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...
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