The Agency for Healthcare Research and Quality reported that the number of patients in hospitals with pressure ulcers, which developed either before or after admission, increased by 80% from 1993-2006. Reasons for this included aging population, fragmented medical care, and nursing shortages

The Agency for Healthcare Research and Quality reported that the number of patients in hospitals with pressure ulcers, which developed either before or after admission, increased by 80% from 1993-2006. Reasons for this included aging population, fragmented medical care, and nursing shortages.

Pressure ulcer incidence

  • 1.3-3 million adults in the US are affected by pressure ulcers
  • Individuals aged 70-75 years of age have double the incidence of those aged 55-69
  • Two thirds of those affected are female (this is because males have much more lean body mass)
  • 4-38% are in acute care
  • 2.2-24% are in long-term care
  • 0-17% are in home care

“The Agency for Healthcare Research and Quality reported that the number of patients in hospitals with pressure ulcers, which developed either before or after admission, increased by 80% from 1993-2006. Reasons for this included aging population, fragmented medical care, and nursing shortages.”

Risk factors

  • Older age
  • Cognitive impairment
  • Physical impairments
  • Comorbid conditions that affect tissue integrity and healing (malnutrition, oedema, impaired microcirculation)
  • Critical illness with inflammation
  • Obesity

“While there is no information available for SA with regard to the cost of pressure ulcers,” said Donoghue. “In the US pressure ulcer related admissions average 13 to 14 days at an approximate cost of R240 533 to R293 825 compared to five days at R144 032 without pressure ulcers.

Nutritional requirements

When calculating patients’ nutritional requirements one needs to look at energy, protein, fluid and electrolyte, micronutrient requirements.

Micronutrient requirements – standard multivitamins with minerals are recommended for patients with wounds and if deficiencies are confirmed or suspected:

  • Vitamin A: stimulates epithelialisation and immune response
  • Vitamin C: enhances iron absorption and increases resistance against infection
  • Copper: plays a role in collagen cross-linkage, and rebuilding of tissue
  • Magnesium: plays a role in tissue regeneration
  • Zinc: is involved in fibroblast proliferation
  • Iron: enhances oxygen delivery to tissues
  • Vitamin K: synthesis of prothrombin in the liver.

 

Summary

  • Conduct nutrition screening of all patients on admission and after any change in condition
  • Refer patient immediately for full nutrition assessment by a registered dietitian
  • Provide adequate kilocalories, protein, and micronutrients through nutrition therapy
  • Provide adequate fluids
  • Monitor patients nutritional as well as fluid intake
  • Maintain euglycemia
  • Offer oral supplements to individuals who are unable to maintain adequate nutrition through diet alone.

 

Prof Magda Mulder

Prof Mulder is Head of Nursing at the University of the Free State. She presented on ‘Controversies in staging of pressure ulcers’.“Current classification systems are misleading,” said Mulder. “They imply that pressure ulcers progress from stage 1, to stage 2, to stage 3, to stage 4. Some pressure ulcers may initially originate in the deep tissue compartment, i.e. the inside-out-theory. “Eliminating numerical pressure ulcer classification systems may offer benefit from clinical, scientific, epidemiological, regulatory, legal, and economic perspectives. Because there are problems with both the validity and reliability of current classification systems, clinical practice guidelines and protocols based on these classification systems should not be considered the legal standard of care.”

The current classification systems have financial implications (penalties and/or reimbursement) and may place patients/healthcare professionals in jeopardy. “It is important to recognise that some patients may develop pressure ulcers despite clinical practices that are based on current evidence or standards of care. “Intrinsic or extensive factors can modify the development of superficial skin changes and deep pressure ulcers.”

  • Intrinsic factors: poor nutritional intake, hypoproteinaemia, low systolic blood pressure, anaemia, neuropathy, prominent bony prominence
  • Extrinsic factors: shape of heal, skin temperature, pressure, friction, shear.

 

Charlotte Teimers Hartkopp

Hartkopp is Global Medical Education Manager at Coloplast. She gave feedback from the European Pressure Ulcer Advisory Panel, 2015.

Braden scale and incontinence

  • Exposure to moisture is recognised as a factor in the development of pressure ulcers
  • Approximately 220 000 records studied: Result was that incontinence significantly increased the risk of facility-acquired pressure ulcers vs patients with no incontinence
  • Even patients with a low pressure ulcer risk have increased rates of stage 1 and 2 pressure ulcers if incontinence is present.

French national pressure ulcer 10 year prevalence survey

  • 21 600 questionnaires were sent out, 1 700 patents had a pressure ulcer
  • Patients with a pressure ulcer are on average eight years older than those without – age is a confounding factor
  • Incontinence, particularly double incontinence is also a confounding factor.

Other observations

  • Medical devices and vulnerable skin: Over 33% of pressure ulcers occurring in hospitals is due to medical devices
  • It is important to include the grade unstageable/ungradable in your monitoring scheme
  • There was a high amount of presentations on using computerised models of how the pressure can occur/is distributed
  • Increasing number of presentations on electrical stimulation of healings of pressure ulcers.