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Diagnosis and Treatment |

Pressure Ulcers in the Nursing Home

David M. Smith, MD
[+] Article and Author Information

For affiliations and current author address, see end of text. Acknowledgments: The author thanks Drs. Christopher Callahan, Jeffrey Darnell, Terrance Drake, and David Wilcox for review of drafts; David Gregory for the illustrations; and Jane Egan, RN, Terryl Adams, RN, Gayle Redmon, the Skin Care Resource Team of Wishard Memorial Hospital, and Rebecca York for technical assistance. Requests for Reprints: David M. Smith, MD, Richard L. Roudebush Veterans Affairs Medical Center (111GIM), 1481 West Tenth Street, Indianapolis, IN 46202. Current Author Address: Dr. Smith: Richard L. Roudebush Veterans Affairs Medical Center (111GIM), 1481 West Tenth Street, Indianapolis, IN 46202.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1995;123(6):433-438. doi:10.7326/0003-4819-123-6-199509150-00008
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Objective: To review the literature on the causes, epidemiology, prevention, and treatment of pressure ulcers in nursing homes and to summarize this information for clinicians caring for nursing home residents.

Data Sources: A MEDLINE search of English-language articles published between 1980 and October 1994 using the terms decubitus ulcer and elderly. References from identified articles were also examined.

Study Selection: Articles were excluded if the title indicated that patients were not nursing home residents (unless data from nursing homes were limited or unavailable), that patients were not elderly, or that the ulcers were related to peripheral vascular disease or neuropathy.

Data Extraction: Selected studies either contained original data or were meta-analyses. Prevalence studies were required to have an identifiable denominator; risk factor and incidence studies were required to have an identifiable cohort and a specified duration of follow-up. Preference was given to risk factors identified through multivariate analyses. Studies of preventive and therapeutic interventions were required to have an identifiable control group; preference was given to randomized, controlled trials.

Data Synthesis: Seventeen percent to 35% of patients have pressure ulcers at the time of admission to a nursing home, and the prevalence of pressure ulcers among nursing home residents ranges from 7% to 23%. Among high-risk patients, the incidence of pressure ulcers is estimated to be 14/1000 patient-days. Residents at higher risk for developing ulcers are those who have limited ability to reposition themselves, can-not sense the need to reposition, have fecal incontinence, or cannot feed themselves. Occlusive dressings are as effective and less costly than traditional wet-to-dry saline dressings for treating earlier stages of pressure ulcers. There is no consensus on the use of specialized beds in the nursing home for promoting the healing of advanced-stage ulcers or for reducing the incidence of ulcers in high-risk patients. Specific interventions should not detract from careful, total assessment and management of the patient.

Conclusions: Pressure ulcers in the nursing home are common problems associated with significant morbidity and mortality. Because resident characteristics can identify residents likely to develop ulcers, preventive measures can be implemented early. Therapy for advanced stages of pressure ulcers is expensive and prolonged. Involvement of the physician with the multidisciplinary nursing home team is essential for prevention and therapy.

Figures

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Figure 1.
Classification of pressure ulcers.

Stage 1, nonblanchable erythema. Stage 2, partial-thickness skin loss. Stage 3, full-thickness skin loss. Stage 4, full-thickness skin loss with extensive destruction. (Figure adapted with permission from Braun JL, Silvetti AN, Xakellis GC. What really works for pressure sores. Patient Care. 1992; 28:63-74.).

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Figure 2.
Positions of the bed-bound patient.topmiddlebottom

In the supine position ( ), the body weight is placed on the bony prominence of sacrum or coccyx and heels. In the lateral position ( ), the weight is placed on the prominence of the hips and malleoli of the ankles. These exposures can be avoided by propping the patient in the 30-degree lateral position ( ) with pillows.

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Figure 3.
Pressure ulcer prevalence at hospital discharge over time.

The bar graph shows the trend over time for discharges from short-stay hospitals in the United States for persons age 65 years and older per 100 000-persons. The total discharges for all diagnoses are indicated by the hatched bars with reference to the right vertical axis. The discharges for which a pressure ulcer (ICD-9-CM code 707.0) was any of all listed diagnoses are indicated by the solid black bars with reference to the left vertical axis.

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