CLINICAL
Nursing aspects of pressure sore
prevention and therapy
Fiona Culley
T he exact state of pressure sore occur-
rence in the UK remains difficult to
determine, particularly in coinmunit)'
settings. Dissemination of pressure sore preva-
lence and incidence rates, and a growth in the
number ot tissue viability specialist posts arc
some of the factors contributing to a greater
emphasis on audit of the current status, prac-
tices and outcomes relating to pressure sore
prevention and management, thus raising the
profile of pressure sore strategies within health-
care organizations.
At a more extensive level the National
Pressure Ulcer Advisory Panel (NPUAP) was
established in the USA in 1989 to provide a
forum for expert opinion, to guide research,
education and public policy. Members of the
panel who include representatives from the
healthcare professions, as well as equipment
manufacturers, have produced comprchensi\'e
clinical practice guidelines, based upon scientif-
ic evidence and clinical expertise (Agency for
Health Care Policy and Research (AHCPR),
1994). A similar approach has heen adopted by
the recently formed European Pressure Ulcer
Advisory Panel (EPUAP), who has gathered
experts from 14 European countries with the
aim of improving outcomes in pressure ulcer
prevention and therapy (see Pp. 888-90)
While many examples of good practice have
been reported in the literature, and shared at
conferences as well as through professional
interest groups such as the Tissue Viabilitj'
Societ)' and Wound Care Society, examples of
fragmented approaches to pressure area man-
agement have been observed in clinical settings.
The National Audit Commission (1995) high-
lighted some .serious lapses in pressure sore pre-
vention in the elderly which were mainly due to
poor risk assessment and inadequate documen-
tation and communication of care. O'Dea
(1993) revealed that 33% of hospital patients
with identified pressure damage remained
nursed on standard hospital mattresses. During
the same period it was estimated that pressure
sores were costing the NHS 32Qm in pro-
Abstract
Pressure sores remain a significant problem in hospitals and domestic
settings, affecting people of all ages, social class and race. Associated
complications may be life threatening, e.g. sepsis and osteomyelitis.
Other less dangerous, but nevertheless compromising outcomes such as
pain, discomfort and low self-esteem and body image can cause personal
suffering, and may add extra demand for limited resources. The exact
state of pressure sore occurrence remains difficult to determine,
particularly in the community. Recent trends in pressure area
management present a multidisciplinary approach, eroding traditional
perceptions of pressure sores as a solely nursing problem. Written from a
nursing perspective, this article summarizes principles of good practice
relating to pressure sore prevention and therapy, emphasizing the
importance of documenting observed events, rather than assumptions or
opinions, and the need for healthcare professionals to approach problems
and needs from a collaborative stance. Pressure sore risk assessment
and classification are discussed, and an overview of nutrition, moving and
handling, selecting support surfaces, principles of wound management,
and skin care are considered.
longed hospital stays. The true costs of pressure
sores remain impossihie to quantify, although a
clearer picture of some expenditure, such as
equipmeiir funding and litigation costs, is
beginning to emerge.
Educational initiatives and research pro-
grammes are necessary to support the develop-
ment (jf practice, and are critical constituents of
quality improvement and accountable practice.
Healthcare providers are continuing to forge
links with academic institutions aiitl commer-
cial organizations to this end.
RISK ASSESSMENT
Tingle (1997) cites several legal cases arising
from 'poor pressure area care' in acute hospital
trusts and nursing homes. All were attributed
to insufficient identification of risk factors, with
no evidence of risk assessment. Settlements Fiona Culley is Senior
awarded for suffering related to the develop- Lecturer, Department of
Po^t Registration Nursing,
ment of pressure sores ranged from 4500 to Universit>- of Hertfordshire.
12 500. Although the courts provide one Herts
means of settling complaints, the proceedings
LLINICAL
are often costly, timely and discriminatory.
Classification
Alternative dispute resolution (out-of-court)
can be costs shouid also he considered. Because of the
particularly difficult necessarily confidential and discreet nature of
managing complaints, it is difficult to assess or
in darkly pigmented
predict such figures.
skin, as blanching or The obligation of professional accountabil-
non-blanching iry for acts and omissions relating to the duty
hyperaemia and of care is explicitly communicated to nurses
via the UKCC's Code of Professional
superficial epidermal Conduct (UKCC, 1992a). Pressure sore risk
breaks can be very assessment is part of being accountable, and
hard to detect. the measurement of commonly recognized
intrinsic and extrinsic risk factors may help to
Similarly, necrotic support decision making. Risk factors must
pressure sores are be documented (UKCC, 1993) and, more
difficult to classify as importantly., acted upon.
Like other aspects of care, assessment,
the full extent of reassessment and evaluation of the patient's
tissue damage pressure sore risk status are the responsibility
cannot be seen until of the registered nurse with the relevant
knowledge and comprehension of the com-
the area is plex aetiology of pressure sores. The UKCC
debrided. {1992a,b) specifies that registered nurses,
healthcare assistants and student nurses must
not work beyond their level of competence.
Effective risk management is dependent on an
appropriate skill mix, for which the nurse
manager is answerable.
In many healthcare contexts, formally
established pressure sore risk assessment
scales such as Norton (Norton et al, 1962),
Waterlow (1985) and Braden (Bergstrom and
Braden, 1987) are used to encourage system-
atic evaluation of an individual's at-risk sta-
tus. Although such tools have been criticized
for their lack of validity and reliability and
weak predictive value (Bridel, 1993), they
remain a useful aide-memoire to prompt
review of the commonly recognized causative
factors of tissue damage. They are not intend-
ed for use as a prescriber of specific pressure
reducing or relieving support surfaces, but
rather to indicate the degree of risk, and the
risk factors that particularly relate to an indi-
vidual's condition at any given time.
If the employing authority does not use an
established assessment tool, it should be able
to demonstrate that similar processes of sys-
tematic review have been implemented.
Undoubtedly, other members of the multidis-
ciplinary healthcare team may significantly
contribute to risk assessment and manage-
ment., and a collaborative approach is a criti-
cal success factor.
The patient's management is communicated
through accurate documentation, which may
at some time be needed as reference for inves-
tigation of complaints, or even be subpoenaed
by a court of law as documentary evidence
(Dimond, 1995). In addition to written notes,
photographic records can prove invaluable.
Where possible, photographs should be taken
by a trained medical photographer. Ethical
principles of consent and confidentiality
should always be honoured. As part of assess-
ment, there should be a record of the degree of
skin and tissue damage. Classification (grad-
ing) of such information is of prime impor-
tance in facilitating communication bet^veen
staff, to help monitor healing.
CLASSIFICATION (GRADING) OF
PRESSURE SORES
Although several methods exist for classifying
or grading pressure sores (David et al, 1983;
Torrance, 1983; Reid and Morison, 1994;
NPUAP in AHCPR, 1994), they all use the
same approach, i.e. allocating a score to the
skin structures and other tissues involved.
Like risk assessment, classification is extreme-
ly reliant upon an understanding of rhe relat-
ed anatomy, and is the responsibility of a
suitably experienced registered nurse.
Classification can be particularly difficult
in darkly pigmented skin, as blanching or
non-blanching hyperaemia and superficial
epidermal breaks can be very hard to detect.
Similarly, necrotic pressure sores are difficult
to classify as the full extent of tissue damage
cannot be seen until the area is debrided.
Also, most classification systems make no
provision for the appearance of blistered skin.
While it is sometimes complicated, pressure
sore classification should not be abandoned,
but needs to be an integral part of nursing
documentation, so that a clear account of
when tissue damage was first identified and
the outcomes of care are evident. Once risk
assessment and classification have been car-
ried out, the necessary principles of pressure
sore prevention and therapy can be applied.
PRINCIPLES OF GOOD PRACTICE
Skin care
The maintenance of a good skin condition
can greatly minimize the risk of tissue break-
down. Healthy skin will be clean and well
 hydrated. Skin over bony prominences should
most not be massaged or rubbed, as this will exac-
patients, regular erbate friction and could cause tissue damage
repositioning is an (Dyson, 1978; Ek et al, 1985). An increase in
humidity and moisture exacerbates skin mac-
effective strategy eration, compromising tissue viability; conse-
towards reducing quently, plastic sheeting and layers of inconti-
and/or relieving nence padding, for example, should be avoid-
ed wherever possible, or at least be changed
interface pressure at the earliest opportunity. Placing extra lay-
the amount of ers between the skin and the support surface
pressure generated is likely to reduce its effectiveness.
Mechanical skin injury from friction may
between the patient's he reduced by the careful application of
skin and the barrier dressings such as film dressings (Hall,
support surface... 1983; Hampton, 1998); however, if film
dressings are used, care must be taken to
Of primary ensure that they stay in place, and do
importance not wrinkle, as this can cause additional risk
is the patient's to tissues.
mobility. hlutntion
The effect of nutritional status upon tissue
integrity has been shown greater considera-
tion in recent years. Lennard-Jones (1992)
reported that more than 50% of malnour-
ished hospital patients may go unnoticed in
the UK, Patients with complex wounds are at
greater risk of malnutrition because of
increased metabolic needs, increased loss of
nutrients, and poor dietary intake due to loss
of interest and appetite. People with pressure
sores that produce copious amounts of exu-
date are at particular risk. The British
Association of Parenteral and Enteral
Nutrition (BAPEN, 1994) advocates that all
patients at risk of, or diagnosed as, being mal-
nourished, should undergo nutritional assess-
ment on, or before, admission to hospital,
and have access to a muItidiscipHnary nutri-
tional support team. In reality, however,
many healthcare providers do not have the
resources to meet this objective, meanwhile
the escalating costs of tissue breakdown or
delayed healing may go unrecognized.
Moving and bandling
I'or most patients, regular repositioning is an
effective strategy towards reducing and/or
relieving interface pressure the amount of
pressure generated between the patient's skin
and the support surface (Fletcher, 1996). Of
primary importance is the patient's mobility.
Friction and shear may occur when the
patient is moving in bed, or from bed to chair
(Dealey, 1997). The Manual Handling
Operations Regulations (Health and Safety
Executive, 1992) has helped to improve
awareness and technique, as well as increase
access to a variety of mechanical aids.
Appropriate training in the use of such aids is
imperative, as misuse can also cause tissue
damage.
A repositioning schedule should be estab-
lished for those people with restricted mobil-
ity in bed or a chair. It remains unclear how
often a person should be moved, and even
when pressure relieving/reducing support sur-
faces are used, regular repositioning remains
important tor promoting comfort and assist-
ing with pulmonary drainage.
An alternative to traditional positioning
techniques is the use of the 30 tilt. With this
technique, a pillow is used to tilt the patient
at an angle of 30" when lying in bed. This has
been shown to reduce interface pressure on
the buttocks (Preston, 198S). However, it is
not suitable for all patients. For instance,
those with contractures or muscle spasm may
have difficulty in tolerating the position, or
may be unable to straighten their limbs suffi-
ciently (Dealey, 1997).
Using pressure relieving/reducing support
surfaces
As part of a wider treatment plan, another
major aspect of pressure sore prevention and
therapy in hospitals and domestic settings is
the use of pressure reducing/relieving support
surfaces. Young (1992) reported 18 different
categories of such equipment, represented by
70 different brand names. Despite the avail-
ability of a wide range of equipment, for both
rental and purchase, there is little evidence to
support the efficacy of some devices {Hitch,
1995; Fletcher, 1996) and no compelling evi-
dence that one support surface consistently
performs better than all others under all cir-
cumstances (AHCPR, 1994). While capillary
closing pressure is a measure of the effective-
ness of support systems, its measurement is
impractical and unlikely to be performed
within the care environment. However, evi-
dence of non-blanching hyperacmia should
be regarded as a reliable clinical indicator
that the existing support surface is not ade-
quately relieving localized pressure, and an
explanation of how care and equipment use
was modified should be documented. Within
the UK, the number of field-based clinical
 trials appears to he increasing, with manufac-
turing companies working in collabt)ratiun
with hospital personnel, community health
staff, and academic institutions.
Dealcy (1497) reports on a national politi-
cal debate, which highlighted The Health uf
the NLUIOU (Department of Health, 1991) tar-
gets anti indicated a need for a specialist nurse
knowledgeahle in the- ubc of pressure-reliev-
injj equipment, to reduce the coniple.\ity of
product selection and usage. Several factors
influence the selection of equipment [Tal){c
1). Equal attention should he paid to the
patient's need for support surfaces when seat-
ed as well as in bed.
Wound management
Once tissue damage is identified and classi-
heel, it is necessary to select appropriate topi-
cal therapy based upon holistic wound assess-
ment, takinn into acLOunt the multiplicity of
factors known to promote healing. The man-
Table 1 . Factors influencing
the selection of equipment
Resources
Risk status
Condition and comfort ofthe patient
Patient's weight and build
Acceptability to the patient {or resident)
and carer
Degree of tissue damage
Ability to tolerate a moving, rather than
non-moving surface
Safety factors
Source: Young (1992)
Table 2 . Criteria of an ideal dressing
Removes excess exudate and to.xic components
Maintains high humidity at wound-dressing interface
Allows gaseous exchange
Provides thermal insulation
Impermeable to microorganisms
Free from particulate and toxic contaminants
Removable without causing trauma
Turner (1982)
agement of patients with wounds is a complex
activity, encompassing more than simply the
selection of an appropriate dressing product.
Recent advances in the development of
wound contact materials, however, have
resulted in a rapid proliferation of different
t>pes of dressings., making the selection of
an appropriate product confusing. One
framework offering criteria for the opti-
mum wound dressing is that of Turner
(1982) shown in Table 1.
Commonly used contemporary wound
dressings in the UK include alginates.,
enzymes, foams, hydrocolloids. hydrogels
and film membranes. Local and systemic
infection must be reduced with appropriate
antibiotic therapy. Most modern dressings are
reported to be comfortable to wear, with dress-
ing changes generally less painful than those
associated with traditional applications. Some
ilifficulties in obtaining the complete range ot
dressings are reported b\' practitioners, particu-
larh' those in\'olved in community care where
drug tariffs continue to restrict tbe range of
dressings available.
On rarer occasions, chronic pressure sores
may require surgical intervention, most com-
monl) skin grafts and tissue flaps (Black and
l^ilack, 19S7). Where such surgery is indicated
the patient is referred to the specialist plastic
surgeon., following a comprehensive health
assessment.
CONCLUSION
As more is understood about tbe complex
nature of pressure sore prevention and man-
agement., the relationship bet^veen social and
political influences and healthcare becomes
increasinglj- apparent. With appropriate educa-
tion and clinical e\ iJence, It is hoped that prac-
titioners will respond positively to the many
challenges of pressure sore prevention and ther-
apy, and contribute towards the development
of local and national standards for got)d prac-
tice. Although a lack of consensus may appear
to impair the development of risk assessment
and classification tools, it is anticipated tbat
established forums such as NPUAP and EPUAP
will promote further dialogue and action.
Introducing and retaining pressure sores
on die wider political agenda should heighten
awareness of the extent of the problem,
and should prompt regular appraisal of profes-
sional boundaries.
 Effective pressure e pressure sore pr(,-\encion nnd ther-
apy strategies re!\' upon many diflcrent areas
sore prevention
of expertise, including physiological, psy-
and therapy chosocial and financial perspectives. Each of
strategies rely upon these areas needs to he examined through fur-
ther i.|ualir.uive AW^ quanrirarive studies, if
many different areas pressure arc'a management is to he appropri-
of expertise, ately resourced and de\'cKipcd. EH
including
AMCPR (l'J94) Trc.ilrnefit nf Pressure Vh-fn.
physiological, (JIIIICJI I'rjctice CiiitdeHiie Xn IS. United Sr.ues
Dcpartmt-nt of Health aiul Hiini,in Services,
psychosocial and KockvillcUSA
BL-r{;sm)m N, Bradcn U (1987}'Ihe Bra Jcii scale tor
financiai prcdicrmti pressure sore risk, iV/(rs Kes 56(4):
211^-10
perspectives. Each of Black J, Black S (!''S71 Surj-ical m.inat;ement ..f
pressure ulet-rs. \'iiis Clin \'"ylh Anicricj 22(2):
these areas needs to 42^>
Brii.k'1 J (1*^^*1) T h e .uriu!(it;y i>f p r e s s u r e s u r e s . }
be examined Wnuiui Circ 2 ( 4 ) : 2;^0-2..>K
V,:\\'EK I I'''Ml Sl.i'uLirJs .uiJ Guniclincs for
through further \ii(ii!i(iii,!l Supjxiil fur l\iihi!l$ .iiiJ
I'.APEN. M.itdcnlie.id
qualitative and David ]A, Chapman KG. Chai-trnaii E| (19S3) An
hircstigjtinit of (.iirroil MdhnJs i'scJ in \ui:<i'r^
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S.ihsbiii y
Dcpartmcni ut Weaiili (1491) J!,e Uvuhh u/ ihe
Sjtion. 1IMSO, l.nndon
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KEY POINTS

Dissemination of prevalence and incidence data, and a growth in the tissue

viability nurse population, are among the influences raising the profile of pressure
sore strategies within healthcare organizations.

Fragmented approaches to pressure area management continue and may be

reduced by education initiatives and research programmes aimed at supporting the
development of practice.

The evidence base underpinning tissue viability practice should encompass

physiological, psychosocial and financial issues, each being interdependent.

The escalating costs of tissue breakdown and delayed healing are impossible to
quantify, and often go unrecognized.

Assessment, reassessment and evaluation of pressure sore risk status are the
responsibility of registered nurses with the related knowledge and understanding of
the complex aetiology of pressure sore development.