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Editor's Page

An Evolving Understanding of Pressure Ulcers and Skin Failure

Gregg Warshaw, MD; Medical Editor

July 2012

Pressure ulcers, also referred to as decubitus ulcers or bedsores, have been noted throughout history, with reports dating back to ancient Egypt. Although we have come a long way in understanding and managing pressure ulcers, they are still commonly encountered in long-term care (LTC) residents and among populations in acute care settings. Studies have reported the incidence of pressure ulcers to be between 2.6% and 24% in LTC facilities. Although pressure ulcers are now largely considered to be preventable, it has been acknowledged by various medical organizations, including AMDA—Dedicated to Long Term Care Medicine (formerly the American Medical Directors Association), that certain factors can thwart even the best efforts to prevent these painful lesions. In some cases, however, the cause can only be attributed to substandard care, which itself may arise from a variety of factors, including a lack of resources, inadequate staff training on pressure ulcer prevention and treatment, and a lack of facility-wide protocols with regard to pressure ulcer management. 

This issue of Annals of Long-Term Care: Clinical Care and Aging® (ALTC) includes an American Association for Long Term Care Nursing article, “Pressure Ulcer Prevention Education: Creative Ways to Engage Staff”, which outlines the steps that one nurse educator took at her facility to teach staff  about pressure ulcers and how to prevent them. Her approach incorporates a variety of creative elements as a means of keeping students engaged, and she reports that within 5 years of implementing her teaching strategy, the nosocomial pressure ulcer rate at her institution dropped from 13% to 3%. Although staff education is an important facet of a prevention strategy, numerous other factors are equally important, including use of a validated pressure ulcer risk assessment tool and attention to proper nutrition and hydration. We include a tip sheet that outlines the Braden Scale for Predicting Pressure Sore Risk, which is among the most widely used tools for predicting the development of pressure ulcers. In addition, you’ll find “Issues and Challenges of Modified-Texture Foods in Long-Term Care: A Workshop Report,” which examines how modified-texture foods (MTFs), particularly pureed foods, can lead to undernutrition in LTC residents. In the article, the researchers note that MTFs often offer suboptimal nutrition compared with regular foods and they report that there is a lack of standardization when MTFs are produced in-house. Because nutrition is essential for pressure ulcers to heal, this may be an area for healthcare providers to review when a patient with a pressure ulcer is also receiving MTFs.     

Another condition that is increasingly being encountered in the LTC setting is skin failure (ie, an event in which the skin and underlying tissue die due to hypoperfusion secondary to severe dysfunction or failure of other organ systems, resulting in sloughing), which has now been recognized as a distinct condition and a contributing factor to pressure ulcer development. More research is needed to understand the multitude of physiological and biological changes that occur to organ systems, including the skin, as people age. It is also still unclear which patients may be prone to developing skin failure, as not all patients who have pressure ulcers at the end of life also have skin failure. In “Skin Failure: Identifying and Managing an Underrecognized Condition”, the authors differentiate between skin failure and pressure ulcers, and they outline skin failure prediction tools and plans of care.

As always, we welcome your thoughts on the articles contained in this issue of ALTC. Your feedback can be sent to our assistant editor, Allison Musante, at amusante@hmpcommunications.com. We also encourage you to visit our Website and take this month’s poll: “Before recommending a diet of MTFs (ie, pureed, minced foods) to your residents, do you administer a screening or assessment tool, such as the Mini Nutritional Assessment or the Nutrition and Swallowing Checklist, to identify residents at risk of nutritional and swallowing problems?” Poll results will be posted online and in an upcoming journal e-newsletter. 

Thank you for reading!

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