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The Wound Healing Society is a professional organization of physicians, nurses, physical therapists, basic scientists, clinical researchers, and industrial researchers dedicated to assuring that every patient receives optimal wound care. Its mission is to advance the science and practice of wound healing. To that end, the following comprehensive, evidence- and consensus-based guidelines were developed to address the Prevention of Pressure Ulcers. The guidelines are presented in generic terms; the details of specific tests, therapies, and procedures are the discretion of an interdisciplinary team of health care professionals who establish, implement, and evaluate policies and procedures directed at the prevention of pressure ulcers.

METHODS

  1. Top of page
  2. METHODS
  3. GUIDELINES

PubMed, EMBASE, and CINAHL and the Cochrane Database of Systematic Reviews were searched and reviewed for evidence on pressure ulcer prevention. In addition, a search of health care databases for current evidence-based guidelines addressing the prevention of pressure ulcers was conducted using electronic and online resources. The panel classified studies based on whether the intervention being evaluated addressed pressure ulcer risk screening (PURS) and assessment (PURA), pressure ulcer prevention plans of care (PUPCP) (including interdisciplinary approaches), selection of support surfaces, friction and shear prevention, management of moisture and incontinence, nutrition, and patient and caregiver education.

Evidence references for each standard are listed and coded. The code abbreviations for the evidence citations were as follows:

STATStatistical analysis, meta analysis, consensus statement by commissioned panel of experts
RCTRandomized clinical trial
CLIN SClinical series
LIT REVLiterature review
RETRO SRetrospective series review
EXPLaboratory or animal study
TECHTechnique or methodology description
PATH SPathological series review

Classification of evidence

The strength of evidence supporting a guideline is listed as Level I, Level II, or Level III using the following definitions:

  • Level I: Meta-analysis of multiple RCTs or at least two RCTs supporting the intervention in the guideline or multiple laboratory or animal experiments with at least two clinical series supporting the laboratory results.
  • Level II: Less evidence than Level I, but at least one RCT and at least two significant clinical series or expert opinion papers with literature reviews supporting the intervention. Experimental evidence that is quite convincing but without support by adequate human experience.
  • Level III: Suggestive data of proof-of-principle, but lacking sufficient data such as meta-analysis, RCT, or multiple clinical series.

GUIDELINES

  1. Top of page
  2. METHODS
  3. GUIDELINES

1. Pressure Ulcer Risk Screening (PURS)Preamble: Pressure ulcer prevention is an important issue in every health care setting. Pressure ulcers are areas of localized tissue destruction caused by unrelieved pressure, shear, and friction to the skin. Contributing risk factors increase the person's susceptibility to a complex etiology that causes pressure ulcers. Common risk factors have been identified: immobility, friction and shear, moisture, incontinence, poor nutrition, perfusion, age, skin condition, and altered level of consciousness. Individuals at high risk should be screened and assessed and efforts can be focused with interdisciplinary plans of care for preventing pressure ulcers in these patients.

Patients who are at risk should be identified by PURS shortly after admission to a health care setting. While there are limited definitive studies, the best current evidence and expert opinion suggest the following guidelines.

Guideline #1.1: All patients admitted to the health care setting shall undergo a PURS by or under the supervision of a registered nurse or health care professional with training and expertise in wound care within the time frame specified by organization policy or as required by regulation within 12 hours of admission. In nursing home settings, the window for screening is the MDS, which should be completed in 7 days. (Examples of “training and expertise” in wound care include academic course work, continuing education hours, or contact hours on basic and advanced wound care and wound bed preparation or national certification in wound care through organizations such as the Wound, Ostomy and Continence Nurses Society [WOCN] or the American Academy of Wound Management).

Level of evidence: II

Principle: The best-practice process of pressure ulcer prevention requires a series of steps with feedback loops. These steps include PURS, pressure ulcer risk assessment (PURA), formulation of a pressure ulcer prevention care plan (PUPCP), implementation of the plan, monitoring, reassessment of the care plan, reevaluation of the health care setting, and then either reformulation of the care plan or termination of therapy. Reported time of pressure ulcer development after admission ranged from 1 to 59 days.

Acute care: Pressure ulcers usually develop within the first 2 weeks of hospitalization. ICU patients who developed pressure ulcers did so within the first 72 hours of admission to the ICU. Fifteen percent of elderly patients will develop pressure ulcers within the first week of hospitalization. Long-term care residents usually develop pressure ulcers within the first 4 weeks of admission. Risk assessment screening tools may be helpful to identify patients at risk for pressure ulcer development. Several risk-screening assessment tools are available that consist of subscales for determining risk score. A tool may be used to classify pressure ulcer risk. The Braden scale is the only scale that has been extensively tested in adults across health care settings. Predictive ability of pressure ulcer risk scales is not yet determined; there are not high levels of reliability and validity reported with their use.

PURS recommendations: The Braden scale has been the most extensively studied. The Braden scale consists of six parameters (sensory perception, mobility, activity, moisture, nutrition, and friction and shear) with potential scores from 6 to 23. Lower total scores indicate greater risk of developing pressure ulcers. If other major risk factors are present (e.g., age, fever, poor dietary intake of protein, diastolic pressure <60, and/or hemodynamic instability), advance to next level of risk. Mild risk=15–18; moderate risk=13–14; high risk=10–12; very high risk=9 or below.

The Norton scale is a PURA scale that consists of five parameters (general physical condition, mental condition, activity, mobility, and incontinence) each rated on a scale of 1–4, with lower numbers associated with greater impairment and potential total scores ranging from 5 to 20. Mild risk=14; moderate risk=13; high risk=12. The reliability and validity of the tool has not been established.

Braden Q scores: This scale was adapted from the Braden scale for use in the pediatric population. Mild risk=25; moderate risk=21; high risk=16.

Level of evidence: II, III

Resident Assessment Protocol for nursing homes: This is the only assessment tool recognized by CMS for PURA in nursing homes. The Braden scale does not perform well in settings outside the hospital. Both the Norton Score and the Braden scale have good sensitivity (73–92% and 83–100%, respectively) and specificity (61–94% and 64–77%, respectively), but have poor positive predictive value in nursing home residents (around 37% at a pressure ulcer incidence of 20%). In populations with a lower incidence of pressure ulcers, such as nursing home residents, the same sensitivity and specificity would produce a positive predictive value of 2%. The Norton and Braden scales show a 0.73 kappa statistic agreement among at-risk patients, with the Norton Score tending to classify patients at risk when the Braden scale classified them as not at risk. The net effect of poor positive predictive value means that many patients who will not develop pressure ulcers will receive expensive and unnecessary treatment.

Level of evidence: II, III

Evidence:

  • 1
    Agency for Healthcare Research and Quality. Clinical practice guidelines online. Available at: http://www.ahrq.gov/clinic/cpgonline.htm. Accessed December 2, 2002 [STAT].
  • 2
    Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273: 865–70 [CLIN S].
  • 3
    Ayello EA, Braden BJ. How and why to do pressure ulcer risk assessment. Adv Wound Care 2002; 15: 125–31 [LIT REV].
  • 4
    Bergstrom N, Braden B, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10 [LIT REV].
  • 5
    Bergstrom N, Braden B, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10 [CLIN S].
  • 6
    Bergstrom N, Demuth PJ, Braden B. A clinical trial of the Braden Scale for predicting pressure sore risk. Nurs Clin North Am 1987; 22: 417–28 [CLIN S].
  • 7
    Braden BJ, Bergstrom N. Predictive validity of the Braden Scale for pressure sore risk in a nursing home population. Res Nurs Health 1994; 17: 459–70 [CLIN S].
  • 8
    Braden BJ, Bergstrom NA. Clinical utility of the Braden scale for predicting pressure sore risk. Decubitus 1989; 2: 44–51 [TECH].
  • 9
    Deeks JJ. Pressure sore prevention using and evaluating risk assessment tools. Br J Nurs 1996; 5: 313–4, 316–20 [LIT REV].
  • 10
    Edwards M. Pressure sore risk calculators: some methodological issues. J Clin Nurs 1996; 5: 307–12 [TECH] [LIT REV].
  • 11
    Flanagan M. Pressure Sore Risk Assessment Scales. J Wound Care 1993; 2: 162–7 [LIT REV].
  • 12
    Flanagan M. Who is at risk of a pressure sore? A practical review of risk assessment systems. Prof Nurse 1995; 10: 305–8.
  • 13
    Gordon MD, Gottschlich MM, Helvig EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [LIT REV].
  • 14
    Hagisawa S, Barbenel J. The limits of pressure sore prevention. J R Soc Med 1999; 92: 576–8 [CLIN S].
  • 15
    Langemo DK, Olson B, Hunter S, Burd C, Hansen D. Incidence of pressure sores in acute care, rehabilitation, extended care, home health, and hospice in one locale. Decubitus 1989; 2: 42 [CLIN S].
  • 16
    Lyder CH. Pressure ulcer prevention and management. JAMA 2003; 289: 223–6 [LIT REV].
  • 17
    Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001; 161: 1549–54 [RETRO S].
  • 18
    National Pressure Ulcer Advisory Panel. Available at: http://www.npuap.org. Accessed December 2, 2002 [STAT].
  • 19
    National Pressure Ulcer Advisory Panel. Pressure ulcers: incidence, economics, risk assessment. West Dundee, IL: Consensus Development Conference Statement, S-N Publications, 1989:3–4. Available at: http://www.npuap.org/positn2.htm. Accessed December 11, 2002 [STAT].
  • 20
    Norton D. Calculating the risk: reflections on the Norton Scale. Decubitus 1989; 2: 24–31 [LIT REV].
  • 21
    Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatri Nurs 1996; 1: 7–18 [CLIN S].
  • 22
    Smith DM, Winsemius DK, Besdine RW. Pressure sores in the elderly: can this outcome be improved? J Gen Intern Med 1991; 6: 81–93 [CLIN S].
  • 23
    Stotts N. Risk factors associated with pressure ulcer development in surgical patients. Decubitus 1989; 2: 59 [CLIN S].
  • 24
    Thomas DR. Issues and dilemmas in managing pressure ulcers. J Gerontol: Med Sci 2001; 56: M238–340 [LIT REV].
  • 25
    Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301 [LIT REV].
  • 26
    Towey AP, Erland SM. Validity and reliability of an assessment tool for pressure ulcer risk. Decubitus 1988; 1: 40–8 [CLIN S].
  • 27
    van Marum RJ, Ooms ME, Ribbe MW, van Eijk JT. The Dutch pressure sore assessment score or the Norton scale for identifying at-risk nursing home patients? Age Ageing 2000; 29: 63–8 [CLIN S].
  • 28
    Whitfield MD, Kaltenthaler EC, Akehurst RL, Walters SJ, Paisley S. How effective are prevention strategies in reducing the prevalence of pressure ulcers? J Wound Care 2000; 9: 261–6 [LIT REV].
  • 29
    Wound Ostomy Continence Nurses Society. Guideline for prevention and management of pressure ulcers. WOCN clinical practice guideline series. Glenview, IL: WOCN, 2003 [STAT].
  • 30
    Xakellis GC, Frantz RA, Arteaga M, Nguyen M, Lewis A. A comparison of patient risk for pressure ulcer development with nursing use of preventive interventions. J Am Geriatr Soc 1992; 40: 1250–4 [CLIN S].

Guideline #1.2: The result of the PURS shall be documented and appropriate assessment and intervention initiated within 24 hours of admission. In nursing home settings, the window for screening and appropriate assessment and intervention is the MDS, which should be completed in 7 days.

Level of evidence: II

Principle: A skin risk screening assessment tool may be most helpful when used in combination of strategies including additional skin assessment policies and procedures, skin care teams, and educational programs.

Evidence:

  • 1
    Bennett RG, O'Sullivan J, DeVito EM, Remsberg R. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc 2000; 48: 73–81 [CLIN S].
  • 2
    Bergstrom NA, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S].
  • 3
    Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001; 161: 1549–54 [RETRO S].
  • 4
    McGough A. Epidemiological issues in monitoring pressure damage. J Wound Care 1998; 7: 214–5 [LIT REV].
  • 5
    Staas WE Jr., Cioschi HM. Pressure sores—a multifaceted approach to prevention and treatment. West J Med 1991; 154: 539–44 [CLIN S].

Guideline #1.3: A procedure for pressure ulcer rescreening should be implemented within 48 hours or when there is a significant change in the individual's condition; transfer to ICU, system or organ failure, septicemia, chronic ICU status with prolonged ventilator support, fever, hemodynamic instability, urinary tract infection in nursing home residents, etc.

Level of evidence: II

Principle: The best practice process of pressure ulcer prevention requires a series of steps with feedback loops. These steps include PURS, PURA, formulation of a PUPCP, implementation of the plan, monitoring, reassessment of the care plan, reevaluation of the health care setting, and then either reformulation of the care plan or termination of therapy.

Evidence:

  • 1
    Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA 1995; 273: 865–70 [CLIN S].
  • 2
    Carlson EV, Kemp MG, Shott S. Predicting the risk of pressure ulcers in critically ill patients. Am J Crit Care 1999; 8: 262–9 [CLIN S].
  • 3
    Fogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Rep Regen 2008; 16: 11–8 [RETRO S].
  • 4
    Versluysen M. Pressure sores in elderly patients: the epidemiology related to hip operations. J Bone Joint Surg Br 1985; 7: 10 [CLIN S].

Guideline #1.4: A schedule for reassessing risk should be based on the acuity of the individual and awareness of when pressure ulcers occur in a particular clinical setting.

Level of evidence: II, III

Principle: Note that there is limited evidence that risk assessment leads to a reduction in frequency of pressure ulcers. The data show that risk assessment did not prevent development of pressure ulcers. In fact, at-risk patients who received proper interventions had a higher incidence of pressure ulcers. Other studies demonstrate similar findings. There are limits of risk factor identification; a number of risk factors are not modifiable, such as fecal incontinence, mobility, level of consciousness, or even nutrition.

Evidence:

  • 1
    Bliss M, Simini B. When are the seeds of postoperative pressure sores sown: often during surgery. BMJ 1999; 319: 863–4 [LIT REV].
  • 2
    Hagisawa S, Barbenel J. The limits of pressure sore prevention. J R Soc Med 1999; 92: 576–8 [CLIN S].
  • 3
    McGough A. Epidemiological issues in monitoring pressure damage. J Wound Care 1998; 7: 214–5 [LIT REV].
  • 4
    Schoonhoven L, Defloor T, van der Tweel I, Buskens E, Grypdonck MH. Risk indicators for pressure ulcers during surgery. Appl Nurs Res 2002; 16: 163–73 [CLIN S].
  • 5
    Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301 [LIT REV].

2. Pressure Ulcer Risk Assessment (PURA): It plays a significant role in the prevention of pressure ulcers. Patients who are at risk should be identified by PURA shortly after admission to a health care setting. While there are limited definitive studies, the best current evidence and expert opinion suggest the following guidelines.

Guideline #2.1: The PURA shall be performed by or under the supervision of a registered nurse or health care professional with training and expertise in wound care within the time frame specified by organization policy or as required by regulation. (Examples of “training and expertise” in wound care include academic course work, continuing education hours, or contact hours on basic and advanced wound care and wound bed preparation or national certification in wound care through Wound Ostomy and Continence Nurses Society.)

Level of evidence: II

Principle: Each patient shall undergo a thorough PURA by or under the supervision of a registered nurse or health care professional with training and expertise in wound care to determine and assess the risk factors and care needs and the type of preventive care to be provided.

Evidence:

  • 1
    Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med 1997; 13: 421–36 [LIT REV].
  • 2
    Ayello EA, Lyder CH. Pressure ulcers in persons of color, race, and ethnicity. In: Cuddigan J, editor. Pressure ulcers in America: prevalence, incidence and implications for the future. Washington, DC: National Pressure Ulcer Advisory Panel, 2001: 153–62 [LIT REV].
  • 3
    Brandeis GH, Morris JN, Nash DJ. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264: 2905–9 [CLIN S].
  • 4
    Bergstrom NA, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S].
  • 5
    Bergstrom N. Lack of nutrition in AHCPR prevention guideline. Decubitus 1993; 6: 4,6 Level [LIT REV].
  • 6
    Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive ability of the Braden scale. Nurs Res 1998; 47: 261–9 [CLIN S].
  • 7
    Bergstrom N, Bennett MA, Carlson CE, Alvarez OM, Frantz RA, Garber SL, Jackson BS, Kaminski MV, Kemp MG, Krouskop TA, Lewis VL, Jr., Maklebust J, Margolis DJ, Marvel EM, Reger SI, Rodeheaver GT, Salcido R, Xakellis GC, Yarkony GM. Treatment of pressure ulcers. Clinical practice guideline no. 15. AHCPR publication no. 95-0652. Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research, 1994 [STAT].
  • 8
    Berlowitz DR, Brandeis GH, Morris JN, Ash AS, Anderson JJ, Kader B, Moskowitz MA. Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49: 866–71 [CLIN S].
  • 9
    Berlowitz DR, Brandeis GH, Anderson JJ, Ash AS, Kader B, Morris JN, Moskowitz MA. Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49: 872–6 [CLIN S].
  • 10
    Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, Manciet G, Dartigues JF. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. Nutrition 2000; 16: 1–5 [RCT].
  • 11
    Brandeis GH, Ooi WL, Hossain M, Morris JN, Lipsitz LA. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994; 42: 388–93 [CLIN S].
  • 12
    Delmi M, Rapin CH, Bengoa M, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335: 1013–6 [RCT].
  • 13
    Ek AC, Unosson M, Larsson J, Von Schenck H, Bjurulf P. The development and healing of pressure sores related to the nutritional state. Clin Nutr 1991; 10: 245–50 [CLIN S].
  • 14
    Fogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Repair Regen 2008; 16: 11–8 [RETRO S].
  • 15
    Fritsch DE, Coffee TL, Yowler CJ. Characteristics of burn patients developing pressure ulcers. J Burn Care Rehabil 2001; 22: 293–9 [CLIN S].
  • 16
    Green MF, Exton-Smith AN, Helps EP, et al. Prophylaxis of pressure sores using a new lotion. Modern Geriatr 1974; 4: 376–82 [CLIN S].
  • 17
    Gordon M, Hockless R, Jecker G, Duval K, Owen S, Marvin J. Use of the Braden scale to predict occurrence of pressure sores in the pediatric burn population. J Burn Care Rehabil 2002; 23 (Suppl.): S84 [CLIN S].
  • 18
    Hartgrink HH, WillejKoing P, Hermans J, Breslau PJ. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998; 17: 287–92 [RCT].
  • 19
    Houwing RH, Rozendaal M, Wouters-Wesseling W, Beulens JW, Buskens E, Haalboom JR. A randomized, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients. Clin Nutr 2003; 22: 401–5 [RCT].
  • 20
    Hill-Rom Inc. National Pressure Ulcer Prevalence Survey. Company Report. Charleston, SC: Hill-Rom Inc., 1999 [CLIN S].
  • 21
    Jiricka MJ, Ryan P, Carvalho MA, Bukvich J. Pressure ulcer risk factors in an ICU population. Am J Crit Care 1995; 4: 361–7 [CLIN S].
  • 22
    Krause JS, Vines CL, Farley TL, Sniezek J, Coker J. An exploratory study of pressure ulcers after spinal cord injury; relationship to protective behaviors and risk factors. Arch Phys Rehabil 2001; 82: 107–13 [CLIN S].
  • 23
    Makelbust J, Sieggreen M. Etiology and pathophysiology. In: Maklebust J, Fieggreen M, editors. Pressure ulcers: guidelines for prevention and Management, 3rd ed. Springhouse, PA; Springhouse Corp, 2001: 24 [LIT REV].
  • 24
    Meehan M. National Pressure Ulcer prevalence survey. Adv Wound Care 1994; 7: 27–30 [CLIN S].
  • 25
    Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing a dry visco-elastic polymer pad and guideline operating table mattress in the prevention of post-operative pressure sores. Int J Nurs Stud 1998; 35: 193–203 [RCT].
  • 26
    Ooka M, Kemp MG, McMyn R, Shott S. Evaluation of three types of support surfaces for preventing pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs 1995; 22: 271–9 [CLIN S].
  • 27
    Peerless JR, Davies A, Klein D, Yu D. Skin complications in the intensive care unit. Clin Chest Med 1999; 20: 453–67 [CLIN S].
  • 28
    Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs 1996; 1: 7–18 [CLIN S].
  • 29
    Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974–84 [LIT REV].
  • 30
    Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure ulcers—a randomized trial [review]. AORN J 2001; 73: 921–33, 37–8 [RCT].
  • 31
    Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anaesthesia 2000; 55: 221–4 [CLIN S].
  • 32
    Thomas DR. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997; 13: 497–511 [LIT REV].
  • 33
    Thomas DR. Issues and dilemmas in managing pressure ulcers. J Gerontol A Biol Sci Med Sci 2001; 56: M238–340 [LIT REV].
  • 34
    Torra i Bou JE, Segovia Gómez T, Verdú Soriano J, Nolasco Bonmatí A, Rueda López J, Arboix i Perejamo M. The effectiveness of a hyperoxygentated fatty acid compound preventing pressure ulcers. J Wound Care 2005; 14: 117–21 [RCT].
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    Van der Cammen TJ, O'Callaghan U, Whitefield M. Prevention of pressure sores: a comparison of new and old pressure sore treatments. Br J Clin Pract 1987; 41: 1009–11 [RCT].
  • 36
    Whittington K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000; 27: 209–15 [CLIN S].

Guideline #2.2: The PURA shall include identification of subjective, objective, and psychosocial factors to determine and assess the risk factors and care needs and the type of preventative care to be provided. The following key points are recommended for documentation and shall be addressed when appropriate:

The subjective/objective assessment of skin status and bony prominences and risk for pressure ulcers should include information from the patient and his/her medical record. Elements that should be documented as part of the subjective assessment of skin status and bony prominences include:

  • Description of skin changes as well as any actions taken, recent trauma, friction, shear, or immobility.
  • Use of special garments, shoes, heel, and elbow protectors, orthotic or orthopedic devices.
  • History of pressure ulcers and presence of current ulcer.
  • Previous treatments or surgical interventions that increase risk for pressure ulcers.
  • Factors that impede healing status, such as comorbid conditions or medications.
  • Medical history (history of stroke).
  • Reported usual body weight; desirable body weight, recent change in body weight (quantified) and a decrease in subcutaneous tissue, appetite, dental health, oral and gastrointestinal history, including chewing and swallowing difficulties and a person's ability to feed himself or herself, drug/nutrient interactions, medical/surgical history or interventions that influence nutritional intake or absorption of nutrients; recent changes in dietary intake (quantitative and qualitative).
  • Alcohol and substance abuse, use of tobacco.
  • Gastrointestinal and elimination symptoms (including normal bowel/bladder habits, incontinence, and diarrhea; describe onset, duration, and aggravating and relieving factors of incontinence).
  • Recent changes in functional capacities (e.g., activities of daily living, immobility, ability to move, reposition and turn, level of consciousness, ability and willingness to follow instruction, employment, recreation).

Level of evidence: II, III

Elements that should be documented as part of the objective assessment for risk of pressure ulcers include:

  • Advanced age (>75 years of age having an odds ratio of >12.6).
  • African-American race.
  • Female gender.
  • Disorders of skin integrity. Daily inspection of skin (dryness and/moisture/shear and friction) and bony prominences and specific vulnerable pressure points for bed- or chair-bound individuals in acute care settings (supine position: occiput, sacrum, heels, spine, elbows, ankles; sitting position: ischial tuberosities, coccyx; side-lying position: trochanters); in long-term care and nursing home settings, inspection may be less frequent—occurring when bathing or providing skin care, yet should still be assessed head to toe and documented on a regular basis as determined by initial risk assessment, changes in risk status, and facility protocol.
  • Assessment for immobility (confined to bed, chairs, wheelchairs, recliners, and couches); individuals who have contractures; who have limited range of motion and limited function; or those who may require assistance in ambulating, moving, turning, repositioning, or getting out of bed or chairs should be carefully monitored for pressure ulcer development; assessment for friction and shearing (individuals who cannot lift themselves during repositioning and transferring at risk for friction injuries; shear injuries commonly occur when the head of the bed is elevated and the individual slides downward).
  • Assessment for incontinence.
  • Admitting diagnosis that may affect skin integrity (gangrene, burns, osteomyelitis, edema, and infections) and wound healing (including immune status and diabetes).
  • Concurrent medical and surgical problems that may affect skin integrity (burns, edema, organ system failure, septicemia, ICU length of stay, ventilator days, advanced cancer, terminal illness, and diabetes) and wound healing (including infections, e.g., urinary tract infections, bacterial infections, pneumonia, anemia, and immune status).
  • Assessment of nutrition status data obtained from the physical examination includes weight, BMI, and anthropometric and laboratory evaluations. Other elements of an objective assessment of nutrition status that may be helpful include lab values listed below such as serum transferrin, prealbumin, and resting energy expenditure. Nutritional requirements and nutrition support options should be determined as an integral part of the initial risk assessment for each individual.
  • Laboratory data as available which may include but are not limited to complete blood count with red cell indices, total lymphocyte count, serum electrolytes, blood urea nitrogen, creatinine, serum glucose, serum albumin, prealbumin, C-reactive protein, transferrin, serum cholesterol, serum triglycerides, and liver function studies.

Level of evidence: II

Principle: Each patient shall undergo a thorough PURA to assess the risk factors and care needs and the type of preventative care to be provided. Additional considerations, which impact pressure ulcer prevention measures, and should be addressed on an individual basis include:

  • Age differences: Seniors and children are at high risk. Individuals over 65 years of age are at high risk for developing pressure ulcers, neonates and children younger than 5 years old are at high risk, with the head (occiput) being the most common site of pressure ulcer occurrence.

Level of evidence: II

  • Gender and racial differences: Female gender, African-American race, and advanced age are identified as risk factors for pressure ulcer diagnosis in acute care hospitals.
  • Spinal cord injury (SCI): Patients with SCI are at high risk of developing pressure ulcers with high rates of recurrence.

Level of evidence: II

The following are associated with increased risk: history of ulcers, younger age at onset and duration of SCI, greater disability and difficulty with practicing good skin care, and extent of paralysis. Pressure ulcers are least likely to occur among individuals with SCI who maintain a normal weight, return to work and family roles, do not have a history of tobacco use, suicidal behaviors, incarcerations, or alcohol or drug abuse.

Level of evidence: II

  • Potential sites for pressure ulcers: The most common anatomic sites at risk for pressure ulcers are the sacrum or coccyx and heels. Other areas identified as common sites for pressure ulcers are the ankle, buttocks, and occipital areas.

Level of evidence: II

  • Critically ill patients: Among burn patients with increased moisture as determined by the Braden scale, developed pressure ulcers; wound drainage and incontinence were also identified as contributing factors. Pressure ulcers are four times more likely in ICU patients exposed to moisture and two times more likely in patients with sensory perception or perfusion problems.

Level of evidence: II

  • Other significant factors related to the development of pressure ulcers in critically ill patients include norepinethrine administration, APACHE II score >13, length of stay, anemia, and fecal incontinence.

Level of evidence: I, II

  • Immobilized low weight patients: Patients with a lower BMI developed pressure ulcers.

Level of evidence: I, II

  • Postoperative patients with a longer duration of surgery and length of time in a hypotensive state have an increased risk of developing pressure ulcers.

Level of evidence: II

  • Acute care hospitalized patients diagnosed with pressure ulcers have three categories of risk factors including skin integrity (presence of gangrene, nutritional deficiencies, diabetes, and anemia), system failure (paralysis, senility, respiratory failure, acute renal failure, CVA and congestive heart failure [nonhypertensive]), and infections (septicemia, osteomyelitis, pneumonia, bacterial infections, and urinary tract infections).

Level of evidence: I, II, III

  • Inadequate nutritional intake: According to the US Department of Health and Human Service's clinical practice guidelines for the prevention of pressure ulcers, assessment of the adequacy of nutritional intake (serum albumin, total lymphocyte count, nitrogen balance, hydration status, and micronutrients) is correlated with skin integrity and should be frequently addressed. Note that although poor nutrition is part of total patient care and should be addressed in each patient, no nutritional intervention has shown effectiveness in prevention of pressure ulcers in published studies.

Evidence:

  • 1
    Allman RM. Pressure ulcer prevalence, incidence, risk factors, and impact. Clin Geriatr Med 1997; 13: 421–36 [LIT REV].
  • 2
    Ayello EA, Lyder CH. Pressure ulcers in persons of color, race, and ethnicity. In: Cuddigan J, editor. Pressure ulcers in America: prevalence, incidence and implications for the future. Washington, DC: National Pressure Ulcer Advisory Panel, 2001: 153–62.
  • 3
    Brandeis GH, Morris JN, Nash DJ. The epidemiology and natural history of pressure ulcers in elderly nursing home residents. JAMA 1990; 264: 2905–9 [CLIN S].
  • 4
    Bergstrom NA, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S].
  • 5
    Bergstrom N. Lack of nutrition in AHCPR prevention guideline. Decubitus 1993; 6: 4,6. Level [LIT REV].
  • 6
    Bergstrom N, Braden B, Kemp M, Champagne M, Ruby E. Predicting pressure ulcer risk: a multisite study of the predictive ability of the Braden scale. Nurs Res 1998; 47: 261–9 [CLIN S].
  • 7
    Bergstrom N, Bennett MA, Carlson CE, Alvarez OM, Frantz RA, Garber SL, Jackson BS, Kaminski MV, Kemp MG, Krouskop TA, Lewis VL, Jr., Maklebust J, Margolis DJ, Marvel EM, Reger SI, Rodeheaver GT, Salcido R, Xakellis GC, Yarkony GM. Treatment of pressure ulcers. Clinical practice guideline No. 15. AHCPR publication no. 95-0652. Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research, 1994 [STAT].
  • 8
    Berlowitz DR, Brandeis GH, Morris JN, Ash AS, Anderson JJ, Kader B, Moskowitz MA. Deriving a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49: 866–71 [CLIN S].
  • 9
    Berlowitz DR, Brandeis GH, Anderson JJ, Ash AS, Kader B, Morris JN, Moskowitz MA. Evaluation of a risk-adjustment model for pressure ulcer development using the Minimum Data Set. J Am Geriatr Soc 2001; 49: 872–6 [CLIN S].
  • 10
    Bliss M, Simini B. When are the seeds of postoperative pressure sores sown? Often during surgery. BMJ 1999; 319: 863–4.
  • 11
    Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, Manciet G, Dartigues JF. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. CAGE GROUP. Nutrition 2000; 16: 1–5 [RCT].
  • 12
    Brandeis GH, Ooi WL, Hossain M, Morris JN, Lipsitz LA. A longitudinal study of risk factors associated with the formation of pressure ulcers in nursing homes. J Am Geriatr Soc 1994; 42: 388–93 [CLIN S].
  • 13
    Delmi M, Rapin CH, Bengoa M, Delmas PD, Vasey H, Bonjour JP. Dietary supplementation in elderly patients with fractured neck of the femur. Lancet 1990; 335: 1013–6 [RCT].
  • 14
    Ek AC, Unosson M, Larsson J, Von Schenck H, Bjurulf P. The development and healing of pressure sores related to the nutritional state. Clin Nutr 1991; 10: 245–50 [CLIN S].
  • 15
    Fogerty M, Abumrad N, Nanney L, Arbogast P, Poulose B, Barbul A. Risk factors for pressure ulcers in acute care hospitals. Wound Rep Regen 2008; 16: 11–8 [RETRO S].
  • 16
    Fritsch DE, Coffee TL, Yowler CJ. Characteristics of burn patients developing pressure ulcers. J Burn Care Rehabil 2001; 22: 23–9 [CLIN S].
  • 17
    Green MF, Exton-Smith AN, Helps EP, et al. Prophylaxis of pressure sores using a new lotion. Modern Geriatr 1974; 4: 376–82 [CLIN S].
  • 18
    Gordon M, Hockless R, Jecker G, Duval K, Owen S, Marvin J. Use of the Braden scale to predict occurrence of pressure sores in the pediatric burn population. J Burn Care Rehabil 2002; 23 (Suppl.): S84 [CLIN S].
  • 19
    Hartgrink HH, WillejKoing P, Hermans J, Breslau PJ. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998; 17: 287–92 [RCT].
  • 20
    Houwing RH, Rozendaal M, Wouters-Wesseling W, Beulens JW, Buskens E, Haalboom JR. A randomized, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip-fracture patients. Clin Nutr 2003; 22: 401–5 [RCT].
  • 21
    Hill-Rom Inc. National Pressure Ulcer Prevalence Survey. Company Report. Charleston, SC: Hill-Rom Inc., 1999 [CLIN S].
  • 22
    Jiricka MJ, Ryan P, Carvalho MA, Bukvich J. Pressure ulcer risk factors in an ICU population. Am J Crit Care 1995; 4: 361–7 [CLIN S].
  • 23
    Krause JS, Vines CL, Farley TL, Sniezek J, Coker J. An exploratory study of pressure ulcers after spinal cord injury; relationship to protective behaviors and risk factors. Arch Phys Rehabil 2001; 82: 107–13 [CLIN S].
  • 24
    Makelbust J, Sieggreen M. Etiology and pathophysiology. In: Maklebust J, Fieggreen M, editors. Pressure ulcers: guidelines for prevention and management, 3rd ed. Springhouse, PA: Springhouse Corp., 2001: 24 [LIT REV].
  • 25
    Meehan M. National pressure ulcer prevalence survey. Adv Wound Care 1994; 7: 27–30 [CLIN S].
  • 26
    Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing a dry visco-elastic polymer pad and guideline operating table mattress in the prevention of postoperative pressure sores. Int J Nurs Stud 1998; 35: 193–203 [RCT].
  • 27
    Ooka M, Kemp MG, McMyn R, Shott S. Evaluation of three types of support surfaces for preventing pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs 1995; 22: 271–9 [CLIN S].
  • 28
    Peerless JR, Davies A, Klein D, Yu D. Skin complications in the intensive care unit. Clin Chest Med 1999; 20: 453–67 [CLIN S].
  • 29
    Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs 1996; 1: 7–18 [CLIN S].
  • 30
    Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974–84 [LIT REV].
  • 31
    Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure ulcers—a randomized trial [review]. AORN J 2001; 73: 921–33, 37–8 [RCT].
  • 32
    Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anaesthesia 2000; 55: 221–4 [CLIN S].
  • 33
    Thomas DR. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997; 13: 497–511 [LIT REV].
  • 34
    Thomas DR. Issues and dilemmas in managing pressure ulcers. J Gerontol Med Sci Biol Sci 2001; 56: M238–340 [LIT REV].
  • 35
    Torra i Bou JE, Segovia Gómez T, Verdú Soriano J, Nolasco Bonmatí A, Rueda López J, Arboix i Perejamo M. The effectiveness of a hyperoxygentated fatty acid compound preventing pressure ulcers. J Wound Care 2005; 14: 117–21 [RCT].
  • 36
    van der Cammen TJ, O'Callaghan U, Whitefield M. Prevention of pressure sores: a comparison of new and old pressure sore treatments. Br J Clin Pract 1987; 41: 1009–11 [RCT].
  • 37
    Whittington, K, Patrick M, Roberts JL. A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs 2000; 27:209–15 [CLIN S].

Guideline #2.3: The subjective and objective assessments of pressure ulcer risk shall be summarized and documented in the patient's medical record.

Guideline #2.3a: The patient's skin status and bony prominence assessment shall be summarized based on the findings of the subjective and objective PURA and should include prevention measures (turning-positioning program, bed surface pressure relief therapy, minimizing friction and shear, managing incontinence) for optimal skin integrity requirements.

Guideline #2.3b: The patient's nutritional requirements shall be summarized based on the findings of the subjective and objective nutrition assessments and should include protein, calorie, fluid, electrolyte, and micronutrient requirements.

Guideline #2.3c: The patient and caregiver educational requirements shall be summarized based on the findings of the subjective and objective nutrition assessments and should include causes and risk factors for pressure ulcer development, and ways to minimize risk.

Level of evidence: II, III

Principle: The PURA shall be documented and be available to all health care providers.

Evidence:

  • 1
    National Pressure Ulcer Advisory Panel. Pressure ulcers: incidence, economics, risk assessment. West Dundee, IL: Consensus Development Conference statement, S-N Publications, 1989:3–4. Available at: http://www.npuap.org/positn2.htm. Accessed December 11, 2002 [STAT].

3. Development of Pressure Ulcer Prevention Care Plan (PUPCP)

Preamble: Development of a PUPCP plays a significant role in the prevention of pressure ulcers. Clinical settings and patients who are at risk should have a prevention plan to target prevention efforts to minimize risk. While there are limited definitive studies, the best current evidence and expert opinion suggest the following guidelines.

Guideline #3.1: The policy and procedure for the prevention plan for pressure ulcers shall be formalized and documented. The pressure ulcer prevention plan shall include identification of high-risk settings and groups to target prevention efforts to minimize risk.

Level of evidence: II, III

Principle: The policy and procedure for the prevention of pressure ulcers should ensure that the objective of care is to identify etiologic factors contributing to pressure ulcer occurrence, conduct regular risk screening and assessments using valid and reliable tools, develop, implement, and evaluate evidence-based programs for prevention of pressure ulcers (including identification of risk factors, skin and bony prominence assessment and care, demonstration of proper body positioning, selection and use of support surfaces and skin protection devices), and treatments and use of appropriate nutritional interventions.

Evidence:

  • 1
    Berlowitz DR, Young GJ, Hickey EC, Saliba D, Mittman BS, Czarnowski E, Simon B, Anderson JJ, Ash AS, Rubenstein LV, Moskowitz MA. Quality improvement implementation in the nursing home. Health Serv Res 2003; 38 (Part 1): 65–83 [CLIN S].
  • 2
    Hopkins B, Hanlon M, Yauk S, Sykes S, Rose T, Cleary A. Reducing nosocomial pressure ulcers in an acute care facility. J Nurs Care Qual 2000; 14: 28–36 [CLIN S].
  • 3
    Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001; 161: 1549–54 [CLIN S].
  • 4
    Cuddigan J, Ayello EA, Sussman C, editors. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston, VA: National Pressure Ulcer Advisory Panel, 2001 [STAT].
  • 5
    Pieper B, Mott M. Nurses' knowledge of pressure ulcer prevention, staging, and description. Adv Wound Care 1995; 8: 34, 38–40 [CLIN S].
  • 6
    Pieper B, Sugrue M, Weiland M, Sprague K, Heimann C. Presence of pressure ulcer prevention methods used among patients considered at risk versus those considered not at risk. J Wound Ostomy Continence Nurs 1997; 24: 191–9 [CLIN S].
  • 7
    Sacharok C, Drew J. Use of a total quality management model to reduce pressure ulcer prevalence in the acute care setting. J Wound Ostomy Continence Nurs 1998; 25: 88–92 [CLIN S].
  • 8
    Sinclair L, Berwiczonek H, Thurston N, Butler S, Bulloch G, Ellery C, Giesbrecht G. Evaluation of an evidence-based education program for pressure ulcer. J Wound Ostomy Continence Nurs 2004; 31: 43–50 [LIT REV].
  • 9
    Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301.
  • 10
    Thomas DR, Osterweil D. Is a pressure ulcer a marker for quality of care? J Am Med Dir Assoc 2005; 6: 228–30.
  • 11
    Wipke-Tevis DD, Williams DA, Rantz MJ, Popejoy LL, Madsen RW, Petroski GF, Vogelsmeier AA. Nursing home quality and pressure ulcer prevention and management practices. J Am Geriatr Soc 2004; 52: 583–8.
  • 12
    Young Z, Evans A, Davis J. Clinical issues: nosocomial pressure ulcer prevention: a successful project. JONA 2003; 33: 380–3 [CLIN S].
  • 13
    Zinn JS, Brannon D, Weech R. Quality improvement in nursing care facilities: extent, impetus, and impact. Am J Med Qual 1997; 12: 51–61 [CLIN S].

Guideline #3.2: An interdisciplinary team of health care professionals shall review and evaluate the quality of preventative pressure ulcer care provided at the health care setting at least quarterly. This team ideally will function as an entity or may each contribute independently to the PUPCP. The disciplines responsible for carrying out each planned approach will be designated on the PUPCP. The PUPCP should be developed with an interdisciplinary approach involving the physician, registered nurse, registered dietitian, physical therapist, and other health care personnel as appropriate, and with the involvement of the patient and/or family whenever possible and is based on information from the risk tool and the PURA. The PUPCP information should be completed within 48 hours after the completion of the PURA and incorporated into the overall plan of care in acute care settings. In long-term care settings, an LPN may be assigned to a team and completion of PUPCP information and overall plan of care will be consistent with the policies and guidelines of long-term care settings.

Level of evidence: II, III

Principle: Having an interdisciplinary team of health care providers is the optimal approach to prevention of pressure ulcers. Using a team approach, the objective should be to identify etiologic factors contributing to pressure ulcer occurrence, conduct regular risk screening and assessments using valid and reliable tools, develop, implement, and evaluate evidence-based programs for prevention of pressure ulcers (including identification of risk factors, skin and bony prominence assessment and care, demonstration of proper body positioning, selection and use of support surfaces and skin protection devices, and treatments and use of appropriate nutritional interventions).

  • Although the development of a pressure ulcer may reflect a breakdown in quality of care, it cannot reflect quality of care if the pressure ulcer develops despite consistent application of known interventions. The link to quality of care assumes that consistent application of effective interventions will prevent all pressure ulcers. This has not been demonstrated in the literature. This is a profoundly important issue from a regulatory and medico legal standpoint. Furthermore, Abel RL, Warren K, Bean G, Gabbard B, Lyder CH, Bing M, McCauley C (Quality improvement in nursing homes in Texas: results from a pressure ulcer prevention project. J Am Med Dir Assoc 2005; 6: 181–8) showed a failure of an intense educational intervention to reduce the incidence of pressure ulcers. This dilemma is also cited by Meehan M (Beyond the pressure ulcer blame game: reflections for the future. Ostomy Wound Manage 2000; 46: 46–52). In a survey of 35 nursing homes administered by the Department of Veterans Affairs, the extent of compliance with quality indicators ranged from 2.98 to 4.08 on a 1–5 scale. No significant association was found for compliance with quality indicators and the rate of pressure ulcer development or in adherence to guideline recommendations. No relationship was found between a pressure ulcer quality indicator score and the mean number of pressure ulcer prevention or treatment strategies used in 321 Missouri long-term care facilities. The overall quality indicator score did not differ among homes by type of risk assessment instrument used, the wound care protocol used, or whether a wound care specialist nurse was responsible for care. In a national random sample of 2,425 hospitalized Medicare beneficiaries, the overall documentation of compliance with quality indicators was also poor. However, there was no link between documentation of a quality indicator and incidence of pressure ulcers. In fact, older adults who had documentation of being at risk and/or who received a pressure-reducing device and/or were turned every 2 hours had a higher incidence of pressure ulcer development. Although the chart documentation of prevention interventions was poor, these data suggest that the actual application of selected interventions described as quality indicators was not effective in reducing the incidence of pressure ulcers. However, the NPUAP recommends that the incidence of pressure ulcers an indicator of quality in health care institutions. Prevalence and incidence outcome studies can be useful in determining the effectiveness of prevention and treatment strategies in health care settings and establish benchmarking measures. Education of the interdisciplinary team, nursing staff, and other health care professionals is an integral part of reducing the incidence of pressure ulcers. The NPUAP has developed competency-based curricula for pressure ulcer prevention.

Evidence:

  • 1
    Berlowitz DR, Young GJ, Hickey EC, Saliba D, Mittman BS, Czarnowski E, Simon B, Anderson JJ, Ash AS, Rubenstein LV, Moskowitz MA. Quality improvement implementation in the nursing home. Health Serv Res 2003; 38 (Part 1): 65–83 [CLIN S].
  • 2
    Hopkins B, Hanlon M, Yauk S, Sykes S, Rose T, Cleary A. Reducing nosocomial pressure ulcers in an acute care facility. J Nurs Care Qual 2000; 14: 28–36 [CLIN S].
  • 3
    Lyder CH, Preston J, Grady JN, Scinto J, Allman R, Bergstrom N, Rodeheaver G. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med 2001; 161: 1549–54 [CLIN S].
  • 4
    Cuddigan J, Ayello EA, Sussman C, editors. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston, VA: National Pressure Ulcer Advisory Panel, 2001 [STAT].
  • 5
    Pieper B, Mott M. Nurses' knowledge of pressure ulcer prevention, staging, and description. Adv Wound Care 1995; 8: 34, 38–40 [CLIN S].
  • 6
    Pieper B, Sugrue M, Weiland M, Sprague K, Heimann C. Presence of pressure ulcer prevention methods used among patients considered at risk versus those considered not at risk. J Wound Ostomy Continence Nurs 1997; 24: 191–9 [CLIN S].
  • 7
    Pieper B, Sugru M, Weiland M, Sprague K, Heiman C. Risk factors, prevention methods, and wound care for patients with pressure ulcers. Clin Nurse Spec 1998; 12: 7 [CLIN S].
  • 8
    Sacharok C, Drew J. Use of a total quality management model to reduce pressure ulcer prevalence in the acute care setting. J Wound Ostomy Continence Nurs 1998; 25: 88–92 [CLIN S].
  • 9
    Sinclair L, Berwiczonek H, Thurston N, Butler S, Bulloch G, Ellery C, Giesbrecht G. Evaluation of an evidence-based education program for pressure ulcer. J Wound Ostomy Continence Nurs 2004; 31: 43–50 [LIT REV].
  • 10
    Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301.
  • 11
    Thomas DR, Osterweil D. Is a pressure ulcer a marker for quality of care? J Am Med Dir Assoc 2005; 6: 228–30.
  • 12
    Wipke-Tevis DD, Williams DA, Rantz MJ, Popejoy LL, Madsen RW, Petroski GF, Vogelsmeier AA. Nursing home quality and pressure ulcer prevention and management practices. J Am Geriatr Soc 2004; 52: 583–8.
  • 13
    Young Z, Evans A, Davis J. Clinical issues: nosocomial pressure ulcer prevention: a successful project. JONA 2003; 33: 380–3 [CLIN S].
  • 14
    Zinn JS, Brannon D, Weech R. Quality improvement in nursing care facilities: extent, impetus, and impact. Am J Med Qual 1997; 12: 51–61 [CLIN S].
  • 15
    Ratliff CR, WOCN. WOCN's evidence-based pressure ulcer guidelines. Adv Skin Wound Care 2005; 18: 204–8.

4. Selection of prevention interventions

Preamble: There are many pressure ulcer prevention interventions to consider. Selection of pressure prevention interventions should be appropriate to the patient's individualized needs. Guidelines assist the health care provider in making decisions regarding the best cost-effective practice.

Guideline #4.1: The interventions selected to prevent pressure ulcers shall be appropriate to the patient's risk factors, skin status and assessment of bony prominences, nutritional status, mobility, risk of incontinence, pressure, friction and shear, medical condition, and goals expressed by the patient and/or family. If the resident is not competent, the designated individual with durable power of attorney/health care shall be an active participant.

Level of evidence: I, II, III

Principle: Prevention intervention selections should be tailored to the individual's needs and should be evidence based. Consideration of the least invasive, most cost-effective therapy is preferred.

Evidence:

  • 1
    Iglesias C, Nixon J, Cranny G, Nelson EA, Hawkins K, Phillips A, Torgerson D, Mason S, Cullum N, PRESSURE Trial Group. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. BMJ 2006; 332: 1416–8 [RCT].
  • 2
    Inman K, Sibbald WJ, Rutledge FS, Clark BJ. Clinical utility and cost effectiveness of an air suspension bed in the prevention of pressure ulcers. JAMA 1993; 269: 1139–43 [RCT].
  • 3
    Fleurence RL. Cost-effectiveness of pressure relieving devices for the prevention and treatment of pressure ulcers. Int J Technol Assess Health Care 2005; 21: 334–41 [CLIN S].
  • 4
    Ratliff CR, WOCN. WOCN's evidence-based pressure ulcer guidelines. Adv Skin Wound Care 2005; 18: 204–8.

5. Consideration of positioning and support surfaces

Preamble: Pressure ulcers are areas of localized tissue destruction caused by unrelieved pressure, shear, and friction to the skin (Bennett et al., 1979; Bergstrom, 1987; Braden & Bergstrom, 1987; Daniel, Priest & Wheatley, 1981).

Guideline #5.1: Provide frequent position changes using pillows and wedges to reduce pressure on bony prominences (Bergstrom & Braden, 1992; Knox, Anderson, & Anderson, 1994).

Level of evidence: II

Principle: Pressure ulcers are thought to be caused by unrelieved pressure and compression of soft tissues against bony prominences. Relieving pressure over bony prominences can be achieved. Pillows under calves decrease heel interface pressures (Tymec, Pieper & Bollman, 1997). No specific support surface or heel product has been proven superior in decreasing pressure at the heel (Whittemore, 1998; De Keyser, Dejaeger, De Meyst & Evers, 1994; Flemister, 1991; Guin, Hudson & Gallo, 1991; Pinzur et al., 1991).

Evidence:

  • 1
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Pressure ulcers in adults: prediction and prevention (AHCPR publication no. 92-0047). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1992 [STAT].
  • 2
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Treatment of pressure ulcers in adults: prediction and prevention (AHCPR publication no. 95-0652). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1994 [STAT].
  • 3
    Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S].
  • 4
    Defloor T, De Bacquer D, Grydonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud 2005; 42: 37–46 [CLIN S].
  • 5
    Defloor T. Less frequent turning intervals and yet less pressure ulcers. Tijdschr Gerontol Geriatr 2001; 32: 174–7 [CLIN S].
  • 6
    De Keyser G, Dejaeer H, De Meyst H, Evers G. Pressure-reducing effects of heel protectors. Adv Wound Care 1994; 7: 30–2 [CLIN S].
  • 7
    Flemister B. A pilot study of interface pressure with heel protectors used for pressure reduction. J ET Nurs 1991; 18: 158–61 [CLIN S].
  • 8
    Guin, P, Hudson A, Gallo J. The efficacy of six heel pressure reducing devices. Decubitus 1991; 4: 15–23 [CLIN S].
  • 9
    Knox DM, Anderson TM, Anderson PS. Effects of different turn intervals on skin of healthy older adults. Adv Wound Care 1994; 15: 270–6 [CLIN S].
  • 10
    Pinzur M, Schumacher D, Reddy N, Osterman H, Havey R, Patwardin A. Preventing heel ulcers: a comparison of prophylactic body-support systems. Arch Phys Med Rehabil 1991; 72: 508–10 [CLIN S].
  • 11
    Reddy M, Gill S, Rochon P. Preventing pressure ulcers: a systematic review. JAMA 2006; 296: 974–84 [LIT REV].
  • 12
    Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301 [LIT REV].
  • 13
    Tymec A, Pieper B, Bollman K. A comparison of two pressure-relieving devices on the prevention of heel ulcers. Adv Wound Care 1997; 10: 39–44 [CLIN S].
  • 14
    Whittemore R. Pressure reduction support surfaces: a review of the literature. J Wound Ostomy Continence Nurs 1998; 25: 6–25 [LIT REV].

Guideline #5.2: Avoid foam rings or donuts for pressure reduction; they concentrate the pressure to surrounding tissue (AHCPR, 1992). Foam wheelchair cushions are recommended (Conine et al., 1994).

Level of evidence: I, II, III

Principle: Seat cushions reduce pressure in the sitting position. Ring cushions or donut devices have been shown to increase edema and venous congestion.

Evidence:

  • 1
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Pressure ulcers in adults: prediction and prevention (AHCPR publication no. 92-0047). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1992 [STAT].
  • 2
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Treatment of pressure ulcers in adults: prediction and prevention (AHCPR publication no. 95-0652). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1994 [STAT].
  • 3
    Conine TA, Hershler C, Daechsel D, Peel C, Pearson A. Pressure sore prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions. Int J Rehabil Res 1994; 17: 123–37 [CLIN S].
  • 4
    Yuen HK, Garrett D. Comparison of three wheelchair cushions for effectiveness of pressure relief. Am J Occup Ther 2001; 55: 470–5 [CLIN S].

Guideline #5.3: Pressure prevention interventions shall be provided through use of pressure-reducing or relieving devices to relieve pressure.

Level of evidence: I, II, III

Principle: Pressure-reducing or relieving devices work by redistributing pressure over the bony prominences. Static support surfaces are mattresses or mattress overlays that are applied to a mattress and are filled with air, water, gel, foam or a combination of these. Alternating support surfaces or dynamic support surface mattresses have been associated with lower incidence of pressure ulcers compared with standard hospital mattresses. High-specification foam bed surface has been effective in decreasing the incidence of pressure ulcers in high-risk patients. (A variety of pressure-reducing mattresses or devices lower the incidence of pressure ulcers when compared with a standard hospital mattress. At-risk patients should not be placed on an ordinary, guideline hospital foam mattress. Turning every 4 hours in combination with the use of a pressure-reducing mattress was shown to decrease the occurrence of pressure ulcers compared with turning every 6 hours on a pressure-reducing mattress or turning every 2–4 hours on a nonpressure-reducing mattress. Bed surfaces that provide pressure reduction include nonpowered surface mattress replacements, powered single-zone surfaces, low-air-loss multizone customized beds and mattresses; pressure relieving surfaces include air-fluidized beds and lateral rotation dynamic air therapy beds. There is insufficient evidence to support the choice of one specific bed surface/device over another for prevention of pressure ulcers. Efficacy of these devices is inconclusive; most support surface studies rely only on interface pressure measurements as an outcome.

Evidence:

  • 1
    Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitations. JAMA 1995; 273: 865–70 [RCT].
  • 2
    Andersen KE, Jensen O, Kvorning SA, Bach E. Decubitus prophylaxis: a prospective trial on the efficiency of alternating pressure air mattresses and water-mattresses. Acta Derm Venereol 1983; 63: 227–30 [CLIN S].
  • 3
    Aronovitch SA, Wilber M, Slezak S, Martin T, Utter D. A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy Wound Manage 1999; 45: 34–40, 42–4 [RCT].
  • 4
    Blumer KA. Prevention of pressure necrosis over the medial epicondyle: the use of eggcrate cuffs. J Burn Care Rehabil 1988; 9: 291–2 [CLIN S].
  • 5
    Bergstrom N, Braden N, Kemp M, Champagne M, Ruby E. Multisite study of incidence of pressure ulcers and the relationship between risk level, demographic characteristics, diagnoses, and prescription of preventive interventions. J Am Geriatr Soc 1996; 44: 22–30 [CLIN S].
  • 6
    Brienza DM, Geyer MJ. Understanding support surface technologies. Adv Skin Wound Care 2000; 13: 237–44 [TECH].
  • 7
    Conine TA, Hershler C, Daechsel D, Peel C, Pearson A. Pressure sore prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions. Int J Rehabil Res 1994; 17: 123–37 [CLIN S].
  • 8
    Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW. Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev 2000; 2: CD001735. Update in: Cochrane Database Syst Rev 2004; 3: CD001735 [STAT].
  • 9
    Defloor T, DeShuijmer JDS. Preventing pressure ulcers: an evaluation of four operating table mattresses. Appl Nurs Res 2000; 13: 2–11 [CLIN S].
  • 10
    Defloor T. Less frequent turning intervals and yet less pressure ulcers. Tijdschr Gerontol Geriatr 2001; 32: 174–7 [CLIN S].
  • 11
    Defloor T, De Bacquer D, Grydonck MH. The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers. Int J Nurs Stud 2005; 42: 37–46 [CLIN S].
  • 12
    Dunlop V. Preliminary results of a randomized controlled study of a pressure ulcer prevention system. Adv Wound Care 1998; 11 (Suppl. 3): 14 [RCT].
  • 13
    Ewing MR, Garrow C, Pressley TA, Ashley C, Kinsella NM. Further experiences in the use of sheepskin as an aid in nursing. Med J Aust 1964; 16: 139–41 [CLIN S].
  • 14
    Exton-Smith AN, Overstall PW, Wedgewood J, Wallace G. Use of the “air wave system” to prevent pressure sores in hospital. Lancet 1982; 1: 1288–90 [RCT].
  • 15
    Fontaine R, Risley S, Castellino R. A quantitative analysis of pressure and shear in the effectiveness of support surfaces. J Wound Ostomy Continence Nurs 1998; 25: 233–9 [CLIN S].
  • 16
    Gebhardt KS. A randomized trial of alternating pressure (AP) and constant low pressure (CLP) supports for the prevention of pressure sores. J Tissue Viability 1994; 4: 93 [RCT].
  • 17
    Gebhardt KS, Bliss M, Winright P, Thomas J. Pressure relieving supports in an ICU. J Wound Care 1996; 5: 116–21 [CLIN S].
  • 18
    Goldstone LA, Norris M, O'Reilly M, White J. A clinical trial of a bead bed system for the prevention of pressure sores in elderly orthopaedic patients. J Adv Nurs 1982; 7: 545–8 [RCT].
  • 19
    Hofman A, Geelkerken RH, Wille J, Hamming JJ, Hermans J, Breslau PJ. Pressure sores and pressure decreasing mattresses: controlled clinical trial. Lancet 1994; 343: 568–71 [RCT]
  • 20
    Gray DG, Smith M. Comparison of a new foam mattress with the standard hospital mattress. J Wound Care 2000; 9: 29–31 [RCT].
  • 21
    Hardin JB, Cronin SN, Cahil K. Comparison of the effectiveness of two pressure-relieving surfaces: low-air-loss versus static fluid. Ostomy/Wound Manage 2000; 46: 50–6 [CLIN S].
  • 22
    Iglesias C, Nixon J, Cranny G, Nelson EA, Hawkins K, Phillips A, Torgerson D, Mason S, Cullum N, PRESSURE Trial Group. Pressure relieving support surfaces (PRESSURE) trial: cost effectiveness analysis. BMJ 2006; 332: 1416–8 [RCT].
  • 23
    Jesurum J, Joseph K, Davis J, Suki R. Balloons, beds and breakdown. Effects of low-air-loss therapy on the development of pressure ulcers in cardiovascular surgical patients with intra-aortic balloon pump support. Crit Care Nurs Clin North Am 1996; 8: 423–40 [CLIN S].
  • 24
    Jolley DJ, Wright R, McGowan S, Hickey MB, Campbell DA, Sinclair RD, Montgomery KC. Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomized controlled trial. Med J Aust 2004; 180: 324–7 [RCT].
  • 25
    Lazzara D, Buschmann M. Prevention of pressure ulcers in elderly nursing home residents: special support surfaces the answer? Decubitus 1991; 4: 42–44, 46, 48 [CLIN S].
  • 26
    Lyder CH. Pressure ulcer prevention and management. JAMA 2003; 289: 223–6 [CLIN S].
  • 27
    Meehan M. National pressure ulcer prevalence survey. Adv Wound Care 1994; 7: 27–30 [CLIN S].
  • 28
    Nixon J, Cranny G, Iglesias C, Nelson EA, Hawkins K, Phillips A, Torgerson D, Mason S, Cullum N. Randomised controlled trial of alternating pressure mattresses compared with alternating pressure overlays for the prevention of pressure ulcers: PRESSURE (pressure relieving support surfaces) trial. BMJ 2006; 332: 1413–5 [RCT].
  • 29
    Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing dry visco-elastic polymer pad and guideline operating table mattress in the prevention of post-operative pressure sores. Int J Nurs Stud 1998; 35: 193–203 [RCT].
  • 30
    Ooka M, Kemp M, McMyn R, Shott S. Evaluation of three types of support surfaces for preventing pressure ulcers in patients in a surgical intensive care unit. J Wound Ostomy Continence Nurs 1995; 22: 271–9 [CLIN S].
  • 31
    Russell JA, Lichtenstein SL. Randomized controlled trial to determine the safety and efficacy of a multi-cell pulsating dynamic mattress system in the prevention of pressure ulcers in patients undergoing cardiovascular surgery. Ostomy/Wound Manage 2000; 46: 46–55 [RCT].
  • 32
    Russell LJ, Reynolds TM, Park C, Rithalia S, Gonsalkorale M, Birch J, Torgerson D, Iglesias C; PPUS-1 Study Group. Randomized clinical trial comparing 2 support surfaces: results of the Prevention of Pressure Ulcers Study. Adv Skin Wound Care 2003; 16: 317–27 [RCT].
  • 33
    Santy JE, Butler MK, Whyman JD. A comparison study of 6 types of hospital mattresses to determine which most effectively reduces the incidence of pressure sores in elderly patients with hip fractures in a District General Hospital. Report to Northern & Yorkshire Regional Health Authority 1994 [RCT].
  • 34
    Scott EM, Leaper DJ, Clark M, Kelly PJ. Effects of warming therapy on pressure ulcers—a randomized trial [review]. AORN J 2001; 73: 921–33, 37–8 [RCT].
  • 35
    Takala J, Varmavuo S, Soppi E. Prevention of pressure sores in acute respiratory failure: a randomized controlled trial. Clin Intensive Care 1996; 7: 228–35 [RCT].
  • 36
    Taylor L. Evaluating the Pegasus Trinova: a data hierarchy approach. Br J Nurs 1999; 8: 771–4, 776–8 [RCT].
  • 37
    Vyhlidal S, Moxness D, Bosak K, Van Meter F, Bergstrom N. Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers. Appl Nurs Res 1997; 10: 111–20 [RCT].
  • 38
    Wound Ostomy Continence Nurses Society. Guideline for prevention and management of pressure ulcers. WOCN Clinical practice guideline series. Glenview, IL: WOCN, 2003 [STAT].
  • 39
    Yarbrough DR III, Philbeck TE Jr., Simmons FM, Finnell K, Smith P, Warren JB, Burleson DG. Therapeutic and financial outcomes using a pulsating low-air-loss surface for patients surviving severe posterior burns. Ostomy Wound Manage 2000; 46: 64–9 [CLIN S].

Guideline #5.4: Avoid ordinary sheepskin for pressure reduction; it provides comfort but does not relieve pressure to tissue (Pieper, 1998). Dense specialized sheepskin is recommended (Jolly, Wright McGowan, 2004).

Level of evidence: I, II

Principle: There is limited evidence that dense specialized sheepskin will reduce the incidence of pressure ulcers.

Evidence:

  • 1
    Ewing MR, Garrow C, Pressley TA, Ashley C, Kinsella NM. Further experiences in the use of sheepskin as an aid in nursing. Med J Aust 1964; 16: 139–41 [CLIN S].
  • 2
    Pieper B, Sugru M, Weiland M, Sprague K, Heiman C. Risk factors, prevention methods, and wound care for patients with pressure ulcers. Clin Nurse Spec 1998; 12: 7 [CLIN S].
  • 3
    Jolley DJ, Wright R, McGowan S, Hickey MB, Campbell DA, Sinclair RD, Montgomery KC. Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomized controlled trial. Med J Aust 2004; 180: 324–7 [RCT].

Guideline #5.5: Limit the amount of time the head of the bed is elevated; lower head of bed 1 hour after meals to prevent pressure over bony prominences; assess the sacral area more frequently if this is not possible (WOCN Clinical Guidelines, 2003).

Level of evidence: II, III

Principle: Elevation of the head of the bed may result in shear and friction forces between the skin and the bed surface; this may predispose to the development of pressure ulcers.

Evidence:

  • 1
    Thomas DR. Management of pressure ulcers. J Am Med Dir Assoc 2006; 7: 46–59 [LIT REV].
  • 2
    Young T. The 30 degree tilt position vs. the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: a randomized controlled trial. J Tissue Viability 2004; 14: 88–96 [RCT].
  • 3
    Wound Ostomy Continence Nurses society. Guideline for prevention and management of pressure ulcers. WOCN Clinical practice guideline series. Glenview, IL: WOCN, 2003 [STAT].

Guideline #5.6: Pressure prevention interventions shall be provided through regular and frequent turning and repositioning for bed and chair bound patients (Kosiak, 1961; Gordon et al., 2004). Reposition at least every hour to reduce pressure for chair-bound patients with attention to the patient's anatomy, postural alignment, and distribution of weight and support of feet (WOCN Clinical Guidelines, 2003; AHCPR, 1992).

Level of evidence: II

Principle: Pressure ulcers are thought to be caused by unrelieved pressure and compression of soft tissues against bony prominences. Relieving pressure over bony prominences can be achieved. Reductions in pressure incidence have been achieved by repositioning every 4 hours for bed-bound patients. For the chair-bound patient, tissue pressure between the sitting surface and bony prominence should be relieved. Reposition the sitting individual to relieve pressure at least every hour. For those who can reposition themselves, pressure relief should be encouraged every 15 minutes such as chair push-ups. Constant low-pressure devices and seat cushions have not been proven efficacious in reducing the incidence of pressure ulcers for chair-bound individuals. Gel or air-pressure reducing chair cushions are more effective than foam in preventing ischial pressure ulcers. The Roho cushion was demonstrated to be more effective in relieving pressure at the seating surface when compared with the Jay and Pindot cushions.

Evidence:

  • 1
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Pressure ulcers in adults: prediction and prevention (AHCPR publication no. 92-0047). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1992 [STAT].
  • 2
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Treatment of pressure ulcers in adults: prediction and prevention (AHCPR publication no. 95-0652). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1994 [STAT].
  • 3
    Clark M. Repositioning to prevent pressure sores—what is the evidence? Nursing Standard 1998; 13: 56–64 [LIT REV].
  • 4
    Conine TA, Hershier C, Daechsel D, Peel C, Peerson A. Pressure sore prophylaxis in elderly patients using polyurethane foam or Jay wheelchair cushions. Int J Rehabil Res 1994; 17: 123–37 [RCT].
  • 5
    Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW. Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev 2000; 2: CD001735. Update in: Cochrane Database Syst Rev 2004; 3: CD001735 [STAT].
  • 6
    Defloor T. Less frequent turning intervals and yet less pressure ulcers. Tijdschr Gerontol Geriatr 2001; 32: 174–7 [CLIN S].
  • 7
    Gordon MD, Gottschlich MM, Helvig EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [LIT REV].
  • 8
    Knox DM, Anderson TM, Anderson PS. Effects of different turn intervals on skin of healthy older adults. Adv Wound Care 1994; 7: 48–56 [CLIN S].
  • 9
    Kosiak M. Etiology of decubitus ulcers. Arch Phys Med Rehabil 1961; 42: 19–29 [CLIN S].
  • 10
    Thomas DR. Are all pressure ulcers avoidable? J Am Med Dir Assoc 2001; 2: 297–301 [LIT REV].
  • 11
    Wound Ostomy Continence Nurses society. Guideline for prevention and management of pressure ulcers. WOCN Clinical practice guideline series. Glenview, IL: WOCN, 2003 [STAT].
  • 12
    Yuen HK, Garrett D. Comparison of three wheelchair cushions for effectiveness of pressure relief. Am J Occup Ther 2001; 55: 470–5 [CLIN S].

Guideline #5.7: Pressure reduction using specialized foam overlays should be used as a preventative measure in the operating room for patients assessed to be at high risk for pressure ulcer development.

Level of evidence: I, II

Principle: Convoluted foam, cubed foam, and specialized thicker, denser sheepskin overlays are the only overlay surfaces shown to reduce the incidence of pressure ulcers in these settings.

Evidence:

  • 1
    Aronovitch SA, Wilber M, Slezak S, Martin T, Utter D. A comparative study of an alternating air mattress for the prevention of pressure ulcers in surgical patients. Ostomy Wound Manage 1999; 45: 34–40, 42–4 [RCT].
  • 2
    Cullum N, Deeks J, Sheldon TA, Song F, Fletcher AW. Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev 2000; 2: CD001735. Update in: Cochrane Database Syst Rev 2004; 3: CD001735 [STAT].
  • 3
    Dunlop V. Preliminary results of a randomized controlled study of a pressure ulcer prevention system. Adv Wound Care 1998; 11 (Suppl. 3): 14 [RCT].
  • 4
    Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing dry visco-elastic polymer pad and guideline operating table mattress in the prevention of post-operative pressure sores. Int J Nurs Stud 1998; 35: 193–203 [RCT].

6. Consideration of friction and shear prevention interventions shall be provided to prevent the formation of pressure ulcers

Preamble: Shear and friction to the skin is a contributing risk factor increasing a person's susceptibility to a complex etiology that causes pressure ulcers.

Guideline #6.1: Avoid vigorous massage over bony prominences.

Level of evidence: III

Principle: Friction damage occurs when repetitive friction results in parallel rubbing or sanding of the epidermis.

Evidence:

  • 1
    Agency for Healthcare Research and Quality. Clinical practice guidelines online. Available at: http://www.ahrq.gov/clinic/cpgonline.htm. Accessed December 2, 2002 [STAT].
  • 2
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Pressure ulcers in adults: prediction and prevention (AHCPR publication no. 92-0047). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1992 [STAT].
  • 3
    Gordon MD, Gottschlich MM, Helvig, EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [STAT].

Guideline #6.2: Use overhead trapeze bars, when possible, to facilitate the patient to assist with mobility.

Level of evidence: III

Principle: Shear force is a key factor in the development of pressure ulcers.

Evidence:

  • 1
    Agency for Healthcare Research and Quality. Clinical practice guidelines online. Available at: http://www.ahrq.gov/clinic/cpgonline.htm. Accessed December 2, 2002 [STAT].
  • 2
    Agency for Health Care Policy and Research, US Department of Health and Human Services. Pressure ulcers in adults: prediction and prevention (AHCPR publication no. 92-0047). Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, 1992 [STAT].
  • 3
    Makelbust J, Sieggreen M. Etiology and pathophysiology. In: Maklebust J, Fieggreen M, editors. Pressure ulcers: guidelines for prevention and Management, 3rd ed. Springhouse, PA: Springhouse Corp., 2001: 24 [CLIN S] [STAT].
  • 4
    Wound Ostomy Continence Nurses society. Guideline for prevention and management of pressure ulcers. WOCN Clinical practice guideline series. Glenview, IL: Wound Ostomy Continence Nurses, 2003 [STAT].

Guideline #6.3: Clean and dry the skin after each incontinence occurrence.

Level of evidence: II

Principle: Friction and shear are enhanced in the presence of moisture.

Evidence:

  • 1
    Ratliff, CR, Rodeheaver GT. Correlation of semi-quantitative swab cultures to quantitative swab cultures from chronic wounds. Wounds 2002; 4: 329–33 [CLIN S].

Guideline #6.4: The use of cornstarch to decrease skin resistance, protective application of hydrocolloids, hexachlorophene lotion, hyperoxygenated fatty acid preparations, or sheet hydrogel dressings may protect vulnerable skin surfaces (Gordon et al., 2004; Green et al., 1974; Torra I Bou et al., 2005).

Level of evidence: I, II, III

Principle:

Friction combined with pressure and moisture results in damage more readily. Friction injuries occur more frequently on elbows or where skin is fragile or macerated.

Evidence:

  • 1
    Gordon MD, Gottschlich MM, Helvig, EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [STAT].
  • 2
    Green MF, Exton-Smith AN, Helps EP, et al. Prophylaxis of pressure sores using a new lotion. Modern Geriatr 1974; 4: 376–82 [RCT].
  • 3
    Torra i Bou JE, Segovia Gómez T, Verdú Soriano J, Nolasco Bonmatí A, Rueda López J, Arboix i Perejamo M. The effectiveness of a hyperoxygenated fatty acid compound in preventing pressure ulcers. J Wound Care 2005; 14: 117–21 [RCT].

Guideline #6.5: Use lift sheets or devices to turn or transfer patients to avoid dragging or pulling that can result in friction injuries (WOCN Clinical Guidelines, 2003).

Level of evidence: III

Principle: Friction combined with pressure and moisture results in damage more readily. Friction injuries occur more frequently on elbows or where skin is fragile or macerated.

Evidence:

  • 1
    Gordon MD, Gottschlich MM, Helvig, EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [STAT].
  • 2
    Wound Ostomy Continence Nurses society. Guideline for prevention and management of pressure ulcers. WOCN Clinical practice guideline series. Glenview, IL: Wound Ostomy Continence Nurses, 2003 [STAT].

Guideline #6.6: Maintain head of bed at, or below, 30° or at the lowest degree of elevation consistent with the patient's medical condition to prevent sliding and shear-related injury.

Level of evidence: III

Principle: Elevation of the head of the bed may result in shear and friction forces between the skin and the bed surface; this may predispose to the development of pressure ulcers.

Evidence:

  • 1
    Makelbust J, Sieggreen M. Etiology and pathophysiology. In: Maklebust J, Fieggreen M, editors. Pressure ulcers: guidelines for prevention and Management, 3rd ed. Springhouse, PA: Springhouse Corp., 2001: 24 [CLIN S] [STAT].
  • 2
    Wound Ostomy Continence Nurses society. Guideline for prevention and management of pressure ulcers. WOCN Clinical practice guideline series. Glenview, IL: Wound Ostomy Continence Nurses, 2003 [STAT].

7. Management of moisture or incontinence shall be provided to prevent the formation of pressure ulcers

Preamble: Moisture or incontinence is a contributing risk factor increasing the person's susceptibility to a complex etiology that causes pressure ulcers.

Guideline #7.1: Use of gentle skin cleansers designed for intact skin should be used to remove excrement. Products that contain surfactant facilitate the removal of urine and stool and require less abrasive force.

Level of evidence: II, III

Principle: Moisture removes oils on the skin, making it friable and contributing to maceration of tissues and softening of the skin's connective tissue and erosion of the epidermis; increasing the likelihood of pressure sore development. Use of strong soaps (bar soap) emulsifies the lipids in the skin and increases the skin pH, reducing the protective normal skin barriers. AHCPR guidelines recognize that skin exposure to urine and feces increases the risk of pressure ulcers.

Evidence:

  • 1
    Agency for Healthcare Research and Quality. Clinical practice guidelines online. Available at: http://www.ahrq.gov/clinic/cpgonline.htm. Accessed December 2, 2002 [STAT].
  • 2
    Bates-Jensen BM, Alessi CA, Al-Samarrai NR, Schnelle JF. The effects of an exercise and incontinence intervention on skin health outcomes in nursing home residents. J Am Geriatr Soc 2003; 51: 348–55 [RCT].
  • 3
    Gordon MD, Gottschlich MM, Helvig EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil 2004; 25: 388–410 [LIT REV].

8. Management of nutrition shall be provided to prevent the formation of pressure ulcers

Preamble: Managing nutrition is essential to the prevention of pressure ulcers. Nutrition is considered a significant factor in the prevention of pressure ulcers. Protein, carbohydrates, vitamins, minerals, and trace elements are required for wound healing. There is limited evidence documenting the effectiveness of nutritional management in the prevention of pressure ulcers.

Guideline #8.1: The nutrition management plan to prevent pressure ulcers should provide adequate daily calories, protein, carbohydrates, fat, vitamins, and minerals to meet individual energy needs. Provide nutrition (parenteral or enteral) appropriate to individual needs, goals of care, and patient preferences.

Level of evidence: I, II, III

Principle: Nutrition is essential in maintaining skin integrity; if nutritional risk or malnutrition occurs, the patient is at risk for the development of pressure ulcers. The impact of nutrition in the prevention of pressure ulcers remains controversial.

Evidence:

  • 1
    Allman RM, Laprade CA, Noel LB. Pressure sores among hospitalized patients. Ann Intern Med 1986; 105: 337–42 [STAT].
  • 2
    Baker JP, Detsky AS, Withwell J, Langer B, Jeejeebhoy KN. A comparison of the predictive value of nutritional assessment techniques. Hum Nutr Clin Nutr 1982; 36C: 233–41 [CLIN S].
  • 3
    Bergstrom NA, Braden BJ. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S].
  • 4
    Berlowitz DR, Wilking SV. Risk factors for pressure sores: a comparison of cross-sectional and cohort-derived data. J Am Geriatr Soc 1989; 37: 1043–50 [CLIN S].
  • 5
    Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, Manciet G, Dartigues JF. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation. Nutrition 2000; 16: 1–5 [RCT].
  • 6
    Hartgrink HH, Wille J, Konig P, Hermans J, Breslau PJ. Pressure sores and tube feeding in patients with a fracture of the hip. Clin Nutr 1998; 17: 287–92 [RCT].
  • 7
    Houwing R, Rozendaal M, Wouters Wesseling W, Beulens JWJ, Buskens E, Haalboom J. A randomized, double-blind assessment of the effect of nutritional supplementation on the prevention of pressure ulcers in hip fracture patients. Clin Nutr 2003; 22: 401–5 [RCT].
  • 8
    Langer G, Schloemer G, Knerr A, Kuss O, Behrens J. Nutritional interventions for preventing and treating pressure ulcers. The Cochrane Database of Systematic Reviews 2003, Art. No.: CD003216, doi: 10.1002/14651858 [STAT].
  • 9
    Mathus-Vliegen EM. Old age, malnutrition, and pressure sores: an ill-fated alliance. J Gerontol A Biol Sci Med Sci 2004; 59: 355–60 [LIT REV].
  • 10
    Murden RA, Ainslie NK. Recent weight loss is related to short-term mortality in nursing homes. J Gen Intern Med 1994; 9: 648–50 [CLIN S].
  • 11
    Sullivan DH, Johnson LE, Bopp MM, Roberson PK. Prognostic significance of monthly weight fluctuations among older nursing home residents. J Gerontol A Biol Sci Med Sci 2004; 59: M633–9 [RCT].
  • 12
    Thomas DR, Verdery RB, Gardner L, Kant AK, Lindsay J. A prospective study of outcome from protein-energy malnutrition in nursing home residents. JPEN J Parenter Enteral Nutr 1991; 15: 400–4 [CLIN S].
  • 13
    Thomas DR. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997; 13: 497–512 [LIT REV].

Guideline #8.2: Provide ongoing weekly nutrition assessment and reassessment to ensure adequacy of dietary intake in acutely ill patients; nutrition assessment in nursing home residents shall be compatible with guidelines for nursing homes.

Level of evidence: II, III

Principle: Nutrition is essential in maintaining skin integrity; if nutritional risk or malnutrition occurs the patient is at risk for the development of pressure ulcers. Long-term care residents are at particularly high risk for developing pressure ulcers. Risk assessment tools such as the Braden scale include nutrition assessment as an integral part of overall assessment of risk for pressure ulcer development.

Evidence:

  • 1
    Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc 1992; 40: 747–58 [CLIN S].
  • 2
    Bergstrom N, Braden B, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nurs Res 1987; 36: 205–10 [LIT REV].
  • 3
    Bergstrom N, Demuth PJ, Braden B. A clinical trial of the Braden scale for predicting pressure sore risk. Nurs Clin North Am 1987; 22: 417–28 [CLIN S].
  • 4
    Braden BJ, Bergstrom N. Predictive validity of the Braden scale for pressure sore risk in a nursing home population. Res Nurs Health 1994; 17: 459–70 [CLIN S].
  • 5
    Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, Manciet G, Dartigues JF. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation. Nutrition 2000; 16: 1–5 [RCT].
  • 6
    Durfee SM, Gallagher-Allred C, Pasquale J, Stechmiller J. Standards for specialized nutrition for adult residents of long term care facilities. Nutr Clin Pract 2006; 21: 96–104 [STAT].
  • 7
    Thomas DR. The role of nutrition in prevention and healing of pressure ulcers. Clin Geriatr Med 1997; 13: 497–511 [LIT REV].
  • 8
    Thomas DR. Issues and dilemmas in managing pressure ulcers. J Gerontol A Biol Sci Med Sci 2001; 56: M238–340 [LIT REV].
  • 9
    Thomas DR, Ashmen W, Morley JE, Evans JE. Nutritional management in long-term care: development of a clinical guideline. J Gerontol A Biol Sci Med Sci 2000; 55: 725–34 [STAT].

9. Health care provider, patient and/or caregiver education

Preamble: Despite many of the advances in wound care, the challenge of preventing pressure ulcers remains due to the complexity of predisposing factors. This is compounded by the need to educate health care providers, patients, family, and/or caregivers about pressure ulcer prevention.

Guideline #9.1: The health care provider, patient, and/or caregiver should understand the importance of the following in preventing pressure ulcers in at-risk adults: regularly inspecting skin and bony prominences; following recommended skin-care regimens, avoiding vigorous massage of reddened areas and bony prominences; preventing friction and shearing forces, including frequent turning, repositioning, and the use of pressure-reducing devices if patient is confined to bed and/or chair; avoiding donut-type devices; maintaining adequate hydration and nutrition; monitoring weight loss, poor appetite, or gastrointestinal changes that interfere with eating; and promptly reporting changes in medical status and nutritional problems.

Level of evidence: II, III

Principle: Health care providers, patients, families, and caregivers need to be educated about pressure ulcer risk prevention.

Evidence:

  • 1
    Kumura S, Pacala JT. Pressure ulcers in adults: family physicians' knowledge, attitudes, practice preferences and awareness of AHCPR guidelines. J Fam Pract 1997; 44: 361–8 [CLIN S].
  • 2
    Pieper B, Mott M. Nurses' knowledge of pressure ulcer prevention, staging and description. Adv Wound Care 1995; 8: 38–40 [CLIN S].
  • 3
    Thomas DR. Issues and dilemmas in the prevention and treatment of pressure ulcers: a review. J Gerontol A Biol Sci Med Sci 2001; 56A: M328–40 [LIT REV].

10. Interdisciplinary approach

Preamble: Preventing pressure ulcers is less costly than treating pressure ulcers. The economic significance of pressure ulcers necessitates the importance of an interdisciplinary approach for their prevention.

Guideline #10.1: An interdisciplinary team of appropriate health care professionals, including a physician, advanced practice nurse and/or registered nurse/LPN for nursing homes, registered dietitian, physical therapist, occupational therapist, social worker, and other health care professionals as appropriate shall be identified to establish, develop, and implement policies and procedures for the prevention of pressure ulcers.

Level of evidence: II, III

Principle: Efforts to implement pressure ulcer prevention protocols through development of policies and procedures demonstrates a reduction in the prevalence of pressure ulcers. Note that this reference, and a number of others, has not demonstrated an effect in reducing the incidence of pressure ulcers that was sustained in time. No change in pressure ulcer prevalence has been observed since implementation of the Omnibus Budget Reconciliation Act of 1987 in a nationally derived sample of long-term nursing home residents. The relative odds of having a pressure ulcer increased by 6% from 1992–1994 to 1997–1998 for all pressure ulcer stages and increased 21% for stages 2 and greater. The risk-adjusted incidence rate of developing a pressure ulcer in Department of Veterans Affairs nursing facilities in 1997 was similar to the rate in 1990. However, the severity of new pressure ulcers was higher in 1997. Arguably, this represents either a complete failure to implement recommended interventions or a complete failure of the nature of the quality improvement interventions.

Evidence:

  • 1
    Berlowitz DR, Young GJ, Brandeis GH, Kader B, Anderson JJ. Health care reorganization and quality of care: unintended effects on pressure ulcer prevention. Med Care 2001; 39: 138–46 [CLIN S].
  • 2
    Coleman EA, Martau JM, Lin MK, Kramer AM. Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA '87. Omnibus Budget Reconciliation Act. J Am Geriatr Soc 2002; 50: 728–32 [CLIN S].
  • 3
    Granick MS, McGowan E, Long CD. Outcome assessment of an in-hospital cross-functional wound care team. Plast Reconstr Surg 1998; 101: 1243–7 [CLIN S].
  • 4
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