© The Medical-Legal News 2007
By Jeanne Campbell, BSN, RN, C, CLNC
Pressure ulcers, decubitus ulcers, bedsores… they are all used interchangeably in the medical community. Here are some basics you should consider about this sometimes life-altering and even deadly development in medical-legal cases.
In 2000, a nationwide initiative was introduced, Healthy People 2010. This initiative was designed to improve care in all areas of healthcare from the emergency room, to acute and critical care to rehabilitative and extended care settings. It sets goals for people to attain increased quality of life and health for every one in the U.S., not just for those with insurance and access to healthcare.
One of the 467 objectives in this important project is to reduce the number of nursing home patients with a diagnosis of pressure ulcer. It is imperative to prevent skin breakdown with every admission to every level of healthcare. Pressure ulcers can be prevented through diligent care and continued education to all levels of staff.
Basic definition: An area of cellular necrosis (tissue death), usually over a bony prominence that results from pressure, moisture, shearing, poor nutrition, altered circulation, friction or fever.
What’s normal? Persons with normal feeling, ability to move and mental abilities have a natural feedback system that “tells” them to change positions. These changes in position shift the pressure before any irreversible damage is done.
Problem: When pressure is placed on the skin, soft tissue, muscle and bone by the person lying in bed or sitting in a chair without frequent position changes, pressure sores can arise. Their extent depends on several different factors: Age (increased age equals increased risk), weight (too heavy or too thin), nutritional status, inactivity and immobility, incontinence (accidental urination or bowel movements in the bed), sweating, decreased sensation, mental abilities (confusion), medical history (diabetes, anemia, edema or swelling, AIDS or decreased immune state from cancer).
What happens? A person who is left in one position for too long (sometimes just as little as one hour!) has places over bony areas (such as the tailbone, sides of the hips, spine, heels, back of the head, ears, elbows and shoulder blades) that have all of the blood pressed out. When the blood is pressed out, the tissues (skin and muscle) don’t receive enough blood to stay healthy.
All body parts need a good blood supply to stay healthy — if there is a decrease in blood supply, the tissue dies.
The development of a pressure sore can be complicated because at first glance there may only be some redness and no broken skin, but in reality the damage may already be done, as deep as down to the bone. Essentially, healthcare providers are only able to see “the tip of the iceberg” at first, and then as the body sheds dead tissue, an open sore develops.
The body, with the aid of appropriate wound care treatment, discards the dead tissue and only at this point can the body regrow new tissue to replace what was damaged. This process can take days to months, depending on several factors such as continued risk factors, severity of the original wound and if it was treated appropriately.
How bad can it get? There are four stages, or severities, of pressure sores:
n Stage I is when the skin over the pressure area is not broken, but is red. It still blanches (when pressed on by your finger, turns white then back to red or pink).
n Stage II is when the skin is actually broken open down through the epidermis (first layer of skin) and dermis (second layer of skin).
n Stage III is when the skin is broken open down into the subcutaneous tissue (fatty tissue just above the muscles).
n Stage IV is when the skin is broken open down into the muscle, bone and tendon.
The longer a person is left with pressure over a bony part of the body, the more severe the pressure sore will be.
In many patients, a pressure sore requires an extended stay in a healthcare facility or home-bound status, which drastically changes their quality of life. Often in older adults this change in environment leads to increased confusion and anxiety, making it even more difficult to get them back to a level of independence.
• Financial issues: According to the Ostomy Wound Management’s web site’s latest article, “Pressure ulcers also increase length of stay by an average additional 3.5 to 5 days,” and, “The cost of managing pressure ulcers in all settings ranges from $1.335 billion to $8.5 billion per year.”
Points to ponder
• All healthcare facilities should have guidelines, standards, policies and procedures that all nursing personnel must follow in order to successfully prevent pressure sores.
• Patients who have neurological impairments (paraplegics, quadriplegics, strokes) have a higher risk for developing pressure sores.
• Pressure sores are listed as the direct cause of death in a number of paraplegics. Christopher Reeves, the Superman movie actor, died from an infection from a bedsore.
• People who have developed, and even healed pressure sores, have a higher chance of developing another pressure sore.
• Pressure ulcers are largely preventable and there are only a very small percentage of pressure sores that could not have been prevented after all measures were taken.
• Every nursing student in the U.S. is taught, in his or her first few classes of nursing school, about this basic function of nurses: How to prevent painful, life-changing, life-threatening pressure sores. •
Jeanne Campbell is a legal nurse consultant in Chandlersville, Ohio, firstname.lastname@example.org.