Risk Of Pressure Ulcer Formation Research Articles

A pressure monitoring approach for pressure ulcer prevention

BackgroundA pressure ulcer (PU) is a debilitating condition that disproportionately affects people with impaired mobility. PUs facilitate tissue damage due to prolonged unrelieved pressure, degrading quality of life with a considerable socio-economic impact. While rapid treatment is crucial, an effective  prevention strategy may help avoid the development of PUs altogether. While pressure monitoring is currently used in PU prevention, available monitoring approaches are not formalised and do not appropriately account for accumulation and relief of the effect of an applied pressure over a prolonged duration. The aim of this study was to define an approach that incorporates the accumulation and relief of an applied load to enable continuous pressure monitoring.ResultsA tunable continuous pressure magnitude and duration monitoring approach that can account for accumulated damaging effect of an applied pressure and pressure relief over a prolonged period is proposed. Unlike classic pressure monitoring approaches, the presented method provides ongoing indication of the net impact of a load during and after loading.ConclusionsThe tunable continuous pressure magnitude and duration monitoring approach proposed here may further development towards formalised pressure monitoring approaches that aim to provide information on the risk of PU formation in real-time.

A facial ulcer secondary to a non-invasive ventilation mask in COVID-19 pneumonia

Sir, An 83-year-old patient hospitalized in the intensive care unit (ICU) of the pulmonary department for chronic respiratory failure complicated by severe COVID-19 pneumonia with respiratory involvement of 50% of the lungs. The comorbidities included diabetes, uncontrolled hypertension, ischemic heart disease, Parkinson’s disease, and bronchial asthma. The patient was unable to maintain adequate arterial oxygen saturation with a face mask and nasal prongs. The attending physician ordered non-invasive ventilation (NIV) and a continuous positive airway pressure (CPAP) mask was applied. On day ten of the patient’s ICU stay, his attending physician noticed a grade II cheekbone ulcer. The patient was put on a paraffin dressing. The evolution was marked five days later by a worsening in the stage of the pressure ulcer, which had become a stage III ulcer and, therefore, our opinion was requested. An examination of the patient revealed a well-adjusted, full-face mask with pressure against the zygomatic bone aggravated by the application of compresses, which further increased the aggression against the bone. A dermatological examination found two necrotic patches on both cheekbones without a peripheral detachment or inflammatory border (Fig. 1). There were no signs of bacterial infection. Upon investigation, the caregivers revealed that the CPAP mask had been left in place for nearly eighteen hours daily without formal monitoring or the inspection of the pressure areas. Fortunately, the patient’s condition began to improve as did her arterial oxygen saturation. The pulmonologist was gradually attempting to remove the patient from NIV. Strict monitoring of the pressure points was recommended and the patient was put on a hydrogel dressing for five days until the necrosis was eliminated, then on a hydrocolloid dressing after the mechanical removal of the remnants of the necrosis and fibrin with good improvement of the ulcer. The COVID-19 epidemic represents a new challenge for critical care physicians (ICU). In the context of this epidemic, the management of arterial oxygenation during critical care procedures is one of the main challenges for ICU physicians. As an effective means of ensuring satisfactory arterial oxygenation during COVID-19 pneumonia, more than 50% of patients treated in China required non-invasive ventilation (NIV) [1]. During NIV with headgear, ICU nurses should focus on interventions that help to improve the patient’s comfort to maximize the acceptability of the device and minimize mask-induced skin irritability [1]. Skin pressure sores secondary to helmet application may be prevented by applying hydrocolloid dressings associated with close monitoring of the patient’s tolerance to the pressure exerted by the mask [2]. The development of NIV-related pressure sores is due to a combination of pressure effects and shear forces exerted by the presence of a mask, pressure changes during the different phases of ventilation, and the tension of the mask’s strap [3]. The use of oronasal masks and increased time on NIV increases the risk of pressure ulcer formation, as do patient factors such as age, sensory impairment, chronic skin conditions, and hypotension [4]. Oronasal masks remain the most popular interface, with a European survey revealing that they are the first choice in 70% of cases. The reasons given by respondents for their choice were the reduction of air leakage, patient comfort, and cost [5].

Cellular and molecular changes that predispose skin in chronic spinal cord injury to pressure ulcer formation.

Patients with spinal cord injury have a predisposition to develop pressure ulcers. Specific characteristics of the patients' skin potentially involved have not yet been identified. The purpose of this investigation was to determine whether loss of neuronal control affects cellular and molecular homeostasis in the skin. Intact afflicted skin, wound edge of pressure ulcers, and control skin were analysed. Platelets, transforming growth factor‐β1, and activin A were identified by immunohistochemistry. Transforming growth factor‐β‐like activity was determined by bioassay, and gene expression by DNA microarray analysis or RT‐PCR. In afflicted skin, enhanced platelet extravasation was detected. Transforming growth factor‐β1 and activin A accumulated in the dermal‐epidermal junction zone. Transforming growth factor‐β‐like activity and activin A expression were increased in intact afflicted skin (compared to control skin) and were further enhanced in pressure ulcers. In vitro, activity was generated by fibroblast‐epithelial cell interactions, which also induced activin A. Thus, loss of neuronal control in spinal cord injury appears to trigger inappropriate wound healing processes in the patients' skin. Plasma leakage and increased transforming growth factor‐β‐like activity combined with shear forces potentially enhance the risk for pressure ulcer formation.

A randomized controlled trial to compare the interface pressures of alternating pressure overlay with gel pad versus gel pad alone during prolonged surgery

IntroductionProlonged surgery is a known risk of pressure ulcer formation. Pressure ulcers affect the quality of life, are a significant cause of morbidity and mortality, and pose a burden on the healthcare system. This study aimed to compare the effectiveness of an alternating pressure (AP) overlay with Gel pad against the Gel pad in reducing interface pressure (IP) during prolonged surgery. MethodsA total of 180 participants from a tertiary hospital were randomized to AP overlay with Gel pad group (n = 90) and Gel pad group (n = 90). Patients were placed supine on the pressure redistributing surfaces, and IP data under the sacrum and ischial tuberosities were collected at an interval of 30 min from 0 min up to a maximum of 570 min. ResultsBased on data from 133 participants, the average IPs during all the deflation cycles of the AP overlay (with Gel pad) were significantly lower than the average continuous IP recorded for Gel pad throughout the measuring period (p < 0.001). Only three patients (2.26% of study participants) – Gel pad group (n = 2; 2.99%) and AP overlay with Gel pad group (n = 1; 1.52%) developed post-operative pressure ulcer (p = 0.5687). ConclusionsThe lower IP during deflation cycles of the AP overlay (with Gel pad) suggests its potential effectiveness in preventing pressure ulcer formation in patients undergoing prolonged surgery. The prevention and reduction of pressure ulcers will have a considerable impact on the improved quality of life and cost savings for the patient. The study findings may facilitate the formulation of policies for preventing pressure ulcer development in the perioperative setting.

2731 Duodenal Pressure Ulcer Secondary to Migratory PEG Tube

INTRODUCTION: Percutaneous endoscopic gastrostomy (PEG) tubes allow for long-term nutritional support in patients with preserved gastrointestinal function and dysphagia. The procedure and long-term presence of a PEG tube is well tolerated, with a complication rate of 0.4% to 4.4%. Adverse events include infection, skin breakdown, and aspiration. Upper GI bleeding, secondary to gastric or duodenal pressure ulcers is a rare complication. We present a case of duodenal pressure ulcers secondary to a PEG tube, along with a review of the literature and a proposed mechanism for this injury. CASE DESCRIPTION/METHODS: A 94-year-old non-verbal woman with a history of dementia and oral squamous cell carcinoma presented to the ED for RLQ abdominal pain. She was found to have leakage around the replacement PEG tube. Given comorbidities, patient was initially managed conservatively, but eventually underwent an endoscopy (EGD) due to persistent melena and down trending hemoglobin. The EGD demonstrated that the intragastric retention balloon had migrated beyond the pyloric channel resulting in a partial gastric outlet obstruction. The balloon was deflated revealing a large nonbleeding duodenal pressure ulcer. Since no stigmata of bleeding were identified, the replacement PEG was removed and new mushroom catheter and internal bumper was placed through the original tract. The patient was placed on an IV PPI to allow for adequate healing and melena resolved. DISCUSSION: Standard replacement PEG tubes are secured with an external bumper on the skin with an intragastric saline filled balloon. Ideal distance between the retainer and skin is 1-2 cm. If a PEG balloon is pulled too tightly there is a risk for pressure ulcer formation at the gastrostomy site. Conversely, if the PEG tube is too loose there is the risk of PEG balloon migration. With intense gastric peristalsis, the saline-filled balloon can migrate through the stomach, pylorus, and into the duodenum. While this is rare, case reports of gastric and duodenal outlet obstruction have been observed. In this case, the migration of the balloon into the duodenum led to a partial gastric outlet obstruction leading the patient to present with leakage, pain, melena, and anemia due to a large duodenal pressure ulcer. Proper PEG placement and care should be the main source of pressure ulcer prevention, and this rare complication should be considered in patients with melena and anemia.

Best Practices for Pressure Ulcer Prevention in the Burn Center.

The State of Pennsylvania Hospital Engagement Network, in collaboration with a hospital system in Southwestern Pennsylvania, established a goal of reducing hospital-acquired pressure ulcers by 20%. A 6-month unfavorable trend of nurse-sensitive clinical indicators called for immediate process improvement. A retrospective chart review resulted in identification of predominant risk factors placing the burn patient at high risk for pressure ulcer formation. Implementations of pressure ulcer prevention measures were inconsistent. Nurses demonstrated varied levels of knowledge about products used for prevention. It became imperative to examine processes within the unit and provide nursing with education, access to skin care supplies, and advanced skin/wound care products for maintaining skin integrity. Creation of evidence-based guidelines was necessary to improve patient outcomes. A collaborative team approach influenced nursing and physician awareness of pressure ulcer risk. Evidence-based prevention guidelines were developed, and consistency in early intervention was achieved, supporting our culture of safety. A change in interprofessional collaborative practice and positive trend in pressure ulcer incidence data supports the success of our program.

Early Detection of Pressure Ulcer Development Following Traumatic Spinal Cord Injury Using Inflammatory Mediators

ObjectiveTo identify changes in concentrations of inflammatory mediators in plasma and urine after traumatic spinal cord injury (SCI) and before the occurrence of a first pressure ulcer. DesignRetrospective; secondary analysis of existing data. SettingAcute hospitalization and inpatient rehabilitation sites at a university medical center. ParticipantsIndividuals with a pressure ulcer and plasma samples (n=17) and individuals with a pressure ulcer and urine samples (n=15) were matched by age and plasma/urine sample days to individuals with SCI and no pressure ulcer (N=35). InterventionsNot applicable. Main Outcome MeasuresPlasma and urine samples were assayed in patients with SCI, capturing samples within 4 days after the SCI to a week before the formation of the first pressure ulcer. The Wilcoxon signed-rank test was performed to identify changes in the inflammatory mediators between the 2 time points. ResultsAn increase in concentration of the chemokine interferon-γ–induced protein of 10kd/CXCL10 in plasma (P<.01) and a decrease in concentration of the cytokine interferon-α in urine (P=.01) were observed before occurrence of a first pressure ulcer (∼4d) compared with matched controls. ConclusionsAltered levels of inflammatory mediators in plasma and urine may be associated with pressure ulcer development after traumatic SCI. These inflammatory mediators should be explored as possible biomarkers for identifying individuals at risk for pressure ulcer formation.

Transfemoral Amputation Following Chronic Spinal Cord Injury: A Prosthetic Solution for Improved Balance, Seating, Dynamic Function and Body Image

Background: Advances in the care and rehabilitation of patients with spinal cord injuries (SCI) have resulted in extended survival. As SCI patients age, chronic lower extremity ischemic complications are resulting in amputations. The literature relating to lower extremity amputation and prosthesis in SCI patients is sparse. Limb amputation may cause weight distribution imbalances, leading to back pain and increased risk of pressure ulcer formation. Lower extremity amputation challenges skin management, sitting balance, functional range and body image. Case Description and Methods: We report a systematic retrospective review of a disability adaptation equipment entrepreneur with T4 AIS B paraplegia patient who underwent right transfemoral amputation because of poor wound healing in the setting of severe peripheral vascular disease. The prosthetic prescription included a total-contact socket with a knee-flexed formed prosthesis, mirroring the opposite limb. The socket design allowed decompression of the right ischium and secured the patient in the wheel chair for seated reach and leverage in work. The patient consistently used the prosthesis over 10 years and recognized a variety of benefits including improved seating stability, functional reach, transfers, cosmesis, dressing options and body image, and documented increase in community activity. Conclusion: Lower extremity prosthesis fitting for patients with SCI and amputation can improve posture, seating, transfers, static and dynamic balance, participation in functional activities, and community reintegration. Clinical Significance: Active patients with paraplegia and new transfemoral amputation should be offered a trial of a prothesis to enhance mobility. Many of the medical and functional consequences of amputation after SCI can be prevented with careful prosthesis selection, prescription, and training patients in the use of lower extremity prosthesis.

Patient repositioning and pressure ulcer risk�Monitoring interface pressures of at-risk patients

Repositioning patients regularly to prevent pressure ulcers and reduce interface pressures is the standard of care, yet prior work has found that standard repositioning does not relieve all areas of at-risk tissue in nondisabled subjects. To determine whether this holds true for high-risk patients, we assessed the effectiveness of routine repositioning in relieving at-risk tissue of the perisacral area using interface pressure mapping. Bedridden patients at risk for pressure ulcer formation (n = 23, Braden score <18) had their perisacral skin-bed interface pressures recorded every 30 s while they received routine repositioning care for 4-6 h. All participants had specific skin areas (206 +/- 182 cm(2)) that exceeded elevated pressure thresholds for >95% of the observation period. Thirteen participants were observed in three distinct positions (supine, turned left, turned right), and all had specific skin areas (166 +/- 184 cm(2)) that exceeded pressure thresholds for >95% of the observation period. At-risk patients have skin areas that are likely always at risk throughout their hospital stay despite repositioning. Healthcare providers are unaware of the actual tissue-relieving effectiveness (or lack thereof) of their repositioning interventions, which may partially explain why pressure ulcer mitigation strategies are not always successful. Relieving at-risk tissue is a necessary part of pressure ulcer prevention, but the repositioning practice itself needs improvement.

Wound healing and nutrition: going beyond dressings with a balanced care plan.

As the largest organ of the body, the human skin protects all subcutaneous tissues. Despite its many attributes, the skin is vulnerable to pressure ulcers. The number of pressure ulcers and venous leg ulcers is on the rise, but healing rates have not improved over the past decade. The reason may be a tendency to focus on one or two fundamentals of wound healing, but not on all 3 fundamentals equally. The 3 fundamentals of wound healing are (1) pressure relief and nursing care, (2) dressings, and (3) nutrition. Nutrition is the area that is most often overlooked, which commonly causes the care plan to be out of balance. In the United States, few clinicians would consider malnutrition to be an issue in the homecare and long-term care setting, yet nutritional status and risk for pressure ulcer formation are well documented and strongly correlated. Our aging population will continue to survive previously catastrophic events, only to present with pressure ulcers or the potential for developing pressure ulcers. Clinicians caring for residents with pressure ulcers must strike a balance between pressure relief, dressings, and nutrition. Functional gastrointestinal-tract impairments must be diagnosed and addressed. Wounds must be treated aggressively with high-protein calorically-balanced diets because wounds heal from the inside out.

Using the discrete choice experimental design to investigate decision-making about pressure ulcer prevention by community nurses

This study investigates the preferences of senior community nurses who work as district nurse team leaders in selecting preventive care plans for elderly people at high risk of pressure ulcer formation. The discrete choice experiment (DCE) technique was used. Focus group work produced the following five attributes of nurse decision-making: 'ease of care plan management', 'impact of care plan on patient's lifestyle', 'speed of obtaining the equipment', 'affordability', 'evidence-based practice'. These were incorporated into a self-administered questionnaire, posted to 102 nurses from two integrated acute/community NHS Trusts in Wales. A response rate of 55% was achieved. Respondents were asked to rate the importance of the selected attributes on a 5-point scale. They rated 'evidence-based practice', 'impact of care plan on patient's lifestyle', 'ease of care plan management' and 'speed of obtaining the equipment' highly, whereas 'affordability' was of less importance. However, regression analysis, which is part of the DCE technique, produced a somewhat different picture, with 'impact' being least and 'affordability' most statistically significant. The reasons for this apparent anomaly are discussed and the paper concludes that the DCE approach is capable of yielding important information, which is not produced by simple rating exercises. Such information is potentially of value in the context of modernisation and service configuration.

Old Age, Malnutrition, and Pressure Sores: An Ill-Fated Alliance

Wound healing is a complex, tightly regulated process, consisting of three distinct phases. In each phase of wound healing, energy and macronutrients are required. Moreover, animal studies have established a specific role for certain nutrients such as the amino acid arginine, the vitamins A, B, and C, and the elements selenium, manganese, zinc, and copper. Chronic wounds such as pressure ulcers have extensively been investigated as to the risk of development, prevention, and cure. Here, the combination of old age, malnutrition, and pressure ulcers is highly unfortunate. Energy and nutrients, such as proteins and vitamins B and C, being deficient at old age are needed in pressure ulcer healing. Malnutrition is associated with skin anergy and with immobility because of mental apathy and muscle wasting. Severe malnutrition, impaired oral intake, and the risk of pressure ulcer formation appear to be interrelated. Adequate nutrition may reverse the underfed state unless an underlying wasting disease was present and appeared to reduce the prevalence and incidence in cross-sectional and prospective observational studies. However, attempts to prevent pressure ulcers by nutritional intervention were divergent in outcome, reflecting the difficulties to meet the daily requirements in elderly persons and the lack of knowledge about true nutritional needs in wound healing. The consumption of a diet high in protein and energy may promote pressure ulcer healing. When considering nutritional support, oral supplementation should be weighted against tube feeding, as the associated morbidity of tube feeding, i.e., diarrhea, fecal incontinence, and restricted mobility being in themselves risk factors for pressure ulcers, might obscure the favorable effects of adequate nutrition. Despite the evidence in animal studies, none of the above-mentioned specific nutrients promoted the healing of pressure ulcers in humans. Therefore, the attention should be focused on early recognition of a depleted nutritional status and an adequate and supervised intake of energy (35 kcal/kg) and protein (1.5 g/kg) with provision of the recommended daily allowances of micronutrients and with correction of the nutrient deficiencies of old age.

CASE REPORT OF A PRESSURE ULCER IN AN INFANT RECEIVING EXTRACORPOREAL LIFE SUPPORT

This case report describes a 4350-gram male infant of 38 weeks gestation who was placed on extracorporeal life support. On day 4 of life, a large bilateral ecchymotic area involving the scapula and extending to the mid sacral-lumbar-thoracic area was noted, placing the infant at significant risk for pressure ulcer formation. The infant's initial presentation, evaluation, treatment, and response to therapy are discussed. A review of the anatomy and physiology of neonatal skin and the etiology of pressure ulcers is described. The incidence and staging of pressure ulcers is outlined, and high-risk infants and skin zones are identified. Skin care challenges in the patient on extracorporeal life support (ECLS) are outlined, and strategies to assess and treat affected areas are offered. The use of a novel mattress surface for global pressure reduction in the infant undergoing ECLS therapy is discussed.

A team approach for risk assessment, prevention, and treatment of pressure ulcers in nursing home patients.

The article describes a unique decentralized wound care program instituted in a nursing home care unit of a Veterans Affairs hospital. This decentralized, interdisciplinary approach to wound care has been effective in reducing the incidence and prevalence of pressure ulcers in a nursing home population over the last 2 years. Prevention was a major focus of the program. The Braden scale was used to identify patients at risk for pressure ulcer formation; proper measures were introduced to reduce identified risk. This collaborative team effort led to improved patient care and decreased incidence and prevalence of pressure ulcers in this population.