A pressure sore is an area of localised damage to the skin and may involve underlying structures. Tissue damage can be restricted to superficial epidermal loss or extend to involve muscle and bone. Banks (1992, cited in Alexander, Fawcett & Runicman, 2001). The pressure sore problem presents major challenges for nurses as the problem is widespread and persistent, affecting patients from all walks of life and with a range of illnesses. It causes diminished quality of life and distress to patients and carers and it makes major financial demands on the health service.

The true cost of pressure sores is not known, the estimated range from £60million to £200 million per year, Department of health (1993), cited in Clay, 2000), pressure sores not only cost money but can cause other problems, they may lengthen a patients stay in hospital, cause extra work for nursing staff, increase the potential for litigation. Research has shown 9% of all patients admitted to hospital develop pressure sores with a further 9% at risk, Dealey (1992, cited in Quinn, 1999), patients aged 65 and over are at greatest risk with 49% in this age range.

It is estimated the 95% of sores are preventable. Waterlow, 1988, cited in Quinn, 1999), for nurses, the difficulties arise in trying to identify patients who might develop a pressure sore, and when they are at risk of doing so. Pressure sores result from areas of previously healthy tissue becoming devitalised, resulting in localised tissue death. Pressure ulcers are prevented through the knowledge and skills of the nurse by correct handling techniques when manoeuvring the patients, positioning of patients in their bed will be (tilted to a 30 degree angle), and also equipment used to relieve pressure.

Nutrition should also be considered as an essential part of wound healing. All patients should be screened for malnutrition and should receive an appropriate level of nutritional support. All members of the multidisciplinary team should be on the look out for malnutrition and embrace nutrition as an essential part of wound management. Nutritional assessment is of paramount importance in identifying the appropriate means of nutritional support that can reduce the risk of developing pressure ulcers and should be part of the initial nursing assessment.

Older people should be reassessed at regular intervals, within the tertiary health care system patients nutritional needs are looked after by a dietician who is part of the multidisciplinary team. The tissue viability nurses also play a key part in the formulation of a strategy to prevent ulcers, particularly through their staff education role. Nurses need to identify who is at risk and care for patients on the most appropriate surface. A combination of good nursing techniques and preventive aids will definitely be necessary.

This includes the mattresses on the bed, and the chairs they may sit on during the day, Dealey, (1992, cited in Quinn, 2000); in tertiary health care settings the majority of the patients are immobile with chronic illnesses, and are elderly. They are dependent on the nurse’s care for their day-to-day needs. If a patient has a pressure ulcer on their posterior the nurse would turn the patient on their side alternating two hourly, this process will give the patient relief.

If a patient is confined to a chair the patient can be manoeuvred using hoists such as the ‘sara’ or the ‘oxford’ hoist again to give the patient relief, this is again done two hourly. If movement is restricted a care plan will be devised by nursing staff to keep the patient off the ulcer as much as possible. There should be a multidisciplinary approach to a selection of equipment and should be installed within four hours of admission. Preventative aids in the tertiary health care setting include special mattresses and beds, chair’s are used which must be of the correct height and depth for the patient.

Sheepskins are also used which is a mechanical aid to relieve patients who are at low risk. When possible carers and relatives should encourage patients to change position, to sit in chairs as opposed to remaining in bed during the day known as chair-nursing, is widely thought to prevent pressure sores and other complications associated with bed-rest. A study by Gebhardt and Bliss 1994, cited in Clay, 2000), did not support this but suggested that the development of pressure ulcers is strongly correlated with the length of time spent sitting.

Pressure sores develop in a number of ways, as a result of direct, unrelieved pressure of soft tissues against bone. Where friction occurs between the patient and the surface of a bed or chair; this can happen if the patient is moved and the skin is dragged over a sheet. As a result of the shear force which frequently accompanies both direct pressure and friction; shear forces develop in tissues that are distorted and pulled, so that the blood supply is disrupted.

Physiological studies have demonstrated that the relationship between exposure to pressure and tissue impairment depends on two characteristics of the pressure, intensity and duration. One of the most fascinating features of the human body is the ability to repair damaged tissues. In the elderly this ability will decrease with age. Also the affects of the ageing process are often compounded by concurrent illnesses and malnutrition. Wounds in elderly patients do however heal with good effect in most instances but it takes longer.

A holistic approach to the patient’s well being as a whole is needed and also a holistic approach to wound care is the key and if all the factors are not addressed then the wound healing will not prevail. A starting point in any management regimen should be a holistic assessment in order to determine the underlying aetiology and why the patient has a wound that is unwilling to heal. This can only be determined through full clinical history, physical examination, and appropriate laboratory testing and haemodynamic assessment.

The need to consider strategies for preventing pressure ulcers for people who live in residential accommodation such as nursing homes has also emerged. For example a study of 2,245 residents in 95 nursing homes conducted by Robert (1994, cited in Gould, D 2001) identified a prevalence of 7. 5 per cent. This number is too high to be ignored and may be an indicator of a problem that is set to grow; there is every indication that people living in nursing homes are becoming increasingly frail, elderly and dependent (Malone and Mckenzie, 2000, cited in Gould, D, 2001).

As most pressure ulcers appear to develop in older people, it is evident that clear strategies for assessment and prevention should be in place. Unfortunately such people frequently receive all or most of their care from health care assistants who have had very little training. There are many key points that a nurse should take into consideration when assessing and treating a patient who is ‘at risk’.

Firstly, holistic assessment should be the starting point in any treatment regimen, secondly, nurses should avoid focusing on the wound in isolation and concentrate on the patient as a whole, thirdly, and the patient’s medical history and medication provide clues as to the underlying causes of the ulcer. And finally observing the patients limbs should be taken irrespective of whether the limbs are ulcerated or not. To assess every patient from first principals would involve synthesising an enourmous quantity of information, risk assessment (RAS), is used as a short hand approach.

The Waterlow score is the most popular RAS used in the UK today and is the one being most written about, however it is important to be aware of the Norton score in view of its historical importance as the very first RAS. The Braden scale is also used in some trusts although it has been adopted more widely in the USA than the UK. The Waterlow scoring system is more comprehensive than the other scales mentioned taking into consideration the patients weight, continence state, skin type, mobility, age, sex, nutritional status, neurological deficits, surgery/trauma and medication Waterlow 1985, cited in Gould, 2001).

Each risk category is allocated a numeral score and their product yields an overall score, a high score is indicative of a patient being at increased risk. Risk is indicated at a score of 10-14, 15-20 is a high risk and a score of 20 or more is a very high risk. The Waterlow score has generated a considerable amount of correspondence in the nursing press since its introduction into clinical practice. One of the major reasons for using an RAS is that it is seen as a rapid and convenient means of identifying patients at risk, and their degree of risk.

This is because the RAS, at least in theory, consists of a synthesis of all those factors that make the individual vulnerable to tissue impairment. Comparison of the most commonly used RASs serves to indicate the weakness inherent in this assumption, however both the Waterlow score and the Braden scale take into consideration many more clinical variables than the Norton score. The exact nature of the variables included by each RAS is different; the Norton score ignores the effect of shearing altogether, but this is considered an important contributory factor in other RASs which have been more recently developed, for example the Braden scale.

Nobody really knows which variables should actually be included in the ideal RAS, whether they should all be given the same weight or whether the same RAS is suitable for use across the full range of settings where care is delivered. This point is illustrated in the apparent increased susceptibility to pressure ulcer formation that is seen in older people. One possible solution may be to select the most appropriate RAS to meet the needs of a particular patient population.

This approach is not without its difficulties practitioners will not be in a position to decide which RAS to use if a trust-wide policy has been agreed. Risk assessment tools should be regarded as indicators rather than predictors (Simpson 1996, cited in Clay 2000) and take second place to clinical judgement as the basis for patient management decisions. Risk assessment should always be followed by preventive action, part of which should include regular reassessment of the risk, the frequency of which will depend on alteration in the patient’s condition.

Risk assessment should be based on the patient’s clinical presentation and consideration of known intrinsic and extrinsic risk factors. Intrinsic factors are those relating to patients physical or medical condition (nutritional status, mobility, neurological disease, while extrinsic ones are those deriving from the environment such as skin hygiene, medication and the support systems employed to relieve pressure, Barbenel, (1991, cited in Gould, 2001).

There are many risk assessment tools currently available for use in pressure ulcer prevention, but their reliability and validity have been questioned. Flanagan, (1993, cited in Dowsett, 2001) Hamiliton, (1992, cited in Dowsett, 2001). Tools such as the Braden scale (Bergstrom, 1987, cited in Gould, 2001) and the Waterlow score, Waterlow (1985, cited in Gould, 2001), should be used as an aide memoire to enhance clinical judgement, not to replace it. It is essential that the chosen tool is used consistently and that it is appropriate for the patient.

The assessment should be recorded accurately and in detail and should be easily accessible to all members of the interdisciplinary team (Roycroft-Malone 2000, cited in Dowsett, (2001). Patient records should be legible and regularly updated. Once a patient has been identified, as being at risk of pressure ulcer damage a number of measures should be taken to reduce and manage the risk. These include repositioning techniques, correct manual handling, use of pressure redistributing equipment, addressing underlying problems such as malnutrition and incontinence, the need for patient and carer information and education.

Regular re-assessment is necessary to evaluate the effectiveness of intervention measures and to insure rehabilitation of the patient. In reality, patients often develop pressure ulcers, and intervention strategies need to be examined using critical analysis, reflection, clinical supervision and audit. These components form part of the clinical governance initiative and, when used correctly, can help to reduce pressure ulcer development. Conclusion Pressure ulcers are costly to both patients and the NHS.

It is therefore of paramount importance that the treatment regime is based on a holistic assessment to determine the underlying aetiology. It is only then that the appropriate care plan for the patients can be formulated. The effective management of patients with wounds requires an understanding of the healing process in conjunction with an organised approach to both assessment and management, and includes, assessment of the individual’s overall health, taking into account factors which might impair healing. Assessment of the wound.

Planning the management of the individual, taking into account the social and physical environment, and using the most appropriate dressing materials available. Involving the patient, where possible, in wound care, evaluation and reassessment of the individual until the wound heals or the needs of the patient change. Historically risk assessments have been of value because they have drawn attention to the need to assess tissue viability status and this predated the introduction of risk assessment more generally into health care settings by many years.

However, experience has shown that the incidence of pressure ulcers is only likely to fall if all patients are assessed and reassessed at regular intervals as part of routine care and if the findings are carefully recorded in their notes. This is especially important for those in primary care settings where risk status is subject to rapid change and more than one health professional may be responsible for delivering care. It goes without saying that unless appropriate pressure-relieving interventions are instituted, prevention will not be achieved.

Further research is needed to determine which of those risk assessments currently available is most valid and reliable, this work is currently in progress but it is most likely that none of the RASs presently used meet these criteria, so work is also needed to determine which risk factors genuinely contribute to tissue impairment. It is not surprising that pressure sore prevalence and incidence data are considered to be key indicators of the quality of care delivered. Although deaths directly ascribable to pressure sores are difficult to determine, there is no doubt that pressure sores are associated with increased mortality.