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The management of chronic wounds is a significant part of the workload for any nurse caring for elderly vulnerable people since these patients are more prone to the conditions that can lead to chronic wounding.  Chronic wounds like pressure ulcers demands a detailed and individual treatment plans depending upon the nature of the wound and the circumstances of the patient. The experience of having a pressure ulcer can result in the loss of a patient’s sense of self. Exudation and malodour may lead to social problems and this, along with skin problems, may decrease a patient’s quality of life. Hence Pressure ulcers need to be prevented as far as possible in all care settings.  Pressure ulcer management involves treating infection, providing a moist wound-healing environment and choosing the appropriate dressing.  Various studies on the topic have found that a multidisciplinary approach is the efficient mode for care of patients with pressure ulcers. This essay is a review of the various studies evaluating the best practices of nursing management of pressure ulcers. New nursing interventions and pressure-redistributing devices in intensive care units, and specific risk factors affecting critically ill patients, mean that different factors must be taken into consideration in preventing pressure ulcers. 
Pressure Ulcers, Aetiology:
A pressure ulcer is an area of skin especially the areas of superficial or deep- tissue that has been damaged by pressure, friction shear or a combination of these factors There are many factors attributing to the risk of pressure ulcers and the major ones are obesity, immobilisation and malnutrition while old age, malignancy, venous insufficiency, diabetics and history contribute to delay in healing.  Pressure ulcers are found mostly in bedridden patients with spinal injury etc pressure ulcers develop as a result of prolonged periods of immobility during unrelieved pressure which compresses tissues that overlie bony prominences.  Once the pressure ulcer has developed, it tends to deteriorate owing to the patient’s physical characteristics, such as extreme bony prominence, and poor condition in general.  (Sanada et al., 2008).
The nature of the excessive pressure is important in the development of pressure ulcers. The principal factor in pressure ulcer development is excessive tissue pressure that prevents the normal supply of blood to the affected area. The severity of skin and tissue damage will depend on how long the patient has been exposed to these excess pressures.  In the words of Betsy Myers, prevention is the best intervention for pressure ulcers. By being aware of the risk factors for pressure ulcer development, assessing for changes in risk factors on an ongoing basis, and addressing risk factors, the incidence of pressure ulcers can be markedly reduced. 
Several risk factors have been identified for the development of pressure ulcers and are classified into extrinsic and intrinsic factors. Extrinsic factors include interface pressure, shearing forces, friction and moisture. Intrinsic factors are the nutritional status of the patient, patient age, immobility, incontinence, circulatory factors, and neurological disease. Three main mechanical factors are thought to contribute in the development of pressure ulcers: pressure, friction and shear.  Pressure ulcers are present in patients with intensive immobility and recovery is delayed for these patients due to many reasons including the accompanying medical complications like infections extending the hospitalization period for patients. Methods to measure immobility are not generally available in clinical settings. 
A successful wound management should include assessment, planning, management, reassessment, admission, transfer, reporting and audit. As per EPUAP guidelines (2010), all patients with wounds should be reassessed and documented at least weekly and the treatment methods and any alterations to be discussed with the patient. Prevention of pressure ulcers helps reduce patient suffering. The first step in pressure ulcer prevention is to identify those patients at risk and a variety of risk assessment tools have been developed since the 1960s. It is important that an assessment tool is appropriate for the specific patient setting in which it is used. 
A study conducted by Ingela Henoch (2003) gives the following details on risk assessment tools for pressure ulcers. Accordingly, risk assessment tools are developed from nursing experience and research on the causes of pressure ulcers. An appropriate risk assessment tool should assess only necessary factors, facilitate the nurse’s work, be easy to use, require minimal training, have clear management guidelines and prevent pressure ulcers.  The major assessment tools to study the risk factors of pressure ulcers are the Norton scale, the Braden Scale and the Waterlow scale.
The original Norton scale, used since the 1960s, includes physical state, mental state, mobility, activity and incontinence but excluded age and malnutrition since the scale was developed for use with the elderly and was considered a part of general physical condition (Norton, 1989). The Norton scale is revised and the modern version is known as the modified Norton scale. The Braden scale focuses on measuring intensity and duration of pressure, and sensitivity of the patient’s skin (Bergstrom et al, 1987). The Waterlow scale was compiled in Great Britain in 1984 and consists of two parts, one measuring pressure ulcer risk and the other outlining a prevention and treatment policy (Waterlow, 1991). The scale includes several factors particularly directed to acutely ill patients that are omitted in the Norton scale. In her study testing the various scales for their ability to detect differences between the patient groups with and without pressure ulcers, Ingela concludes finding the scale which became HoRT scale to be superior with regard to statistical significance and validity. Reliability was determined by comparing the scale’s predictions with the actual numbers of patients with and without ulcers. 
Sensitivity and specificity, and measures derived from these, are epidemiological tools in evaluating the predictive validity of diagnostic screening tests. The risk assessment tools are treated as if they are diagnostic screening tests, while in contrast with such screening tests, risk assessment scales are not intended to identify the existence of pressure ulcers, but to identify the risk that pressure ulcers will occur.
The old saying ‘prevention is better than cure’ is apt in the case of pressure ulcers and the very probability that a patient will develop pressure ulcer can be checked if proper preventive measures are used. Patients identified as being at risk will develop pressure ulcers only if preventive measures fail. As per Laat et al’s study, use of effective prevention will alter the sensitivity and specificity of the risk assessment scale. Laat et al finds that there is still no evidence for a valid risk assessment tool in critically ill patients. In general, Laat et al recommends prevalence and incidence studies to be designed and executed in accordance with the EPUAP guidelines and also call for a well-designed research on the epidemiological aspects, risk factors and risk assessment of pressure ulcers in critically ill patients to gain more insight into the nature and extent of this problem.
Classification of pressure ulcers
Depending on various characteristics, pressure ulcers are classified under the International NPUAP- EPUAP Pressure Ulcer Classification System. Accordingly there are 4 grades (stage or category) from 1 to 4 and their characteristics are as follows:
GRADE 1: Non-blanchable erythema of intact skin; Discolouration of the skin, warmth, oedema, induration or hardness can also be used as indicators, particularly on individuals with darker skin.
GRADE 2: partial thickness skin loss involving epidermis or dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.
GRADE 3: full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia
GRADE 4: extensive destruction, tissue necrosis, or damage to muscle, bone or supporting structures with/without full thickness skin loss.
Pressure ulcer grade should be recorded using the EPUAP classification system and all pressure ulcers graded 2 and above should be documented as a local clinical incident.
Current Nursing Management Practices of Pressure Ulcers:
A failure to correctly assess and treat wounds will lead to a failure to heal. It is important that a competent practitioner undertakes the assessment process and plans the care.  A successful wound management should include assessment, planning, management, reassessment, admission, transfer, reporting and audit. As per EPUAP all patients with wounds should be reassessed and documented at least weekly and the treatment methods and any alterations to be discussed with the patient. 
As Karen’s (2005) describes in her book, the previous practice of pressure ulcer management was called back round process which involved nurses washing and massaging the pressure areas of bedfast patients and applying a range of lotions, creams, powder, oils and spirits in an attempt to prevent breakdown of the skin. If a pressure ulcer were to occur then treatments varied. They included: lying the patient on their side to reduce pressure and administering oxygen, by placing an oxygen mask over the ulcer to maintain a dry environment; placing a dressing of egg white over the affected area, with the thought that it would heal the ulcer due to the protein content of the egg. 
The treatment needs of a pressure ulcer change over time, in terms of both healing and deterioration. Treatment strategies should be continuously re-evaluated based on the current status of the ulcer.  All patients with wounds will need to have a holistic assessment, including environment, cause, location, site, dimensions, exudates amount and type, nutritional status, local signs of infection, pain, wound appearance, surrounding skin, undermining/ tracking, odour, assessment of the skin as a sensory organ and the patient’s knowledge and understanding of their wound and general condition. The wound assessment should be documented on an appropriate wound assessment tool, within 24 hours of admission to a hospital setting and within one week of referral to primary care. 
Cleansing and Wound Dressing:
Likewise, special care and research to be done before deciding on the cleansing agents to be used and the modes of wound dressing to be made and this differs in different cases. Wounds should only be cleansed when they are dirty, with either warm normal saline or tap water, and not on a daily basis. In the case of pressure ulcer the wound shall be cleansed if there are any visible signs of debris or if the ulcer is contaminated with bodily fluids. EPUAP recommends that antiseptics and antibiotics should not be regularly used, however they may be considered when bacterial loads need to be controlled or until inflammation is reduced. 
Positioning and Repositioning:
Zena et al’s (EWMA 2010) study agrees to the fact that repositioning is an important component and is advocated to be the best strategy in the management of a pressure ulcer patient. There are a number of interventions required for the management of a pressure ulcer patient like nutritional care, pressure reducing/ relieving surfaces and skin and wound care. 
Positioning of patients who spend substantial periods of time in a chair or wheelchair should take into account, distribution of weight, postural alignment and support of feet. 
Pressure-redistributing mattresses or other pressure redistributing measures in combination with body repositioning are the main preventive measures for general and critically ill patients. Routinely turning immobilised critically ill patients every two hours is the accepted standard of practice, yet it is not practical all the times and most critically ill patients are not repositioned according to this standard. In the case of patients with pressure ulcers, instead of the standard hospital foam mattress, Higher- specification foam mattresses should be preferred. In a detailed study conducted by Laat et al (2006), they could find no superior device than a higher specification foam mattress for Pressure ulcer patients.  Pressure ulcers are a significant problem for hospitalised patients. Effective management of patients at risk of or with pressure ulcers is the key to achieving good clinical outcomes. While pressure-redistributing surfaces can help in the management of patients at risk of pressure ulceration, there is little available clinical evidence on which is most appropriate. 
The presence of a wound may cause psychological distress to some patients and hence effective communication with the patient is vital. 
Since pressure ulcers occur in patients who are immobile in majority cases of bed ridden patients, occurrence of the same is considered to be a nursing problem. Nurses are considered to be responsible for the assessment and prevention of pressure ulcers and the role of Doctors come only secondary to the role of a nurse in this particular case. All the reviews and detailed studies on the pressure ulcer indicates the need of an interdisciplinary approach for the management of a pressure ulcer participating almost all level of practitioners like doctors, nurses, therapists, dieticians, porters etc. It is the first and foremost obligation of a nurse to conduct ongoing, repeated assessment of risk factors of pressure ulcers since early detection and treatment are vital for the treatment procedure.
As Julie (EWMA 2009) points out that current nursing documentation of pressure ulcer prevention and management is not adequate and that risk assessment tools although not perfect do have a role to play in the identification of those at risk of pressure ulceration by raising awareness. Reporting and high quality documentation is essential to the process of reduction in the incidence and prevalence of pressure ulcers.  In the words of Karen (2005), a crucial feature for the prevention of pressure ulcers is correct and early identification of patients at risk. Risk assessment tools are meant as a part of holistic assessment and not to replace clinical judgment. The majority of patients admitted to a care setting, including those patients who are being nursed in a community setting, should be assessed, regardless of their age, gender or weight, and the results documented. If a patient is assessed as being at risk, then preventative measures should be implemented immediately and documented. Failure to do so will be viewed as negligence in the part of the practitioner, as harming the patient and may be viewed as a breach of human rights. 
According to Irene (2010), goals for pressure ulcer prevention require the selection of a bed that has a pressure redistribution surface such as air bladders, high-density foam, or alternating pressure surfaces. Careful and frequent skin assessments, frequent repositioning, managing moisture, and maximizing nutritional support are common interventions for prevention of pressure ulcers. Progressive mobility techniques and repositioning techniques used to prevent pressure ulcers are designed to promote the best outcomes while preventing dangerous complications. 
Evaluating the Japanese Government’s new incentive system for taking care of high risk patients, Sanada et al (2010) is of the opinion that for an effective strategy on pressure ulcer management, we need to focus on human resources, not on materials and devices. 
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