A pressure ulcer (also known as a pressure sore, bed sore, and decubitus ulcer) is defined as an area of injury to skin and/or underlying tissue, usually over a bony prominence (e.g., heel or sacrum) caused by friction, shear, or prolonged pressure. Pressure ulcers are “staged” to describe the severity of tissue injury and destruction.
A stage I pressure ulcer is defined as intact skin with non-blanchable redness over a bony prominence. When compared to adjacent tissue, a stage I pressure ulcer may have a different skin temperature (warmth or coolness), tissue consistency (firm or soft feel), and/or sensation (pain).
A stage II pressure ulcer involves partial thickness skin loss that appears as a shiny or dry shallow open ulcer with a red pink wound bed and no slough (i.e., dead tissue that is moist, stringy, and yellow or gray) or bruising. A stage II pressure ulcer may also appear as an intact or ruptured serum-filled blister.
A stage III pressure ulcer involves full thickness tissue loss that may expose subcutaneous fat. Bone, tendon, and muscle are typically not exposed with a stage III pressure ulcer. While slough may be present with a stage III pressure ulcer, the extent of tissue loss remains visible. A stage III pressure ulcer may also involve undermining (i.e., destruction of tissue extending under the edges of the skin so that the pressure ulcer is larger at its base than at the skin surface) and tunneling (i.e., passageways of tissue destruction under the skin’s surface with an opening at the skin level from the edge of the wound).
A stage IV pressure ulcer involves full thickness tissue loss with exposed bone, muscle, and/or tendon. Slough and eschar (i.e., dead tissue that has become leathery or thick and black) may be present on some or all of the wound bed of a stage IV pressure ulcer, and undermining and tunneling are often present. A stage IV pressure ulcer may extend into muscle and supporting structures, making osteomyelitis (i.e., bone infection) possible.
A pressure ulcer is “unstageable” when it involves full thickness loss that covers the base of the wound with slough or eschar such that the true depth and, therefore, the stage of the ulcer cannot be determined.
Aside from stageable and unstageable pressure ulcers, a pressure ulcer may also involve deep tissue injury (DTI). Suspected deep tissue injury may occur with a purple or maroon area under intact skin or a blood-filled blister. The bruising indicates possible deep tissue injury. When compared to adjacent tissue, a deep tissue injury may have a different skin temperature (warmth or coolness), tissue consistency (firm, mushy, or boggy), and sensation (pain). A deep tissue injury may also involve a thin blister over a dark wound bed followed by a thin layer of eschar.
Pressure ulcer prevention in nursing homes and assisted living facilities is critical. Specifically, nursing homes and assisted living facilities must prevent new pressure ulcers from developing, prevent existing pressure ulcers from getting worse, promote healing of all pressure ulcers, and prevent healed pressure ulcers from recurring. In a nursing home, the nursing home must ensure a patient who enters the facility without pressure ulcers does not develop them unless the patient’s clinical condition demonstrates the pressure ulcers were unavoidable. The nursing home must also ensure a patient with pressure ulcers receives necessary treatment and services to promote healing, prevent infection of an existing ulcer, and prevent new pressure ulcers from developing. In an assisted living facility, the facility must provide services to prevent clinically avoidable complications, including the development and deterioration of pressure ulcers.
Pressure ulcer prevention in a nursing home or assisted living facility requires staff to identify a patient’s risk of developing pressure ulcers. The nursing home or assisted living facility must start its prevention by assessing the patient for the risk of developing pressure ulcers. Risk assessments are usually performed by using a Braden scale or Norton scale. The Braden scale is most frequently used, followed closely by the Norton scale. However, no particular standardized risk assessment or form includes all relevant risk factors (e.g., prior pressure ulcers, diabetes, vascular disease, previous pressure ulcers, etc.), so while the use of one of these scales may be necessary, a single form may not be sufficient unless all relevant risk factors are considered.
Once a patient’s risk of developing a pressure ulcer has been properly identified, the nursing home or assisted living facility must develop a care plan that minimizes the role played by each potential risk factor. Risk factors include unrelieved pressure, friction and shear, moisture, poor nutrition and hydration, and pain. With respect to avoiding unrelieved pressure, staff should turn and reposition patients in bed every two hours and more often as necessary, “float” (suspend) the heels off of the mattress or chair at all times for complete pressure relief, and ensure patients are not positioned on existing ulcers. When patients are in a chair, the patients should be repositioned and off-loaded at least once every hour.
With respect to the risk of friction and shear, the patient’s bed should be elevated at a maximum of 30 degrees unless otherwise clinically necessary, and proper transfer technique (e. g. sheet transfer) should be used during all transfers. A nursing home or assisted living facility should also use heel protectors at all times to minimize the effects of friction and shear on patients’ heels. However, heel protectors, while helpful against the effects of friction and shear, are inadequate by themselves as pressure-relieving or pressure-reducing devices. With respect to the effects of moisture, urine and feces are skin toxins that make skin more vulnerable and more prone to breakdown. As such, a nursing home or assisted living facility should require its staff to clean urine and feces from the skin of its patients as soon as possible. With respect to nutrition, poor nutrition depletes protein stores and results in less energy to meet the body’s needs. A nursing home or assisted living facility should ensure adequate nutrition and hydration at all times.
Finally, with respect to pain, pressure ulcers have been described by researchers as “a significant and increasing source of considerable human suffering.” Pressure ulcers are themselves painful. Aside from the inherent pain of a pressure ulcer, a pressure ulcer becomes more painful during a patient’s movement and activity, during routine procedures like dressing changes and wound cleansing, and when the ulcer is debrided or surgery on the ulcer is required. Since severe pressure ulcers result in more severe and persistent pain, a nursing home or assisted living facility should ensure a patient with pressure ulcers does not experience avoidable pain.
Finally, in Virginia, an assisted living facility cannot admit or retain patients with stage IV pressure ulcers. An assisted living facility in Virginia also cannot admit or retain patients with stage III pressure ulcers unless the ulcers are determined by an independent physician to be healing and, then, only if a licensed health care professional under a physician’s or other prescriber’s treatment plan performs necessary dressing changes. An assisted living facility cannot admit or retain a patient with any pressure ulcer unless the facility can provide services necessary to prevent the development of new ulcers and the deterioration of existing ulcers.