Nursing Care for Bed Sore and Treatment

Bed Sore and Treatment and Nursing Care

Pressure Ulcers as Health Issue,Etiology of Pressure Ulcer,Health Issues of Pressure Ulcer,Ulcer Preventive Nursing Care,Pressure Measuring  Tools,Nursing Guidelines for Pressure Ulcer,Objective of Ulcer Treatment.

Pressure Ulcers as Health Issue

     Pressure ulcers remain a common health problem throughout the health care system. It has been conservatively estimated that annually 1 million adults develop pressure ulcers. The incidence rates vary greatly depending on the health care sector. 

    However, pressure ulcer incidence rates for hospitals range from 0.4% to 38%, for skilled nursing facilities from 2.2% to 23.9%, and for home health agencies from 0% to 17% (Cuddigan, Ayello, Sussman, & Baranoski, 2001) . The annual cost to treat pressure ulcers has been estimated at $1.335 billion, with an average cost range of $1.190 to $10.185 or more (Kerstein et al., 2001).

Etiology of Pressure Ulcer

    The development of pressure ulcers occurs when there is sufficient pressure over time to cause capillary destruction, resulting in tissue necrosis. 

    Although the amount of time and pressure needed to obstruct normal capillary closure vary (acuity of patient), research has found that capillary pressure ranges from 20 mm Hg to 40 mm Hg, with 32 mm Hg considered the average. However, this goal standard is being revisited, since it is possible to develop pressure ulcers at much lower pressures.

Health Issues of Pressure Ulcer

    The development of a pressure ulcer and/ or failure to prevent the ulcer from progressing to a more severe stage can result in negative consequences for the health care system. Litigation has significantly increased related to pressure ulcer development. 

    More-over, the US Centers of Medicare and Medicaid Services (formerly, Health Care Financing Administration) consider the development of pressure ulcers as a failure in delivery of quality services, since the prevention of these ulcers depends on the cooperation from the entire health care team.

Ulcer Preventive Nursing Care

    Nursing research has remained at the fore-front in building the knowledge base related to pressure ulcer prevention. The first step in effective pressure ulcer prevention is identifying those patients at risk for ulcers. Conservatively, there are over 100 health factors: associated with pressure ulcer development. 

    The development of pressure ulcer prediction tools has made a significant difference in identifying those vulnerable adults and children at risk for ulcer development. Nursing research has led to the development of pressure ulcer prediction tools. 

    Some of the most common prediction tools are the Braden Scale for Predicting Pressure Ulcer Risk and the Norton Scale (US Agency for Health Care Policy and Research, 1992). 

    The Braden and Norton Scales have good sensitivity (83%-100% and 73%-92% respectively) and good specificity (64%-77% and 61%-94% respectively), but have low positive predictive value (approximately 40% and 20% respectively) (Bergstrom, Braden, Laguzza, & Holzman, 1987; Norton, D., McLaren, & Exton-Smith, 1975). 

    Thus, there are patients who are receiving preventive interventions that are truly not at risk. Moreover, optimal cut off scores may be different depending on patient population; Thus, continued research in this area is greatly needed.

Pressure Measuring  Tools 

    The use of pressure ulcer prediction tools in non-White populations has been questioned,since many of the prediction tools being used have not been validated in non-White populations.Several nursing research studies examining the predictive validity of these pressure ulcer prediction tools have emerged in the nursing research literature. 

    Lyder and others (1999) examined the predictive validity of the Beaden Scale in Blacks and Hispanics. 

    The scale was found to be highly predictive (p=.01) when an optimal cut-off score of 18 or below was used. Conversely, Pang and Wong (1998) investigated the predictive validity of the Braden Scale, the Norton Scale, and the Waterlow Scale (primarily used in the United Kingdom) in a Chinese population. 

    These researchers found that the Braden Scale had the best sensitivity (91%) and specificity (62%) It appears that the Braden Scale may provide an overall better sensitivity and specificity in non-White populations; however there remains a paucity of nursing research examining both risk factors and validation of prediction scales in non-white populations.

Nursing Guidelines for Pressure Ulcer

    The development of the Agency for Health Care Policy and Research (now the Agency for Health Care Research and Quality) guidelines for pressure ulcer prevention was a mile stone for both distilling and disseminating current research knowledge on the most effective methods for preventing these ulcers. 

    Led by nurse researcher Dr. Bergstrom, these guidelines provided key areas for clinicians to consider for pressure ulcer prevention (risk assessment, repositioning, use of support surfaces, etc.). 

    Because pressure ulcer development is a multivariate problem, no studies could be found that successfully implemented the guidelines in its entirety. 

    Gunningberg, Lindholm, Carlsson, and Sjoden, (2001), investigating the incidence of pressure ulcers in 1997 and 1999 among patients with hip fractures, found significant reduction in rates (55% in 1997 to 29% in 1999). 

    They attributed these reductions in pressure ulcer incidence rates to performance of systematic risk assessment upon admission, accurately staging pressure ulcers, using pressure reducing mattresses, and continuing education of staff. 

    Similar results have been noted in other studies when they implement a similar pressure ulcer prevention program (Xakellis, Frantz, Lewis, & Harvey, 1998; Lyder, Shannon, Empleo-Frazier, McGehee, & White, 2002). 

    Although nursing research studies have identified the principles of pressure ulcer prevention, additional studies are needed to determine optimal titration levels for preventive strategies based on the patient pressure ulcer risk levels and cost of interventions to the health care system (resources, staff burden, Etc.).

Objective of Ulcer Treatment 

    In 1994, the Agency for Health Care Policy and Research (led by Dr Nancy Bergstrom) published guidelines on the treatment of pressure ulcers. Nurse researchers have been quite active in leading the knowledge development in specific areas of pressure ulcer treatment, in particular, tools to objectively monitor pressure ulcer healing. 

    Bates-Jensen, Vredevoe, and Brecht (1992) developed the Pressure Sore Status Tool (PSST) to assess the healing of pressure ulcers. The content validity of the PSST was established by a panel of 20 experts. Interrater reliability was established, r = .91 for first observation and r = .92 for second observation (Bates-Jensen et al., 1992). 

    Another area in which nurse researchers have made an impact has been the evaluation of dressings to assist in the healing of pressure ulcers. Studies have found that, compared to traditional gauze, modern wound dressings heal pressure ulcers faster, are more economical, and save on caregiver time (Bolton, van Rijswick, & Shaffer, 1997).

    Much research is still needed on examining the outcome (healing rates, costs, etc.) of standardized protocols for pressure ulcer treatment. Nursing studies are needed on developing and implementing alternative therapies for healing pressure ulcers. 

    Qualitative studies are needed to understand the "lived experience" of patients with pressure ulcers. Finally, nursing researchers can take the lead on developing and evaluating appropriate levels of pressure ulcer care for patients receiving palliative care.