Putting the Pressure on Prevention

Pressure wounds cost health-care systems billions of dollars to treat. They can also cost your client's their independence.

Most people realize that Christopher Reeve raised public awareness for people living with disabilities and that he defied the odds by living a few years beyond life expectancy for someone with his level of paralysis. What many people may not realize is that Christopher Reeve died from a heart attack brought on by a systemic infection resulting from a pressure sore.

Common in people with spinal cord injuries (SCI), pressure sores are skin wounds caused by unrelieved pressure that prevents blood from reaching vulnerable parts of the body. Pressure wounds are debilitating, painful, costly and take a significant amount of time to heal.

Nearly 300,000 Americans have spinal cord injuries and, according to the Centers for Disease Control (CDC), the United States spends at least $1.2 billion to treat pressure sores. In order to avoid the considerable physical and financial toll of developing pressure sores, many physical therapists (PTs), occupational therapists (OTs) and other industry advocates seek to educate patients on their best option: Prevention.

"Pressure wound prevention is far easier than trying to cure a pressure wound, and far less expensive," says K.C. Jensen, Lauren Comfortechnology, New Philadelphia, Ohio.

Prevention of soft tissue breakdown is of great concern among clinicians and HME providers in home health. And the first step toward prevention is education.

"The terms pressure ulcer and friction/shear wound often get mixed together as the presentation can be very similar, but the causes are very different and so is the equipment used to prevent them," says Trudie Read, OTR/L, clinical education specialist for Varilite, Seattle.

"A friction/shear wound is when the tissue is torn, pierced, cut or otherwise broken by friction forces acting on the skin interface or shearing forces acting between the bony prominence and skin interface. A wound caused by friction or shearing forces in pressure-sensitive areas, such as the ischial tuberosities and the sacrum, has the potential of developing into a pressure ulcer by being exposed to prolonged pressure," Read says.

A pressure ulcer, Read explains, "is an area of localized destruction caused by the compression of soft tissue over a bony prominence and an external surface for a prolonged period of time. The compression of soft tissue interfaces with the tissue blood supply, leading to vascular insufficiency, tissue anoxia and cell death."

Distributing pressure is a way of preventing the development of pressure ulcers, but not shearing/friction force wounds. "Shearing and friction forces have to be addressed by lifting and handling techniques during transfers and repositioning with such items of equipment as tilt-in-space," Read explains.

People who have upper body strength and have the ability to reposition themselves have a greater chance of avoiding pressure wounds.

"I tell my customers that there is a very good reason why Medicare will reimburse, at a minimum, a general purpose wheelchair cushion for anyone who qualifies for a Medicare reimbursable wheelchair," Jensen says. "Medicare knows that anyone who spends a significant amount of time in a wheelchair is at least at some level of risk. And prevention is a great deal less painful, less time consuming and less costly than curing a pressure wound."

Who's at Risk?
While patients with limited mobility need to be assessed for the right preventative seating and positioning products and support surfaces, they also need to understand the significance that lifestyle factors play in the prevention of pressure wound development.

While enterostomal therapists (ETs), PTs and OTs help patients to reduce extrinsic risk factors — pressure, shear, friction and moisture — to allow for an environment of healthy blood flow, there are a number of intrinsic risk factors that clinicians cannot control.

"Lifestyle choices have a big impact on someone's risk for pressure wounds," says Tina Roesler, MSPT, ABDA, director of training and education for The ROHO Group, Belleville, Ill. "People tend to focus on clients who are inactive, when in reality, a person with an active lifestyle and multiple risk factors may develop pressure ulcers more frequently."

Roesler explains that active users, with SCI for example, may be participating in more high-risk activities. "They are transferring to different surfaces and from different heights and are up for more hours during the day. Combine this with other intrinsic risk — lack of sensation, decreased muscle mass, diminished blood flow from lower extremities and extrinsic risk — and you have a very high-risk client," Roesler says.

Lifestyle choices such as a poor diet and smoking can greatly increase the likelihood of pressure ulcer development.

"Tobacco, alcohol and drug use affect tissue health. A person's nutrition can be affected by their lifestyle as access to nutritional foods may be difficult, says Read. A risk-taking lifestyle attitude will have many effects, such as the potential for trauma, belief of susceptibility, lack of preventative measures and failure to seek assistance."

Other questions to consider: Does the patient suffer from a chronic disease? How is the patient's overall health? His or her age? Does he/she take medications? Are there any psychological barriers? What is the patient's living situation?

The Risk Factor Checklist can help you identify if your client is at risk for developing pressure sores. Risk Factor Checklist

Clients must be assessed holistically, factoring in their current condition with their lifestyle choices. "We need to make sure we are addressing the whole patient," says Cynthia Fleck, R.N., BSN, ET, WOCN, a board-certified wound specialist for Medline Industries Advanced Wound Care Division.

"In the home health care arena, our main partners are our patients and their support systems: family, friends, significant others and the community," Fleck says. "These people rely on us to be more than providers of medical equipment and care; they require us to be problem solvers. Educating these key people can mean the difference between wound success and failure."

Your clients can use the Prevention Activities Checklist to increase their awareness of how their daily choices may put them at risk for the development of a pressure wound.

Patients can improve their overall quality of life through education, the appropriate products and through the understanding of the considerable role that lifestyle choices play in reducing the risk. Currently, the problem is getting worse, with approximately one third of patients with SCI developing pressure sores.

"There needs to be more public awareness of pressure wounds and more funding out there on the prevention side," Read says. "It's crazy that insurance companies won't pay for a $300 pressure-distributing wheelchair cushion, but they will cover surgery that will cost tens of thousands of dollars."

"We are an aging population and that includes people using wheelchairs, so this problem of pressure ulcer development is only going to grow," she says.

Roesler agrees on the need for more public awareness, specifically on the implications of pressure wounds: "The education needs to extend to wheelchair users, clinicians and suppliers. Many suppliers and clinicians are unaware of the devastating effects of pressure wounds and there are simple preventative measures that we can take with clients to minimize risk.

"There is a tendency for people to think that pressure wounds only happen to their critically ill relatives who are receiving poor care — but Christopher Reeve is a high-profile example of how this is wrong."

Prevention Activities Checklist

Prevention Activities Checklist for the Client:

  • Check your body for any skin irritations or red patches, especially in areas where bones come into contact with surfaces such as buttocks and heels.
  • Work with an occupational therapist on a plan that balances work, play and rest. Address how to manage that balance should a sore emerge.
  • Relieve pressure by changing positions every hour.
  • Get enough rest.
  • Consider the impact of employment on your condition.
  • If you identify a red patch, notify your physician immediately.
  • Early detection is the best tool. Keep pressure off the wound.
  • Maintain proper hygiene which is extremely important in preventing pressure wounds from developing.
  • Wear soft, absorbent material with a quick-drying surface to minimize contact between urine or fecal matter and skin.
  • Clean skin as soon as it is soiled.
  • Inspect skin at least once a day to identify problem areas before they become serious. Pay special attention to pressure points and reddened areas that do not fade after you change position. Use a mirror or ask for a caregiver's help for hard-to-see areas.
  • Use a soft sponge or cloth to reduce friction.
  • Bathe with warm water and mild soap. Avoid moisturizers or soap with alcohol.
  • Keep skin moist with cream or oil, but minimize moisture from wounds, urine, stool or sweat.
  • Avoid cold or dry air.
  • Use special ointments to protect skin from unwanted moisture. A thin layer of cornstarch can reduce friction damage.
  • Poor nutrition affects the entire body. Healthy eating means healthier skin and circulation. Eat a balanced diet, if at all possible. If not, talk to your health-care provider about nutritional supplements. Protein and calories are particularly important.
  • If you smoke, keep in mind the skin of smokers heals slowly and inefficiently, as smoking affects the blood supply to the skin. A single cigarette can markedly reduce blood circulation for more than one hour. The causes include constriction of the blood vessels by nicotine, or carbon monoxide interfering with the ability of blood to deliver oxygen to the tissues. This inability to heal may cause the wounds to become infected or re-open.

(The American Occupational Therapy Association as well as Dan M. Eilerman, PT and clinical education specialist for Varilite, Seattle, contributed to the compilation of this list.)

Risk Factor Checklist

  • Immobility — most significant factor, leads to tissue being exposed to pressure over a long period of time.
  • Spasticity
  • Edema
  • Skinny Body Type — makes for less padding over bony prominences, such as ischial tuberosities, sacrum and trochanters, so the blood supply is quickly restricted.
  • Hx Tissue Damage — such as previous pressure ulcer or burn/ scar tissue is less tolerant to pressure
  • Obesity/Poor Nutrition — inadequate caloric intake decreases subcutaneous tissue
  • Tobacco/ Alcohol/Drug Abuse — affects circulation and tissue health and affects attention to personal care
  • Incontinence/Moisture — moist skin and acidity in urine affects skin integrity
  • Poor Hygiene
  • Advanced Age — the natural aging process decreases the skin's tolerance to pressure
  • Altered Mental State
  • Chronic Disease State and Medications — affects healing
  • Peripheral Vascular Disease
  • Cognition — poor safety awareness may result in trauma
  • Decreased Range of Motion — leads to poor posture
  • Dependence with Functional Tasks — such as transfers and personal care
  • Stress / Depression — affects attention to personal care and seeking assistance
  • Friction and Shear
  • Previous History — a previously injured area is at best 70 percent to 80 percent the strength it was before
  • (Trudie Read, OTR/L, clinical education specialist for Varilite and Tina Roesler, director of training and education for The Roho Group, contributed to the compilation of this list.)

This article originally appeared in the January 2005 issue of Mobility Management.

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