Articles Posted in Pressure Ulcers

Some recent discoveries have shown that there is a need to redefine the National Pressure Ulcer Advisory Panel’s (NPUAP) definition of deep tissue injury.  Although etiological studies of deep tissue injury (DTI) primarily pertained to the characterization of biomechanical factors influencing its onset and progression, new findings suggest that the criteria of DTI should be evaluated and refined.  According to a recent article published by Ostomy Wound Management (OWM), there are several reasons why the current definition is insufficient:
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The prevalence of chronic wounds located in the lower extremity area is high among older adults.  Not only can they be extremely deleterious and pose major health risks, they also increase socioeconomic burden because of the high expenses of wound care, long duration of healing time, increased complication rate and negative effect on patients’ and loved ones’ quality of life.  Chronic wounds are related to heightened mortality and significant morbidity because of infection, loss of ability to perform daily activities, pain, and psychosocial issues. Health care clinicians must be trained to identify and diagnose wounds, as well as provide proper management of their etiology. The four most common chronic wounds are venous leg ulcers, diabetic foot ulcers, pressure ulcers, and arterial ulcers.  Although there have been recent advances in wound care, care providers are still struggling to provide the best quality of care in this area, especially for elderly people living in nursing homes and assisted living facilities.

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According to the New York Times, the federal government will be implementing significant changes to the rating system of nursing homes in the United States. Currently, the ratings are based on a five star system that is scrutinized by the public. This five star rating system “has been criticized for its reliance on self-reported, unverified data.” The current system was implemented five years ago and evaluates staffing levels and quality of care, which is reported by the nursing homes and not audited by the federal government.  This flawed rating system “relied heavily on unverified and incomplete information that even homes with a documented history of quality problems were earning top ratings.” In 2009 37% of nursing homes had ratings of four or five stars and by 2013 over 50% had exceedingly high ratings. With more than 15,000 nursing homes in the United States, it is crucial that the optimal quality of care is guaranteed by skilled nursing facilities.  Continue reading

 

 

The American Association of Retired Persons (AARP), the SCAN Health Plan, and The Commonwealth Fund produced the second annual State Long-Term Services and Supports (LTSS) Scorecard, which gages system performance from the perspective of service users and their families.  The finest quality of care in a skilled nursing facility should be a guarantee, especially with the influx of senior citizens our nation will encounter within the next ten years. The “Baby Boom Generation” will rapidly increase the percentage of elderly residing in a nursing facility which in turn, will generate a higher demand for excellence in quality of care.   Therefore, the slow pace of improvement must speed up to be better equipped for the aging of the baby boomers.  The LTSS Scorecard is designed to measure how each state performs in its assistance and support for the elderly, adults with disabilities, and their family caretakers.   It is intended to help states improve their LTSS systems so that the elderly and adults with disabilities can better choose and control their lives, in an effort to maximize their welfare and independence.  Continue reading

Unfortunately, pressure ulcers are preventable, yet common conditions which arise in elderly individuals who reside in nursing homes and other healthcare settings. Not only do these severe wounds cause physical discomfort and pain, but a study published in Wounds delved into the social and psychological effects of pressure ulcers which contribute to a reduced quality of life. For example, studies have shown that those who have pressure ulcers for six or more months are more likely to suffer from pessimism, which may affect their nutrition, susceptibility to depression, and ability to heal.

Pressure ulcers are known to impact general physical health, as complications and even death may occur. Additionally, pain almost always accompanies the presence of a pressure ulcer, and studies have shown that 84% of those with pressure ulcers have reported pain even while they are at rest, with some expressing their pain to be at an excruciating level. In addition, many have expressed experiencing fatigue due to sleep disruptions because of the presence of the ulcers. Thus, because of these ongoing factors, patients already experience a diminished quality of life.

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Recent research has been conducted to explain why the elderly population may be at higher risk for pressure ulcer development. Our skin functions as a defensive barrier against physical and chemical trauma and disease. However, research has uncovered correlations between skin changes that occur with age which may serve as risk factors for pressure sores. This is because various changes in the skin’s structure occur with time, impacting the skin’s ability to heal wounds quickly and leaving it more vulnerable. The skin of elderly individuals has increasingly fewer epidermal cell layers thus deteriorating its ability to serve as an effective barrier. Additionally, as people age, subcutaneous fat will deteriorate. This will have the effect of decreasing support of one’s skin from underlying bone. In addition, skin will generally respond with less vasodilation when there is external pressure, furthering the likelihood for pressure sore development.

Because of these changes, elderly individuals in nursing homes are highly susceptible to the development of pressure ulcers. Despite the fact that it is highly preventable, statistics reveal that about 2.5 million people develop pressure sores every year in the United States alone. Of these individuals, up to 24% develop pressure sores in long term care facilities, while 38% develop pressure sores during their stay at acute care hospitals. Pressure sores not only diminish an individual’s quality of life but may also lead to death. Thus, early identification and treatment are critical in preventing the development and worsening of sores, and the complications that may result due to their development.

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Many elderly residents who are hospitalized or living in nursing homes frequently develop pressure ulcers, the development of which risk further complications and even death. Consequently, caretakers for the elderly, particularly those in hospitals and nursing homes, must take precautions to prevent pressure ulcer development within this population. Studies have been conducted demonstrating a correlation between hypotension, or low blood pressure. Specifically, hypotension has been demonstrated to be an important risk factor in the development of pressure ulcers because research has found that hypotension in elderly patients, particularly those in poorer health, contributed to decreased blood flow at pressure points. This, in turn, would contribute to the death of cells and tissue in that area, leading to pressure ulcers.

However, a legal doctrine known as the ‘egg-shell skull’ rule can apply in this context. This rule holds an individual responsible for all consequences arising from their injury-causing actions towards another, even if the resulting injury to the victim is one that is unusually severe due to an underlying or pre-existing condition. Therefore, those caring for the elderly must be especially vigilant in protecting patients against pressure sores, particularly if an elderly patient is at risk for hypotension. This can be done by promptly identifying which elderly patients have hypotension, or those who are susceptible to developing hypotension, and allocating proper attention and resources to such patients. By doing so, caretakers can identify which elderly patients are particularly vulnerable to pressure ulcer development due to their clinical condition and can take early preventative measures before pressure ulcers arise and complications occur.

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A new study published by the Journal of the American Geriatrics Society concluded that there is a direct correlation between pressure ulcers (bedsores) developed during hospitalization, patient mortality and hospital re-admittance. According to the study, not only did seniors that developed pressure ulcers during their hospital stay have a higher chance of returning to the hospital within 30 days, but they also had a higher chance of dying during this subsequent hospital stay.

The lead researcher of this study by the UCLA School of Nursing, Dr. Courtney Lynder, was quoted saying, “It is incumbent upon hospitals to identify individuals at high risk for these ulcers and implement preventive interventions immediately upon admission”. The study found that approximately 4.5 percent of the patients being tracked in the study developed a pressure ulcer during their hospital stay. The majority of these patients developed the bedsores in the pelvic area such as the hip and tailbone. Of the nearly 3,000 patients that were admitted to the hospital with a pressure ulcer, 16.7 percent developed a new pressure ulcer on another part of their body during their hospital stay.

This study uncovers how serious the issue of pressure ulcers really is, especially in patients who are already at high risk of developing these wounds. Whether pressure ulcers are developed within the confines of a hospital or a nursing home, they are extremely painful and detrimental to the health of residents. Skilled nursing facilities must be vigilant to prevent such conditions from occurring by taking the necessary precautions such as alternating the position of immobile bedridden patients at least every hour and properly assessing the level of severity of the pressure ulcer, in order to implement the appropriate treatments. Effective treatment and prevention of pressure sores, however, is only possible with sufficient staff that are well-trained. If your loved one has developed multiple pressure ulcers, this may be a sign that his or her nursing home is understaffed. Unfortunately, maintaining a high quality of care is not always a priority in some nursing homes, especially in those that seek to increase profits by understaffing. This is an affront to the dignity and respect that nursing home residents deserve and a direct violation of their Patients’ Rights.

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The Journal of the American Medical Directors Association (JAMDA) recently published an article titled, “Factors Associated with Physician and Nurse Practitioner Pressure Ulcer Staging Practices in Rehabilitative and Long-Term Care” that studied patterns of assessment, staging, and documentation practices concerning pressure ulcer wounds in skilled nursing facilities.

The study investigated patients within two different facilities: a chronic hospital and a nursing home facility that each provided 140 beds, 100 of which were long term care and 40 of which were rehabilitative. They examined data provided by two different sources: a provider and a nurse from the chronic hospital and the nursing home. Both facilities established weekly wound rounds and created a wound log in order to keep track of patients with developing pressure ulcers. Of the 57 subjects involved with the study, the health care provider only documented pressure ulcer stages for 30. In comparison, the nurse was able to document a pressure ulcer stage for 52 of the 57 subjects.

Researchers found that there is noticeable confusion in the determination of pressure ulcer stages between providers and nurses, and that there is a lack of a standardized means to clearly categorize the stage of a pressure ulcer. These inconsistencies in the staging of pressure ulcers can be fatal, as applying improper treatments could result in further injury or death of the patient. For example, if an uneducated nurse treated a Stage 3 pressure ulcer as a Stage 1, the treatment would be nowhere near effective enough to heal the wound, and could lead to the patient’s death. Therefore, it is very important that the medical providers and nurses are able to accurately assess the stage of pressure ulcers.

However, even when the staging of a patient’s pressure ulcer is consistent among different staff members of the nursing home, the study notes that “documentation practices are of particular importance as discrepancies between nursing documentation…may compromise patient care.” For instance, if one nurse fails to document that a patient is beginning to develop a pressure ulcer, the nurse working the next shift may be unaware of this new condition and fail to provide the patient with the proper care. Consequently, the pressure ulcer will be allowed to become more severe. Ultimately, the nursing home staff is responsible for maintaining organized records of their patients’ health.

It becomes apparent that a nursing home’s staff plays an instrumental role in the treatment and prevention of pressure ulcers. Unfortunately, however, pressure ulcers are often caused by a facilities’ lack of staff or education. You should also be cautious of the quality of your loved one’s nursing staff. Even if it appears that the facility is fully staffed, many nursing homes often cut costs by hiring less licensed nurses and more nursing assistants, thus sacrificing the qualifications needed to properly care for patients. Studies have actually linked lower levels of direct care from Registered Nurses to increased incidents of pressure ulcers.

The providers and nurses within JAMDA’s study display an alarming lack of knowledge concerning pressure ulcers. Providers and nurses alike should be able to understand the importance of clearly documenting pressure ulcers. Either ignoring or incorrectly assessing the stage of a pressure ulcer violates the Patients’ Bill of Rights, which states that skilled nursing facilities are obligated to ensure that patients are free from developing pressure sores. Moreover, if the patient does develop a pressure sore, the patient has a right to receive the appropriate treatments and care.

It is much easier to prevent a pressure ulcer from forming in the first place, as treating an already developed pressure ulcer can be problematic. There are many preventative measures that can be taken, ranging from movement and position changes to a nutritious, well balanced diet. However, for these preventative measures to be effectively carried out, one of the most important factors in preventing pressure ulcers is that an adequate nursing staff level should be provided by the health facility to their patients.

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A recent study, published in the Journal of Clinical Nursing, looks at how the level of education about pressure sore prevention among nursing home staff affects the level of care provided to residents. The article, titled “Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes”, relates the results of a survey of registered nurses and assistant. The survey team interviewed 145 nursing staff across 9 different nursing homes and observed the care of 615 residents.

The findings of the study show that knowledge about pressure sore prevention is very low, with registered nurses scoring on average 29.3%. The mean score for certified nursing assistants is even lower at 28.7%. RNs and nursing assistants are in charge of taking steps to prevent the development of pressure sores. And yet this study found that the full measures stipulated by nursing home guidelines were only carried out in 6.9% of residents designated as at risk for pressure sores.

Pressure sores, or Decubitus Ulcers, are areas of dead skin tissue, which can be very painful and lead to infection and the breakdown of skin and muscle. These sores arise from extended periods of unrelieved pressure on a person’s skin. They are commonly found on the joints, back, and head, where the skin contacts or rubs against a bed or chair. Pressure sores are classified in four stages of severity, with stage IV resulting in extreme skin breakdown to the extent that the bone may be exposed. Pressure sores of any stage are very painful and can lead to a lower quality of life.

The development of pressure ulcers is preventable. By moving and changing position periodically, pressure on the skin can be relieved and pressure sores prevented. Other factors such as a healthy diet and good hygiene also help. Nursing staff play a vital role in this process. They are responsible for turning and repositioning at risk residents as well as assisting in activities that help build muscle and maintain skin health. These nurses and nursing assistants should be informed of pressure ulcer prevention measures as well as the proper care procedures if for any reason a resident does develop an ulcer.

One of the main reasons that residents in nursing homes develop pressure sores is understaffing. Many nursing facilities do not have adequate numbers of staff to perform the duties necessary to prevent pressure ulcers in all of the residents. This does not excuse the facilities as the Patients Bill of Rights mandates that all those residing in care facilities have the right to be free from developing any bed sores. It is the responsibility of the nursing home to hire enough staff to properly care for all of the residents. The RNs and nursing assistants should also be fully educated, in subjects such as pressure sore prevention, so that they can provide the care and attention that each and every person in a nursing home deserves.

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