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CHAPTER 14
Pressure Area Care and Tissue Viability
Introduction
Pressure ulcers have been known to exist since ancient Egyptian times, and probably for as long as humans have been in existence (Robertson et al. 1990). They are largely a preventable problem, yet despite the advances in technology, preventative aids and increased financial expenditure, remain a common and debilitating concern (EPUAP 2002). Pressure ulcers are painful, impacting negatively on all domains of the activities of daily living (Gorecki et al. 2009). They commonly occur in those who cannot reposition themselves to relieve pressure on their bony prominences (Robertson et al. 1990), such as the very old, the malnourished, those with acute illness and those undergoing surgery (Robertson et al. 1990). Thus, it is suggested that the majority of pressure ulcers occur during an episode of hospitalisation of an individual in an acute care setting (EPUAP 2002). This has significant implications for the health service, as length of stay is protracted for those with pressure ulcers when compared to their matched counterparts (Graves et al. 2005). Furthermore, direct resource costs are also increased, all of which serve to impact negatively on achieving diagnostic related goals (Bennett et al. 2004).
Definition of a Pressure Ulcer
The European Pressure Ulcer Advisory panel and the National Pressure Ulcer Advisory Panel (EPUAP/NPUAP 2009) suggest that 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. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.’ Understanding the exact definition of a pressure ulcer is important as it provides a clear description of the key aetiological factors that cause pressure ulcers (i.e. pressure or pressure in combination with shear).
Prevalence and Incidence
From the international literature, pressure ulcer prevalence figures vary from 6.8% to 53.2% (Davis and Caseby 2001, Bours et al. 2002, Tannen et al. 2006, Capon et al. 2007, Keelaghan et al. 2008, Paquay et al. 2008). As with prevalence data, incidence figures differ across countries and across clinical settings. The literature reports figures of between 9.7% and 38.1% (Martin et al. 1995, Bergstrom et al. 1996, Goodridge et al. 1998, Ooi et al. 1999, Davis and Caseby 2001, Horn et al. 2004, Defloor et al. 2005, Vanderwee et al. 2007). Among surgical patients, specifically, pressure ulcer prevalence rates of 8.5% and 33% (Versluysen 1986, Karadag and Gümüskaya 2006), and incidence rates of between 14.1% and 54.8% (Schoonhoven et al. 2002a, Lindgren et al. 2005, Aronovitch 2007) have been reported. The majority of ulcers are noted on the heel and the sacrum, and are mainly stage 1 and 2 pressure ulcer damage. Furthermore, it is suggested that 23% of all nosocomial pressure ulcers develop in the operating department (Aronovitch 1999).
Pressure Ulcer Classification
Blanching erythema
After a period of pressure on superficial tissues, there will be a corresponding deprivation of oxygen to that area (Mayrovitz et al. 1999). To compensate for the loss of oxygenation after removal of pressure, there is a rapid increase in blood flow to the affected part. This is called reactive hyperaemia and is one of the body’s compensatory mechanisms (Bliss 1998). The aim of this process is to restore normal blood flow and to prevent tissue death. Reactive hyperaemia is evident to the naked eye as a reddened patch over the affected skin (Bliss 1998). Blanching hyperaemia, when the reddened area blanches (turns white) on gentle compression of the skin (Collier 1999), indicates that no permanent damage has occurred; however, it is pathologically different to normal skin (Witkowski and Parish 1982).
Non-blanching erythema
The classification of early pressure ulcer damage, non-blanching erythema, has been widely welcomed by practitioners. However, the original definition, ‘tissue redness that does not blanch (turn white) when pressed’ was not without problems because the definition is unsuitable for individuals with darkly pigmented skin (Henderson et al. 1997). To overcome the limitations of the original definition of non-blanching erythema, the EPUAP/NPUAP (2009) suggest that ‘darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.’
Pressure ulcer classification systems
A variety of pressure ulcer classification tools are currently in use; perhaps the most common are the Stirling Scale (1 or 2 digit) in the UK (Reid and Morison 1994), the original NPUAP Scale in the USA (NPUAP 1989) and the original EPUAP Scale (EPUAP 1999). The Stirling Scale has five stages ranging from no damage to full-scale tissue destruction, and includes a subset of descriptors for each stage (Reid and Morison 1994). While working on the latest guidelines for prevention and management of pressure ulcers (EPUAP/NPUAP 2009), the EPUAP and NPUAP developed a common international definition and classification system for pressure ulcers. The system includes four categories/stages from non-blanchable erythema to full thickness tissue loss. For the USA, two additional categories/stages have been included: ‘unstageable/unclassified’, which is full thickness skin or tissue loss where the depth is unknown, and ‘suspected deep tissue injury’, where the depth of damage is unknown (EPUAP/NPUAP 2009). A recent systematic review concludes that there is insufficient evidence to suggest which pressure ulcer classification system to recommend for clinical practice (Kottner et al. 2009). Studies conducted are so heterogeneous that it is impossible to synthesise the evidence in a clear and meaningful way (Kottner et al. 2009).
Risk Assessment Tools
Risk has been defined as the probability of an individual developing a specific problem (i.e. a pressure ulcer) (Deeks et al
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