One of the challenges facing hospitals and nursing homes is the prevention of pressure ulcers and deep tissue injuries. The elderly who are confined to bed are especially vulnerable to such injuries. However, patients who are not elderly and not permanently confined to bed are also vulnerable if they have limited mobility, limited sensation in affected areas, and nutritional issues.

The general consensus in the medical community is that most pressure ulcers are avoidable if adequate precautions are taken. Pressure ulcers that develop into deep tissue injuries are even more preventable. Prevention requires vigilance and proactive nursing care to prevent the ulcers and once they do develop to keep them from becoming deep tissue injuries. Frequent periodic repositioning is critical. The standard of care for any patient with any stage of pressure ulcer is to not apply pressure to the tissues. There is an old adage that "you ccan put anything on a pressure ulcer except the patient."

It is routine in nursing homes and hospitals to use a scale to determine if the resident or patient is at risk for development of the wound. It is called the Braden scale and it takes into consideration such factors as mobility, level of activity, sensation, nutrition, whether the area affected is moist or damp, and friction and shear. The following factors in an assessment will lead to a high Braden scale which means that there is little risk that a pressure sore will occur:

• Patient responds to verbal commands and has no sensory deficit which would limit ability to feel or voice pain or discomfort.

• Skin is usually dry and linen only requires changing at routine intervals

• The patient or resident walks outside the room at least twice a day and once in the room every two hours during waking hours.

• The patient makes major and frequent change in position without assistance.

• The patient eats most meals and eats a total of 4 or more servings of meat and dairy products, and occasionally eats between meals.

• The patient moves in bed and in the chair independently and has sufficient muscle strength to lift up completely in bed.

The patient is at high risk for development of a pressure sore if sensory perception is completely limited, the skin is moist almost constantly because of perspiration or urine, the patient is confined to bed and does not make even slight changes in body or extremity position; the patient never eats a complete meal and requires moderate to maximum assistance in moving.

There is a standard staging method for such ulcers. If the ulcer appears to only affect the skin, it is Stage I. If it develops into blisters or the outer layers of skin are broken down, it becomes a Stage II ulcer. A Stage III ulcer is deeper into the tissue, but the bone or joint is not exposed. In the Stage IV deep tissue ulcer, bone, tendon or muscle is exposed. The risk for infection rises dramatically the deeper the wound is.

Many hospitals now have clinics to treat not only pressure ulcers and deep tissue ulcers, but surgical wounds and other kinds of wounds. Medical advances have been made in the field of wound healing that has led to better outcomes.

However, as an English poet wrote: "Better put a strong fence around the top of the clif, than an ambulance down in the valley."

Unfortunately, these ulcers still occur with some frequency. I had a case a few years ago in which the ulcers were allowed to progress to the point that the patient ultimately died; the emergency room doctor cried when he saw the wounds for the first time. This deep tissue wound was totally avoidable.

When these pressure wounds develop into deep tissue wounds, tens of thousands of dollars are expended in treatment, months and years of misery wreck the lives of the patients, and there is an increased risk that the ulcer may reappear in the future. While awareness of the ulcers has increased and the ability to prevent them with technological advances has improved, they still do occur. In some cases, they originate from staffing issues in which nurses and nurses' aides are stretched to the limit. If this is the primary cause, then economics is the root cause.

There is a national organization called the National Pressure Ulcer Advisory Panel dedicated to the prevention and management of pressure ulcers. It was started in 1987. Through its efforts and the efforts of others, the incidence of these ulcers has declined, but their work is unfortunately not finished.

Bob Buckley is an attorney in Independence. Email him at