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Файл:Clinical nursing practice. Study aid for foreign students of medical university
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quent changes or for emergencies when the dressing becomes soiled or
soaked through. Teaching needs to include:
• Why sterile equipment and dressings are used.
• How wounds become infected and from which sources.
• How to re-sterilize any re-usable equipment and how to dispose
safely of used dressings and equipment.
• How to prevent the spread of infection within the home.
• How to open and use a dressing pack.
• The no-touch technique for cleaning and covering the wound.
• How to secure the dressing.
• An explanation of what the normal appearance of the wound should
be. This way, if there are any problems, the nurse can be called immediately.
People with stomas or a tracheostomy are usually discharged as self
caring. The role of the community nurse in this case is to provide advice,
support, and teaching and to deal with any problems the person experiences in self-care.
5.5. CONCLUDING DISCUSSION
In this section we have explored developments in clinical nursing
practice in a number of inter-related areas: hand washing, the aseptic technique, tissue damage and repair, the principles of wound management and
procedure guidelines for changing wound dressings. In the final part we
looked at how the theory and principles, which were discussed mainly in
relation to a hospital nursing setting, can be adapted to meet the differing
context of community nursing.
Each of these areas of nursing practice has been challenged and
changed as a result of the development of specialist knowledge relating to
infection control, wound healing and management and the practice of nursing. They each offer examples of the development of nursing practice
through critical thinking and research.
The clinical nursing procedure guidelines illustrate the ways in which
research findings can be used to provide a rationale for nursing actions.
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This in turn enables us to develop and apply accepted standards of practice
to guide the management of care and the teaching of patients, clients and
other health care personnel.
In some instances, research findings have radically altered our understanding of some of the most basic of nursing procedures and practices,
such as our hand-washing technique or our knowledge of what constitutes
an optimum wound dressing. It can be both threatening and liberating to
discover that the knowledge underpinning areas of care that were previously taken for granted, is subject to change and that our practice must change
accordingly. However, if the aim of high quality care is to be achieved and
the ethical principles of beneficence and non-maleficence are to be maintained, it is essential that we actively seek a better knowledge base to inform our thinking; a rationale for our actions; and culturally, ethically and
professionally appropriate and agreed standards of care for our practice,
for it is through these that we are professionally accountable.
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6. TISSUE VIABILITY NURSING — PRESSURE SORES
6.1. INTRODUCTION
This section will develop further the discussion on tissue damage and
repair and wound management that you covered in the previous section. It
uses the framework of the nursing process to examine developments in tissue viability nursing relating to the prevention and management of pressure sores or “decubitus ulcers”. The material presented relates mostly to
the management of patients/clients who are nursed in a hospital setting. It
is important to remember, however, that there are very large numbers of
people at risk of, or with, pressure sores who are cared for in the community, often by family and friends as well as health care workers.
The learning objectives for this section are:
1. To identify the factors likely to lead to the development of pressure
sores.
2. To increase your knowledge base in relation to assessing how far
a person is at risk of developing pressure sores.
3. To review your knowledge of the principles of preventing tissue
damage through the effects of pressure and shearing force.
4. To develop your understanding of the principles of the nursing
management of pressure sores.
Definition. There has been much international debate about the most
appropriate or accurate term to use to describe the tissue damage and tissue
distortion which occurs as a result of damage caused by direct pressure or
shearing forces. Generally, the terms “decubitus ulcer”, “pressure ulcer” or
“pressure sore” are used. The extent of the damage can range from persis-
tent erythema to necrotic ulceration involving muscle, tendon and bone.
6.2. BACKGROUND INFORMATION
The a etiology of pressure sores. All nurses will have encountered
the problem of pressure sores during their working lives. For some who
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nurse people who are at high risk of developing sores, pressure sores and
their prevention will be part of everyday practice.
Three major factors have been identified as being significant contributory factors in the development of pressure sores. These are:
1. Pressure. The weight of the person's body squeezes the tissues
against the supporting surface and a bony prominence. This squeezing of
vulnerable tissues is further increased by heavy bed clothes, tight coverings or the person's clothing, such as shoes. Normally, none of these factors would cause a pressure sore, but in combination with other factors
such as immobility or loss of sensation, they present a great risk to tissue
viability.
It is generally well known that a high external pressure over a body
site can lead to ischemia in a short time. It is less well known that low
pressure over a long period of time may be equally harmful. The blood
pressure at the arterial end of the capillaries is approximately 30 mm Hg,
while at the venous end this drops to 10 mm Hg (the average mean capillary pressure equals about 17 mm Hg). Any external pressures exceeding
this will cause capillary obstruction. Tissues that are dependent on these
capillaries are deprived of their blood supply and will eventually die. Research has demonstrated, however, that with constant pressure, even in
denigrated tissues, a critical period of one to two hours exists before pathological changes occur.
2. Shearing. Disruption and mechanical damage to the tissues can al-
so occur as a result of indirect pressure. This is caused by the movement of
the tissues against a surface, or “shearing”. The Shearing Force — the
'Forward Slide 'Phenomenon micro-circulation in the underlying tissues is
disrupted and the tissue dies of anoxia. Shearing can occur when a person
slips down the bed or is dragged up the bed. Shearing due to sliding can
cause deep tissue damage, as can direct pressure. In more serious cases,
lymphatic vessels and muscle fibers become tom, resulting in a deep pressure ulcer. Deep damage may not be visible until some time after the damage has occurred, as the overlying skin can remain intact for up to two
weeks over a disrupted muscle.
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3. Friction. This is a component of shearing which causes stripping
of the stratum comeum of the skin, leading to superficial ulceration. Friction is increased by moisture. Those people who are most vulnerable are
those who are incontinent, who sweat, who wear damp, non-absorbent clothing next to their skin, or who sit on non-absorbent or moisture-retaining
surfaces (such as plastic chairs, draw sheets with plastic underneath, or irregularly changed continence aids) (fig. 7).
Fig. 7. Friction
Pressure sores are most likely to develop on parts of the body which
are weight bearing when sitting or lying, and where the bone is close to the
surface (fig. 8).
Fig. 8. Areas most at risk of pressure sores
Body outlines (front and back) for the risk of pressure sores:
• Sacral area.
• Coccygeal area.
• Ischial tuberosities.
• Greater trochanters.
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• Heels.
• External malleoli.
• Elbows.
• Scapulae.
• Back of the skull.
6.3. ASSESSING RISK AND THE NEED FOR CARE
Patients or clients are at risk of developing pressures sores because
parts of their bodies (for whatever reason) are subjected to pressures of
sufficient force and duration to cause death of tissues. In health, our normal response to undesirable (uncomfortable) levels of pressure is to relieve
pressure by moving and re-distributing our weight. Watch any group of
students in class or at a lecture; there is a constant shifting of position,
crossing and uncrossing of legs and so on. These are normal responses to
pressure. Enforced immobility, for whatever reason, can interfere with this
response and put us at risk of developing a pressure sore. It is important
that people who are vulnerable to pressure sores are identified and measures
taken to prevent sores developing.
There have been many studies to identify which patients or clients
are at risk of developing pressure sores. One of the most widely known is
that which led to the development of the Norton Risk Assessment Score.
This was a research tool which involved using a simple formula for
assessing the individual risk of developing a sore. The person was assessed
in relation to five criteria and awarded a score (of between one and four)
for each of the criteria (see tab. 9). The total score achieved was used to
indicate an individual's risk. People with scores of 14 or below were considered to be at greatest risk, requiring preventative interventions.
Many nurses in different countries have used this tool to help them in
identifying patients/clients who are at risk of developing pressure sores
and planning prevention measures accordingly. One of the advantages of
the score is that it is easy to use. However, it was developed from work
carried out with a sample of elderly hospital patients more than three dec-
127
ades ago. Our knowledge of the factors associated with tissue damage due
to pressure has become more sophisticated in this time. In addition, developments in medical technology mean that many patients/clients who would
previously not have survived their diseases or injuries now require nursing
care and the prevention of pressure sores.
Table 9
The Norton Scale (31)
Physical
condition
Score
Mental
condition
Score
Activity
Score
Mobility
Score
Incontinent
Score
Good
4
Alert
4
Ambulant
4
Full 4 Not
4
Fair
3
Apathetic
3
Walk/help
3
Slightly
limited
3
Occasionally
2
Poor
2
Confused
2
Chair
bound
2
Very
limited
2
Usually/urine
2
Very Bad
1
Stupors
1
Bedfast
1
Immobile
1
Doubly
1
This does not detract from the usefulness of such an assessment tool —
there have been many other such tools tested and validated for use with
specific client groups (from those who are chair bound as a result of spinal
injury, but are otherwise fit and well, to patients who are severely ill and
being cared for in intensive care units).
Exercise. Factors likely to lead to the development of pressure sores
Many predisposing factors are involved in the development of pressure sores. For example, being immobile and without human help to stand
or walk, or being incontinent of urine or faces.
Draw a table with two columns (similar to the example given in Table 11, below). From your own knowledge and experience, identify in the
left-hand column as many things as you can think of that might put a person at risk of developing pressure damage. In the right-hand column, try to
identify how why this is so.
You may find it helpful to think about different client groups or care
settings in order to encourage you to think about this exercise in the widest
possible terms.
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Table 10
Two examples of predisposing factors in the development
of pressure sores
Factor
How
1. Being immobile and without
human assistance
Without help, the person is unable to relieve
pressure, for example on the sacrum and
buttocks. Sores develop because of unrelieved
pressure over time
2. Being incontinent of urine and
or faeces
Incontinence can lead to skin cooling and
excoriation. Moisture increases the effect
of shearing force as a result of increased surface
tension between the skin and the surface
the person is lying or sitting on. Tissues “stick”
to the surface more and the distorting effect on
the capillary system of slipping, dragging or poor
lifting is increased
Assessment of risk needs to be holistic in its focus if it is to be effective (see Chapter 4 on a systematic approach to nursing for more information about the importance of holistic assessment of people as individuals). A patient/client's risk of developing pressure sores should be assessed
either on admission to hospital or when he or she first comes into contact
with the health services in the community.
A risk assessment tool can be an important aid in this process (tab.
10). Current research suggests that a scale developed by Waterlow (tab.
11) may be more accurate in identifying risk across a range of client
groups, than the previously almost universally used Norton Scale.
A recent study comparing the use of the Norton and Waterlow scales
showed that 22 (75,7 %) of the patients who were predicted as being at
risk on admission using Waterlow’s scale (a score of 10 and over), developed pressure ulcers, compared to 18 (62 %) of patients using a score of
16 or less on the Norton scale. The author concluded that the Waterlow
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scale was more accurate at predicting the ulcer formation. Further research
in this area, with a larger sample of patients is required.
Table 11
Waterlow pressure sore prevention/treatment policy
Build/weight
for height
♦
Skin type
Visual risk areas
♦
Sex
Age
*
Special risks
*
Average
Above average
Obese
Below average
0
1
2
3
Healthy
Tissue paper
Dry
Edematous
Clammy (raised
temperature)
Discolored
Broken/spot
0
1
1
1
1
2
3
Male
Female
14–49
50–64
65–74
75–80
81+
1
2
1
2
3
4
5
Tissue
malnutrition:
Terminal cachexia
Cardiac failure
Peripheral
Vascular disease
Anaemia
Smoking
8
5
5
2
1
Continence
*
Mobility
*
Appetite
*
Neurological
deficit
♦
Complete/catheterized
Occasionally incontinent
Catheterized/
incontinent of faeces
Doubly incontinent
0
1
2
3
Fully
Restless/fidgety
Apathetic
Restricted
Inert/traction
Chair bound
0
1
2
3
4
5
Average
Poor
Nasogatric tube/
fluids only
Nil by mouth/
anorexic
0
1
2
3
e.g. diabetes,
multiple sclerosis,
CVA, Motor/
sensory, Paraplegia
4–6
Major
surgery/trauma
Medication
Orthopedic —
below waist,
Spinal
On table > 2 hours
5
5
Cytotoxics
High-dose steroids
Antiinflammatory
4
Instructions'. Ring scores in table, add total. Several scores per category can be used.
Although there are certain predisposing factors which place people at
risk of pressure sore development, these are subject to factors which are
unique to the individual and the environment. These individual factors
need to be taken into account when assessing, planning, implementing and
evaluating care. This requires skills of critical analysis from the nurse in
interpreting the information about an individual, in relation to our knowledge
of pressure sores.
130
Without such critical thinking, tools such as risk scores can become
another way of implementing “routine” care for all patients/clients with
a particular score, rather than using them to help us in the assessment,
planning, implementation and evaluation of individualized, person — centred care.
6.4. ASSESSMENT OF EXISTING PRESSURE SORES
If tissue damage is present, it is important to make an assessment of
the following:
1. The likely major causes:
• Asking the person themselves (if possible) what he or she thinks
has contributed to the development of the sore(s).
• Reviewing the person's present condition, past and present medical
history and prescribed medications, for factors which predispose towards
the development of pressure sores.
• Review the person's risk score. Although risk assessment tools are
used to identify overall risk, they are also useful for identifying the different factors which may have contributed towards a sore forming. If, for example a person has a Waterlow risk score of 30, by reviewing the different
risk factors which contributed to the overall score, it is possible to form
a good picture of the particular combination of risks for that individual patient/client. (This approach can similarly be used in planning individualized care to prevent sores from developing).
2. Preventative measures used so far.
Review any preventative measures that have been used so far, and
the person's own perception of how effective or otherwise they have been.
Sometimes aids used for prevention have themselves been implicated in
causing tissue damage and pressure sores. The classic example is the widespread and almost routine use several years ago of foam ring cushions to
prevent pressure sores developing over the ischial tuberosities on the buttocks and over the coccyx. Far from relieving pressure, these rings were
probably causing pressure sores. They increased pressure at the point of
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