Can Mrs. T Be Protected From New Pressure Ulcers?



July 10, 2009

In This Article

Mrs. T: A Changing Situation and an Emergency Department Visit

Taken to the emergency department (ED) because of a new unsteady gait and change in mental status developing over the previous 2 days, Mrs. T is admitted to the hospital with a diagnosis of pneumonia. She is an 89-year-old African American woman who, despite numerous chronic conditions, has lived independently in the community in generally good health. Mrs. T's medical history includes hypertension, hypothyroidism, diabetes, peripheral vascular disease, osteoarthritis, anemia of chronic disease, glaucoma, psoriasis, and urge incontinence. Mrs. T's son, who accompanies her, tells the staff that his mother has lost quite a bit of weight over the previous few months, although he is not able to say exactly how much. The expected length of stay for Mrs. T is 5 days and it is likely that she will require rehabilitation care following the hospitalization. During that time, can the nursing staff prevent Mrs. T from developing a pressure ulcer?

The Implications of Pressure Ulcers

In fiscal year 2007, the Centers for Medicare & Medicaid Services (CMS) reported the occurrence of 257,412 preventable pressure ulcers (PUs) in patients admitted for other primary diagnoses.[1,2] The additional cost when a PU develops as a secondary diagnosis is estimated to be more than $43,000 per hospital stay.[1,2] In addition to the clinical, ethical, and practical reasons to prevent PUs whenever possible, CMS has added a strong financial incentive by implementing plans to exclude hospital charges incurred as a consequence of preventable injuries and conditions.[3,4] A hospital's costs related to the care of a PU not identified as "present on admission" will not be reimbursed by CMS; other third-party payers are adopting a similar stance.[1]

Data from a recent 6-year period reveal that PUs develop in approximately 7% of all acute care patients during hospitalization.[5,6] This percentage varies by population and institution, but consistently, elders are among those at greatest risk for PUs.[7,8,9,10,11] Although the preventability of all PUs is debated,[4,12,13,14,15,16,17] the fact that many and perhaps most PUs can be prevented is undeniable.

To all patients, these basic principles to prevent development of PUs apply:

  • Reduce pressure to skin especially over bony prominences through repositioning and/or pressure-relieving devices;

  • Encourage mobility or assist with repositioning; protect skin from irritants including urine, fecal matter, and sweat;

  • Prevent friction or shearing of the skin; and

  • Maintain or restore nutritional status.

Good care, however, requires the individualization of each patient's care plan. Each patient's unique factors must be assessed and addressed. The first step is to assess the patient's skin at the time of admission, looking for open areas as well as skin that is fragile, discolored, irregularly textured, scarred or scabbed, and either warmer or cooler than expected. Special attention should be given to skin over bony prominences, under or between folds of skin, and in and around the perineal area. Any irregularities should be documented and described, including location, color, size, skin quality and integrity, temperature, and patient's report of discomfort at the site (eg. pain, pain-free, itching, burning).