PUs (i.e. bed sores) are infections for patients that typically have longer length of stays at hospitals and long-term care facilities. Due to the long length of patients stays in hospitals, (i.e. 2-4 weeks), Medicare insurance may not reimburse for ulcers that occur during such episode of stay and will potentially require medical evaluation.The development of theoretical framework is to determine patient, treatment, and facility characteristics associated with Pressure Ulcers (PU) development in hypothetical example of health organization- i.e. Truman Medical Center (TMC).
Considerations:
- A hypothetical example of research healthcare organization is TMC.
- The conclusion section of this research was included in response to the case study questions.
- Minimum number of pages have not been specified, as requirement for this research paper.
- Introduction:
Management and Clinical Administrators of TMC (TMC) decides that due to the long length of stays of some of its patients (i.e. 2-4 weeks) and that Medicare will not reimburse for ulcers that occur during the patients stay— they need to evaluate the situation, formally.
As part of the clinical team leads for the evaluation of the PUs (PU) in TMC, I created nine important steps to evaluate the current situation. These critical steps are part of the recommendations that will be presented to senior management team of TMC. Additionally, these important steps include why PUs occur in a hospital setting (specifically in TMC), and the types of preventive measures that should be used in the hospital settings? They also include hypothetical findings, with charts and graphs (if applicable), et cetera. They also include conclusion section about the issues and study of PU in the hospital settings.
PU (i.e. bed sores) are issue for patients that typically have longer length of stays at hospitals and long-term care facilities.
- Response to The Case Study Questions:-
- Define and Identify the Existing Problems of PUs:
The first step in research process is to define and identify a problem or develop a research question. According to National Database of Nursing Quality Indicators (n.d.), PU is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure is the force that is applied vertically or perpendicular to the surface of the skin. Pressure compresses underlying tissue and small blood vessels deterring blood flow and nutrient supply. Tissues become ischemic and are damaged or die. Shear occurs when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow.
Residents with PUs exhibit decreased quality of life, and increased morbidity and mortality rates. PU (i.e. pressure sores) remain to be a common health problem, particularly among the physically limited or incapacitated elderly individuals. The problem exists within the entire health framework, including hospitals like TMC, clinics, long-term care facilities and private homes. For many elderly patients especially, PUs may become chronic for no apparent reason and remain so for lengthy periods of time, even for the remainder of the patient’s lifetime. A large number of grade 3 and 4 PUs become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis).
The identified problem or question is that PUs are issues for patients that normally have longer length of stays at TMC and its long-term care facilities. Long term stays of the existing patients in TMC can risk acquiring PU.
According to Healthwise Staff, Thompson (2011), there are four stages of pressure sores, namely:
- Stage 1: Sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
- Stage 2: The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
- Stage 3: The sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
- Stage 4: The pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.
- Verify The Diagnosis and Determining The Etiology of The Disease:
Many factors act synergistically to cause PUs. The first potential risk factor according to Kelly and Mobily (1991) is the process of aging on patient’s skin. The second risk factor is the pathology and structural impairment associated with a disease that is undermining the physiological infrastructure of the skin. The third contributing factor is malnutrition–as part of a chronic disease that reduces muscle mass, thins the skin and reduces immunocompetence. However, the most significant risk factor is the functional outcome of disease, including immobility, incontinence and impaired cognition. These functional impairments, particularly immobility, increase the vulnerability of the skin to extrinsic factors, such as pressure, shearing forces, friction and wetness that reduce the integrity of the skin tissue and result in development of PUs.
Research by Inouye, Studenski and Tinnetti (2007), stated that PUs reflect a geriatric syndrome, which multifactorial pathological conditions are present and the accumulated effects of impairment of multiple systems aggravate the vulnerability of the older person to development of these ulcers. Multiple etiological factors interacting in pathogenetic pathways cause a single manifestation, e.g. a PU.
In terms of the risk-factor assessment, PUs should comprise both a local evaluation of the wound and a systemic assessment of the patient including aging, co-morbidities, social, family and emotional factors. A number of confounding elements are allied with the cause and determination of PUs, in hospital facility, such as TMC.
- Formulation of Research Problem and Objectives:
The research problem may be something the TMC identifies as a problem–some knowledge or information that is needed by it, or the desire to identify a specific indicator of measurement. Formulation of research problem requires understanding the pathogenesis of PUs.
The pathogenesis of PUs is traditionally divided into local and systemic factors. Geriatricians view these risk factors, in terms of ‘intrinsic’ (internal) and ‘extrinsic’ (external) factors. Local factors relating to the wound, such as hypoxia, inadequate vascular supply and infection reflect systemic, intrinsic processes that affect PUs (Farage, Miller, Berardesca, 2009).
Farage, et al. (2009) explored four most common extrinsic (external) physical forces that cause PUs, which are interface (axial) pressure, shearing (tangential) pressure, friction and excessive moisture. The intrinsic (internal) factors focus on the patient’s pathology, including the various facets of multiple diseases that contribute to the development of PUs. The mechanism through which these intrinsic factors work can be explained on the basis of vascular, degenerative, inflammatory or metabolic changes (Farage et al., 2009).
- Development of a Theoretical Framework and Case Definition:
The development of theoretical framework is to pinpoint patient, treatment, and facility characteristics associated with PU (PU) widespread, in TMC.
- Designing Research Methodology:
Retrospective cohort study with suitability random sample.
- Collection, Analysis and Interpretation of Data:
- The setting of this study is hypothetically assumed to be TMC. The collection of data include a total of 500 patients aged 18 or older, with length of stay of 14 days or longer and who did not have an existing PU but were retrospectively (retrospective data collected) assumed to be at risk of developing a PU. The assumptions were defined by the response of the retrospective data to predicting pressure sore risk score of 17 or less, on study admittance(i.e. based on findings that the numbers of PU cases are low but higher than the incidence rate reported by comparable institutions. Comparable institutions reported lower finding than what the team found out. )
- The analysis or measurement of the data collection, which include data collected for each randomly selected participating patient over a 12-week period and include patient characteristics such as demographics, medical history, severity of illness, nutritional factors; treatment characteristics such as nutritional involvements, pressure administration strategies, incontinence handlings and medications; staffing percentages and other Truman medical facility characteristics, and outcome study (retrospective PU development during study period. Data were obtained from medical records, minimum data set and other available written records, such as physician orders and medication logs.
- The interpretation of data: Based on the study, we found out that seventy-five percent (75%) of subjects (n=375) did not develop a PU during the 12-week of study period. The remaining twenty-five percent (25%) of patients (n=125) developed a new PU. Patient, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight lost, oral eating problems, use of catheters, and use of position devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new patient, nutritional intrusion, antidepressant use, use of disposable briefs for more than 14 days, use of disposable briefs for more than 12 days, number of hours of 0.27 hours spent for registered nurses per patient per day, licensed practical nurse turnover rate of less than 25%. For example, when Stage I PUs were excluded from the analyses, the same variables showed significant levels— with the addition of fluid orders that were associated with decreased likelihood of emerging a PU.
- Charts and Graphs:
Controlled Variables include:
75% showed no development of PU, 25% showed development of PU, 375 patients showed no development of PU, 125 patients showed development of PU, and 12-week period of case study.
- Presentation of Conclusion:
The primary principle underlying management of PUs is to prevent their occurrence while taking into consideration the physical and pathological condition of the patient. The multidisciplinary management team must take a broader approach, not only with respect to the wounds, but to the needs of the patient and his/her family. In some temporary circumstances, such as postoperatively or after an acute illness, it will be possible to mobilize the patient rapidly and initiate use of early pressure-relieving devices and frequent repositioning strategies. Nevertheless, should a PU develop, the goal of the treating physician should be to heal the ulcer by addressing and stabilizing underlying illnesses, augmenting caloric and protein intake, and introducing strategies for pressure relief and frequent relocation. In cases where the PU becomes chronic, the physician’s goal changes from that of healing to one of enhancing the patient’s quality of life, controlling the symptoms (pain, discomfort, foul odor, infection), supporting the family, and dealing with ethical and end-of-life issues.
- Preventive Measures and Other Recommendations:
Each health discipline (i.e. nursing staff, aides, physician, dietitian, occupational and physical therapists, or social worker) has special role to play in the assessment and management of patient with PU. The goals of treating a PU include, avoiding any preventable contributing circumstances, such as immobilization after a hip fracture or acute infection. Once a PU has developed, however, the goal is to heal it by optimizing regional blood flow (by use of a stent or vascular bypass surgery), managing underlying illnesses (such as diabetes, hypothyroidism or congestive heart failure) and providing adequate caloric and protein intake (whether through use of dietary supplements by mouth or by use of tube feeding). If the ulcer has become chronic, the ultimate goal changes from healing the wound to controlling symptoms (such as foul odor, pain, discomfort and infection) and preventing complications, thereby contributing to the patient’s overall well-being; providing support for the patient’s family is also important. Recent advances in wound dressings allow for greater control of symptoms and prevention of complications, and have also enabled the affected patient to be integrated more readily into the family setting and in the community at large.
Immobility is a major risk factor associated with PUs and is the focus of preventative and remedial treatment. The assessment and management of a PU require a comprehensive and multidisciplinary approach –this is in order to further understand the patient with the ulcer. Factors to consider include patient’s underlying pathologies (such as obstructive lung disease or peripheral vascular disease), severity of his or her primary illness (such as an infection or hip fracture), co-morbidities, functional state (activities of daily living), nutritional status (swallowing difficulties), and degree of social and emotional support; focusing on just the wound itself is not enough. An understanding of the physiological and pathological processes of aging skin throws light on the etiology and pathogenesis of the development of PUs in the elderly.
- Follow-Up on the Recommendations to Assure Implementation Control Measures:
My team will follow up to make sure full evaluation and pathology of the patients at TMC are taking into account. This is because follow-up strategy will further reaffirm vital responsibilities for treating PU patients. The responsibilities should be shared by a multidisciplinary team, within the TMC. The focus of treatment should be prevention and remedial actions. Medical management functions should include stabilizing and curing all reversible medical conditions, treating all irreversible conditions, and preventing and minimizing complications of the patient’s dysfunctional status. Other facets of treatment may involve the provision of food and fluids, local wound treatment and family support. Follow-up recommendations will also mean engaging in technology advancement that pertain to PU treatment. These advances should be reflected as possible remedies for cures in PU patients.
Possible Work Cited:
Hypothetical Research on Pressure Ulcer (PU) in a Hospital Setting.
PUs (i.e. bed sores) are infections for patients that typically have longer length of stays at hospitals and long-term care facilities. Due to the long length of patients stays in hospitals, (i.e. 2-4 weeks), Medicare insurance may not reimburse for ulcers that occur during such episode of stay and will potentially require medical evaluation.The development of theoretical framework is to determine patient, treatment, and facility characteristics associated with Pressure Ulcers (PU) development in hypothetical example of health organization- i.e. Truman Medical Center (TMC).
Considerations:
- A hypothetical example of research healthcare organization is TMC.
- The conclusion section of this research was included in response to the case study questions.
- Minimum number of pages have not been specified, as requirement for this research paper.
- Introduction:
Management and Clinical Administrators of TMC (TMC) decides that due to the long length of stays of some of its patients (i.e. 2-4 weeks) and that Medicare will not reimburse for ulcers that occur during the patients stay— they need to evaluate the situation, formally.
As part of the clinical team leads for the evaluation of the PUs (PU) in TMC, I created nine important steps to evaluate the current situation. These critical steps are part of the recommendations that will be presented to senior management team of TMC. Additionally, these important steps include why PUs occur in a hospital setting (specifically in TMC), and the types of preventive measures that should be used in the hospital settings? They also include hypothetical findings, with charts and graphs (if applicable), et cetera. They also include conclusion section about the issues and study of PU in the hospital settings.
PU (i.e. bed sores) are issue for patients that typically have longer length of stays at hospitals and long-term care facilities.
- Response to The Case Study Questions:-
- Define and Identify the Existing Problems of PUs:
The first step in research process is to define and identify a problem or develop a research question. According to National Database of Nursing Quality Indicators (n.d.), PU is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. Pressure is the force that is applied vertically or perpendicular to the surface of the skin. Pressure compresses underlying tissue and small blood vessels deterring blood flow and nutrient supply. Tissues become ischemic and are damaged or die. Shear occurs when one layer of tissue slides horizontally over another, deforming adipose and muscle tissue, and disrupting blood flow.
Residents with PUs exhibit decreased quality of life, and increased morbidity and mortality rates. PU (i.e. pressure sores) remain to be a common health problem, particularly among the physically limited or incapacitated elderly individuals. The problem exists within the entire health framework, including hospitals like TMC, clinics, long-term care facilities and private homes. For many elderly patients especially, PUs may become chronic for no apparent reason and remain so for lengthy periods of time, even for the remainder of the patient’s lifetime. A large number of grade 3 and 4 PUs become chronic wounds, and the afflicted patient may even die from an ulcer complication (sepsis or osteomyelitis).
The identified problem or question is that PUs are issues for patients that normally have longer length of stays at TMC and its long-term care facilities. Long term stays of the existing patients in TMC can risk acquiring PU.
According to Healthwise Staff, Thompson (2011), there are four stages of pressure sores, namely:
- Stage 1: Sores are not open wounds. The skin may be painful, but it has no breaks or tears. The skin appears reddened and does not blanch (lose color briefly when you press your finger on it and then remove your finger). In a dark-skinned person, the area may appear to be a different color than the surrounding skin, but it may not look red. Skin temperature is often warmer. And the stage 1 sore can feel either firmer or softer than the area around it.
- Stage 2: The skin breaks open, wears away, or forms an ulcer, which is usually tender and painful. The sore expands into deeper layers of the skin. It can look like a scrape (abrasion), blister, or a shallow crater in the skin. Sometimes this stage looks like a blister filled with clear fluid. At this stage, some skin may be damaged beyond repair or may die.
- Stage 3: The sore gets worse and extends into the tissue beneath the skin, forming a small crater. Fat may show in the sore, but not muscle, tendon, or bone.
- Stage 4: The pressure sore is very deep, reaching into muscle and bone and causing extensive damage. Damage to deeper tissues, tendons, and joints may occur.
- Verify The Diagnosis and Determining The Etiology of The Disease:
Many factors act synergistically to cause PUs. The first potential risk factor according to Kelly and Mobily (1991) is the process of aging on patient’s skin. The second risk factor is the pathology and structural impairment associated with a disease that is undermining the physiological infrastructure of the skin. The third contributing factor is malnutrition–as part of a chronic disease that reduces muscle mass, thins the skin and reduces immunocompetence. However, the most significant risk factor is the functional outcome of disease, including immobility, incontinence and impaired cognition. These functional impairments, particularly immobility, increase the vulnerability of the skin to extrinsic factors, such as pressure, shearing forces, friction and wetness that reduce the integrity of the skin tissue and result in development of PUs.
Research by Inouye, Studenski and Tinnetti (2007), stated that PUs reflect a geriatric syndrome, which multifactorial pathological conditions are present and the accumulated effects of impairment of multiple systems aggravate the vulnerability of the older person to development of these ulcers. Multiple etiological factors interacting in pathogenetic pathways cause a single manifestation, e.g. a PU.
In terms of the risk-factor assessment, PUs should comprise both a local evaluation of the wound and a systemic assessment of the patient including aging, co-morbidities, social, family and emotional factors. A number of confounding elements are allied with the cause and determination of PUs, in hospital facility, such as TMC.
- Formulation of Research Problem and Objectives:
The research problem may be something the TMC identifies as a problem–some knowledge or information that is needed by it, or the desire to identify a specific indicator of measurement. Formulation of research problem requires understanding the pathogenesis of PUs.
The pathogenesis of PUs is traditionally divided into local and systemic factors. Geriatricians view these risk factors, in terms of ‘intrinsic’ (internal) and ‘extrinsic’ (external) factors. Local factors relating to the wound, such as hypoxia, inadequate vascular supply and infection reflect systemic, intrinsic processes that affect PUs (Farage, Miller, Berardesca, 2009).
Farage, et al. (2009) explored four most common extrinsic (external) physical forces that cause PUs, which are interface (axial) pressure, shearing (tangential) pressure, friction and excessive moisture. The intrinsic (internal) factors focus on the patient’s pathology, including the various facets of multiple diseases that contribute to the development of PUs. The mechanism through which these intrinsic factors work can be explained on the basis of vascular, degenerative, inflammatory or metabolic changes (Farage et al., 2009).
- Development of a Theoretical Framework and Case Definition:
The development of theoretical framework is to pinpoint patient, treatment, and facility characteristics associated with PU (PU) widespread, in TMC.
- Designing Research Methodology:
Retrospective cohort study with suitability random sample.
- Collection, Analysis and Interpretation of Data:
- The setting of this study is hypothetically assumed to be TMC. The collection of data include a total of 500 patients aged 18 or older, with length of stay of 14 days or longer and who did not have an existing PU but were retrospectively (retrospective data collected) assumed to be at risk of developing a PU. The assumptions were defined by the response of the retrospective data to predicting pressure sore risk score of 17 or less, on study admittance(i.e. based on findings that the numbers of PU cases are low but higher than the incidence rate reported by comparable institutions. Comparable institutions reported lower finding than what the team found out. )
- The analysis or measurement of the data collection, which include data collected for each randomly selected participating patient over a 12-week period and include patient characteristics such as demographics, medical history, severity of illness, nutritional factors; treatment characteristics such as nutritional involvements, pressure administration strategies, incontinence handlings and medications; staffing percentages and other Truman medical facility characteristics, and outcome study (retrospective PU development during study period. Data were obtained from medical records, minimum data set and other available written records, such as physician orders and medication logs.
- The interpretation of data: Based on the study, we found out that seventy-five percent (75%) of subjects (n=375) did not develop a PU during the 12-week of study period. The remaining twenty-five percent (25%) of patients (n=125) developed a new PU. Patient, treatment, and facility characteristics associated with greater likelihood of developing a Stage I to IV PU included higher initial severity of illness, history of recent PU, significant weight lost, oral eating problems, use of catheters, and use of position devices. Characteristics associated with decreased likelihood of developing a Stage I to IV PU included new patient, nutritional intrusion, antidepressant use, use of disposable briefs for more than 14 days, use of disposable briefs for more than 12 days, number of hours of 0.27 hours spent for registered nurses per patient per day, licensed practical nurse turnover rate of less than 25%. For example, when Stage I PUs were excluded from the analyses, the same variables showed significant levels— with the addition of fluid orders that were associated with decreased likelihood of emerging a PU.
- Charts and Graphs:
Controlled Variables include:
75% showed no development of PU, 25% showed development of PU, 375 patients showed no development of PU, 125 patients showed development of PU, and 12-week period of case study.
- Presentation of Conclusion:
The primary principle underlying management of PUs is to prevent their occurrence while taking into consideration the physical and pathological condition of the patient. The multidisciplinary management team must take a broader approach, not only with respect to the wounds, but to the needs of the patient and his/her family. In some temporary circumstances, such as postoperatively or after an acute illness, it will be possible to mobilize the patient rapidly and initiate use of early pressure-relieving devices and frequent repositioning strategies. Nevertheless, should a PU develop, the goal of the treating physician should be to heal the ulcer by addressing and stabilizing underlying illnesses, augmenting caloric and protein intake, and introducing strategies for pressure relief and frequent relocation. In cases where the PU becomes chronic, the physician’s goal changes from that of healing to one of enhancing the patient’s quality of life, controlling the symptoms (pain, discomfort, foul odor, infection), supporting the family, and dealing with ethical and end-of-life issues.
- Preventive Measures and Other Recommendations:
Each health discipline (i.e. nursing staff, aides, physician, dietitian, occupational and physical therapists, or social worker) has special role to play in the assessment and management of patient with PU. The goals of treating a PU include, avoiding any preventable contributing circumstances, such as immobilization after a hip fracture or acute infection. Once a PU has developed, however, the goal is to heal it by optimizing regional blood flow (by use of a stent or vascular bypass surgery), managing underlying illnesses (such as diabetes, hypothyroidism or congestive heart failure) and providing adequate caloric and protein intake (whether through use of dietary supplements by mouth or by use of tube feeding). If the ulcer has become chronic, the ultimate goal changes from healing the wound to controlling symptoms (such as foul odor, pain, discomfort and infection) and preventing complications, thereby contributing to the patient’s overall well-being; providing support for the patient’s family is also important. Recent advances in wound dressings allow for greater control of symptoms and prevention of complications, and have also enabled the affected patient to be integrated more readily into the family setting and in the community at large.
Immobility is a major risk factor associated with PUs and is the focus of preventative and remedial treatment. The assessment and management of a PU require a comprehensive and multidisciplinary approach –this is in order to further understand the patient with the ulcer. Factors to consider include patient’s underlying pathologies (such as obstructive lung disease or peripheral vascular disease), severity of his or her primary illness (such as an infection or hip fracture), co-morbidities, functional state (activities of daily living), nutritional status (swallowing difficulties), and degree of social and emotional support; focusing on just the wound itself is not enough. An understanding of the physiological and pathological processes of aging skin throws light on the etiology and pathogenesis of the development of PUs in the elderly.
- Follow-Up on the Recommendations to Assure Implementation Control Measures:
My team will follow up to make sure full evaluation and pathology of the patients at TMC are taking into account. This is because follow-up strategy will further reaffirm vital responsibilities for treating PU patients. The responsibilities should be shared by a multidisciplinary team, within the TMC. The focus of treatment should be prevention and remedial actions. Medical management functions should include stabilizing and curing all reversible medical conditions, treating all irreversible conditions, and preventing and minimizing complications of the patient’s dysfunctional status. Other facets of treatment may involve the provision of food and fluids, local wound treatment and family support. Follow-up recommendations will also mean engaging in technology advancement that pertain to PU treatment. These advances should be reflected as possible remedies for cures in PU patients.
Possible Work Cited:
- National Database of Nursing Quality Indicators. (n.d.). What Is a PU? Retrieved April 12, 2013 from https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinition_1.aspx
- Inouye SK, Studenski S, Tinetti Me, et al. (September, 2007). Geriatric Syndromes: Clinical, Research and Policy Implication of a Core Geriatric Concept. Journal of the American Geriatrics Society; 55: 780-91
- Kelley LS, Mobily PR. (September, 1991). Latrogenesis in The elderly: Impaired Skin Integrity. Journal of Gerontological; 17 (9): 24-9
- Farage MA, Miller KW, Berardesca E, et al. (2009). Clinical Implications of Aging Skin: Cutaneous Disorders in The elderly. American Journal of Clinical Dermatology; 10 (2): 73-86
- Thompson, E. G. (February 11, 2011). Skin Problems and Treatments Healthcare: Stages of Pressure Sores. WebMD. Retrieved April 12, 2013 from (http://www.webmd.com/skin-problems-and-treatments/four-stages-of-pressure-sores
- National Database of Nursing Quality Indicators. (n.d.). What Is a PU? Retrieved April 12, 2013 from https://www.nursingquality.org/NDNQIPressureUlcerTraining/Module1/PressureUlcerDefinition_1.aspx
- Inouye SK, Studenski S, Tinetti Me, et al. (September, 2007). Geriatric Syndromes: Clinical, Research and Policy Implication of a Core Geriatric Concept. Journal of the American Geriatrics Society; 55: 780-91
- Kelley LS, Mobily PR. (September, 1991). Latrogenesis in The elderly: Impaired Skin Integrity. Journal of Gerontological; 17 (9): 24-9
- Farage MA, Miller KW, Berardesca E, et al. (2009). Clinical Implications of Aging Skin: Cutaneous Disorders in The elderly. American Journal of Clinical Dermatology; 10 (2): 73-86
- Thompson, E. G. (February 11, 2011). Skin Problems and Treatments Healthcare: Stages of Pressure Sores. WebMD. Retrieved April 12, 2013 from (http://www.webmd.com/skin-problems-and-treatments/four-stages-of-pressure-sores
