The aetiology of pressure ulcers

The aetiology of pressure ulcers is in some parts insubstantial due to the numerous influences that apply to the formation of a pressure ulcer. There are, none the less, a diverse array of contributing factors that have been proven to impair the structure of the skin and disrupt the healing processes, for example heart complications, lack of mobility, nutrition, sensory loss, temperature and age effecting the skins texture and strength. The most significant rationale behind the choice of clinical skill is to assist in the advancement of knowledge base, as Ali & Atkin (2004, p. 03) accurately specify, ‘we need to use our increasing knowledge base to transform service provision and provide better primary care’. As health professionals it needs to be realised that we are a vital link between patients and other specialised health care services, Morison (2001, p. 4) points out the importance of, ‘health care professionals as patient advocates in relation to tissue viability services’, if we do not make it our duty to be knowledgeable of what options our patients have it is impossible to administer care holistically as if our duty as a health care professional.

In recent studies it has shown that pressure ulcers are most prominent with surgical patients, research has also shown that the surgical patient develops a pressure ulcer 8 times more than the non surgical patient (Pulskamp, 2007). Interestingly it shows that not only are pressure ulcers observed in older patients but just as often in the younger ago groups, with an increase in occurrence in those who receive neck and head surgeries (Bader et al, 2005), In a study is it is shown that adaptation to the operating table diminished sharply the incidence of pressure ulcer development.

Bader et al found that often Pressure ulcers are observed after 2 weeks of being admitted, this then contradicts the theory that ‘pressure ulcers are caused by inadequate nursing care’, this then can only suggest that pressure ulcers develop during an operation, during periods of treatment or during investigations, for example X-ray departments where the mattresses are not adapted to the variety of different patients with a different variety of problems.

To reduce occurrence and risk there must be put in place preventative measures in terms of risk assessments but as Pulskamp (2007) points out, ‘There is no validated tool to predict risk of pressure ulcers in the surgical patient’. There are numerous pressure ulcer risk assessment tools in use, yet none being significantly more preferred than others and each with particular strengths and weaknesses.

In 2003 the National Institution for Clinical Excellence produced the guidelines, ‘pressure ulcer risk assessment and prevention, including the use of pressure relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care’. They suggest that in order to maximise the effectiveness of the guidelines, they should be enhanced by implementing them in working partnerships such as tissue viability teams. The aim of the guidelines, as LittleJohns & Rawlins (2005, p. 9) highlight, are to ‘inform clinical practice and to direct clinical decision making in order to improve patient outcomes with regard to pressure ulcer prevention and management’. To encourage the use of this guideline the National Institution of Clinical Excellence suggest, ‘incorporating guidance into continuing professional development programmes (in order to) further encourage its use in clinical practice’ (LittleJohns & Rawlins, 2005, p. 100). After initial implementation an audit was arried out which highlighted significant pitfalls in implementation of the guidelines in clinical practice, for example being unable to record timings or risk assessments, repositioning charts not being used and seating assessments n out being carried out, this highlights the need for flexibility in future risk assessments as clinical issues often arise and cannot be avoided in the busy schedules of health care professionals and can often become barriers to the effective implementation there for making the correct use of the guidelines impossible risks unattended concerning the patients.

They also voice the fear that the guidelines are simplifying clinical decision making and urge professionals to adopt any particular recommendations in light of such issues as available resources, local policies, patient circumstance and updates research findings.

The European Pressure Ulcer Advisory Panel quick reference guidelines on prevention for developing pressure ulcers (2009) have a in depth and diverse approach on the assessment of pressure sores and contributing factors, their guidelines investigate not only the treatment of pressure ulcers but use of pressure ulcer prevention devices and wound management with a grading system to reflect the severity of the sore.

The advisory panel suggests that, ‘pressure ulcers need to be assessed in the context of the patients overall condition’, they also identify ‘nutrition, pain and psychosocial factors as potential areas of complication, looking into the localization, grade, size, wound bed, exudates, pain and status of the surrounding skin’ (Dealey, 2005, p. 138).

One of the pitfalls of this particular assessment strategies is the actual analysis of the pressure ulcer itself, one must have gained adequate back ground knowledge and experience on the analysis of a sore and the most suitable wound management product (for example dressings or antibiotics if the wound appears infected) to truly be able to grade it, Dealey (2005, p. 142) herself discusses, ‘accurate assessment is necessary in order to select a suitable wound management product’.