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AUGUST 2013
OCTOBER 2013
Why do Pressure
Pressure
Ulcers:
Ulcers
Occur?
An Overview of a
Pathophysiology
Painful
Problem of
Pressure Ulcers
BY: KINDAH JARADEH
Education
Evidence
Evaluation
Pressure Ulcers:
An Overview of a Painful Problem
Introduction
Pressure ulcers, commonly known as bedsores, are a problem experienced
internationally. They affect patient quality of life and impose a heavy resource
and financial burden on healthcare systems.
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Similarly, in the United Kingdom, pressure ulcer care costs the healthcare
system 2.1 billion per year ($3.4 billion).x These costs are driven by nursing
time to monitor, assess, and dress wounds, utilization of appropriate
treatment therapies, as well as duration of hospital stay, based on the
severity of the pressure ulcer. For example, the most severe pressure ulcers
(Stage IV) require an average of 155 days recovery timex and $129,248 for
treatment of the ulcer and related complications during a single hospital
admission.xi The result is an average hospital length of stay (LOS) that is 4.5
times longer than patients without pressure ulcers.xii
Normal or
Healthy Skin
Stage I:
Non-blanchable
erythema
Stage II:
Partial
Thickness Skin
Loss
Description
Example
Intact skin
No visible bruising or skin discoloration
Skin is pain-free, and temperature is consistent across surface
Intact skin with non-blanchable redness of a localized area,
usually over a bony prominence
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
Partial thickness loss of dermis presenting as a shallow open
ulcer with a red pink wound bed, without slough
May also present as an intact or open/ruptured serum-filled or
sero-sanginous filled blister
Presents as a shiny or dry, shallow ulcer without slough or
bruising
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Stage
Stage III:
Full Thickness
Skin Loss
Stage IV:
Full Thickness
Tissue Loss
Description
Full thickness tissue loss
Subcutaneous fat may be visible but bone, tendon, or muscle
is not exposed or directly palpable
Slough may be present but does not obscure the depth of
tissue loss
May include undermining and tunneling
Full thickness tissue loss with exposed bone, tendon or muscle
Slough or eschar* may be present.
Often includes undermining and tunneling
Category/Stage IV ulcers can extend into muscle and/or
supporting structures such as fascia, tendon or joint capsule
Exposed bone/muscle is visible or directly palpable
Unstageable:
Full Thickness
Tissue loss with
Unknown Depth
Deep Tissue
Injury (DTI) with
Unknown Depth
Example
xxxii
xxxiii
Slough: Soft, yellow, brown, or gray material and is characterized by its stringy, adherent quality
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(Stage IV becomes Stage III, then Stage II, Stage I, until the skin is again
healthy). However, experts now dismiss this practice because it is
physiologically incorrect. While pressure ulcers do heal to a progressively
shallower depth, a healing wound is not filled by normal tissue; lost muscle,
subcutaneous fat, and dermis is not replaced. xvi Rather, the wound is
replaced by scar tissue that is composed of endothelial cells, fibroblasts,
collagen, and extracellular matrix.xvi Therefore, it is not appropriate to say that
a Stage II pressure ulcer will heal to a Stage I assessment.xvii Instead, a
pressure ulcer maintains its first classification stage, and the term healing is
added as a prefix. For example, a Stage IV pressure ulcer that is improving is
designated a healing Stage IV pressure ulcer; it is no longer reverse
staged to Stage III or II.
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Specificity
Odds
Ratio
95%
Confidence Interval
Braden
Scale
57.1%
67.5%
4.08
2.56-6.48
Norton
Scale
46.8%
61.8%
2.16
1.03-4.54
Waterlow
Scale
82.4%
27.4%
2.05
1.11-3.76
Clinical
Judgment
50.6%
60.1%
1.69
0.76-3.75
Tool
2. Dark Skin Tones: Data show Stage I pressure ulcers are missed
in patients with dark skin tones; instead, such patients develop
four times as many Stage II pressure ulcers as compared to Stage
I pressure ulcers.
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Stage
I
45%
40%
38%
37%
35%
39%
41%
Stage
II
Stage
III
32%
Stage IV
30%
Eschar
25%
20%
13%
15%
10%
6%
5%
9%
6%
7%
6%
9%
7%
13%
13%
11%
9%
5%
0%
Light
Medium
Dark
Figure 1: Prevalence of Pressure Ulcers by Skin Color.v
Page 7
Endnotes
i
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel, 2009. Prevention and Treatment of Pressure Ulcers: Clinical Practice
Guidelines. Washington, DC: National Pressure Ulcer Advisory Panel.
ii
iii
iv
Lindan, O., Greenway, R.M. and Piazza, J.M., 1965. Pressure distribution of the
surface of the human body. Arch Phys Med Rehabil, 46, pp. 378-385.
Vangilder, C., Macfarlane, G., Meyer, S. and Others. 2008. Results of nine
international pressure ulcer prevalence surveys: 1989 to 2005. Ostomy Wound
Management, 54 (2), p. 40-54.
vi
Vangilder, C.M., Amlung, S., Harrison, P. and Meyer, S. 2009. Results of the 20082009 International Pressure Ulcer prevalence Survey and a 3-year, acute care,
unit-specific analysis. Ostomy Wound Management, 55 (11), pp. 39-45.
vii
Marois, C.L., 2010. Pressure Ulcer Reduction and Elimination. Covidien. Available
at: <http://www.covidien.com/imageServer.aspx?contentID=20369&contenttype=
application/pdf> [Accessed 29 August 2013].
viii
ix
Agency for Healthcare Research and Quality (AHRQ). Preventing pressure ulcers in
hospitals: A toolkit for improving quality of care. Available on:
<http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressureulcers/pressureulcertoolkit/putoolkit.pdf> [Accessed 1 July 2013].
Dealey, C., Posnett, J. and Walker, A. 2012. The cost of pressure ulcers in the United
Kingdom. Journal of Wound Care, 21 (6), pp. 261-266.
xi
Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., Golinko, M.,
Yan, A., Lyder, C. and Vladeck, B. 2010. High cost of stage IV pressure ulcers. The
American Journal of Surgery, 200 (4), pp. 473-477.
Allman, R., Laprade, C., Noel, L., Walker, J., Moorer, C., Dear, M. and Smith, C.
1986. Pressure sores among hospitalized patients. Annals of Internal Medicine, 105
(3), pp. 337-342.
xiii
xiv
xiii
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<http://www.merckmanuals.com/professional/dermatologic_disorders/pressure_ulcer
s/pressure_ulcers.html> [Accessed: 30 Aug 2013].
xvi
Thomas D.R., Rodeheaver G.T., Bartolucci A.A., Franz, R.A., Sussman, C., Ferrell,
B.A., Cuddigan, J., Slotts, N.A., and Maklebust, J., 1997. Pressure ulcer scale for
healing: Derivation and validation of the PUSH tool. Adv Wound Care, 10(5), pp.96101.
xvii
National Pressure Ulcer Advisory Panel. The facts of reverse staging in 2000,
(online) Available at: < http://www.npuap.org/wp-content/uploads/2012/01/ReverseStaging-Position-Statement > [Accessed 19 November 2012].
xviii
Black, J.M., Edsberg, L.E., Baharestani, M.M., Langemo, D., Goldberg, M.,
McNichol, L., Cuddigan, J. and the National Pressure Ulcer Advisory Panel, 2011.
Pressure ulcers: avoidable or unavoidable? Results of the National Pressure Ulcer
Advisory Panel consensus conference. Ostomy Wound Management, 57(2), pp. 24
37.
xix
Mattie, A. S., & Webster, B. L. Centers for Medicare and Medicaid Services never
events: an analysis and recommendations to hospitals. The health care manager,
27(4), pp. 338349.
xx
xxi
xxii
Halfens, R., Bours, G. and Van Ast, W. 2001. Relevance of the diagnosis stage 1
pressure ulcer: an empirical study of the clinical course of stage 1 ulcers in acute
care and long-term care hospital populations. Journal of Clinical Nursing, 10 (6), pp.
748-757.
xxiii
Kottner, J. and Dassen, T., 2010. Pressure ulcer risk assessment in critical care:
Interrater reliability and validity studies of the Braden and Waterlow scales and
subjective ratings in two intensive care units. International Journal of Nursing
Studies, 47(6), pp. 671-677.
xxiv
Thomas, D.R., 2001. Issues and dilemmas in managing pressure ulcers. J Gerontol
Med Sci, 56, pp. 238-340.
xxv
Bethell, E., 1992. Controversies in classifying and assessing grade 1 pressure ulcers.
Nursing Times 99, pp. 7375.
xxvi
Quintavalle, P. R., Lyder, C. H., Mertz, P. J., Phillips-Jones, C. and Dyson, M.,
2006. Use of high-resolution, high-frequency diagnostic ultrasound to investigate the
pathogenesis of pressure ulcer development. Advances in Skin Wound Care 19, pp.
498505.
xxvii
Bates-Jensen, B., McCreath, H.E., Pongquan, V., and Apeles, N.C.R., 2007. SubEpidermal Moisture Differentiates Erythema and Stage I Pressure Ulcers in Nursing
Home Residents. Wound Repair and Regeneration, 16, pp. 189-197.
xxviii
Harrow J.J. and Mayrovitz H.N., 2006. Initial assessment of tissue water content
surrounding pressure ulcers in spinal cord injury patients. [Abstract]. Available at: <
Page 9
ttp://clinsoft.org/drmayrovitz/POSTER-ABSTRACTS/23.html> [Accessed 29
August 2013].
xxxii
xxxiii
Lin, V., Cardenas, D., Cutter, N., Frost, F., Hammond, M., Lindblom, L., Perkash, I.,
Waters, R., Woolsey, R., Priebe, M. and Others, 2003. Principles of Pressure Ulcer
Management. Demos Medical Publishing.
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