Pressure Area Pain Predicts Development of Pressure Ulcers

In a prospective cohort study published in the British Medical Journal, researchers from several universities in the United Kingdom found that pain experienced at pressure areas on the skin surface independently predicted the development of pressure ulcers in acutely ill patients in hospital and community settings.¹

Earlier findings show that patients with pressure ulcers have reported feeling pain at pressure areas before the ulcers developed, and that healthcare providers ignored their complaints, although no known studies have explored pain as a potential risk factor for pressure ulcers.² The current study’s investigators previously observed pressure area pain in 233 of 1769 (12.6%) hospital inpatients with no pressure ulcers.³ In the present study, they aimed to determine whether pain at pressure areas would predict the onset of stage ≥2 pressure ulcers in patients at high risk of developing them.

The final sample included 602 adult patients recruited from 26 centers with established prevention and management policies for pressure ulcers. Patients admitted to obstetrics, pediatrics, day surgery, or psychiatric wards were excluded, as were patients deemed too unwell to participate and patients with 2 or more existing stage ≥2 ulcers at specific pressure area sites. Participants were assessed twice a week for up to 30 days by clinical research nurses who classified any existing pressure ulcers and noted whether intact skin was healthy or had alterations such as redness, dryness, or scarring.

According to the study results, approximately 25% of patients developed 1 or more stage ≥2 ulcers, and 77.1% of patients reported the presence of pain in a healthy, altered, or stage 1 skin site. Of the latter group, 28% (130) of patients developed a stage ≥2 ulcer vs 15.9% (22) of patients who did not report pain.

Pain was found to be a risk factor for stage ≥2 ulcer development across 4 multivariate logistic regression analyses and was associated with accelerated time to ulcer development. Additional risk factors were baseline alterations to intact skin and the presence of a stage 1 ulcer.

Future studies should attempt to replicate the current findings and should consider including skin site and patient level analyses. “This area of practice requires improved assessment, incorporation into risk assessment, and treatment strategies to alleviate pain” and decrease ulcer development through pressure relief and reduction, the investigators wrote.

Summary and Clinical Applicability

Pain at pressure area skin sites was found to predict the development of stage ≥2 pressure ulcers in high-risk patients in hospital and community settings. 

Limitations and Disclosures

The study’s outcome assessment was not blinded, which could have introduced bias. In addition, the researchers note that the sample is not representative of the general population, as patients with cognitive problems and severe or terminal illness were excluded from the study.

Drs Nixon, Nelson, Coleman, Brown, Muir, and Dealey have received funding from various relevant organizations.

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References

1. Smith IL, Brown S, McGinnis E, et al. Exploring the role of pain as an early predictor of category 2 pressure ulcers: a prospective cohort study. BMJ Open. 2017;7:e013623. doi: 10.1136/bmjopen-2016-013623
2. Gorecki C, Brown JM, Nelson EA, et al. Impact of pressure ulcers on quality of life in older patients: a systematic review. J Am Geriatr Soc. 2009;57(7):1175-1183.
3. Briggs M, Collinson M, Wilson L, et al. The prevalence of pain at pressure areas and pressure ulcers in hospitalised patients. BMC Nursing. 2013;12:19.