Pressure ulcers represent a concern that is common to the home health and hospice environments. Thousands of patients in home care and palliative settings face the risks of developing pressure ulcers. Unfortunately, many nurses are unaware of the ways, in which the incidence of pressure ulcers could be successfully reduced. Prevention and treatment strategies for pressure ulcers should account for the specificity of the home care and hospice nursing environments.
According to Porth (2011), pressure ulcers develop as a result of skin ischemia caused by the external pressure and shearing forces leading to blood vessels’ stretching and injury. Such external pressures can be great and applied for a short period of time or be milder but exert some force over an extended time period (Foster & Prevost, 2012). Ulcers often develop from a small skin defect, and shearing and moisture greatly contribute to their development and expansion (Foster & Prevost, 2012). “Shearing causes mechanical destruction of deep tissues as skin and underlying tissues are pulled in opposite directions, tearing blood vessels and leading to local ischemia” (Foster & Prevost, 2012, p. 180). Shearing is the result of the tissues sliding against each other, but it is not always the primary cause of ulceration. Foster and Prevost (2012) suggest that ulcers can develop from the skin traumas of diverse etiology, for instance, skin maceration generated by incontinence. It is wrong to believe that pressure ulcers are synonymous to bed sores, since ulcers develop in a variety of care settings and are not necessarily confined to bed (Foster & Prevost, 2012).
Nursing interventions to reduce the incidence or alleviate the sufferings from pressure ulcers encompass numerous activities. Nursing interventions against pressure ulcers in home care may slightly differ from the ones used in palliative care environments. Both hospice and home care nurses should start their interventions with a detailed assessment of skin and pressure ulcer risks (Bergquist-Beringer & Daley, 2011; Nenna, 2011). Nurses agree that all patients who are admitted for home care should be assessed for the risks of developing pressure ulcers (Bergquist-Beringer & Daley, 2011). However, while pressure ulcer prevention and interventions in home care are based on caregiver and patient education (Bergquist-Beringer & Daley, 2011), caring for palliative care patients requires a balanced approach that incorporates realistic life expectancy estimates, goals of end-of-life care, and effective wound management to relieve the patient’s sufferings as he/she is approaching the end of life (Nenna, 2011). End-of-life patients are particularly vulnerable to developing pressure ulcers, even in the presence of the most effective preventative measures (Nenna, 2011). Unlike home care settings where prevention is the top priority, in end-of-life care it is comfort that should guide nurses’ wound management decisions (Nenna, 2011). When the wound cannot be healed, palliation, symptom management, and provision of adequate psychological support should become the fundamental elements of effective end-of-life management (Stephen-Haynes, 2012).
Reifsnyder (2005) writes that, although pressure ulcers occur in every healthcare setting, little is known about their prevalence and incidence. No data as to the prevalence and incidence of pressure ulcers in Oregon is currently available. Still, Salcido and Lorenzo (2012) report approximately 1 million pressure ulcers that occur in the United States annually. In nursing homes, prevalence of pressure ulcers ranges between 2.6 and 24 percent (Salcido & Lorenzo, 2012). Asimus and Li (2011) suggest that prevalence of pressure ulcers in home care patients is 8.9 percent, and mobility remains a significant factor of risk, contributing to at least 31 percent of pressure ulcers developed at home. Of all home care patients, only 28.2 percent develop pressure ulcers during hospitalization, with the rest being attributed to poor home care (Asimus & Li, 2011).
Numerous evidence-based recommendations have been developed to stop the growing incidence of pressure ulcers in home and palliative care. The highest level of evidence is currently available for negative pressure therapy, vitamins and minerals, specialized mattresses, and ultrasound therapy (Levine, Sinno, Levine & Saadeh, 2013). Certainly, the choice of specific interventions will depend on the goals of care and the nature of the nursing care setting. For instance, in end-of-life care, even effective nutrition may not be successful in reducing the scope of pressure ulcers (Nenna, 2011). However, in all cases, a holistic assessment that involves the patient, family members, and nurses should be performed to develop an individualized plan of care for pressure ulcers.
- Asimus, M. & Li, P. (2011). Pressure ulcers in home care settings: Is it overlooked? Wound Practice and Research, 19(2), 88-97.
- Bergquist-Beringer, S. & Daley, C.M. (2011). Adapting pressure ulcer prevention for use in home health care. Journal of the Wound, Ostomy, and Continence Nurses Society, 38(2), 145-154.
- Foster, J.G. & Prevost, S.E. (2012). Advanced practice nursing of adults in acute care. Philadelphia, PA: F.A. Davis Company.