Pressure Ulcers in the Elderly During Hospital Stay

Pressure Ulcers in the Elderly During Hospital Stays

Pressure ulcers are potentially fatal skin lesions that develop especially in frail, elderly patients on bony or cartilaginous areas such as the sacrum, elbows, and ankles. Within acute care in the United States, the incidence of pressure ulcers lies between 0.4% and 38%. The incidence within long-term and home care is significantly lower while intensive care units report that 8% to 40% of ICU patients develop pressure ulcers during the hospital stay (Cuddigan, Berlowitz & Ayello, 2001). An epidemiological study of pressure ulcers reports that hospital-acquired pressure ulcers cost the U.S. $2.2 to $3.6 billion per year in 1999 (Vandenkerkhof, Friedberg & Harrison, 2011). These statistics carry important implications for guidelines of identification and treatment of pressure ulcers in the United States. In the complexity of the medical system, the application of Jean Watson's Theory of Nursing Caring and the developing role of the nurse practitioner may play a vital role in preventing pressure ulcers and improving care for patients.

Literature Review

Growing evidence suggests that many pressure ulcers begin to develop after only a few hours of immobility-induced pressure. In response to this observation, Baumgarten et al. examined the incidence of hospital-acquired pressure ulcers in the first 2 days of a hospital stay and identified common patient characteristics associated with higher incidence (2006). The authors examined patients using standardized diagnostic criteria and classified the pressure ulcers as preexisting, possibly hospital-acquired, or definitely hospital-acquired. The overall incidence of pressure ulcers in patients examined after 2 days in the hospital was 6.2%. The findings show strong, statistically significant associations between pressure ulcer incidence and patients needing help to turn in bed, living in nursing homes before hospitalization, being hospitalized in the previous six months, having a BMI of less than 18.5, being at risk for nutrition-related complications, and with moisture due to urinary and fecal incontinence.

In a related study, Baumgarten et al. examined the extrinsic risk factors for pressure ulcers early in the hospital stay (2008). Based on the understanding that treatment in the emergency department of acute care facilities is often associated with lengthy waiting times and thus increased risk for developing pressure ulcers, the authors aimed to identify the impact of extrinsic factors of care such as length of emergency department stay, night or weekend admission and potentially immobilizing procedures. The findings show that an ICU stay is associated with a 2-fold increase in the likelihood of developing at least one possibly- or definitely-hospital acquired pressure ulcer. One proposed explanation for this association is that regular repositioning of the patient, a standard prevention technique, may be difficult in ICU patients due to its impact on hemodynamic stability and ventilator management.

Responding to conflicting evidence of body mass index association with pressure ulcers, Compher and colleagues conducted a study that examined the influence of obesity on the incidence of pressure ulcers in elderly hospitalized patients (Compher, Kinosian, Ratcliffe & Baumgarten, 2007). The findings suggest that extra body fat reduces the risk of pressure ulcers elderly patient when compared to underweight and optimally weight patients. Conversely, patients who were underweight had a significantly higher risk of developing pressure ulcers in the hospital.

Rigor Analysis and Theoretical Framework of Research

Extensive research has been conducted on pressure ulcers. One limitation of these studies is the heavy reliance on subjective diagnostic procedures. Nurses are most frequently recruited to evaluate the presence and extent of pressure ulcers in study subjects. Differences in training and personal judgment can naturally introduce a degree of variability in pressure ulcer diagnoses. Many studies conduct inter-rater variability testing to enhance the quality and consistency of the diagnoses. In the studies cited from Baumgarten et al., the sensitivity and specificity of the research nurses' diagnostic ascertainment of pressure ulcers from digital photographs was 97% (Baumgarten et al., 2006). Such analyses were cited in many but not all studies encountered in the literature review on pressure ulcers.

Another limitation of observation-based studies and specifically for the studies on pressure ulcers is the determination of pressure ulcer onset. One important implication for these studies is the distinction between preexisting pressure ulcers and hospital-acquired pressure ulcers. In order to study the development of pressure ulcers early in a patient's hospital stay, patient examinations were consistently performed on admission and again on the third of fourth day of hospitalization. This was done to ensure that the risk interval was long enough for pressure ulcers initiated early in the hospital stay to become clinically apparent, but short enough that observed pressure ulcers were not pre-existing ones (Baumgarten et al., 2008). Most studies employ a convenience sample and therefore fail to achieve a cross-sectional study population. However, the methodology, which seeks to eliminate all confounding variables including comorbid diseases that may influence the development of pressure ulcers, is rigorously enforced.

Most studies on pressure ulcers are predicated on the theoretical assumption that greater focus on the identification of pressure ulcers early in the patient's hospitalization can lead to prevention and improve the patient's quality of life and reduce medical costs. The theoretical framework for studying pressure ulcers appears to revolve around preventative measures. The theory that emerges from the studies is that pressure ulcers are a natural product of immobility in the elderly and that research should be targeted towards identifying the risk factors and prevention techniques that can delay or minimize the incidence of these skin lesions. This rationale is reasonable for the goals of any medical clinic; that is to improve patient outcomes and limit preventable medical costs. The studies by Baumgarten and Compher cited above operate under this theoretical framework.

The evidence across studies is generally consistent and yields a reasonable level of confidence. Pressure ulcers are consistently associated with longer hospital stays, especially in the intensive care unit, with less mobility, poor dietary health, and urinary and fecal incontinence. Obesity was frequently cited as a preventative factor. The rigor of the studies is high and consistently identifies major limitations and restrictions of the methodology. The studies offer different interpretation of the data and tentatively declare the general outcomes. The consistency across studies validates the evidence and strengthens the credibility of each individual study. The primary underlying implication to emerge from the literature review that relates most pertinently to the role of the nurse practitioner is that pressure ulcer treatment relies on prevention and extensive monitoring of the patient.

Jean Watson's Theory of Human Caring

The components of Jean Watson's Theory of Human Caring emphasize precisely the kind of extensive treatment that the sensitive patients with pressure ulcers require. In her theory, Jean Watson promotes caring as the core of nursing practice (Cara, 2003). The theory extorts that making a conscious effort to preserve human caring within the clinical, administrative and educational practice of a nurse can improve patient outcomes by humanizing the patient-nurse relationship. The primary patient population commonly afflicted with pressure ulcers is elderly, frail and often suffers from comorbid degenerating illnesses. As part of the carative factors in her theory, Watson emphasizes the creation of a supportive, and protective mental, physical and spiritual environment. This element of her theory appears especially applicable to this patient population, as the advanced practice nurse must make the patient comfortable in dealing with sensitive mental and physical boundaries.

Further, the standard treatment for patients at risk for pressure ulcers is persistent movement and monitoring, which requires the constant presence and awareness of the nurse practitioner. It seems that patient neglect and insufficient patient monitoring frequently initiates the formation of pressure ulcers. Applying Watson's belief in being authentically present could help to improve the process of identifying pressure ulcers as nurses spend more time with the patient and become more aware of the risk factors associated with pressure ulcers. For instance, a study conducted by Sergi et al. demonstrated that nutritional assessment is important in preventing and identifying patients at risk for pressure ulcers (Sergi et al., 2007). Malnutrition is potentially reversible and its early identification and treatment can affect pressure ulcer onset and progression. While malnutrition may not be the primary reason for hospitalization, a nurse abiding by the Jean Watson Theory of Human Caring would make the patient aware of this specific risk factor for developing pressure ulcers. In doing so, the advance practice nurse would be applying one of the essential tenets of Watson's theory -- the promotion of health through knowledge and intervention.

Role of the Advanced Practice Nurse

In light of the theory's emphasis on knowledge and the skill needed for valid diagnostic identification of pressure ulcers, the experienced advanced practice nurse emerges as an important element in patient treatment. The Whafedale Model developed in Leeds, England, places an emphasis on the kind of extensive monitoring and close patient contact espoused by Watson and required to identify pressure ulcers early in a patient's hospital stay (Clegg, Bradley, Smith & Kirk, 2006). The vision of the model is to improve the quality and speed of assessment, diagnosis and onset of treatment. According to the pressure ulcer literature and specifically, the study presented by Baumgarten et al. (2008), these are some of the extrinsic risk factors for pressure ulcers. The extended nursing role in this model includes patient history taking, ordering diagnostic tests and prescribing treatment. One of the definitive objectives of the model relates to timeliness. Each patient is reviewed and progress recorded every 48 hours, while an advanced practice nurse sees new admissions within one hour. This system would ensure that formations of pressure ulcers early on in a patient's hospital stay would be identified very early. An analysis of the nurse practitioner's role conducted by Schroeder (2008) further emphasizes the qualifications and educational preparation that makes the advanced practice nurse well suited for such a role in the hospital.

Improving care in Practice Area: Action Plan and Measurable Outcomes

Currently, the resources in the author's practice area are overloaded. Trends are towards shorter hospital stay for patients, leading frequently to a breakdown of the continuity of care. In the groundbreaking report, "To Err is Human: Building a Safer Health System," published in 2000, the National Institute of Medicine identified breakdown of communication, time of day and electronic monitoring as major sources of errors leading to adverse events in the hospital. These are precisely the kinds of errors seen in the practice area that undermine the treatment of pressure ulcers. Each can be addressed in a specific way.

Communication breakdown occurs most often when the patient is transferred from the emergency room to an intensive care unit or a hospital ward. Either first signs of pressure ulcers are not documented or treatment is initiated but not adequately communicated to the receiving hospital unit. Treatment is aborted, the pressure ulcers continue to grow and the patient's condition worsens. One specific way for an advanced practice nurse to change this problem is to implement a checklist. More attention must be paid to pressure ulcers in a patient's primary assessment and continued monitoring must be ensured. A checklist in the patient's chart listing risk factors that apply to the patient can improve the continuity of treatment.