Pressure ulcers/injuries pose a major risk to patients by increasing morbidity and mortality and causing significant discomfort.¹ They are also prevalent, particularly in long-term care facilities, where patient populations may be at higher risk of developing pressure injuries as a result of factors of age, immobility, and comorbidities.² To reduce the incidence of pressure injuries effectively, nurses and other health care professionals should be aware of the risk factors and the means to evaluate patients. This will allow caregivers to take steps to prevent problems before they develop and treat them more effectively if they do.

Pressure Ulcer/Injury Risk Factors

• Immobility – Perhaps the greatest risk factor for pressure injuries is immobility. Because pressure injuries are caused by sustained pressure, patients who are unable to change positions independently are much more likely to develop them. Immobile patients are also more likely to be unable to feel pressure injuries developing, further adding to the risk.³
• Moisture and Incontinence – Incontinence and moisture-associated skin damage can increase the risk of pressure injuries, as well as increase the risk of more serious complications from the tissue damage, such as infection. Open pressure injuries can become infected if exposed to incontinence, thus posing a risk of irritation, sepsis or even death.^3,4
• Diabetes – Diabetes can increase the risk of pressure injuries because of reduced circulation and nerve damage. Diabetes may also make a patient more susceptible to infection.³
• Nutrition – Overall nutrition can affect skin health, particularly in patients with lowered albumin levels.³ To reduce this risk, patients should be on a program of standardized energy and protein intake, according to National Pressure Ulcer Advisory Panel (NPUAP) guidelines. ⁴
• Recent Surgery – Surgery can weaken the skin and make the patient more susceptible to injury, particularly when the surgery lasts longer than three hours or the patient already has other risk factors.³
• Medications – Certain medications, such as steroids, increase the risk of pressure injuries.
• Other Medical Conditions – Medical conditions can increase a patient's risk of developing pressure injuries. Some conditions that may increase a patient's risk include diabetes, peripheral vascular disease, congestive heart failure, cerebrovascular accident (stroke), dementia, renal disease, and depression.
• Sensory Perception – Patients who have limited ability to feel pain or discomfort are at greater risk of damage because they may not be able to respond to the early stages of the condition and are more likely not to shift from positions of sustained pressure.
• Age – Age is one of the major risk factors for pressure injuries. It increases the likelihood that the patient will be affected by another risk factor such as immobility or incontinence, as well as contributing additional risk factors, such as thinner, more sensitive skin. ³

Pressure Ulcer/Injury Risk Assessment Tools

To measure a patient's risk for pressure injuries effectively and take the appropriate prevention steps, health care professionals should use standardized assessment tools such as the Braden Scale For Prediction Pressure Sore Risk® (Braden Scale) or the Pressure Ulcer Scale for Healing (PUSH Tool). The Braden Scale offers a simple six risk factor assessment that takes into account sensory perception, moisture, physical activity, mobility, nutrition, and exposure to friction and shear. Each of these is rated on a three- or four-point scale (one representing the greatest risk), with a combined score of 12 or less indicating a patient who has a high risk of pressure injuries. The PUSH Tool was developed by the National Pressure Ulcer Advisory Panel (NPUAP) to monitor healing over time. The PUSH Tool monitors three parameters: surface area of the wound, wound exudate, and type of wound tissue. The scores are rated from 0 to 10 according to the size of the wound. Tissue types are noted, scoring from 0 to 4. A comparison of total scores measured over time provides a status of wound healing progress or decline.

The NPUAP recommends that individuals who are at high risk for pressure injuries have their skin assessed as soon as possible on admission to the health care facility and on an ongoing basis after their admission. The assessment should include identification of any erythema, measurement of skin temperature, and note of changes in tissue consistency. Localized pain should also be measured to identify areas where damage may be developing.⁴ Proactive assessment can help prevent the development of pressure injuries in the care facility, thereby helping to reduce incidence rates. By working to stop damage before it develops into a pressure injury, health care providers can help improve patient outcomes, reduce complications, and control costs in the facility. ^1,4

References:

1. Bauer K, Rock K, Nazzal M, Jones O, Qu W. Pressure Ulcers in the United States' Inpatient Population From 2008 to 2012: Results of a Retrospective Nationwide Study. Ostomy Wound Manage. 2016 Nov;62(11):30-38.

2. White-Chu EF, Flock P, Struck B, Aronson L. Pressure ulcers in long-term care. Clin Geriatr Med. 2011 May;27(2):241-58. doi: 10.1016/j.cger.2011.02.001.

3. Primiano M, Friend M, McClure C, et al. Pressure ulcer prevalence and risk factors among prolonged surgical procedures in the OR. AORN J. 2011 Dec;94(6):555-66. doi:10.1016/j.aorn.2011.03.014.

4. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler, ed. Cambridge Media: Osborne Park, Western Australia; 2014.