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A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Pressure, over time, occludes blood and lymphatic circulation, causing deficient tissue nutrition and buildup of waste products, due to ischemia. Practitioners should also be aware of the relationship between intensity of pressure and duration of pressure. Specifically, low pressures over a long period of time are as capable of producing tissue damage as high pressure may produce in a short period of time. If pressure is relieved before a critical time period is reached, a normal compensatory mechanism, reactive hyperemia, restores tissue nutrition and compensates for compromised circulation. If pressure is not relieved before the critical time period, the blood vessels collapse and thrombose. The tissues are deprived of oxygen, nutrients and waste removal. In the absence of oxygen, cells use anaerobic pathways for metabolism and produce toxic byproducts. The toxic byproducts lead to tissue acidosis, increased cell membrane permeability, edema, and eventual cell death. Although prolonged uninterrupted pressure is the cause of pressure sores, impaired mobility is probably the most common reason patients are exposed to uninterrupted pressure. These patients (with impaired mobility) cannot adequately alter their position with enough frequency to relieve pressure. Moreover, this immobility, if prolonged, may lead to muscle and soft tissue atrophy, decreasing the bulk over which bony prominences are supported. Muscle and fat tissues are more metabolically active and, thus, more vulnerable to hypoxia with increased susceptibility to pressure damage. It is for that reason that a relatively small surface wound may have significant subsurface damage including tunneling and undermining. Many pressure ulcers can be prevented, and those Stage I pressure ulcers that do appear need not worsen under preventable circumstances. However, even the most vigilant nursing care may not prevent the development and worsening of ulcers in some high-risk individuals. In those cases, intensive therapy must be aimed at reducing risk factors (such as improving nutritional status), at preventive measures (such as frequent turning, and the use of mattress overlays), and at treatment. From a regulatory vantage, pressure ulcers may be classified as “avoidable” or “unavoidable.” Avoidable pressure ulcers are those pressure ulcers that developed when a clinician or facility “did not do one or more of the following: evaluate the residents clinical condition and pressure ulcer risk factors; define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice; monitor and evaluate the impact of the interventions; or revise interventions as appropriate.” Unavoidable pressure ulcers are those that developed “even though the facility had evaluated the resident’s clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice; monitored and evaluated the impact of the interventions and revised the approaches as appropriate.” Of critical importance to the determination of avoidable or unavoidable status is proactive, ongoing and timely documentation of assessments, risk factors, interventions, attempted interventions, effect of interventions, and compliance. Interventions include early detection maneuvers such as risk factor identification by assessing mobility, nutritional factors, continence, and level of consciousness. Before classifying a wound as a pressure wound, great care should be used to establish that there is not another health condition that predisposed the individual to the wound and that would therefore change the wound type. Many lower extremity wounds of diabetic and arterial origin have been mistaken for pressure ulcers, and if care is not used to establish and understand the conditions driving the wound, then some important components of a comprehensive treatment plan may be overlooked. In order to appropriately establish wound type and etiology, a thorough wound assessment should be completed as required by state and federal guidelines. This thorough initial wound assessment or wound reassessment (as a component of a wound status change) is described AHS’ Assessment Guideline. It requires a detailed assessment of the whole patient and their history as well as other factors including duration of the wound, patient’s recollection of the causative factors, complaints of pain, fever, numbness or drainage. References
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