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This essay will examine pressure ulcers. Definitions of a pressure ulcer will be given. Identify some of the causes of pressure ulcers and investigate some of the treatments based on evidence used to treat pressure ulcers. In addition, the anatomy and physiology of the skin will be mention. Though a number of issues would be mentioned, the main focus of the essay will be about treatment of pressure ulcer using Actiform Cool. The role of tissue viability nursing and National Institute of Clinical Excellence (NICE) guidelines will also be mention. A variety of sources and literature will be accessed to gain information that will be relevant to my chosen topic. During this essay, anonymity will be maintained in line with the Nursing and Midwifery Council (NMC) Code of Conduct (2008). Therefore, the names of any NHS Trust, patients and worker will be changed if necessary.
Pressure ulcers as stated by the European Pressure Ulcers Advisory Panel (EPUAP, 2007): “A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.” In addition, National Institute for Clinical Excellence (NICE, 2008) defines a pressure ulcers as “A pressure ulcer is damage that occurs on the skin and underlying tissue. Pressure ulcers are caused by three main things: Pressure - the weight of the body pressing down on the skin. Shear - the layers of the skin are forced to slide over one another or over deeper tissues, for example when you slide down, or are pulled up, a bed or chair or when you are transferring to and from your
wheelchair. Friction - rubbing the skin”.
Some of the pressure ulcers intrinsic causes (inherent to individual) include decrease mobility, incontinence (Horn, 2004), old age, malnutrition, poor hygiene, dry skin, diabetes mellitus and surgery (ex. hip fracture) and anaemia (Gunningberg, 2000). Some extrinsic causes include friction, shearing forces, hypothermia (Scott, 2001) and length of surgery (Houwing, 2004). Pressure ulcers are a common complication of decrease mobility due to hip fracture with reported incidence of between 8.8% and 55% (Baumgarten, 2003). According to Versluysen (1985), 17% of patients that is admitted to hospital for surgery had pressure ulcers upon admission and that 34% developed lesions during the first week of stay in hospital. Versluysen (1986) conducted another study that 66% of the patients with hip fracture developed pressure ulcer, majority of these pressure ulcers appeared during the first 48 hours of admission. Incontinence increases the risk of having a pressure ulcer because of the excessive moisture on the skin, moist skin adhere to the mattress thus results to increased shearing forces ( Defloor and Grypdonck, 1999). Dry skin also increases the risk of having pressure ulcers because of the decreased elasticity of the skin (Gunnigberg, 2000). Surgery itself (Lindgren, 2005) and length of surgery of 4 hours or more (Schoonhoven, 2002) have been reported to increase the risk of developing a pressure ulcer.
In 2005, the National Institute for Clinical Excellence has issued clinical guidelines to the National Health Service (NHS) about pressure ulcers. The guidelines are about prevention and treatment of pressure ulcers, which are recommended for the use of doctors, nurses and other healthcare professionals working in the National Health Service in England and Wales. The guidelines were prepared by healthcare professionals, scientist, and people representing the view of those who have or care for someone with the condition. The groups make a recommendation based on the evidence available at the time the recommendation is made on the best way of treating or managing the condition, and these clinical guidelines are recommended for good practice. Under these NICE guidelines (2005), it recommends that healthcare professional work together with the patients in order for the patients to have an active role in making decision regarding their plan of care with the choice to involve their carer if they wished to. It also mentioned that healthcare team should respect and take into consideration the patient's knowledge, experience, and needs, especially if the patient has have been at risk of developing pressure ulcers for a long time. Moreover, it also mentioned that patients and carer should be given training and information as to the reasons why the patient is at risk of developing pressure ulcer, parts of the body most at risk to have pressure ulcer, how to inspect the skin and recognize the changes in the skin, how to relieve pressure, and provide information to the patient and carer where to find help, advice, and support. Pressure on the skin over bony prominence such as sacrum, hips, elbows, ankles, heels and shoulder causes decreased blood flow to the tissue, thus reducing tissue oxygenation. If this pressure is not relieved, the affected area starts to change colour, redness to patients with fair skin tone and bluish for patients with darker skin tone and deemed to be ‘at risk' (EPUAP, 2009) and may prove to be hard to detect, which then progress to a more intensive tissue injury if no care is given.
Members of the European Pressure Ulcers Advisory Panel and National Pressure Ulcer Advisory Panel (2009) have had ongoing discussion about many similarities the two organization's pressure ulcer grading/staging systems. They developed a common international classification system and definition for pressure ulcers. EPUAP and NPUAP attempted to find a common word to describe the grade and stage but to no avail. The word category was recommended as a neutral term against stage and grade and has the advantage of being non-hierarchical. They recognize that there is a similarity to the words - stage and grade, and therefore, they suggested to use whatever is most clear and understood. The most significant gain from this partnership is that the levels of skin-tissue damage and definition of pressure ulcer are the same, even though they may be labelled differently.
Pressure ulcers are classified into four (4) stages/categories based on the EPUAP (2009) classification system. Non-blanching erythema is labelled as grade/category I, the skin is intact with redness that is non-blanching of a localized area over a bony prominence when light pressure is applied. The affected area may be painful, firm, soft, and warmer or cooler compared to the surrounding tissue. As mentioned earlier, patients with dark skin tone may be difficult to assess and deemed ‘at risk'. Partial thickness skin loss of both or either one of the first or second layer of the skin called epidermis and dermis is classed as stage/category II, this stage/category of pressure ulcer presents itself in many ways, it can be a red or shiny shallow ulcer without slough (layer of dead tissue separated from the surrounding), may also presents itself as an intact or ruptured sero-sanginous filled or serum-filled blister, or just bruising. Stage/category III is characterized with full thickness skin loss; it involves damage to or the loss of subcutaneous fat but not muscle, tendon, or bone. Pressure ulcer in this stage/category varies according to the site affected. Stage/category IV portraits as pressure ulcer with full thickness skin loss with extensive damage of tissue which may include muscles, fascia, and other supporting structure and may put the patient at risk of developing osteomyelitis or osteitis.
NMC Code of Conduct (2008)
EPUAP definition (2007) http://www.npuap.org/pr2.htm
NICE definition http://www.nice.org.uk/nicemedia/pdf/CG029publicinfo.pdf
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Ramir Jayson Mutia, 08B