Chapter 27. Prevention of Pressure Ulcers in Older Patients

Pressure ulcers, localized areas of tissue damage or necrosis that develop due to pressure over a bony prominence, are common causes of morbidity in older hospitalized and institutionalized persons. Other terms referring to the same phenomena are pressure sores, bedsores, and decubitus ulcers. Risk factors include immobility, friction, shear, incontinence, cognitive impairment and poor nutritional status. Pressure ulcers are one indicator of quality of care measured by nursing homes as part of the mandatory Minimum Data Set (MDS), which is required for participation in Medicare and Medicaid. Part of the MDS evaluation includes the Resident Assessment Instrument, which serves as a guide to assess pressure ulcers and many other pertinent clinical problems. Risk assessment is an integral part of prevention efforts. The Norton scale and the Braden scale are widely used tools to identify at-risk patients. The Norton scale assesses five domains: activity, incontinence, mental status, mobility, and physical condition. The Braden scale assesses six domains: activity, dietary intake, friction, mobility, sensory perception, and skin moisture. Agreement between the scales is 0.73 using the kappa statistic. Different strategies have been used for primary prevention. Major clinical guidelines, for pressure ulcer prevention are based primarily on published evidence, and in some areas, on professional judgment and face validity of practices. Turning and/or repositioning patients is a practice with high face validity, but there are no well-designed controlled trials that examine its effect in the absence of other interventions. Other practices include regular skin inspection and assessment, use of appropriate pressure-relief surfaces, improved mobility, adequate nutritional intake, and documentation of the skin examination. Additionally, the use of general educational interventions for hospital staff is supported by before-after study designs. 10 Several reports suggest the value of using topical applications applied to intact skin in an attempt to prevent ulcers. 11, 12 This chapter focuses on the use of pressure-relieving strategies that can be incorporated into hospital or nursing home practice and are based on evidence from controlled clinical trials.