and the pressure ulcer, the mechanism may not be helpful, and they should look for an alternative. Chair cushioning and pillows, foam blocks, and materials inserted between the knees to ease heel pressure are all examples of pressure-relieving equipment. Ring cushions can irritate the skin and should be avoided at all costs.
The evaluation of dietary and skincare needs is another protective measure. An inadequate diet has been linked to an increased risk of pressure ulcers. Oral nutritional supplementation has been demonstrated to reduce risk in one big experiment, but other studies have not confirmed this. There is no conclusive evidence that nutrition plays a role in preventing pressure ulcers. In a recent meta-analysis, dietitian counseling and skin moisturizers are reasonable preventative interventions (Rae et al., 2018). However, it is unclear what role bactericidal and growth factor arrangements have. As a result, there is no evidence that Continence Care programs work. Some pressure ulcers are unavoidable, even with thorough risk assessment and preventive measures.
Prevention and Management
Interdisciplinary teams of healthcare providers work together to treat pressure ulcers. These teams may include primary care physicians and dermatological and infectious disease specialists, social workers, psychologists, dietitians, and podiatrists. Debridement of necrotic tissue is a critical part of pressure ulcer therapy, as is cleaning the wound and controlling the load and colonization of germs. Proper wound dressing is also an important component. Pressure-reducing devices utilized in preventive care can also be employed during therapy. A patient who can change positions on their own can benefit from static devices.
Patients with many big ulcers or a chronic wounds, after flap procedures, or when static gadgets are unsuccessful might require an air-fluidized or a little-air-loss bed. When shifting, debridement and dressing changes are being performed, check the patient’s pain level. Discomfort assessment techniques may be necessary for patients at high risk of developing pressure ulcers since they may not be able to feel the full extent of their pain. The wound is covered, pressure-reducing surfaces are adjusted, the patient is repositioned, and topical or systemic analgesics are administered to alleviate discomfort (Rae et al., 2018). Opioids and nonopioids (such as diamorphine gel, which is not accessible in the United States) have been shown in small randomized trials to minimize pain during debridement or dressing changes.
If the necrotic tissue is removed, it should be debrided until the eschar is eliminated and granulation tissue is seen. Heel ulcers with a stable, dry eschar and no signs of erythema, fluctuance, or drainage, on the other hand, should avoid surgical debridement. Sharp, mechanical, enzymatic, and autolytic debridement procedures are all available. Sharp debridement can be performed with a sterilized knife or scissors at the bedside, but an operating room should be used for more thorough debridement. If infection ensues or thick and widespread eschar needs to be removed, a sharp debridement is necessary. It is advised that lower-edge wounds be assessed for sufficient vascularization following harsh debridement. Sharp debridement is contraindicated in anticoagulated patients.
Moisture-retaining dressings could be utilized for autolytic debridement and help the wound heal faster. Synthetic dressings save caregivers time and effort while also reducing patient discomfort. Transparent films, alginates, hydrogels, hydrocolloids, and foams are among the dressings on this list. Transparent films can be used on their own for partial-thickness sores or in combination with hydrocolloids for extensive wounds. Hydrogels can be used to treat deep wounds with light exudate (Rae et al., 2018). These absorbent materials are helpful for wounds with heavy exudate. Hydrocolloids help preserve moisture and promote debridement by autolysis. Wound features and clinical judgment determine dressing selection; no moist dressing (even saline-moistened gauze) can be considered better than another. A wet-to-dry dressing is not an alternative to a wound dressing; it should only be used for debridement. Because there are so many different wound dressings, caregivers should be familiar with at least one or two of them or seek advice from a wound care specialist.
To avoid bacterial contamination from feces or urine, rectal tubes and catheters may be required. Even though pressure ulcers are usually colonized by germs, wound washing and debridement reduce the bacterial load. Two to four weeks of appropriate wound care should be followed by a two-week trial of relevant antibiotics, for example, silver sulfadiazine cream. When topical antibiotics fail to heal an ulcer or other indications of infection, quantitative bacterial tissue cultures should be conducted (for instance, intensified drainage, smell, erythema, warmth, and pain). Nevertheless, needle extraction or ulcer biopsy (recommended) is more significant clinically than a superficial swab specimen. Systemic antibiotics should not be administered in the absence of signs of progressing cellulitis, osteomyelitis, or bacteremia.
Only half of stage III ulcers and a third of stage IV ulcers are cure within six months of successful treatment, even though above 70% of phase II ulcers heal (Rae et al., 2018). Patients with clear phase III or IV pressure ulcers who are not responding to suitable patient care or whose life quality would be enhanced if the lesion was quickly closed should seek surgical consultation. Surgical options include direct sealing, skin musculocutaneous, skin grafts, and free flaps. Recurrence levels are high, and randomized controlled studies of reattachment surgery are inadequate. Vacuum-assisted closure for continuous phase III and IV ulcers and tissue regeneration are two new treatment approaches explored. It is unknown what role hyperbaric oxygen therapy, ultrasonography, and electromagnetic therapy play.
Pressure sites should be adequately cushioned to reduce the danger of developing a pressure ulcer, or patients should be repositioned regularly to avoid prolonged periods of pressure. Prosthetic and wheelchair users should be fitted appropriately to guarantee that the match is correct and suitable padding is provided. The fitting procedure will be repeated if the wearer’s weight or body shape has changed significantly (Zarei et al., 2019). If the skin is over a pressure point, the erosion of the skin might result in a pressure ulcer, which can be life-threatening. Keeping the skin healthy is an integral part of the care of patients who are at risk. Even with proper padding, it is necessary to change positions regularly to avoid pressure ulcers, which can develop over time, even under external pressures.
Pressure ulcers are difficult to treat, despite their prevalence. Decubitus ulcers, or bedsores, can range from a superficial reddening of the skin to a deep crater with exposed bone or muscle, depending on the severity of the pressure. Pressure ulcers are more likely to occur in patients who cannot walk. People over the age of 65 are at the most significant risk of developing an ulcer, but those with a neurological disability or a severe illness are also at risk. Pressure ulcers affect over 2.5 million people in the United States each year. Immobility, diminished or no sense of touch, and nutritional deficiency are all factors that can lead to the development of pressure ulcers. Insufficiency of movement in the affected limbs can lead to pressure ulcers. NPPES and CMS have registered The Terrace at Crystal LLC as a healthcare provider. The Terrace at Crystal’s staff takes the time to get to know each patient and their specific needs to provide the best care possible. Some people may benefit from physical assistance, such as a trapeze bar, to reposition themselves. As a precautionary measure, patients should be moved frequently to avoid prolonged periods of pressure at the pressure ulcer site.
Atkinson, R. A., & Cullum, N. A. (2018). Interventions for pressure ulcers: A summary of evidence for prevention and treatment. Spinal Cord, 56(3), 186-198.
Kottner, J., Cuddigan, J., Carville, K., Balzer, K., Berlowitz, D., Law, S., Litchford, M., Mitchell, P., Moore, Z., Pittman, J., Sigaudo-Roussel, D., & Haesler, E. (2019). Prevention and treatment of pressure ulcers/injuries: The protocol for the second update of the international Clinical Practice Guideline 2019. Journal of Tissue Viability, 28(2), 51-58.
Rae, K. E., Isbel, S., & Upton, D. (2018). Support surfaces for the treatment and prevention of pressure ulcers: a systematic literature review. Journal of wound care, 27(8), 467-474.
Wong, A., Goh, G., Banks, M. D., & Bauer, J. D. (2019). An economic evaluation of nutrition support in the prevention and treatment of pressure ulcers in acute and chronic care settings: a systematic review. Journal of Parenteral and Enteral Nutrition, 43(3), 376-400.
Zarei, E., Madarshahian, E., Nikkhah, A., & Khodakarim, S. (2019). Incidence of pressure ulcers in intensive care units and direct costs of treatment: Evidence from Iran. Journal of Tissue Viability, 28(2), 70-74.