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Pressure Ulcer Risk Factors Among Hospitalized Patients With Activity Limitation

Objective. To identify specific demographic, medical, functional status, and nutritional characteristics that predict the development of stage 2 or greater pressure ulcers among patients whose activity is limited to bed or chair. Design. Prospective inception cohort study. Setting. Tertiary care, urban, university teaching hospital. Patients. A total of 286 patients fulfilling the following criteria: admitted to the hospital within the previous 3 days, age 55 years or more, expected to be confined to bed or chair for at least 5 days or had a hip fracture, and without a stage 2 or greater pressure ulcer. Main Outcome Measure. Time to in-hospital development of a stage 2 or greater pressure ulcer. Results. Total cumulative incidence of pressure ulcers was 12.9% (n=37) after a median time of 9 days from admission to final skin examination. Age of 75 years or more, dry skin, nonblanchable erythema (a stage 1 pressure ulcer), previous pressure ulcer history, immobility, fecal incontinence, depleted triceps skinfold, lymphopenia (lymphocyte count <1.50109/L), and decreased body weight (<58 kg) were significantly associated with pressure ulcer development by univariate Kaplan-Meier survival analyses (P<.05 by log-rank test). Risk ratios (and 95% confidence intervals) for predictors (P.05) of pressure ulcer development after multivariable Cox regression analysis included the following: nonblanchable erythema, 7.52 (1.00 to 59.12); lymphopenia, 4.86(1.70 to 13.89); immobility, 2.36 (1.14 to 4.85); dry skin, 2.31 (1.02 to 5.21); and decreased body weight, 2.18 (1.05 to 4.52). The 3-week cumulative incidence of pressure ulcers with none, one, two, or three or more of these characteristics was 0%, 11.4%, 39.6%, and 67.9%, respectively (P<.001 by log-rank test). Conclusions. These results suggest that nonblanchable erythema, lymphopenia, immobility, dry skin, and decreased body weight are independent and significant risk factors for pressure ulcers in hospitalized patients whose activity is limited to bed or chair. (JAMA. 1995;273:865-870)

Your Risk

Confinement to bed or a chair, being unable to move, loss of bowel or bladder control, poor nutrition, and lowered mental awareness are risk factors that increase your chance of getting pressure ulcers. Your risk results from the number and seriousness of the risk factors that apply to you. 1. Bed or chair confinement. If you must stay in bed, a chair, or a wheelchair, the risk of getting a pressure ulcer can be high. 2. Inability to move. If you cannot change positions without help, you are at great risk. Persons who are in a coma or who are paralyzed or who have a hip fracture are at special risk. Risks of getting pressure ulcers are lower when persons can move by themselves. 3. Loss of bowel or bladder control. If you cannot keep your skin free of urine, stool, or perspiration, you have a higher risk. These sources of moisture may irritate the skin. 4. Poor nutrition. If you cannot eat a balanced diet, your skin may not be properly nourished. Pressure ulcers are more likely to form when skin is not healthy. 5. Lowered mental awareness. When mental awareness is lowered, a person cannot act to prevent pressure ulcers. Mental awareness can be affected by health problems, medications, or anesthesia. Fortunately, you can lower your risk. Following the steps presented here can help you and your health care provider to reduce your risk of pressure ulcers.

Prevention Steps
The following steps for prevention are based on research, professional judgment, and practice. These steps can also keep pressure ulcers from getting worse. Some steps apply to all prevention efforts; others apply only in specific conditions. It may help to talk to a nurse or doctor about which steps are right for you.
Step #1 - Take care of your skin

Your skin should be inspected at least once a day. Pay special attention to any reddened areas that remain after you have changed positions and the pressure has been relieved. This inspection can be done by yourself or your caregiver. A mirror can help when looking at hard-to-see areas. Pay special attention to pressure points shown on page 2. The goal is to find and correct problems before pressure ulcers form. Your skin should be cleaned as soon as it is soiled. A soft cloth or sponge should be used to reduce injury to skin.

Take a bath when needed for comfort or cleanliness. If a daily bath or shower is preferred or necessary, additional measures should be taken to minimize irritation and prevent dry skin. When bathing or showering, warm (not hot) water and a mild soap should be used. To prevent dry skin:

Use creams or oils on your skin. Avoid cold or dry air.

Minimize moisture from urine or stool, perspiration, or wound drainage. Often urine leaks can be treated. To obtain a copy of Managing Urinary Incontinence: A Patient's Guide, call 1-800-358-9295 or write to the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. When moisture cannot be controlled:
1. Pads or briefs that absorb urine and have a quick drying surface that keeps moisture away from the skin should be used. 2. A cream or ointment to protect skin from urine, stool, or wound drainage may be helpful. If you are confined to bed: 1. A special mattress that contains foam, air, gel, or water helps to prevent pressure ulcers. The cost and effectiveness of these products vary greatly. Talk to your health care provider about the best mattress for you. 2. The head of the bed should be raised as little and for as short a time as possible if consistent with medical conditions and other restrictions. When the head of the bed is raised more than 30 degrees, your skin may slide over the bed surface, damaging skin and tiny blood vessels. 3. Pillows or wedges should be used to keep knees or ankles from touching each other. 4. Avoid lying directly on your hip bone (trochanter) when lying on your side. Also, a position that spreads weight and pressure more evenly should be chosen -- pillows may also help. 5. If you are completely immobile, pillows should be put under your legs from midcalf to ankle to keep heels off the bed. Never place pillows behind the knee. If you are in a chair or wheelchair: 1. Foam, gel, or air cushions should be used to relieve pressure. Ask your health care provider which is best for you. Avoid donut-shape cushions because they reduce blood flow and cause tissue to swell, which can increase your risk of getting a pressure ulcer. 2. Avoid sitting without moving or being moved. 3. Good posture and comfort are important.

Eat well

Eat a balanced diet. Protein and calories are very important. Healthy skin is less likely to be damaged. If you are unable to eat a normal diet, talk to your health care provider about nutritional supplements that may be desirable.
Improve your ability to move

A rehabilitation program can help some persons regain movement and independence.

Prevention Steps
Step #2 - Protect your skin from injury

Avoid massage of your skin over bony parts of the body. Massage may squeeze and damage the tissue under the skin and make you more likely to get pressure ulcers. Limit pressure over bony parts by changing positions or having your caregiver change your position.
1. If you are in bed, your position should be changed at least every 2 hours. 2. If you are in a chair, your position should be changed at least every hour. (If you are able to shift your own weight, you should do so every 15 minutes while sitting.)

Reduce friction (rubbing) by making sure you are lifted, rather than dragged, during repositioning. Friction can rub off the top layer of skin and damage blood vessels under the skin. You may be able to help by holding on to a trapeze hanging from an overhead frame (see cover). If nurses or others are helping to lift you, bed sheets or lifters can be used. A thin film of cornstarch can be used on the skin to help reduce damage from friction. Avoid use of donut-shape (ring) cushions. Donut-shape cushions can increase your risk of getting a pressure ulcer by reducing blood flow and causing tissue to swell.

Be Active in Your Care

The best program for preventing pressure ulcers will consider what you want and be based on your condition.

Be sure you: 1. 2. 3. 4. Ask questions. Explain your needs, wants, and concerns. Understand what and why things are being done. Know what is best for you. Talk about what you can do to help prevent pressure ulcers -- at home, in the hospital, or in the nursing home.

You can help to prevent most pressure ulcers. The extra effort can mean better health.

Care by Risk Factors

Risk Factor

Preventive Actions Inspect skin at least once a day. Bathe when needed for comfort or cleanliness. Prevent dry skin. For a person in bed: 1. Change position at least every 2 hours. 2. Use a special mattress that contains foam, air, gel, or water. 3. Raise the head of bed as little and for as short a time as possible. For a person in a chair: 1. Change position every hour. 2. Use foam, gel, or air cushion to relieve pressure. Reduce friction by: 1. Lifting rather than dragging when repositioning. 2. Using corn starch on skin. Avoid use of donut-shape cushions. Participate in a rehabilitation program. Persons confined to chairs should be repositioned every hour if unable to do so themselves. For a person in a chair who is able to shift his or her own weight, change position at least every 15 minutes. Use pillows or wedges to keep knees or ankles from touching each other. When in bed, place pillow under legs from midcalf to ankle to keep heels off the bed. Clean skin as soon as soiled. Assess and treat urine leaks. If moisture cannot be controlled:

Bed or Chair Confinement

Inability to Move

Loss of Bowel or Bladder Control

1. Use absorbent pads and/or briefs with a quick-drying surface. 2. Protect skin with a cream or ointment.

Poor Nutrition

Eat a balanced diet. If a normal diet is not possible, talk to health care provider about nutritional supplements.

Choose preventive actions that apply to the person with lowered Lowered Mental mental awareness. For example, if the person is chairbound, refer to Awareness the specific preventive actions outlined in Risk Factor 1.

Risk Factors for Pressure Ulcers in Hospitalized Elderly without Significant Cognitive Impairment
Abstract and Introduction Abstract

Purpose: To evaluate risk factors for pressure ulcers (PU) in hospitalized elderly without significant cognitive impairment. Methods. From July 2005 to February 2006, 40 hospitalized elderly patients without cognitive deficit were evaluated in a university hospital in Pouso Alegre, Brazil. Twenty patients with a PU formed the study group and 20 without a PU formed the control group. The Mini Mental State Examination (MMSE) was used to assess cognitive status. Pressure ulcers were classified using the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, followed by evaluation of risk factors for PU using the Braden scale. The chi-squared test was applied and for the Braden scale the Mann-Whitney test was used. Results. In the study group, 14 (70%) of the subjects were women and 6 (30%) were men. The average age was 71.5 years. The average score for the MMSE was 19.7. The average time of hospitalization was 23.1 days for the study group and 13 days for the control. In the Braden scale, the risk factors such as humidity, activity, mobility, friction, and shear force were significant (P < 0.05). Conclusion: The data from the present study demonstrate that hospitalized elderly patients have an increased risk for the development of PU. Humidity, activity, mobility, friction, and shear are important risk factors during the hospitalization period.


Pressure ulcers (PU) are defined as skin breakdown and continuum of tissue damage of ischemic etiology secondary to high external pressure, which usually occurs over bony prominences.[1] Seventeen percent of hospitalized patients have or will end up having a PU. In the worldwide geriatric population, 71% of patients 70 years have PU.[2] According to Brazilian estimations, 14% of the population will be 60 years old or more by 2025.[3] In Brazil, national policy considers elderly citizens to be 60 years old or older.[4] Pressure ulcers are caused by intrinsic and extrinsic factors. The intrinsic factors include immobilization, cognitive deficit, chronic illness (eg, diabetes mellitus), poor nutrition, use of steroids, and aging.[5,6] There are 4 extrinsic factors that can cause these wounds-pressure, friction, humidity, and shear force. Pressure is a crucial factor in PU development. Pressure of 70 mmHg over a bony prominence for 2 hours or more is enough to cause an ischemic wound.[1] These factors might predispose a patient to PU development. Several scales are used to analyze PU risk factors. One of these is the Braden Scale, which is based on PU physiology. The Braden Scale considers intensity and duration of pressure and tissue tolerance as critical determinants for PU development.[7] Research shows that PU treatment is costly. A study conducted in the United States by the Agency for Healthcare Policy and Research found that PU treatment costs were more than $1.35 billion annually.[8] The present study was formulated with the understanding of the prevalence of PUs in a growing geriatric population and its significant implication to the health care system. This study attempts to evaluate the risk factors for PUs in hospitalized elderly patients without significant cognitive impairment.

The present study was performed at a university hospital, Hospital das Clnicas Samuel Libnio (CHSL), in Pouso Alegre, Brazil. The institutions Ethics Committee approved the study protocol. It is a transverse, analytic, and controlled study. Twenty elderly patients with a PU, age 60 years and older with no cognitive impairment were evaluated from July 2005 to February 2006. Twenty other hospitalized patients without PUs were assessed as a control group. All enrolled patients signed a consent form. Whenever patients had visual impairment or another disability that made writing difficult, their legal representatives signed the consent form. The patients were hospitalized for at least 24 hours and had 1 or more PU of various stages.

One researcher interviewed all patients. Clinical and demographic data were obtained. The MMSE[9] was administered and a skin evaluation was performed. Pressure ulcers were documented and classified during the interview. Risk factors were assessed with the Braden Scale.[7] The MMSE[9] was used to exclude patients with significant cognitive impairment. The MMSE normal score was adjusted for the patients' educational level as follows: no school = 13 points; 1 to 7 years of school 18 points; 8 or more years of school 26 points. The point total was 30. Patients who did not reach the minimum score according to their level of education were excluded from the study. Pressure ulcers were classified as Stage I---IV according to the National Pressure Ulcer Advisory Panel.[10] Elderly patients with all stages of PUs were included in the study. Stage I is consistent with no blanched erythematic spot. Stage II is when partial skin thickness is lost involving the derma, and the epidermis is lost. Stage III is when all skin thickness is lost, compromising the adjacent muscular fascia. Stage IV is an extensive destruction of the skin with total loss of skin thickness, with important regional necrosis or with damage to tendons, articulations, and other structures. The Braden Scale was used to assess PU risk factors. This scale is based on 6 subscales: sensorial perception, humidity, mobility, nutrition, friction, and shear force. Each subscale ranges from 1 to 4 points except for shear force and friction, which range from 1 to 3 points. Total scores vary from 6 to 23. The higher scores indicate low risk for developing PU.[7] Patients with 18 points or less were considered at a higher risk for developing a PU.[11] This scale has been validated for use in Brazil.[7] The chi-squared test[12] was used for data analysis in order to compare school grade and gender distribution between the study and the control groups. The Mann-Whitney test[12] was used on each of the subscales in order to compare the study and control groups according to the Braden Scale scores. A P value < 0.05 (or 5%) was considered significant.

Pressure Ulcers: Knowing the Risks

Risk Factors for Developing Pressure Ulcers
Pressure ulcers are skin sores that typically develop over bony areas, such as the lower spine, hips, and elbows. Also known as bedsores, pressure ulcers are a common problem for palliative care patients as mobility decreases and patients spend more time in bed.

Pressure ulcers are painful and can be difficult to treat. Preventing pressure ulcers is critical to maintaining comfort, and treating them promptly is essential. But how do you know if your loved one is at risk for developing one? Should you be concerned?
Risks Factors for Developing a Pressure Ulcer

Immobility People at the greatest risk of developing pressure ulcers are those who are immobile. Once a person losses the ability to move and becomes inactive, the risk of developing a bedsore increases. Sensory Loss Patients who have experienced loss of sensation as the result of spinal cord injury or neurological disease have an increased risk of developing pressure ulcers. A person without sensory loss can feel pain and will generally feel uncomfortable after spending a lot of time in one position. When sensory loss occurs, a person may not feel uncomfortable or the need to be repositioned. Changes in Mental Status Likewise, a person with an altered level of consciousness may not feel discomfort or may not be awake enough to physically reposition themselves if they do. Shear Shear is the rubbing of skin and fatty tissues across bones, and it is caused by the combination of gravity and friction. Shear most commonly occurs when a patient is lying with the head of the bed raised. The persons skeleton may slide down in the bed while the skin and fatty tissues stay in place. This type of force causes damage to the underlying blood vessels, resulting in ulcers with a large area of internal tissue damage and less noticeable damage at the surface of the skin. Friction Friction occurs when two surfaces move across one another. Friction decreases the skins tolerance to pressure by causing abrasions and compounds the effect of shear. This can happen when a patient slides down in bed or is repositioned in bed the wrong way. Moisture Moisture is a common problem in people who have become incontinent of urine or stool and have to wear diapers. Moisture from sweat can also be a problem. Moisture removes oils from the skin that normally act to protect it and softens the skins connective tissues, making the effects of shear and friction more damaging.

Incontinence As above, incontinence of bowel movements and urine create moisture on the skin and increase the risk of breakdown. Fecal incontinence has the added risk of damage to the skin from bacteria and enzymes in the stool and also increases the risk of infection. Poor Nutrition Poor nutrition can lead to weight loss which can then increase the pressure on bony areas of the body. Proper nutrition is also important to the healing of pressure ulcers. Age As a person ages, the skin becomes thinner and more fragile, increasing the risk of skin breakdown. If your loved one has any of these risk factors, it's important for you to take steps to prevent a pressure ulcer from developing.