Pressure Ulcers: Aetiology, Risk Factors, and Care Management

This essay comprehensively examines pressure ulcers, beginning with a definition and an overview of their prevalence and associated costs within the NHS. It delves into the risk assessment process, emphasizing the use of the Waterlow tool for identifying patients at risk, and discusses the significance of this assessment in clinical practice. The essay outlines various risk factors, including poor blood circulation, immobility, and malnutrition, and explains how these factors contribute to the development of pressure ulcers. It also highlights the importance of clinical judgment and the application of the clinical reasoning cycle in assessing patients. Furthermore, the essay explores the sociological impact of pressure ulcers and proposes actions to mitigate the identified risk factors, including multi-agency involvement and nutritional support. Finally, it underscores the significance of adhering to local policies and guidelines, in addition to national standards, for effective pressure ulcer management, emphasizing the need for education and resource allocation to reduce the incidence and severity of these ulcers.

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Pressure Ulcers
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Pressure Ulcers
Pressure ulcers develop in patients that sit in a single position for long the sores develop
is specific pressure areas for people who are confined in bed or wheelchairs for a long period of
time. These sores cause serious problems that can be life-threatening to patients if not treated
well. In most cases, people fall under this risk if they are bedridden or spend most of their time in
bed or in a chair (Serrae, Leen, Schols, Hecke, & Verhaeghe, 2017, p. 376). The development of
the sores varies from patient to patient, some patients may develop quickly while others may take
time to develop them. The common symptoms that patients show are swelling, pulse-like
draining and tender areas.
Risk assessment
Risk assessment in pressure ulcers entails determining the people that are at the risk of
developing the problem and at the same time developing preventive measures for addressing the
problem that the patients face. A pressure ulcer is one of the challenging risk factors that
organizations face since, despite the fact that different methods have been proposed on how to
prevent them, their prevalence still high, especially in older people (Moysidis, Niebel & Bartsch,
2011, p. 581). This means that the risk is a burden to all people who are bedridden or sit most of
the time on chairs. The risks that they present are high since they lead to the increased burden of
disease while at the same time present challenges for healthcare teams. Since people in this
category spend most of their time in one position, they are at a higher risk of developing the
condition.
Serrae, Leen, Schols, Hecke, & Verhaeghe (2017, p. 5 argue that pressure ulcer exists in
different stages that patients go through as the signs and symptoms of the disease manifest.
These four stages are normally caused by friction on the sin, shearing, pressure and sometimes

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force that is exerted due to the patient staying in one condition for a long time (Rich, Shardell. &
Hawkes, 2011, p. 1061). The unequal distribution of pressure when patients stay in one condition
for a long time is what causes the pressure ulcer to develop due to poor circulation and thus
increasing the pressure exerted on the surface causing the ulcers to develop. The outcome will be
the skin suffering from any small effects of friction, pressure and shearing forces to form ulcers.
In a study by Kirman (2018, p. 3) it was reported that pressure ulcers have been difficult
to assess since in most cases, the studies done in this field are qualitative and based on random
observation of uncontrolled studies. Which means that some questions have not been asked well
to document the risk of the problem. The cost of treatment has been shown under table one as
shown below to treat a single episode (Bennett, Dealey, & Posnett, 2014, p. 233). The average
cost of pressure ulcers to NHS varies from grade to grade ranging from grade1, 2, 3 and 4. The
cost per day is estimated at £38, £42, £50, and £50 per day respectively for normal healing. On
the other hand, the average cost per episode is £1,064, £ 3,948, £6,350 and £7,750 per episode
per day (NICE, p. 4). Further, Guest, Fuller, Vowden, & Vowden (2018, p. 5) add that pressure
ulcers have been estimated as likely to occur 4-10% of patients that have been admitted in
hospitals. Most studies have reported difficulties quantifying ulcers because they are complex in
nature due to the methods used to collect data on the topic that vary from study to study which
make it difficult to give an accurate figure of the people affected by the problem. Despite the
varying statistics, it has been indicated that at least 2000 patients are reported as having
developed new pressure ulcers each month in the UK (NICE 2019, p. 6). In addition to that,
older people are the ones who are more likely to develop the problem where almost a third of the
older people aged seventy and above have had hip surgery at one point in life. This means that
they have to be bedridden which in turn leads to pressure ulcers. This means that age alone is a

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risk factor since older people are associated with smoking, dry skin, urinary incontinence,
chronic systemic conditions and even hip fracture. People with spinal injuries are also another
special group where 20-30% of people with spinal injuries are likely to develop pressure ulcers.
In the UK this risk is associated more with the older population because there are many
older people who are bedridden or stay longer on wheelchairs. The population of the old keeps
on increasing thus causing an increased burden of the disease and increased NHS costs. Sulliva
& Schoelles (2013, p. 412) Add that despite the fact that many strategies and methods have been
developed to address the problem, there are still challenges that have been reported in patients
and healthcare setting for the people who are developing the pressure sores. This implies that the
risk is high and thus the need to address the issue by educating nurses on how to reduce the
effects of the problem and at the same time ensuring that there is access to enough resources for
use. To assess the risk of the pressure ulcers in the patient, the water low tool will be used to
determine the level of the risk that the patient is facing (Nursing Times, 2010, pp. 4). The role of
this tool is to assist in making professional judgment on the level of risk. The tool containing two
side, the front side is used for assessing and scoring the patient vital signs while the back side is
used for guiding the nurse on how to undergo the process. According to NICE (2019, pp. 7)
when assessing the patients using the water low tool, the terms “at risk” and “high risk” are used
to identify people who have the likelihood of developing pressure ulcers. In this case, adults that
are at risk of developing pressure ulcers are those that are considered to be at the risk of
developing pressure ulcers after assessment while those that are at high risk are the ones that
show multiple risk factors that are identified during assessment like limited mobility, nutritional
deficiency, inability to reposition themselves and significant cognitive impairment. Neonates,
infants, children and young people who are at risk are the ones that after assessment or clinical

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judgment are considered to be at the risk of developing pressure ulcers while at the same time,
those that are at high risk of developing pressure ulcers are the one multiple risk factors limited
mobility, nutritional deficiency, inability to reposition themselves and significant cognitive
impairment.
During the assessment, the nurse is supposed to focus on height, weight, age, the visual
appearance of the skin, appetite and mobility of the patient. When assessing the patients using
the tool, weight/height of the patient, skin type. Visual risk areas, sex, age, continence, mobility
and malnutrition are all assessed and given scores which are totaled to get the overall score. A
score of 10-14 will indicate at risk, 15-19 indicates high risk and a score of 20 above shows that
the patient is at a very high risk (Moore & Patton 2019, p. 4). However, this tool is simplistic and
thus professional judgment is important in determining the level of the risk. The nurse requires
critical thinking and assessment skills to determine the challenge that the patient seems to face.
This means that the role of the nurse is to have proper clinical skills that can be used in
determining the nature of the sores and the stage that the patient is in. Apart from the water low
tool, the clinical reasoning cycle can be applied by the nurse as a way of assessing the condition
of the patient to determine the magnitude of the pressure ulcer. NICE (2019, pp. 8) suggests that
the assessment should focus on identifying the nature of the patient and the high risk or at risk
factors that the patient presents so that a care plan can be developed along the issues identified.
On the other hand, despite the fact that there are national guidelines that need to be used
in the implementation of the pressure ulcer assessment and treatment, there is need to understand
that there are different local policies that apply to the way healthcare professionals and nurses
need to respond to the issues that revolve around pressure ulcer. In the UK, each of the regions

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have their own pressure ulcer treatment and management strategies that need to be observed by
all healthcare professionals. This means that despite the fact that there are NHS and NICE
guidelines, practitioners are supposed to be qualified to carry out the assessment and the risk
assessment should be done at the first day of face-to-face visit with the patient. This means that
practitioners are supposed to follow the hospital guidelines that are set based on the local policies
that the healthcare facility falls in. This implies that practitioners are not supposed to use their
own acquired clinical knowledge but rather use the policy that have been put in place by the
local government in line with NICE and NHS guidelines.
Factors that contribute to the risk
One factor that leads to the development of pressure ulcer is poor blood circulation due to
conditions like diabetes heart condition or kidney disease. Patients with these conditions have
other complications that increase the risk of them developing problem. According to Liao, Burns,
& Jan (2014, p. 28) when the blood circulation is poor due to chronic conditions, then the patient
suffers from high risks of pressure ulcers since these conditions affect blood circulation, lead to
weight loss and make the skin weak.
Sometimes immobile individuals also pose a high risk of developing the problem since it
increases the risk of developing the sores in pressure areas. In the UK, the increasing number of
the older population increases the risk and the medical cost (Vanderwee, Grypdonck & Defloor
2015., p. 264). In most cases, clinicians respond to immobility with interventions like
redistribution of the resting place and turning the patient after a specified period of time to
reduce the risk of pressure ulcers. Immobility levels of the patient can be analyzed through the
use of a physiotherapist who will assess the patient condition and determine how the problem is
exacerbated by the physical conditions of the patient.

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According to the Nursing Times (2014, pp. 5) poor nutrition can also cause skin damage
since the skin becomes unhealthy and unable to heal itself when the pressures start developing.
This means that the skin is resilience is reduced as a result of poor nutrition which increases the
chances of developing the sores. Nutrition is an important element in wound healing since
increased needs for energy, zinc, proteins, and vitamins are relevant in wound healing patterns of
patients. When the skin tissue is damaged, it is supposed to be repaired internally by the body
itself. This quick healing is based on the nutrition levels of the body and the ability to heal
quickly (Saghaleini, et al. 2018, p. 285). Poor nutrition leads to weight loss and due to
inadequate nutrient intake leading low body weight thus the outcome is slow and non-healing
wounds. When assessing the patient under this factor, the dietician needs to be used to assess the
nature of the patient and how he is able to manage his diet.
Lastly, friction on surfaces that the specific body parts lie on can damage the skin and
lead to pressure ulcers. This implies that there are many risk factors that lead to the development
of the problem. In most cases, the conditions that the patient stay in can exacerbate the
development of the condition since the level of friction tears the skin surface (Jiang,, Li, &
Zhang 2014, p. 2823). In most cases, this is not a big challenge if the patient has a resilient skin,
better nutrition and does not suffer from other body conditions can overcome the friction since
the skin will be able to heal well. The services of an occupation therapist can be important is
assisting the patient understand how to deal with different environment and occupational factors
that may cause the problem.
Actions to reduce the risk factors
The common way of prevention is the repositioning of patients to reduce the pressure that
is exerted in one place. This is caused by exposure of specific parts of the body in one position

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for a long time which leads to the development of sores on specific parts of the body. Since
patients who develop this condition stay in one position for a long time, then it means that they
have to be assisted to reposition themselves. For example, in most cases, such patients may be in
ICU or are relying on a wheelchair for movement which makes it difficult for them to move
(Markebust & Krain 2015, p. 23). This prolonged stay in one position and other healthcare
challenges is what leads to the condition. According to Gillespie, et al. (2014, p. 15) suggest that
repositioning allows different body parts of the body to heal because it leads to reduced pressure
on the body that allows the patient to heal. Sometimes, it is also important to focus on diet and
ensure that the patient take appropriate diet so that healing can be enhanced. In most cases, the
service of a dietician is important to focus on the specific foods that need to be taken by the
patient. Diet is an important element in ensuring that the immunity of the patient is improved so
that the patient is able to have a healthy body with increased immunity and improved healing.
Thus apart from repositioning of the patient every time and then there is need to put the patient
on a proper diet that reflects the medical needs of the patient.
The assistance of occupation therapist and physiotherapist can also be important in
assisting patients to manage this condition. Despite the fact that the pressure mattress is regarded
as the best option, it is important to necessitate healing through the services of a physiotherapist
who will assist the patient to manage the physical nature of the body thus increasing healing. The
role of the pressure mattress is to relieve the sores when the patient is resting but the
physiotherapist will be in charge of developing physical therapy that can assist the patient to heal
quickly. On the other hand occupation therapists play an important role in assisting the patient to
manage the different clinical occupation environments that they operate in. Thus the ability of
the patient to manage their body and physical environment are important in ensuring that the

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patient is able to manage and achieve quick recovery. As mentioned above immobility is one of
the challenges that the patient faces as a result of staying in one position for long (Rao, et, al.,
2016, p. 244). Thus the occupation therapist will focus on providing the patient with comfort by
assessing the nature of the ulcers and then proposing the best way for positioning the patient in
response to the condition. Thus since the pressure mattress is a mechanical intervention, then the
presence of the occupation therapist is important in assisting the patient to overcome this
problem.
Another response is the use the maintenance of proper diet and increased nutrition intake
can also be used to increase blood circulation and reduce the risk of pressure ulcers. For the skin
to be maintained, there is need for requires adequate calories, minerals, vitamins, fluids and
proteins within their daily diet that will reduce dehydration of the skin and increase blood
circulation. The focus will be on the foods that increase blood levels in the body while at the
same time focusing on reducing foods that have plenty of fats. In this case the nutritionist/
dietician will work closely with the physiotherapist to ensure that the patient takes a proper diet
while at the same time maintain a healthy lifestyle that will increase blood flow (Tayyib, Coyer,
& Lewis 2016, p. 915). By working together with the nursing professional, the two will ensure
that the patient overcomes skin related challenges like dehydration and poor blood flow which
lead to the development of the ulcers.
In some situations, pressure mattresses are used to relieve the effects of prolonged staying
in one position for long. Meaume & Marty (2018, p. 491) add that the design of the mattresses is
based on air pockets that are designed to exert pressure on the specific parts of the body that
create sores. The beds are specifically designed to ensure that the patient’s body is inclined in a
way that reduces the pressure on the body and thus increase blood flow for the patient and ensure

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that the pressure that is exerted in a similar position is reduced. Thus pressure mattresses increase
blood circulation by shifting the pressure points from one part of the body to the other (Moore &
Cowman 2015, p. 3). Further, the air mattresses are designed with air holes that allow airflow
thus reducing the pressure on the specific part of the body as the pressure is released. This means
that the pressure mattress relieves the areas that sores develop thus leading to the best clinical
outcomes.
The best action
Pressure mattresses offer the best condition for preventing the problem in clinical
settings. In most cases, the best pressure mattress is the automatic one that responds to the body
changes of the patient. Such mattresses are designed with the latest technology that allows them
to reduce the pressure that the patient exerts on different parts of the body. There are other static
types of mattresses that are evenly distributed to increase comfort in the patient and prevent the
condition (Serraes & Beeckman 2016., p. 376). The mattress is designed to mechanically
respond to the body by increasing the comfort that the patient feels. Thus pressure mattresses
offer the best outcomes since they allow the healing of the sores and at the same time prevent the
development of other pressure ulcers on the patient.
Conclusion
Pressure ulcers are one of the burdens that healthcare professionals deal with every time
in healthcare settings. The cost of the problem is high since despite the fact there are
interventions that have been proposed on how to deal with the challenge, there are still
challenges in managing the pressure ulcer since patients are developing the sores and there are
difficulties in managing the patient. Thus there is a need to focus more on how to reduce pressure
ulcers in patients by developing better conditions for meeting the clinical requirements.

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Therefore, there is a need to develop measures for meeting the needs of the patient and
improving the recovery or prevention of pressure ulcers.

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