A multidisciplinary onslaught must be made on the high incidence of pressure sores in the hospital setting, writes Patricia McNallyWhile the nurses role is central to the prevention of pressure sores, training and education in this area has been poor in the past. Poor staffing levels, inadequate equipment and lack of support from other disciplines have compounded the problem.
The past 30 years have yielded more research in this area. Information regarding the causes of pressure sores and methods of prevention is emerging.
A pressure sore is an ulceration of the skin and/or deeper tissue due to unrelieved pressure, shear force(s) and/or frictional force(s).1 There are both intrinsic and extrinsic factors involved in the development of pressure sores.
Intrinsic factors relate to the patients clinical condition. The nature, length and severity of the illness are also a consideration. Severe acute illness with pyrexia is another contributing factor. The elderly are particularly at risk from poor nutritional state, dehydration, poor mobility, incontinence, loss of sensation or vasomotor control and vascular insufficiency. All of these increase their likelihood of developing pressure sores.
Chronic illness, especially neurological deficit with muscular wasting, and/or spasticity also increases the risk, regardless of age group.
Extrinsic factors are concerned with standards of care. These include special measures for pressure relief, frequency of nursing attention and the prevention of contact of urine and faeces with the skin.
Excessive internal pressure
As early as 1929,2 research has shown that pressure sores develop from within and that compression pressure is three to four times greater at the bone than at the surface of the skin. This pressure may also distort collagen and elastic tissue. If high enough, it may overcome intraluminal blood vessel pressure and alter lymphatic vessels.
As a result, toxic intracellular materials and excess fluid remain in the tissues. There is much evidence to suggest that such disruption to blood flow results in loss of nutrient supply, particularly oxygen.
More recent studies have extended the pressure sore model to include the effects of pressure on interstitial fluid flow and lymphatic function.2
The relationship between pressure and time is also a factor in pressure sore development. Both low pressure for long periods and high pressure for short periods cause tissue damage.
Pressure sores are highly unpleasant for the sufferer. They are also a considerable financial burden. Patients with pressure sores stay longer in hospital and require more nursing time.3
In recent years there have been major changes in healthcare with more emphasis on prevention, the introduction of the nursing process and primary nursing, and a move towards a multidisciplinary approach.
The main recommendation of the first European conference on nursing convened by WHO in 1988 was that innovative nursing services should be developed which focus on health rather than disease.4
It said that the nurses practice should be based mainly on the principles inherent in the primary healthcare approach with a focus on multidisciplinary and multisectoral collaboration.4
Nurses, doctors, physiotherapists, occupational therapists, nutritionists and dietitians are all involved in reducing the incidence of pressure sores. Educationalists, administrators and purchasing officers also have a part to play.
The prevalence of pressure sores ranges from 3%-14% in acute hospital patients, with a higher incidence in the elderly.3 The aim must be to reduce this figure as much as possible. Certain strategies can help to achieve this.
The multidisciplinary team should be committed to the development of a pressure sore prevention policy. Education, planning and assessment of care also requires the involvement of all members. In such a group the nurses role is of paramount importance.
Pressure sore management and prevention has always been the nurses area of care and still is seen as such. Since Florence Nightingales proclamation that a pressure sore is the fault of the nurse5 nurses have felt responsible, and even guilty, about the incidence of pressure sores.
Up to date research
In the past, efforts to prevent pressure sores were largely unscientific. Now after at least 30 years of research, the knowledge to prevent and treat them exists, which, according to Morrison appears to be under utilised.6
Nurses, as primary caregivers, are undoubtedly the most important members of the multidisciplinary team. Despite this key role in pressure area care, it seems that nurse education and training on this topic has been minimal. This has resulted in a general lack of confidence, initiative and knowledge among nurses.
Nurses must learn to work more confidently with other professionals in the team.
Doctors have shied away from involvement in pressure sore prevention and treatment. According to a Lancet editorial6 most doctors do not see pressure sore prevention and management as their responsibility. Like nurses they have not received training and education in this important area.
An example of doctors lack of interest in this area is demonstrated by the exclusion of any reference to pressure sores in referral letters. Nurses must make doctors more aware of the problem and its effects. For this reason, regular multidisciplinary team meetings are invaluable.
Physiotherapy involving both active and passive mobilisation of patients can help to reduce the incidence of pressure sores. Physiotherapists also help to train staff in proper patient lifting techniques. This is most important in avoiding friction as a cause of pressure sores.
The beneficial effects of even the most sophisticated support systems can be counteracted if nurses handle patients carelessly. Good lifting technique is very important.6
The physiotherapy profession is generally quite receptive to nurses suggestions and observations. As the patient may only be treated once a day, it is the nurse who must continue with the programme of exercises or mobilisation instigated by the physiotherapist.
Malnutrition is considered to be second only in importance to excessive pressure in the aetiology, pathogenesis, and non-healing of pressure sores.6 Therefore, the role of the nutritionist and the dietitian is an important one.
However, financial constraints permit nutritionists and dietitians to be employed only in the general hospitals. This leaves community and district hospitals and community care at a disadvantage.
The responsibility for patient nutrition in these areas falls on the nurse who must have the knowledge about the importance of protein, minerals and vitamins in preventing pressure sores. It is also the nurse who must encourage and observe what the patient eats.
The occupational therapist is another important member of the multidisciplinary team. Along with patient rehabilitation they have special training in assessing and advising on equipment required for patients at risk. These include special beds, mattresses, overlays, lifting equipment, seating, chairs and wheelchairs.
If possible, the purchasing supplies officer should be a member of the team. Confined by health service budgets, many items purchased can be inferior because they are cheaper. Nursing managers must therefore be able to justify the purchase of superior yet more expensive e