Unpacking the Truths About Pressure Injuries in Nursing Homes

Episode 201
Categories: Bedsores

Are nursing homes failing to prevent pressure injuries? Many residents suffer from these painful wounds due to neglect. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Karen Bauer to talk about the causes, prevention, and treatment of pressure injuries in nursing homes.

Unpacking the Truths About Pressure Injuries in Nursing Homes


Unpacking the Truths about Pressure Ulcer Development in Nursing Homes. Stick around.

Hey out there, everybody. Welcome back to the Nursing Home Abuse Podcast. My name is Rob. I will be your host for this episode. This episode, we’re talking about pressure injury development. In nursing homes, who is prone to pressure injuries, what assessments we can do to understand the risks involved in pressure injury development and interventions and a whole lot more.

All right, so let’s get into the substance, the meat and potatoes, if you will, of This particular episode, again, we have a fantastic guest, Dr. Karen Bauer, a wound certified nurse practitioner with 17 years of experience, specializing in wound and vascular medicine, holding an MS from Ohio state university and a doctorate of nursing practice from the university of Toledo.

She currently directs wound and vascular services at the University of Toledo Medical Center Certified by the American board of wound management. Dr. Bauer serves as a nurse board. Member for the Association of the Advance for the Advancement of Wound Care and is president elect for the Society for Vascular Nursing.

As an avid writer and lecturer, she enjoys spending free time with her daughter, dogs, and indulging in culinary delights. Dr. Karen Bauer. Welcome to the show. 

For detailed studies on this topic, including those by Dr. Bauer, check out PubMed and another study here.

Dr. Bauer: 

Thank you. Thank you so much. I’m excited to be here. 

What Are Some of the Risk Factors for Pressure Injuries in Nursing Homes?


Great. Obviously the topic of pressure injuries is an important one with regard to nursing home long term care.

And that’s why I wanted to have you on just to go over some basics and get your perspective. So the first thing that I want to address would be for people that have a loved one, a nursing home, what are some of the risk factors that nursing home residents might have?

For the development of pressure injuries, like what are some of the clinical conditions that are going to make it more likely that they might develop one? 

Dr. Bauer: 

That’s a great question. And I think that’s something, especially for families, that’s really hard to understand. Because I think for so long we’ve seen pressure injuries as something that happens from the outside, right?

We see it as a break in the skin or a wound. So I think a lot of times families feel like the biggest risk factor is on the outside of the body. When really, if we look at it from a medical or a clinical standpoint, the biggest risk factors are actually internal. So one of the big ones that we see in that post acute care or extended care or nursing facility is simply age.

Learn more about the causes and risk factors for bedsores at Causes of Bedsores.

We know that as we get wiser and mature or older, our skin does the same thing, right? So it loses elasticity. It doesn’t have the backing that it used to have in that in and of itself, right? Puts you at risk for pressure ulcers. Another common thing that we see in the nursing homes is dementia.

So for you and I, we have the wherewithal or the cognitive ability that we’re going to shift our weight naturally. 

And patients with dementia, they simply forget. And sometimes even pain is a good motivator, but. As soon as they’re experiencing the pain, they can’t remember where the pain is, and they don’t reposition.

From there, it’s mobility. We lose our ability to move around as we get older. A lot of the patients in nursing homes have other other things that are going on that are inhibiting them from being able to move. Nutrition. I actually participated in a study where we looked at when patients are in the hospital, what the biggest risk factor is for pressure ulcers.

So it’s a little bit different in the hospital than the nursing home, but nutrition was one of the biggest and really the only thing that really correlated with pressure ulcer development. You think you’re eating enough, but you need tons of protein, you need to be eating and drinking well, of course, like all of those other illnesses that we oftentimes lose sight of.

Diabetes. Hypertension, COPD from patients who have smoked, Peripheral artery disease, vein disease. All of these chronic illnesses that lead a patient to be in a nursing home also contribute to the development of pressure ulcers. 


So that’s a good segue. Can you just briefly, like from a 40, 000 foot view, why is it that COPD, that peripheral artery disease, that diabetes, how do these things contribute?

To develop a pressure injury, like on the inside of the body. What’s that? What’s the basic mechanisms? 

Dr. Bauer: 

So the biggest thing, that’s a great question. The biggest thing is oxygenation. Our skin needs oxygen and nutrients. We need to feed our skin. When you have COPD, you’re not breathing in and processing the oxygen all the way up here in your lungs.

When you have diabetes, the tiny little blood vessels that feed your skin, oxygen, don’t work. Well, hypertension is similar. We have such high pressure in the arteries. That we’re not circulating and oxygenating well. So I think high level, that’s what I would say, but also those chronic illnesses create a state in your body that is inflammatory.

It’s angry. It’s catabolic where your body’s just trying to keep all those things at bay. It’s trying to manage diabetes and other illnesses. And unfortunately your skin just takes a second stage. Cause your body’s really focused on some of those other things. 

How Can Nursing Homes Improve the Prevention of Pressure Injuries?


Okay. So what I hear you say is we have a certain set of clinical conditions that might make it more likely that somebody is going to develop a pressure injury.

So we know that. What does the nursing home do or what can the nursing home do to improve the odds that the pressure injury won’t develop? 

Dr. Bauer: 

So that’s complex. Again, I think that the first thing is being true to that risk assessment. So a lot of nursing facilities have tools, checklists, if you will, that when a resident is admitted to a post acute setting, they should be looking at those factors and they actually get a score for pressure ulcer risk.

So it starts there. Really looking at that risk and looking at that risk uniquely for each resident. Because each resident is going to be a little bit different in each category, so you can’t broadly say this patient scored, 12, so they need all of the things you really need to look at why that patient is scoring low, where they’re scoring low, and then put patient unique care plans in place to address that.


And I don’t want to derail you because that was a terrific answer. Sure. I guess I’ve never thought about that. Usually I think of it in numbers like, okay here’s the Braden scale assessment, which is the, at least in my experience, the most popular pressure injury risk assessment.

For innovative interventions in pressure injury prevention, explore resources like the Quick guide to social care on pressure ulcers by NICE.

And you, it spits out a score based on the score. Okay. Now we’re going to reposition you now we’re going to do it but I guess what I hear you say, what’s really interesting that I’ve never really thought about really hard is that still might not be enough because you’re the risk number.

And that number might correlate to something different from one person to the other, because maybe they got that number because of that, they’re more prone to moisture versus the next resident whose issue is just bed mobility. That’s an interesting thing that you say. Okay. Even if it spits out a high number, the two care plans still might not be the same.

So I just wanted to make that a side. I didn’t mean to throw you off. So now, in terms of, what can the nursing home do, we, it seems that I hear you say we have assessment, and then from the assessment, where do we go from there? 

Gain insights on prevention strategies by listening to the episode Preventing Pressure Ulcers in Nursing Homes.

Dr. Bauer: 

Yeah, so if you look at their guidelines, the post acute care pressure injury prevention guidelines say that we have to do those care plans that are specific to the patient. So with the risk assessment and looking at each of those categories, but then also looking at what other diseases the patient has that may not be captured in that basic risk assessment. So if a patient’s diabetic, getting something on board to control those blood sugars.

If a patient does have COPD, do they need oxygen? How often do they need oxygen? Just at night or all the time? Doing everything that we can to manage the resident as a whole to make sure that not only are we addressing those basic risk factors, but that we’re really holistically looking at the patient.


It seems like there are some standards like when you used to be, when you would go on a will of fortune, you would tell him, you would tell Pat Sajak at the end. These are the letters that I want. And everybody started picking R. S. T. L. E. N. right? Until at some point. You were given those and then you got to get some extra letters.

For comprehensive guidelines on preventing pressure ulcers, the National Pressure Injury Advisory Panel provides valuable resources and guidelines at NPIAP.

So there are some and they’ll make sense in a second. But the analogy that I’m making is that there’s some things that I feel like it’s just going to be standard offloading, turning repositioning. That’s a pretty standard intervention. That’s probably going to work a lot of the time. The nutrition aspect, making sure that somebody is getting the protein they need, making sure they get the fluid they need.

Explore Five Ways to Prevent Pressure Ulcers in Nursing Homes for practical tips and techniques.

What Are Some Innovative Interventions for Preventing Pressure Injuries in Nursing Homes?

Okay, fine. What are some of the more. Innovative interventions that you’ve seen in, in, in your experience that might help prevent pressure ulcer development. 

Dr. Bauer: 

So some of the things there, and I think we have to take this with a grain of salt in the sense that we are in a resource limited situation, right?

So not everybody has access to these things, but some of the things that we’re looking at are this has actually been here for a while, but looking at what’s called sub epidermal moisture which is a long term way to say that there are changes within the skin and under the skin that occur prior to pressure ulcer development that have to do with the moisture of the skin.

And there are ways to monitor that. There are dressings nowadays that are smart dressings that can monitor the patient’s positioning. And some of the factors within the wound help us determine what’s going on in that skin. Sorry, not in the wound, but in the skin before, before that ulcer develops. There’s something called thermography, which is similar where it’s a specialized camera.

And if you have a patient that you feel is particularly at risk, you can utilize that camera to snap a thermographic or a temperature picture of the areas that you feel are at risk or that could be at risk. And they can help identify by heat. Essentially what is going on underneath the skin because these do develop underneath the skin.

For comprehensive strategies and interventions, visit Relias Blog on Preventing Pressure Sores and React to Red – Reducing Pressure Ulcers in Care Home Settings.


First, how that’s pretty wild. How far away or do you think we are from that being typical? 

Dr. Bauer: 

So they’re there. As far as typical. It’s really hard to say because our healthcare system is changing so quickly. 10 years ago I would have said 10 years, but I think with the way things are changing now, I’d like to see these things being really more utilized and cost accessible, the facilities, three to five years, maybe as far as being adopted as an actual standard of care, I think that’s way down the line.

But the access I’m hoping for improves, within the next 3 to 5 years. 

What Practical Implications Do You Have for Nursing Home Policies Related to Pressure Injury Prevention?


Are there any particular policies so for example I had a guest on here, and I know that not every nursing home can do this, but she was, she’s a proponent of a policy of, Every single human person that comes into this long term care facility is a high risk for pressure injury.

Like we’re just gonna, we’re just gonna treat every single person as high risk. So are there any policies that you have seen or any that have any, any effect or could have an effect on pressure injury development that, from your experience 

Dr. Bauer: 

I would agree with that sentiment.

That when you’re in the post acute care setting, you have patients who are recently hospitalized. When you have acute illness your body concentrates on the acute illness on top of the chronic. So I would say any patient with acute illness, high risk for pressure injury when they’re that age. So I would agree with that paradigm.

Other than that, I don’t think so. I think that two things that I like to emphasize are the concept of skin failure. So what do you think of when I say heart failure, 

The heart is failing, right? It’s not a good thing. We know it’s. It’s there, but heart failure isn’t something that happens like that.

It’s insidious. It happens over time. We’ve always thought of the skin as being right now, a pressure injury is right now. Pressure injuries. We need to change that paradigm. So it’s not really a policy or protocol, but that line of thinking that goes with the protocol of everybody in that environment is high risk.

Your skin can chronically fail when you’re diabetic, you have COPD, you have moist skin, you’re not moving, you’re not eating protein over time, your risk increases and increases. And it can take something very small to tip that scale. 

Discover cutting-edge techniques and best practices in Pressure Injury Prevention and Documentation.


That’s something that, um, that I say to my clients is to think of the skin as an organ, because that’s exactly what it is.

And then once you understand that your skin is an organ. You understand better. Okay. Yeah. It’s like the heart can fail that you can have a heart attack. And as you mentioned, there can be a slow moving train of problems . There goes my watermelon book that fell on the ground in case anybody is watching.

That’s what that sound is. Anyway, I need to get phase three. Anyway, it’s only digital. This is phase two. Anyway, Okay. Yes, the skin is an organ and That makes it easier for people to understand. Okay. This is why it’s breaking down or this is how it can happen yeah, so tell me then. Okay.

So what are some? Some things that you would tell a family that has a loved one in a nursing home that is moderate to high risk for pressure injury. What are some things that the family can do to get involved in that, in this process? 

Learn about comprehensive approaches in Comprehensive Pressure Ulcer Prevention in Nursing Homes.

Dr. Bauer: 

Yeah, I’m actually glad you asked that because I think one of the things that I always push is the family really should and has to be involved, both for the sake of the family, for the sake of the patient and then obviously for the nursing home.

I think presence is one, because, when we look at nutrition, the nursing facility has around the clock staffing but they can’t be there and provide the patient all of the time with the social factor that comes with eating. So I think being there for meals sometimes bringing in meals when possible so that the patient doesn’t just have this meal put in front of them and somebody that they may not know extremely well, sitting down to eat with them for a couple minutes, share those moments with the patient or the resident, because the more motivation we have to do the things we need to do, the better.

And similar goes with the turning and repositioning and the getting up for therapy. When you think about that from the resident standpoint, you’ve got a stranger coming in and trying to get you to stand up and you don’t really feel like standing up. So sometimes just family presence where possible even if it’s once a week with therapy and once a week with the dietician, so that there’s that reinforcement of, Hey, We’re here too.

And this is why you need to do this and we’re going to do it with you. So I think number one is just very honestly, that presence and the willingness to communicate. So that as these things do develop, there’s awareness. 

What Is One of the Biggest Drivers of Pressure Injury Development According to Your Research?


Yeah. The family’s there already. So oftentimes I like to read academic literature in this area.

And that’s actually how I found you was a paper that you did it’s pressure and I’ll have this linked in the show notes, but it’s pressure ulcers in the United States inpatient population from 2008 2012 results of a retrospective nationwide study. And I wanted to talk to you a little bit about that.

What kind of how did that come to be? How did that paper come to be? And what were the results? What did you find? 

Dr. Bauer: 

So it came to be just that, this is my daily practice. I spend a lot of time in the post acute setting, but I also spend a lot of time in the acute care of the hospital setting and we have the same questions that you have: why is this happening?

And we were starting to see the paradigm shift from this isn’t on the outside, this is on the inside. That paper just stemmed from us saying, Hey, This is a problem. Let’s see what we can look into. So there’s actually a national database that tracks the diagnosis of inpatients by all the numbers.

It’s like a Dewey decimal system for hospital coding. But actually what we did was look at all the patients who had pressure ulcers in the hospital and then Cross referenced that with other diagnoses, hypertension, COPD, CHF and we actually found that, like I said earlier, the only one that was truly correlative, they all played a role, they all had higher incidence of pressure ulcers in patients with basically every comorbid factor that we looked at versus our truly acute, younger patients, but the biggest one was nutrition so that helps us guide some of our interventions that maybe no matter how much we turn in reposition or how dry we can keep the peri area, things like that, it was that nutrition that really correlated.

And I think that’s the key message that I took away from that project. 

Understand whether pressure ulcers are avoidable in Are Pressure Ulcers Avoidable?


That’s really interesting. That’s fascinating, really. That you could have somebody in space, floating in space, but if you don’t give them the correct food, they could still develop a pressure injury. Because, at the end of the day, it’s the lack of nutrients getting into those tissues.

So if that, if, and if nutrition is key to that. So that makes a lot of sense. Ms. Bauer, thank you. This has been a fantastic episode. I really appreciate you coming on and sharing your knowledge with us. 

Dr. Bauer: 

Yeah, of course. Thank you for having me. I love to do this. So if anybody has any questions or needs anything, I’m happy to do some one on one or point you in the right direction.


For legal support related to bedsores in nursing homes, visit Atlanta Nursing Home Abuse Bedsores Lawyer.


All right. Hopefully you have found this episode educational and entertaining, at least in some respects. I know that we got a little bit of technical difficulties with my watermelon book hitting the ground. I think the thing weighs 35 pounds. So hopefully that didn’t scare you. Maybe we can take that out and post.

New episodes of the nursing home abuse podcast every Monday, wherever you get your podcast from again, if you have any suggestions for content or you want to see a particular guest, please let me know just email me or DM me or however the kids do. And with that folks. We’ll see you next time.

Guest Information: