Centers for Disease Control and Prevention - Research Paper Example

Centers for Disease Control and Prevention Introduction Elderly patients are prone to injury and chronic diseases. These injuries are often attributed to weaker bones, decreased mobility, and reduced dexterity in movements. Chronic diseases on the other hand are attributed to ageing and biological wear and tear which also causes reduced mobility, prolonged bed rest, and increased risk of injury. Due to these risks, elderly patients are prone to falls, falls which often lead to a variety of fractures, the most common being hip fractures. Hip replacement surgeries often follow these injuries. Due to reduced mobility after these surgeries prolonged bed rest often follow. During these prolonged incidents of best rest, elderly adults incur an increased risk for pressure ulcers. Other chronic conditions also present a similar risk of prolonged bed rest including osteoarthritis and cancer. This issue is being reviewed because pressure ulcers are preventable conditions, especially if the adequate nursing management remedies are in place. There are however, factors or issues which impact on the management of pressure ulcers. This review now therefore seeks to evaluate the effective management of pressure ulcers among elderly patients with chronic diseases. Body Prevalence and incidence of pressure ulcers among the elderly According to the Centers for Disease Control and Prevention (2011), about 160,000 nursing home residents have had pressure ulcers, with Stage 2 pressure ulcer being the most common affliction. Residents who were more than 64 years of age were also likely to suffer from this issue and those who have had shorter hospital stays (one year or less) were also more likely to suffer from pressure ulcers, as compared to those who have stayed in nursing homes for longer durations (CDC, 2011). About one in five of these elderly patients with pressure ulcers have gone through weight loss and about 30% of these residents had to receive special wound care services for their health issue. In general, pressure ulcers are attributed to unrelieved pressure on the skin and often develop over bony protrusions. They are also serious medical issues and a common issue encountered among patients in nursing homes. About 2-28% of nursing home elderly patients are suffering from pressure ulcers and these ulcers are graded from stage 1 to stage 4 depending on the range of skin breakage seen on the ulcers. In about 1.5 million nursing home patients, 160,000 have been diagnosed with pressure ulcers at one point during their residence. About 50% of these patients with ulcers suffered from stage 2 ulcers, and the rest were at varying stages (stage 1, 3, and 4). Most sufferers were males and no difference was seen in the incidence of this problem among white and nonwhite populations. Patients with recent weight loss were likely to manifest with pressure ulcers and those who were immobile for prolonged periods were also likely to suffer from pressure ulcers. Patients taking at least eight medications also had a greater prevalence for this problem; moreover, pressure ulcers were also more common among those with bowel and urinary incontinence. Risk factors for the development of pressure ulcers Padula and Williams (2008) discuss that the most common risk factor or cause for these pressure ulcers are unrelieved pressure and shear. Its development is also associated with the tolerance of tissues for pressure, including the duration and intensity of pressure and friction (Padula and Williams, 2008). Tissue tolerance is based on intrinsic elements and extrinsic factors which indicate the degree by which the skin is exposed to elements like shear and friction. Pressure ulcers can develop in as short a span of time as 24 hours, and may take up to five days to manifest (Padula and Williams 2008). Intrinsic elements which contribute to the development of pressure ulcers include: advanced age, altered mental state, impaired circulation, anemia, comorbidities, male gender, black race, surgical intervention, weight, and emergency room stays (Padula and Williams, 2008). ICU risk factors also include emergent admission, repeated surgical interventions, immobility, prolonged hospital stay after surgery, and sepsis (Padula and Williams, 2008). Holm, et.al., (2006) discuss that elderly patients often suffer from multiple diseases which often limit their mobility and which confine them to their beds. The highest predictor for pressure ulcers among elderly patients is hip fractures (Holm, et.al., 2006). The loss of weight, dehydration, reduced mobility, as well as paresis can lead to pressure ulcers because there is less oxygen circulating through the areas at risk for pressure ulcers; moreover, dirt and moisture often pools in these dependent areas, thereby increasing the risk of skin breakdown and eventually of pressure ulcers (Holm, et.al., 2006). Based on these risk factors, the overall conditions which lead up to the development of pressure ulcers among the elderly adults have been laid out. From a nursing perspective, it is appropriate to consider the appropriate and effective remedies and interventions which can be utilized in order to reduce or even eliminate their risk and to improve their management. Effective management of pressure ulcers Madhuri, et.al., (2008) carried out their systematic review evaluating treatments for pressure ulcers. They reviewed a variety of databases for such purpose arriving at 103 randomized controlled trials for their review. Their review revealed that support surfaces were important in the management of pressure ulcers and no significant difference on the type of surface support was seen. Repositioning the patient was also important; moreover, nutritional supplements also emerged as important support treatments for patients with pressure ulcers. Protein supplementation emerged as an effective treatment for pressure ulcers as this supplementation assisted in wound healing. Calcium alginate wound dressings were also helpful in wound healing and in some studies, no wound dressings for pressure ulcers also proved to be superior to other alternatives (Madhuri, et.al., 2008). McInnes, et.al., (2008) also set out the review the impact of pressure-relieving cushions, beds, and mattress overlays as compared to standard support surfaces in managing pressure ulcers. In general, the study revealed that foam alternatives as compared to standard support surfaces were far more effective in managing pressure ulcers. Sheepskin also manifested benefits in the prevention of pressure ulcers, especially among postoperative patients. Using seat cushions, limb protectors, as well as constant low pressure devices also proved crucial in managing pressure ulcers among elderly long-term care patients (McInnes, et.al., 2008). Vanderwee, Grypdonck, and Defloor (2008) support the use of mattresses with lower CIP-values. Moreover, using the pressure relief index (PRI) has also proven to be a valuable tool in establishing whether or not the amount of pressure exerted on the dependent areas of the body would not lead to pressure ulcers. In order to establish blood perfusion in the area affected, a transcutaneous oxygen and carbon dioxide assessment can be carried out. Measuring these would help ensure that oxygen flows through the patient’s skin, thereby preventing the occurrence of any pressure ulcers (Vanderwee, et.al., 2008). The use of air mattresses and water mattresses was also recommended for these patients with studies manifesting improved patient outcomes with the application of these mattress options (Vanderwee, et.al., 2008). The comfort provided by alternating pressure air mattresses (APAM) is also a major consideration for patients with pressure ulcers, and as compared with the constant low-pressure mattresses, there is better flexibility and applicability in opting for the APAMs (Vanderwee, et.al., 2008). Comfort weighs in heavily in patient choices and since comfort would help reduce patient stress and anxiety, it is important for interventions to be implemented in terms of its overall patient impact. Nursing care is also a crucial element in the management of pressure ulcers among elderly patients. Nursing care involves early attention, nursing documentation, reducing mattress pressure, and turning schedules (Holm, et.al., 2006). The role of the nurse would be to monitor the patient’s pressure areas, to place protective bandages, and to educate the patients about ways by which they can help prevent pressure ulcers. Shahin, Dasen, and Halfens (2009) also discuss the use of foam mattresses and alternating air-pressure mattresses in order to distribute the pressure on the patient’s back and heels. Massage also emerged as an effective means of preventing pressure ulcers as it can promote the circulation of blood and the distribution of pressure on the elderly patient’s skin (Shahin, et.al., 2009). Moreover, promoting sufficient nutritional and fluid intake has also been considered as an effective preventive measure against pressure ulcers. This study was able to highlight the contribution of nurses in managing pressure ulcers. Its results attempted to present a randomized and controlled evaluation of their research question. This attempt ensured the validity and reliability of the overall study. Rich, et.al., (2009) also discusses that preventive measures for pressure ulcers have presented with effective options for long-term care elderly patients. Moreover, the authors also recommend the regular application of risk assessment measures in order to evaluate the patient and ensure that those who might develop pressure ulcers or those who already have pressure ulcers are regularly monitored and treated (Rich, et.al., 2009). The measures for prevention which Rich and his colleagues (2009) recommend include that of preventing any skin exposure to moisture from urine, sweat, or any other bodily excretions. They also recommend the use of pressure-reducing scales including mattress overlays in order to reduce the pressure on bony protrusions in dependent areas of the body (Rich, et.al., 2009). Reducing shear forces and angling the bed to below 30 degrees are also appropriate preventive measures for these patients. Rich and his colleagues (2009) also recommend documentation of pressure ulcers and of the interventions being carried out on the patient. These measures help ensure that the progression of the patient’s ulcers would be monitored and that early interventions can be applied to the patient where necessary. In the study by Porreca and Giordano-Jablon (2008), the authors considered the application of adjuvant treatment in the management of basic wound care for stage III and IV pressure ulcers among high-risk patients. The authors studied pulsed radio frequency energy as an adjunct to basic wound care for a 59 year old quadriplegic man with stage III and IV pressure ulcers. After treatment, the patient manifested a decrease in the size of his pressure ulcer to a significant extent with full closure of wound after 11 months of treatment (Porreca and Giordano-Jablon, 2008). The study presented the possible benefit of combining treatments for pressure ulcers, especially for pressure ulcers which are unresponsive to standards treatments. The use of sheepskin based on an Australian study by Mistiaen, Achterberg, Ament, Alfens, and Huizinga (2010) has also been forwarded as an effective means of reducing the occurrence of pressure ulcers. Sheepskin relieves and redistributes pressure on the skin, and minimizes shear stress and friction on the skin. It also has moisture absorbing qualities which helps keep the patient dry, thereby reducing the risk for pressure ulcers (Mistiaen, et.al., 2010). The authors were able to present a different perspective on the management of pressure ulcers. They applied the same concept of reducing and distributing pressure on a patient’s back and then reviewed its general application for elderly patients. The authors were also able to carry out a study which was highly significant to the current considerations on the effective management of pressure ulcers. Fowler, et.al., (2008), also presented similar interventions for the management of pressure ulcers, most especially those which develop at the heel of elderly patients. Fowler, et.al., (2008) recommends the use of pillows for short term use in order to relieve pressure from the heels. Soft pillows can be chosen for these cases and can best be placed longitudinally under the calf with the heels hanging off of the end of the pillow (Fowler, et.al., 2009). Fowler, et.al., (2009) also recommends heel offloading devices which are better than pillows because they stay in intimate contact with the foot for a prolonged period of time. Other options for padding, like sheep skin and rigid splints can also prevent pressure on the heels, however, in some instances relief of pressure may only be to a minimal extent. This is because these options only reduce friction, but actually do not relieve or remove pressure on the heel (Fowler, et.al., 2009). The heel-offloading interventions can therefore be pillow-based, foam, or air based. Regardless of the choice, these tools reduce friction and shear, and also relieve the heel of any significant pressure. Cereda, et.al., (2009) was also able to point out the importance of adequate nutrition for patients with poor clinical outcomes and with high risks for pressure ulcers and other complications. Among long-term elderly nursing home residents, protein malnutrition is often seen and this is an unfortunate condition considering that protein is one of the nutrients which help promote wound healing (Cereda, et.al., 2009). Applying disease-specific nutritional support is beneficial for patients, especially for those with pressure ulcers. In effect, for diabetic patients, a diet low in carbohydrates and high in protein must be considered in order to manage the disease as well as to promote wound healing. Other specific disease-related dietary options should also be considered for elderly patients. Those with arthritis for example must adopt avoid a high protein diet in order to prevent arthritic attacks, but still be able to ensure good wound healing. In effect, the care of patients with pressure ulcers must be specific and patient-based, and must be supported by evidence. Even with the application of preventive measures, pressure ulcers may still eventually be a major problem for patients. In these instances, it is important to consider various management techniques including cleansing, debridement, and exudates management (Lyder and Ayello, 2008). In cleansing, the solution used must be a nontoxic one and it must be carried out at regular intervals, or at least once a day. Once pressure ulcers develop, this cleansing process must immediately start and continue until the wound is completely healed. The solution opted for must also be one which does not cause trauma to the ulcer (Lyder and Ayello, 2008). Debridement can also be applied, especially when the wound is in its advanced stages. This process would remove necrotic tissues and later promote the healing of the wound (Lyder and Ayello, 2008). Managing the bacterial burden must also be an important factor to remember among patients with pressure ulcers. Using antibiotics can help manage infection and also eventually promote wound healing. Using silver-impregnated dressings have also been known to reduce the bacterial burden of pressure ulcers. Finally, the management of exudate is also an essential element in managing pressure ulcers (Lyder and Ayello, 2008). There are various wound dressings available for these pressure ulcers. The options taken must include those wound dressings which are kept dry as much as possible; these dressings must also promote patient comfort and safety. In evaluating the above articles, similar findings were observed. Most of these findings focus on reducing, eliminating, and distributing pressure on the dependent areas of the body. The various methods by which such pressure is to be distributed or reduced is based on a variety of interventions which are all aimed towards similar end goals. Turning and changing the patient’s position regularly, using pressure mats, using sheepskin padding are all meant to distribute pressure on the patient’s back and high-risk areas. The management of pressure ulcers is also based on similar points discussed by the author. These remedies include regular cleaning, frequent position changes, and keeping the patient dry and moisture free. There is an implied agreement among the authors on the importance of reducing infection of the patient’s wound, thereby ensuring the recovery of the pressure ulcer. All of the authors also agree on the importance and prioritization of pressure ulcer prevention as the major key in improving patient outcomes among elderly patients. No noticeable opposing ideas were apparent from the studies presented in the review. Some of the authors were able to present a quantitative approach to the topic and issue being discussed. This allowed for an increased reliability of the results presented; however, it also did not present specific details on a case-to-case basis. The numeric representation of results did not provide a more personal observation of the study. Nevertheless, in general, most of the studies cited herein were able to present interventions which have already been accepted in actual practice. They do not present unfamiliar and unsupported evidence which would reduce the reliability of established practices. Moreover, the authors were also able to present clear and comprehensive details on how each intervention would be applied and how each one would improve the quality of the patient’s life. Conclusion Based on the above studies and considerations, the effective management of pressure ulcers among elderly individuals with chronic illnesses is based on the distribution and relief of pressure on a patient’s dependent and high-risk areas. This management is based on the application of various interventions including the use of pressure mattresses, the use of sheepskin mats, and the observation of frequent position changes. These remedies help prevent the incidence of pressure ulcers and also help prevent the worsening of these pressure ulcers. The management of pressure ulcers is also based on the control of infection and moisture on a patient’s back, elements which often eventually cause the manifestation of pressure ulcers. The studies utilized for this review present evidence-based and highly reliable studies which complement each other and are based on sound health principles. They serve as a strong basis for future research and provide strong support for evidence-based practice for elderly patients who have a high-risk for developing pressure ulcers. References Centers for Disease Control and Prevention (2011). Pressure Ulcers Among Nursing Home Residents. Retrieved 21 March 2012 from http://www.cdc.gov/nchs/data/databriefs/db14.htm Cereda, E., Gini, A., Pedrolli, C., & Vanotti, A. (2009). Disease-Specific, Versus Standard, Nutritional Support for the Treatment of Pressure Ulcers in Institutionalized Older Adults: A Randomized Controlled Trial, JAGS 57:1395–1402. Eman, S., Shahin, M., Dassen, T., Ruud, J., & Halfens, G. (2009). Incidence, prevention and treatment of pressure ulcers in intensive care patients: A longitudinal study. International Journal of Nursing Studies, 46, 413–421. Fowler, E., , Scott-Williams, S., & McGuire, J. (2008). Practice Recommendations for Preventing Heel Pressure Ulcers. Ostomy Wound Management 54(10), 42–57 Holm, B., Mesch, L., & Ove, H. (2006). Importance of nutrition for elderly persons with pressure ulcers or a vulnerability for pressure ulcers: a systematic literature review. Australian Journal of Advanced Nursing, 25(1),77-84 Lyder, C. & Ayello, E. (2008). Chapter 12. Pressure Ulcers: A Patient Safety Issue. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Retrieved 21 March 2012 from http://promptpayprogram.com/qual/nurseshdbk/docs/LyderC_PUPSI.pdf Madhuri, R., Gill, S., & Kalkar, S. (2008). Treatment of Pressure Ulcers: A Systematic Review. JAMA, 300(22), 2647-2662. McInnes, E., Jammali-Blasi, A., Bell-Syer, S., Dumville, J. & Cullum, N. (2008). Support surfaces for pressure ulcer prevention. The Cochrane Collaboration and published in The Cochrane Library, Issue 4. Mistiaen, P., Achtenberg, W., Ament, A., Halfens, R., Huizinga, J., Montgomery, K., Post, H., & Francke, A. (2010). The effectiveness of the Australian Medical Sheepskin for the prevention of pressure ulcers in somatic nursing home patients: a prospective multi-centre randomised controlled trial. Wound Repair and Regeneration, 18(6), 572-579 Padula, C. & Williams, J. (2008). Prevention and early detection of pressure ulcers in hospitalized patients. J Wound Ostomy Continence Nurs, 35(1), pp. 65-75. Porreca, E., & Giordano-Jablon, G. (2008). Treatment of Severe (Stage III and IV) Chronic Pressure Ulcers Using Pulsed Radio Frequency Energy in a Quadriplegic Patient. Eplasty, 8, e49. Rich, S., Shardell, M., Margolis, D., & Baumgarten, M. (2009). Pressure Ulcer Preventive Device Use Among Elderly Patients Early in the Hospital Stay. Nurs Res., 58(2): 95–104. Vanderwee, K., Grypdonck, M. & Defloor, T. (2008). Alternating pressure air mattresses as prevention for pressure ulcers: A literature review. International Journal of Nursing Studies 45, 784–801. Read More