F Tag 314 309 Quality of Care Pressure Ulcer Prevention
PREVENTION OF PRESSURE ULCERS
42 CFR 483.25 © requires that a resident who is admitted without a pressure ulcer
doesn’t develop a pressure ulcer unless clinically unavoidable, and that a resident who has an ulcer receives care and services to promote healing and to prevent additional ulcers.
The first step in prevention is the identification of the resident at risk of developing
pressure ulcers. This is followed by implementation of appropriate individualized
interventions and monitoring for the effectiveness of the interventions.
An admission evaluation helps identify the resident at risk of developing a pressure ulcer, and the resident with existing pressure ulcer(s) or areas of skin that are at risk for breakdown. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure,11 the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches.
In addition, the admission evaluation may identify pre-existing signs (such as a purple or very dark area that is surrounded by profound redness, edema, or induration)12 suggesting that deep tissue damage has already occurred and additional deep tissue loss may occur. This deep tissue damage could lead to the appearance of an unavoidable Stage III or IV pressure ulcer or progression of a Stage I pressure ulcer to an ulcer with eschar or exudate within days after admission. Some situations, which may have contributed to this tissue damage, include pressure resulting from immobility during hospitalization or surgical procedures, during prolonged ambulance transport, or while waiting to be discovered or assisted after a debilitating event, such as a fall or a cerebral
Some evidence suggests that because it may be harder to identify erythema in an older adult with darkly pigmented skin, older individuals with darkly pigmented skin may be more at risk for developing pressure ulcers.13, 14, 15, 16 It may be necessary, therefore, in a darker skinned individual to focus more on other evidence of pressure ulcer development, such as bogginess, induration, coolness, or increased warmth as well as signs of skin discoloration. Multiple factors, including pressure intensity, pressure duration, and tissue tolerance, significantly affect the potential for the development and healing of pressure ulcers. An
individual may also have various intrinsic risks due to aging, for example: decreased subcutaneous tissue and lean muscle mass, decreased skin elasticity, and impaired circulation or innervation.
The comprehensive assessment, which includes the Resident Assessment Instrument (RAI), evaluates the resident’s intrinsic risks, the resident’s skin condition, other factors (including causal factors) which place the resident at risk for developing pressure ulcers and/or experiencing delayed healing, and the nature of the pressure to which the resident may be subjected. The assessment should identify which risk factors can be removed or modified.
The assessment also helps identify the resident who has multi-system organ failure or an end-of-life condition or who is refusing care and treatment. If the resident is refusing care, an evaluation of the basis for the refusal, and the identification and evaluation of potential alternatives is indicated.
This comprehensive assessment should address those factors that have been identified as having an impact on the development, treatment and/or healing of pressure ulcers, including, at a minimum: risk factors, pressure points, under-nutrition and hydration deficits, and moisture and the impact of moisture on skin. Each of these factors is discussed in additional detail in the following sections.
Many studies and professional documents identify risk factors that increase a resident’s susceptibility to develop or to not heal pressure ulcers.17, 18, 19 Examples of these risk factors include, but are not limited to:
– Impaired/decreased mobility and decreased functional ability;
– Co-morbid conditions, such as end stage renal disease, thyroid disease or
– Drugs such as steroids that may affect wound healing;
– Impaired diffuse or localized blood flow, for example, generalized
atherosclerosis or lower extremity arterial insufficiency;
– Resident refusal of some aspects of care and treatment;
– Cognitive impairment;
– Exposure of skin to urinary and fecal incontinence;
– Under nutrition, malnutrition, and hydration deficits; and
– A healed ulcer. The history of a healed pressure ulcer and its stage [if
known] is important, since areas of healed Stage III or IV pressure ulcers are
more likely to have recurrent breakdown.
Some residents have many risk factors for developing pressure ulcers, such as diabetic neuropathy, frailty, cognitive impairment, and under nutrition. Not all factors are fully modifiable and some potentially modifiable factors (e.g., under-nutrition) may not be corrected immediately, despite prompt intervention, while other factors such as pressure may be modified promptly. It may be necessary to stabilize, when possible, the underlying causes (e.g., control blood sugars or ensure adequate food and fluid intake).
Although the requirements do not mandate any specific assessment tool, other than the RAI, validated instruments are available to assess risk for developing pressure ulcers.
Research has shown that a significant number of pressure ulcers develop within the first four weeks after admission to a long term care facility.20 Therefore, many clinicians recommend using a standardized pressure ulcer risk assessment tool to assess a resident’s pressure ulcer risks upon admission, weekly for the first four weeks after admission for each resident at risk, then quarterly, or whenever there is a change in cognition or functional ability.21, 22 A resident’s risk may increase due to an acute illness or condition change (e.g., upper respiratory infection, pneumonia, or exacerbation of underlying congestive heart failure) and may require additional evaluation.
Regardless of any resident’s total risk score, the clinicians responsible for the resident’s care should review each risk factor and potential cause(s) individually23 to: a)Identify those that increase the potential for the resident to develop pressure ulcers; b) Decide whether and to what extent the factor(s) can be modified, stabilized, removed, etc., and c) Determine whether targeted management protocols need to be implemented. In other words, an overall risk score indicating the resident is not at high risk of developing pressure ulcers does not mean that existing risk factors or causes should be considered less important or addressed less vigorously than those factors or causes in the resident whose overall score indicates he or she is at a higher risk of developing a pressure ulcer.
Pressure Points and Tissue Tolerance
Assessment of a resident’s skin condition helps define prevention strategies. The skin assessment should include an evaluation of the skin integrity and tissue tolerance (ability of the skin and its supporting structures to endure the effects of pressure without adverse effects) after pressure to that area has been reduced or redistributed. Tissue closest to the bone may be the first tissue to undergo necrosis. Pressure ulcers are usually located over a bony prominence, such as the sacrum, heel, the greater trochanter, ischial tuberosity, fibular head, scapula, and ankle (malleolus). An at-risk resident who sits too long on a static surface may be more prone to get ischial ulceration. Slouching in a chair may predispose an at-risk resident to pressure ulcers of the spine, scapula, or elbow (elbow ulceration is often related to arm rests or lap boards). Friction and shearing are also important factors in tissue ischemia, necrosis and pressure ulcer formation.
Pressure ulcers may develop at other sites where pressure has impaired the circulation to the tissue, such as pressure from positioning or use of medical devices. For example, pressure ulcers may develop from pressure on an ear lobe related to positioning of the head; pressure or friction on areas (e.g., nares, urinary meatus, extremities) caused by tubes, casts, orthoses, braces, cervical collars, or other medical devices; pressure on the labia or scrotum related to positioning (e.g., against a pommel type cushion); pressure on the foot related to ill-fitting shoes causing blistering; or pressure on legs, arms and fingers due to contractures or deformity resulting from rheumatoid arthritis, etc. While pressure ulcers on the sacrum remain the most common location, pressure ulcers
on the heel are occurring more frequently,24 are difficult to assess and heal, and require early identification of skin compromise over the heel. It is, therefore, important for clinical staff to regularly conduct thorough skin assessments on each resident who is at risk for developing pressure ulcers.
Under-Nutrition and Hydration Deficits
Adequate nutrition and hydration are essential for overall functioning. Nutrition
provides vital energy and building blocks for all of the body’s structures and processes.
Any organ or body system may require additional energy or structural materials for
repair or function. The skin is the body’s largest organ system. It may affect, and be affected by, other body processes and organs. Skin condition reflects overall body function; skin breakdown may be the most visible evidence of a general catabolic state. Weight reflects a balance between intake and utilization of energy. Significant unintended weight loss may indicate under-nutrition or worsening health status. Weight stability (in the absence of fluid excess or loss) is a useful indicator of overall caloric balance. Severely impaired organs (heart, lungs, kidneys, liver, etc.) may be unable to use nutrients effectively. A resident with a pressure ulcer who continues to lose weight either needs additional caloric intake or correction (where possible) of conditions that are creating a hypermetabolic state. Continuing weight loss and failure of a pressure ulcer to heal despite reasonable efforts to improve caloric and nutrient intake may indicate the resident is in multi-system failure or an end-stage or end-of-life condition warranting an additional assessment of the resident’s overall condition. Before instituting a nutritional care plan, it helps to summarize resident specific evidence, including: severity of nutritional compromise, rate of weight loss or appetite decline, probable causes, the individual’s prognosis and projected clinical course, and the resident’s wishes and goals. Because there are no wound-specific nutritional measures, the interdisciplinary team should develop nutritional goals for the whole person. Unless contraindicated, nutritional goals for a resident with nutritional compromise who has a pressure ulcer or is at risk of developing pressure ulcers should
include protein intake of approximately 1.2-1.5 gm/kg body weight daily (higher end of the range for those with larger, more extensive, or multiple wounds). A simple multivitamin is appropriate, but unless the resident has a specific vitamin or mineral deficiency, supplementation with additional vitamins or minerals may not be indicated.
NOTE: Although some laboratory tests may help clinicians evaluate nutritional
issues in a resident with pressure ulcers, no laboratory test is specific or
sensitive enough to warrant serial/repeated testing. Serum albumin, prealbumin
and cholesterol may be useful to help establish overall prognosis;
however, they may not correlate well with clinical observation of
nutritional status.25, 26 At his or her discretion, a practitioner may order
test(s) that provide useful additional information or help with management
of treatable conditions.
Water is essential to maintain adequate body functions. As a major component of blood, water dissolves vitamins, minerals, glucose, amino acids, etc.; transports nutrients into cells; removes waste from the cells; and helps maintain circulating blood volume as well as fluid and electrolyte balance. It is critical that each resident at risk for hydration deficit or imbalance, including the resident with a pressure ulcer or at risk of developing an ulcer, be identified and that hydration needs be addressed.
(The surveyor should refer to the Guidance at 42 CFR 483.25 (i), F325, Nutrition, and 483.25(j), F327 Hydration for investigation of potential non-compliance with the
nutrition and hydration requirements. A low albumin level combined with the facility’s lack of supplementation, for example, is not sufficient to cite a pressure ulcer deficiency.)
Moisture and Its Impact
Both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to breakdown. Some studies have found that fecal incontinence may pose a greater threat to skin integrity,27 most likely due to bile acids and enzymes in the feces. Irritation or maceration resulting from prolonged exposure to urine and feces may hasten skin breakdown, and moisture may make skin more susceptible to damage from friction and shear during repositioning.
It may be difficult to differentiate dermatitis related to incontinence from partial
thickness skin loss (pressure ulcer). This differentiation should be based on the clinical evidence and review of presenting risk factors. A Stage I pressure ulcer usually presents as a localized area of erythema or skin discoloration, while perineal dermatitis may appear as a more diffuse area of erythema or discoloration where the urine or stool has come into contact with the skin. The dermatitis may occur in the area where the incontinence brief or underpad has been used. Also, the dermatitis/rash more typically presents as intense erythema, scaling, itching, papules, weeping and eruptions.28