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Internet Citation: 3. What are the best practices in pressure ulcer prevention that we want to use?. Content last reviewed October Agency for Healthcare Research and Quality, Rockville, MD. Browse Topics. Topics A-Z. National Healthcare Quality and Disparities Report Latest available findings on quality of and access to health care.
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What are the best practices in pressure ulcer prevention that we want to use? Preventing Pressure Ulcers in Hospitals 3. Previous Page. Next Page. Table of Contents Preventing Pressure Ulcers in Hospitals Overview Key Subject Area Index 1. Are we ready for this change?
How will we manage change? How do we implement best practices in our organization? How do we measure our pressure ulcer rates and practices? How do we sustain the redesigned prevention practices? Tools and Resources. Consensus should be reached on the following questions: What "bundle" of best practices do we use?
How should a comprehensive skin assessment be conducted? How should a standardized pressure ulcer risk assessment be conducted? How frequently? How should pressure ulcer care planning based on identified risk be used? What items should be in our bundle?
What additional resources are available to identify best practices for pressure ulcer prevention? Some of the factors that make pressure ulcer prevention so difficult include: It is multidisciplinary: Nurses, physicians, dieticians, physical therapists, and patients and families are among those who need to be invested.
It is multidimensional: Many different discrete areas must be mastered. It needs to be customized: Each patient is different, so care must address their unique needs. It is also highly routinized: The same tasks need to be performed over and over, often many times in a single day without failure.
It is not perceived to be glamorous: The skin as an organ, and patient need for assessment and care, does not enjoy the high status and importance of other clinical areas. The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment.
Standardized pressure ulcer risk assessment. Care planning and implementation to address areas of risk. The challenge to improving care is how to get these key practices completed on a regular basis.
Resources The bundle concept was developed by the Institute for Healthcare Improvement IHI. Additional Information The following article describes successful efforts to improve pressure ulcer prevention that relied on the use of the components in the IHI bundle: Walsh NS, Blanck AW, Barrett KL.
Some of the advantages of these clinical pathways are to: Reduce variation and standardize care. Provide efficient, evidence-based care. Improve outcomes. Educate staff as to best practices.
Improve care planning. Facilitate discussion among staff. Tools An example of a clinical pathway detailing the different components of the bundle is found in Tools and Resources Tool 3A, Pressure Ulcer Prevention Pathway.
This color-coded tool can be used by the hospital unit team in designing the new system, as a training tool for frontline staff, and as an ongoing clinical reference tool on the units. This tool can be modified, or a new one created, to meet the needs of your particular setting.
If you prepared a process map describing your current practices described in section 2 , you can compare that to desired practices outlined on the clinical pathway. Practice Insights Given the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed.
Return to Contents 3. These include: Identify any pressure ulcers that may be present. Assist in risk stratification; any patient with an existing pressure ulcer is at risk for additional ulcers. Determine whether there are other lesions and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage MASD.
Identify other important skin conditions. Provide the data necessary for calculating pressure ulcer incidence and prevalence. Additional Information It is important to differentiate MASD from pressure ulcers. The following articles provide useful insights on how to do this: DeFloor T, Schoonhoven L, Fletcher J, et al.
Statement of the European Pressure Ulcer Advisory Panel: pressure ulcer classification. J Wound Ostomy Continence Nurs ; Gray M, Bliss DZ, Doughty DB. Incontinence associated dermatitis a consensus. J Wound Ostomy Continence Nurs ;34 1 Usual practice includes assessing the following five parameters: Temperature.
Moisture level. Skin integrity skin intact or presence of open areas, rashes, etc. Tools Detailed instructions for assessing each of these areas are found in Tools and Resources Tool 3B, Elements of a Comprehensive Skin Assessment. Practice Insights Take advantage of every patient encounter to evaluate part of the skin.
Always remind staff performing comprehensive skin assessments of the following helpful hints: Don't forget to wash your hands before doing the skin assessment and after and to use gloves. Make sure the patient is comfortable. Minimize exposure of body parts while you are doing the skin assessment.
Ask for assistance if needed to turn the patient in order to examine the patient's backside, with a particular focus on the sacrum. Look at the skin underneath any devices such as oxygen tubing, indwelling urinary catheter, etc.
Make sure to remove compression stockings to check the skin underneath them. Action Steps Assess whether your staff know the frequency with which comprehensive skin assessment should be performed.
Action Steps Assess the following: Are results of the comprehensive skin assessment easily located for all patients? Are staff comfortable reporting any observed skin abnormalities to physicians and nurse managers?
Tools A sample sheet can be found in Tools and Resources Tool 5A, Unit Log. Practice Insights Have a standardized place to record in the medical record the results of the skin assessment. A checklist or standardized computer screens with drop-down prompts with key descriptors of the five components of a minimal skin assessment can help capture the essential information obtained through the patient examination.
Communication among licensed and unlicensed members of the health care team is important in identifying and caring for any skin abnormalities.
Some places have found it effective to use a diagram of a body outline that an unlicensed heath care worker can mark with any skin changes they might see while bathing or performing care activities. Be especially concerned about the following issues: Finding the time for an adequate skin assessment: As much as possible, integrate the comprehensive skin examination into the normal workflow.
But remember that this is a separate process that requires a specific focus by staff if it is to be done correctly. Determining the correct etiology of wounds: Many different types of lesions may occur on the skin and over bony prominences.
In particular, do not confuse moisture-associated skin changes with pressure ulceration. If unsure about the etiology of a lesion, ask someone else who may be more knowledgeable.
Using documentation forms that are not consistent with components of skin assessments: Develop forms that will facilitate the recording of skin assessments.
Having staff who do not feel empowered to report abnormal skin findings: Communication among nursing assistants, nurses, and managers is critical to success. If communication problems exist, staff development activities targeting cross-level communication skills may be in order.
Nurses and managers may need to solicit and positively reinforce such reporting if nursing assistants do not have confidence in this area. Develop methods to facilitate communication.
One example would be a sticky note pad that includes a body outline, patient name, and date. Aides would mark down any suspicious lesions and give the note to nurses. Tools An example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources Tool 3C, Pressure Ulcer Identification Notepad.
Encourage staff to: Ask a colleague to confirm their skin assessments. Having a colleague evaluate the skin assessment will provide feedback as to how they are doing and will help correct documentation errors. Perform skin assessments with an expert. Consider having an expert or nurse from another unit round with unit staff quarterly to confirm findings from the comprehensive skin assessment.
Ask for clarification when they are unsure of a lesion. Take advantage of the local wound care team or other staff who may be more knowledgeable. Use available resources to practice their ability to differentiate the etiology of skin and wound problems. Resources This slide show illustrates how to perform a skin assessment: www.
Practice Insights A full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.
When applying oxygen, check the ears for pressure areas from the tubing. If the patient is on bed rest, look at the back of the head during repositioning. When checking bowel sounds, look into skin folds. When positioning pillows under calves, check the heels and feet using a hand-held mirror makes this easier.
When checking IV sites, check the arms and elbows. Examine the skin under equipment with routine removal e.
Each time you lift a patient or provide care, look at the exposed skin, especially on bony prominences. Action Steps Ask yourself and your team: Do you have a policy about who is responsible for the risk assessment on admission and thereafter?
Does everyone know the process for performing risk assessment? Pressure ulcer risk assessment is essential for a number of reasons: It aids in clinical decisionmaking. Many clinicians are not skilled in identifying patients at risk for developing pressure ulcers.
Use of a standardized risk assessment helps to direct the process by which clinicians identify those at risk and quantify the level of this risk. It allows the selective targeting of preventive interventions.
Pressure ulcer prevention is resource intensive. Resources should be targeted toward those at greatest risk who would most-benefit. It facilitates care planning. Care plans focus on the specific dimensions that place the patient at greatest risk. It facilitates communication between health care workers and care settings.
Workers have a common language by which they describe risk. Action Steps Ask yourself and your team: Do the unit staff understand why they are doing the risk assessment? Are unit staff communicating the risk assessment results to all clinicians who need to know?
Presence of a pressure ulcer: All patients with an existing pressure ulcer should be considered at-risk for an additional ulcer. Prior Stage III or IV pressure ulcers: When Stage III or IV ulcers close through a process of scar tissue formation and eventual epithelialization, the resulting skin is not normal as it lacks its former tensile strength and is very prone to break down again.
Hypoperfusion states: Patients who are not perfusing vital organs as a result of conditions such as sepsis, dehydration, or heart failure are also not adequately perfusing the skin. Minimal amounts of pressure may then cause ulceration. Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels.
Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers. Smoking: Smoking interferes with oxygen delivery. Smoking is associated with recurrence of pressure ulcers postsurgery and likely increases risk of new pressure ulcers.
Restraint use: Patients with physical restraints have limited mobility in addition to having pressure applied at the site of the restraints.
Chemical restraints with resulting sedation may lead to rapid decline in mobility. Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk. The level and completeness of the spinal cord injury is critical in this determination.
Operating room OR and emergency room ER stays: Prolonged time on a hard surface or in one position increases the risk of skin breakdown.
This often happens in an OR or ER, with lengthy procedures, or while transporting a patient,. Always consider the length of time that the patient may need to stay in one position. Patients who undergo a procedure longer than 4 hours are at particularly high risk.
Practice Insights Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development. Action Steps Ask yourself and your team: Are we using a risk assessment tool in conjunction with the assessment of additional specific patient risk factors?
When and what kind of training did the staff receive on how to use and interpret the scales? Are risk assessment results being used as a basis for planning care?
Tools Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale. Resources Consider the following resources for risk assessment in special populations: Palliative Care: Hunters Hill Marie Curie Centre Risk Assessment Tool.
Chaplin J, McGill M. Pressure sore prevention. Palliative Care Today ;8 3 Home Care: Braden Scale for Predicting Pressure Sore Risk in Home Care. Available at: www. Pediatrics: Braden Q 21 days to 8 years. Quigley SM, Curly MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers.
J Spec Pediatr Nurs ;1 1 Glamorgan Scale birth to 18 years. Willock J, Harris C, Harrison J, et al. Identifying the characteristics of children with pressure ulcers. Nursing Times ; 11 Pediatric Waterlow neonate to 16 years. Waterlow J. Pressure sore risk assessment in children. Pediatr Nurs ;9 6 Neonatal Skin Risk Assessment Scale NSARS 26 to 46 weeks.
Huffines B, Logsdon MC. Much research has been conducted on the effectiveness of the use of support surfaces in reducing the incidence of pressure ulcers. A comprehensive literature review by Agostini and colleagues 67 found that there was adequate evidence that specially designed support surfaces effectively prevent the development of pressure ulcers.
However, a major criticism of the current support surface studies was poor methodologic design. Agostini and colleagues noted that many studies had small sample sizes and unclear standardization protocols, and assessments were not blind.
Reddy and colleagues 62 have provided a systematic review of 49 randomized controlled trials that examined the role of support surfaces in preventing pressure ulcers. No one category of support surface was found to be superior to another; however, use of a support surface was more beneficial than a standard mattress.
A prospective study evaluating the clinical effectiveness of three different support surfaces two dynamic mattress replacement surfaces and one static foam mattress replacement found that an equal number of patients developed pressure ulcers on each surface three per surface.
Given the similar clinical effectiveness, cost should be considered in determining the support surface. Four randomized controlled trials evaluated the use of seat cushions in pressure ulcer prevention, and found no difference in ulcer incidence among groups except between foam and gel cushions.
The CMS has divided support surfaces into three categories for reimbursement purposes. Static devices include air, foam convoluted and solid , gel, and water overlays or mattresses. These devices are ideal when a patient is at low risk for pressure ulcer development. Group 2 devices are powered by electricity or pump and are considered dynamic in nature.
These devices include alternating and low-air-loss mattresses. These mattresses are good for patients who are at moderate to high risk for pressure ulcers or have full-thickness pressure ulcers. Group 3 devices, also dynamic, comprises only air-fluidized beds.
These beds are electric and contain silicone-coated beads. When air is pumped through the bed, the beads become liquid.
These beds are used for patients at very high risk for pressure ulcers. More often they are used for patients with nonhealing full-thickness pressure ulcers or when there are numerous truncal full-thickness pressure ulcers.
The NPUAP has suggested new definitions for support surfaces that move away from these categories and divide support surfaces into powered or nonpowered. There remains a paucity of research that demonstrates significant differences in the effectiveness of the various classifications of support surfaces in preventing or healing pressure ulcers.
Therefore, nurses should select a support surface based on the needs and characteristics of the patient and institution e. It is imperative to have the pressure redistribution product e. However, being on a pressure-redistributing mattress or cushion does not negate the need for turning or repositioning.
Controversy remains on how best to do nutritional assessment for patients at risk for developing pressure ulcers. The literature differs about the value of serum albumin; some literature reports that low levels are associated with increased risk. The literature is unclear about protein-calorie malnutrition and its association with pressure ulcer development.
In one prospective study, high-risk patients who were undernourished on admission to the hospital were twice as likely to develop pressure ulcers as adequately nourished patients 17 percent and 9 percent, respectively.
Pressure ulcers occurred in 65 percent of the severely undernourished residents, while no pressure ulcers developed in the mild-to-moderately undernourished or well-nourished residents.
Reddy and colleagues 62 concluded that nutritional supplementation was beneficial in only one of the five randomized controlled trials reviewed in their systematic analysis of interventions targeted at impaired nutrition for pressure ulcer prevention.
Older critically ill patients who had two oral supplements plus the standard hospital diet had lower risk of pressure ulcers compared to those who received only the standard hospital diet. Empirical evidence is lacking that the use of vitamin and mineral supplements in the absence of deficiency actually prevents pressure ulcers.
Before enteral or parental nutrition is used, a critical review of overall goals and wishes of the patient, family, and care team should be considered. Nursing is also concerned with preventing further ulcer deterioration, keeping the ulcer clean and in moisture balance, preventing infections from developing, and keeping the patient free from pain.
Many aspects of managing pressure ulcers are similar to prevention mechanical loading, support surfaces, and nutrition. Clearly, the health care team has to address the underlying causes intrinsic and extrinsic or the pressure ulcer will not close.
In , AHRQ published clinical practice guidelines on treating pressure ulcers. Although the AHRQ document was published 13 years ago, it provides the foundation for treating pressure ulcers.
The document identified specific indices e. The following section supplements this document. Once the pressure ulcer develops, the ulcer should be cleaned with a nontoxic solution.
Cleaning the ulcer removes debris and bacteria from the ulcer bed, factors that may delay ulcer healing. A Cochrane review of published randomized clinical trials found three studies addressing cleansing of pressure ulcers, but this systematic review produced no good trial evidence to support any particular wound cleansing solution or technique for pressure ulcers.
Nurses should use cleansers that do not disrupt or cause trauma to the ulcer. The nurse should assess and stage the pressure ulcer at each dressing change. Experts believe that weekly assessments and staging of pressure ulcers will lead to earlier detection of wound infections as well as being a good parameter for gauging of wound healing.
The staging system is one method of summarizing certain characteristics of pressure ulcers, including the extent of tissue damage. Hence, whether the nurse observes the epidermis, dermis, fat, muscle, bone, or joint determines the stage of pressure ulcer.
Knowing the appropriate stage aids in determining the management of the pressure ulcer. However, staging of pressure ulcers can vary, because different nurses may observe different tissue types. Pressure ulcer staging systems differ, depending on geographic location.
The Europeans use a four-stage system. For Grade 2, indicators include partial thickness skin loss involving epidermis, dermis, or both.
The ulcer is superficial and presents clinically as an abrasion or blister. Grade 3 includes full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia.
Grade 4 includes extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures, with or without full thickness skin loss. The most widely used staging system in the United States was developed in by the NPUAP. If the pressure ulcer is covered with necrotic tissue eschar , it should be noted as unstageable.
In skilled nursing facilities, nurses must stage a pressure ulcer covered with necrotic tissue as Stage IV. The NPUAP staging definitions were refined with input from an online evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination.
The new staging system has six stages: suspected deep tissue injury, Stage I, Stage II, Stage III, Stage IV, and Unstageable. Table 1 presents the NPUAP definition, and Table 2 illustrates the differences between the old and new pressure ulcer staging systems.
The Stage I pressure ulcer may be more difficult to detect in darkly pigmented skin. A quality improvement study in several nursing homes found that by empowering the nursing assistants with education skin assessment , use of pen lights to assess darker skin, mirrors, and financial reward, the researchers were able to reduce the Stage I pressure ulcers in residents with darkly pigmented skin.
Although ultrasound is widely used as a safe and cost-effective technique for noninvasive visualization of specific human anatomy, its use for skin assessment is just now available. Ultrasound utilizes the echoes of sound waves to create images of soft tissue anatomy.
A recent study strongly suggests that clinicians should consider high-frequency ultrasound as an improved method for identifying and implementing good pressure ulcer preventive care. The presence of necrotic devitalized tissue promotes the growth of pathologic organisms and prevents wounds from healing.
No randomized control trials could be found that demonstrated that one debridement technique is superior. Thus, the best method of debridement is determined by the goals of the patient, absence or presence of infection, pain control, amount of devitalized tissue present, and economic considerations for the patient and institution.
Sharp debridement use of scalpel or laser is probably the most effective type of debridement because of the time involved to remove the devitalized tissue. One common form of mechanical treatment is wet-to-dry gauze to adhere to the necrotic tissue, which is then removed. Upon removal of the gauze dressing, necrotic tissue and wound debris are also removed.
The challenge with mechanical debridement is the possibility that healthy granulation tissue may be removed as well, along with the devitalized tissue, thereby delaying wound healing and causing pain.
Thus, CMS suggests that this method of debridement be used in limited circumstances. Autolytic debridement involves the use of semiocclusive transparent film and occlusive dressings hydrocolloids, hydrogels, etc.
Finally, biosurgery maggot therapy is another effective and relatively quick method of debridement. Managing bacterial burden is an important consideration in pressure ulcer care.
All pressure ulcers contain a variety of bacteria. Pressure ulcer bacterial contamination should not impair health. Healing can be impeded when wounds have high levels of bacteria. Robson and Heggers found in 32 pressure ulcers that spontaneous healing occurred only when the microbial population was controlled.
Experts agree that swab cultures should not be used to determine wound infection. Thus, when these signs are present, the nurse should seek additional treatments for the patient.
This will help to safeguard the patient from further ulcer complications. The use of oral antibiotics or topical sulfa silverdiazine has also been found to be effective in decreasing the bioburden in the ulcer bed. One in vivo study found that silver-based dressings decreased specific bacteria e.
This Cochrane review determined that based on only three randomized controlled trials, there remains insufficient evidence to recommend the use of silver-containing dressings or topical agents for treatment of infected or contaminated chronic wounds.
The use of antiseptics to reduce wound contamination continues to be a controversial topic. The ideal agent for an infected pressure ulcer would be bactericidal to a wide range of pathogens and noncytotoxic to leukocytres. In vitro studies of 1 percent povidone-iodine have been found to be toxic to fibroblast, but a solution of 0.
Studies suggest that 0. McKenna and colleagues examined the use of 0. The use of dressings is a major component in maintaining a moist environment. There are more than different modern wound dressings available to manage pressure ulcers. Few randomized controlled studies have been conducted to evaluate the efficacy of dressings within a specific classification.
Therefore, no one category of wound dressings independent of gauze may be better than another category. Most research evaluating the effects of dressings usually compare gauze standard to modern wound dressings nongauze. The studies usually have small sample sizes; thus inferences can be difficult to make.
However, one study investigating wound-healing outcomes using standardized validated protocols found that primarily using nongauze protocols of care matched or surpassed the best previously published results on similar wounds using gauze-based protocols of care, including protocols applying gauze impregnated with growth factors or other agents.
Thus, nongauze protocols of care should be used to accelerate pressure ulcer healing. The use of high-protein diets for patients with protein deficiency is essential to wound healing. To underscore that increasing protein does have a positive effect on wound healing, researchers investigated 28 malnourished patients with a total of 33 truncal pressure ulcers.
Clearly, increasing protein stores for patients with pressure ulcers who are malnourished is essential; however, it is unclear from the literature what the optimum protein intake requirement is for patients with pressure ulcers. Most promising: the use of amino acids such as argine, glutamine, and cysteine have been noted to assist in ulcer healing.
Pressure ulcers can be painful. In particular, patients with Stage IV ulcers can experience significant pain. Hence, the goal of pain management in the patient with pressure ulcers should be to eliminate the cause of pain, to provide analgesia, or both.
This goal was supported recently by the World Union of Wound Healing Societies consensus document, Principles of Best Practice: Minimizing Pain at Wound Dressing-Related Procedures. Dressing removal can potentially cause damage to delicate tissue in the wound and surrounding skin.
Thus, clinicians should use multiple methods to address the pressure ulcer pain. This may include using dressing that mitigates pain during dressing changes, such as dressings containing soft-silicone, and administering analgesic prior to dressing changes.
Presently, there are two instruments that are often used to measure the healing of pressure ulcers. The Pressure Ulcer Scale for Healing PUSH was developed by the NPUAP in Using a Likert scale from 1 to 10 for length and width, a Likert scale from 1 to 3 for exudate amount, and a Likert scale from 1 to 4 for tissue type, the nurse can determine whether a pressure ulcer is healing or nonhealing.
Each of the three ulcer characteristics is recorded as a subscore, then the subscores are added to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration of the pressure ulcer. Few studies have been published that measure the validity and reliability of the PUSH tool.
Thus, the PUSH tool was shown to be a valid instrument for measuring healing in a clinical setting. The Bates-Jensen Wound Assessment Tool BWAT; formerly the Pressure Sore Status Tool, PSST was developed in and is also widely used.
The first 2 items are related to location and shape of the ulcer. The remaining 13 items are scored on the basis of descriptors of each item and ranked on a modified Likert scale 1 being the healthiest attribute of the characteristic and 5 being the least healthy attribute of the characteristic.
The 13 BWAT characteristics that are scored are size, depth, edges, undermining, necrotic tissue type, necrotic tissue amount, exudate type, exudate amount, skin color surrounding wound, peripheral tissue edema, peripheral tissue induration, granulation tissue, and epithelialization.
The 13 item scores are summed to provide a numerical indicator of wound health or degeneration. There is a paucity of validation studies for the BWAT. However, content validity has been established by a panel of 20 experts. Interrater reliability was established by the use of two wound, ostomy, and continence nurses who independently rated 20 pressure ulcers on 10 patients.
Partial thickness wounds healed faster than same-etiology full thickness wounds. The use of adjunctive therapies is the fastest growing area in pressure ulcer management. Adjunctive therapies include electrical stimulation, hyperbaric oxygen, growth factors and skin equivalents, and negative pressure wound therapy.
Except for electrical stimulation, there is a paucity of published research to substantiate the effectiveness of adjunctive therapies in healing pressure ulcers.
Electrical stimulation is the use of electrical current to stimulate a number of cellular processes important to pressure ulcer healing. Electrical stimulation appears to be most effective on healing recalcitrant Stages III and IV pressure ulcers. Negative pressure wound therapy is widely used, although few randomized controlled trials have been published.
This therapy promotes wound healing by applying controlled localized, negative pressure to the wound bed. The use of growth factors and skin equivalents in the healing of pressure ulcers remains under investigation, although the use of cytokine growth factors e.
Three small randomized controlled trials have suggested that growth factors had beneficial results with pressure ulcers, but the findings warrant further exploration.
One animal study used a prospective, randomized, double-blind, placebo-controlled design to evaluate the effect of a specific noninvasive radiofrequency-pulsed electromagnetic field signal on tendon tensile strength at 21 days after transection in a rat model.
Although electroceuticals are promising, additional research is needed to recommend them for pressure ulcer treatment. The use of therapeutic ultrasound for pressure ulcers has also been explored. A Cochrane review found three published randomized clinical trails using therapeutic ultrasound.
Thus, additional studies are needed before this therapy can be supported. Much progress has been made in identifying patients at risk for pressure ulcers.
The use of pressure ulcer prediction tools e. Research has shown that using the AHRQ guidelines on pressure ulcer prediction and prevention can lead to decreased incidence of pressure ulcers. Moreover, internalizing these guidelines throughout the health care system can lead to pressure ulcer reductions.
Much progress has been made in understanding effective wound treatments. Treatments range from using traditional therapies keeping the wound moist, appropriate repositioning, support surfaces, and proper nutrition to the wise use of adjunctive therapies. Although many studies in pressure ulcer prevention and treatment have small sample sizes, there is a growing body of evidence to suggest that newer wound modalities can be effective in preventing and treating pressure ulcers.
Since the original publications of the AHRQ pressure ulcer prevention and treatment guidelines in and , some progress has been made in our understanding of pressure ulcer care.
Nursing research is needed to address many gaps in our understanding of pressure ulcer prevention and treatment. Many risk factors for pressure ulcer development have been identified; however, a hierarchy of risk factors has not been determined.
Thus, research to determine the essential risk factors is still needed. There also remains a dearth of research determining the role that race and ethnicity may have on pressure ulcer development. A small body of research is emerging to suggest that people of color may have an increased risk for pressure ulcer development.
Thus, nurses must actively recruit minority participants to further explore this important variable. Another promising area of nursing research is the use of pressure ulcer prediction tools. Although the Braden Scale was originally published nearly two decades ago, it remains the gold standard.
As the patient population continues to change, nursing research is needed to develop and validate newer pressure ulcer prediction tools. There is a paucity of research on the effects of good skin care on pressure ulcer development.
Randomized clinical trials are needed to validate specifics aspects of skin care bathing schedules, cleansing solutions, water temperature, etc. and their association with pressure ulcer development. However, randomized controlled trials with large numbers of participants are greatly needed.
Evidence is still unclear as to whether there are large differences in the effectiveness of various support surfaces e.
The role of protein-calorie malnutrition and pressure ulcer development remains understudied. Moreover, research into dietary supplements vitamins, minerals, etc. in the absence of a dietary deficiency is lacking.
Additional nursing studies are needed to investigate whether the use of dietary supplements have any effect on pressure ulcer prevention. Recent nursing studies suggested that a comprehensive approach to prevention can lead to significant decreases in pressure ulcer incidence.
However, studies investigating methods to sustain these decreases in pressure ulcer development are greatly needed.
Additional research is also needed to further our understanding of risk level and titration of preventive measures. Staging of pressure ulcers remains more of an art than a science. Additional nursing research is needed to determine effective methods of classifying pressure ulcer depth with good validity and reliability.
There is also a dearth of nursing research on the optimal solution and frequency for cleansing a pressure ulcer.
Moreover, nursing research is needed to determine the optimal method for removing devitalized tissue in a pressure ulcer. No randomized controlled trials could be found that determined the best debridement method for healing pressure ulcers.
Nursing research has identified some clinical characteristics of infected pressure ulcers. However, additional research is needed on the most effective method for treating an infected or contaminated pressure ulcer.
Numerous dressings are currently available to manage wound exudate. However, few randomized controlled trials have been conducted to determine optimal dressings within a classification e.
Many adjunctive therapies are currently being used, but few have extensive research to substantiate their effectiveness in healing pressure ulcers.
Nursing research investigating the role of skin substitutes, growth factors, negative pressure wound therapy, and electroceuticals in healing pressure ulcers is greatly needed. Finally, nursing research evaluating the cost effectiveness of adjunctive treatments in healing pressure ulcers is warranted, given rising health care costs.
The prevention of pressure ulcers represents a marker of quality of care. Pressure ulcers are a major nurse-sensitive outcome. Hence, nursing care has a major effect on pressure ulcer development and prevention.
Prevention of pressure ulcers often involves the use of low technology, but vigilant care is required to address the most consistently reported risk factors for development of pressure ulcers.
The literature suggested that not all pressure ulcers can be prevented, but the use of comprehensive pressure ulcer programs can prevent the majority of pressure ulcers. When the pressure ulcer develops, the goals of healing or preventing deterioration and infection are paramount.
Nursing remains at the forefront of protecting and safeguarding the patient from pressure ulcers. Evaluations of previous review articles and seminal studies that were published before were also included. Research conducted worldwide and published in English between the years and was included for review.
Moreover, studies using descriptive, correlational, longitudinal, and randomized controlled trials were included. Turn recording back on. National Library of Medicine Rockville Pike Bethesda, MD Web Policies FOIA HHS Vulnerability Disclosure.
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Show details Hughes RG, editor. Search term. Chapter 12 Pressure Ulcers: A Patient Safety Issue Courtney H. Author Information and Affiliations Authors Courtney H. Lyder, N. E-mail: ude. ainigriv redyl.
Ayello, Ph. E-mail: moc. olleya htebazile. Background Pressure ulcers remain a major health problem affecting approximately 3 million adults. Incidence, Mortality, and Costs The incidence rates of pressure ulcers vary greatly with the health care settings.
Etiology Pressure ulcers develop when capillaries supplying the skin and subcutaneous tissues are compressed enough to impede perfusion, leading ultimately to tissue necrosis. Risk Factors More than risk factors of pressure ulcers have been identified in the literature. Several key characteristics of facilities that were high users emerged: Administrative level and nursing staff buy-in and support.
Development of an actual process integrating the risk reports into ongoing quality improvement processes. Implementing a Prevention Plan Preventing pressure ulcers can be nursing intensive.
Skin Care Although expert opinion maintains that there is a relationship between skin care and pressure ulcer development, there is a paucity of research to support that. Mechanical Loading One of the most important preventive measures is decreasing mechanical load.
Support Surfaces The use of support surfaces is an important consideration in pressure redistribution. Nutrition Controversy remains on how best to do nutritional assessment for patients at risk for developing pressure ulcers.
Cleansing Once the pressure ulcer develops, the ulcer should be cleaned with a nontoxic solution. Assessment and Staging The nurse should assess and stage the pressure ulcer at each dressing change. Table 1 National Pressure Ulcer Definition.
Table 2 National Pressure Ulcer Staging System. Debridement The presence of necrotic devitalized tissue promotes the growth of pathologic organisms and prevents wounds from healing.
Bacterial Burden Managing bacterial burden is an important consideration in pressure ulcer care. Exudate Management The use of dressings is a major component in maintaining a moist environment. Nutrition The use of high-protein diets for patients with protein deficiency is essential to wound healing.
Pain Management Pressure ulcers can be painful. Monitoring Healing Presently, there are two instruments that are often used to measure the healing of pressure ulcers.
Adjunctive Therapies The use of adjunctive therapies is the fastest growing area in pressure ulcer management. Evidence-Based Practice Implications Much progress has been made in identifying patients at risk for pressure ulcers.
Research Implications Since the original publications of the AHRQ pressure ulcer prevention and treatment guidelines in and , some progress has been made in our understanding of pressure ulcer care. Additional research is also needed to further our understanding of risk level and titration of preventive measures Staging of pressure ulcers remains more of an art than a science.
Conclusion The prevention of pressure ulcers represents a marker of quality of care. Evidence Table Pressure Ulcers—Risk, Assessment, and Prevention.
References 1. Eckman KL. The prevalence of dermal ulcers among persons in the U. who have died. Russo CA, Elixhauser A. Healthcare Cost and Utilization Project. Rockville, MD: Agency for Healthcare Research and Quality; Apr, Hospitalizations related to pressure sores, hospital errors continue to rise.
Nightingale F. Notes on nursing. Philadelphia: Lippincott; p. Bliss MR, Thomas JM. Prof Nurse. Bolton LL, van Rijswijk L, Shaffer FA. Quality wound care equals cost-effective wound care: a clinical model. Adv Skin Wound Care. Lyder C, Grady J, Mathur D, et al.
Preventing pressure ulcers in Connecticut hospitals using the plan-do-study-act model for quality improvement. Jt Comm J Qual Patient Saf. Panel on the Prediction and Prevention of Pressure Ulcers in Adults.
Pressure ulcers in adults: prediction and prevention Clinical Practice Guideline No 3. Rockville, MD: Agency for Health Care Policy and Research; AHCPR Publication No Campell K, Teague L, Hurd T, et al. Health policy and the delivery of evidence-based wound care using regional wound teams.
Healthc Manage Forum. Cuddigan J, Berlowitz DR, Ayello EA. Pressure ulcers in America: prevalence, incidence, and implications for the future. Reston VA: National Pressure Ulcer Advisory Panel; Langemo DK, Olson B, Hunter S, et al. Incidence of pressure sores in acute care, rehabilitation, extended care, home health, and hospice in one locale.
Lyder CH, Preston J, Grady J, et al. Quality of care for hospitalized Medicare patients at risk for pressure ulcers. Arch Intern Med. Bergstrom N, Braden B. A prospective study of pressure sore risk among institutionalized elderly. J Am Geriatr Soc. Allman RM, Goode PS, Patrick MM, et al.
Pressure ulcer risk factors among hospitalized patients with activity limitations. Thomas DR, Goode PS, Tarquine PH, et al. Hospital-acquired pressure ulcers and risk of death.
Oot-Giromini B, Bidwell FC, Heller NB, et al. Pressure ulcer prevention versus treatment, comparative product cost study. Landis EM. Micro-injection studies of capillary blood pressure in human skin. Kosiak M, Kubicek WG, Olson M, et al. Evaluation of pressure as a factor in the production of ischial ulcers.
Arch Phys Med Rehabil. Kosiak M. Etiology and pathology of ischemic ulcers. Lyder C, Preston, Ahearn D, et al. Medicare Quality Indicator System: Pressure ulcer prediction and prevention module: final report. Bliss MR. J Tissue Viability. Allman RM, Laprade CA, Noel LB, et al.
Pressure sores among hospitalized patients. Ann Intern Med. Guralnik JM, Harris TB, White LR, et al. Occurrence and predictors of pressure ulcers in the National Health and Nutrition Examination Survey follow-up. Berlowitz DR, Wilking SV. Risk factors for pressure sores.
A comparison of cross-sectional and cohort-derived data. Brandeis GH, Morris JN, Nash DJ, et al. Epidemiology and natural history of pressure ulcers in elderly nursing home residents. Fuhrer M, Garber S, Rintola D, et al.
Pressure ulcers in community-resident persons with spinal cord injury: prevalence and risk factors. Spector W, Kapp M, Tucker R, et al. Factors associated with presence of decubitus ulcers at admission to nursing homes. Lyder C, Yu C, Emerling J, et al.
The Braden scale for pressure ulcer risk: evaluating the predictive validity in blacks and Hispanic elderly patients. Appl Nurs Res. Fiscella K, Meldrum S, Barnett S, et al.
Separate and unequal: hospital racial segregation and disparity in pressure ulceres in NYC. Baumgarten M, Margolis D, Gruber-Baldini AL, et al. Pressure ulcers and the transition to long-term care. Bergstrom N, Braden BJ, Laguzza A. The Braden Scale for predicting pressure sore risk.
Nurs Res. Braden B, Bergstrom N. A conceptual schema for the study of the etiology of pressure sores. Rehabil Nurs. Maklebust J, Sieggreen MY, Sidor D, et al. Computer-based testing of the Braden Scale for predicting pressure sore risk. Ostomy Wound Manage.
Norton D. Calculating the risk: reflections of the Norton Scale. Bergstrom N, Demuth P, Braden B. A clinical trial of the Braden scale for predicting pressure sore risk.
Nurs Clin North Am. Pang SM, Wong TK. Predicting pressure sore risk with the Norton, Braden, and Waterlow scales in a Hong Kong rehabilitation hospital. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, et al. Risk assessment scales for pressure ulcer prevention: a systematic review.
J Adv Nurs. Perneger T, Rae A, Gaspoz J, et al. Screening for pressure ulcer risk in an acute care hospital: development of a brief beside scale. J Clin Epidemiol. Schoonhoven L, Haalboom J, Bousema M, et al. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers.
Br Med J. Tag F pressure ulcers. Guidance for surveyors in long term care. Issued Nov 12, Teigland C, Gardiner R, Li H, et al. Clinical informatics and its usefulness for assessing risk and preventing falls and pressure ulcers in nursing home environments.
Advances in Patient Safety: From Research to Implementation. Bergstrom N, Braden B, Kemp M, et al. Predicting pressure ulcer risk: a multisite study of the predictive validity of the Braden Scale. Ayello EA, Braden B. How and why to do pressure ulcer risk assessment. Johnson-Pawlson J, Infeld DL.
Nurse staffing and quality of care in nursing facilities. J Gerontol Nurs. Horn S, Buerhaus P, Bergstrom N, et al. RN staffing time and outcomes of long stay nursing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care.
Am J Nurs. Donaldson N, Bolton LB, Aydin C, et al. Policy Polit Nurs Pract. Xakellis GC, Frantz RA, Lewis A, et al. Cost-effectiveness of an intensive pressure ulcer prevention protocol in long term care.
Adv Wound Care. Lyder C, Shannon R, Empleo-Frazier O, et al. A comprehensive program to prevent pressure ulcers: exploring cost and outcomes.
Back to Health A to Z. Prrvention ulcers pressure sores or bed Ulcer prevention measures are areas measyres damage to Ulcfr skin and Caffeine and weight loss tissue Ulcer prevention measures. Preventikn have a higher chance of getting them if you have difficulty moving. Pressure ulcers usually form on bony parts of the body, such as the heels, elbows, hips and tailbone. The ulcers usually develop gradually, but can sometimes appear over a few hours. They can become a blister or open wound.Ulcer prevention measures -
We normally move about constantly, even in our sleep. This stops pressure sores from developing. People who are unable to move around tend to put pressure on the same areas of the body for a long time. If you are ill, bedridden or in a wheelchair, you are at risk of getting pressure sores.
It is much better to prevent pressure sores than to treat them. The National Institute for Health and Care Excellence NICE has guidelines on pressure sores. Separate guidelines are also available in Wales, Scotland and Northern Ireland.
They all recommend that a member of the health care team looking after you should assess your risk of developing pressure sores. They should also create a plan to prevent them.
The areas of skin most at risk of getting sore depend on whether you are lying down or sitting. The following diagrams show the areas most at risk:. A nurse or doctor must examine you when you have a pressure ulcer. They can offer ways of managing and treating a pressure ulcer.
Cancer and cancer treatment can cause skin problems. But skin problems can be treated, and there are ways you can manage them at home. Cancer and its treatment can damage the skin cells and stop them from working properly. Knowing more about how the skin works and what may affect it can help you care for it better.
There are lots of organisations, support groups and helpful books to help you cope with symptoms and side effects caused by cancer and its treatment. If oral dietary intake is inadequate or impractical, enteral or parenteral feeding should be considered, if compatible with the patient's wishes, to achieve positive nitrogen balance approximately 30 to 35 calories per kg per day and 1.
Protein, vitamin C, and zinc supplements should be considered if intake is insufficient and deficiency is present, although data supporting their effectiveness in accelerating healing have been inconsistent. The management of pressure ulcers is interdisciplinary, including primary care physicians, dermatologists, infectious disease consultants, social workers, psychologists, dietitians, podiatrists, home and wound-care nurses, rehabilitation professionals, and surgeons.
The basic components of pressure ulcer management are reducing or relieving pressure on the skin, debriding necrotic tissue, cleansing the wound, managing bacterial load and colonization, and selecting a wound dressing. Figure 6 is a brief overview of these key components.
The pressure-reducing devices used in preventive care also apply to treatment. Static devices are useful in a patient who can change positions independently. A low—air-loss or air-fluidized bed may be necessary for patients with multiple large ulcers or a nonhealing ulcer, after flap surgeries, or when static devices are not effective.
No one device is preferred. Pain assessment should be completed, especially during repositioning, dressing changes, and debridement. Patients at the highest risk of pressure ulcers may not have full sensation or may require alternate pain assessment tools to aid in communication.
The goal is to eliminate pain by covering the wound, adjusting pressure-reducing surfaces, repositioning the patient, and providing topical or systemic analgesia.
Necrotic tissue promotes bacterial growth and impairs wound healing, and it should be debrided until eschar is removed and granulation tissue is present. Debridement, however, is not recommended for heel ulcers that have stable, dry eschar without edema, erythema, fluctuance, or drainage.
Sharp debridement using a sterile scalpel or scissors may be performed at bedside, although more extensive debridement should be performed in the operating room. Sharp debridement is needed if infection occurs or to remove thick and extensive eschar. Healing after sharp debridement requires adequate vascularization; thus, vascular assessment for lower extremity ulcers is recommended.
Mechanical debridement includes wet-to-dry dressings, hydrotherapy, wound irrigation, and whirlpool bath debridement. However, viable tissue may also be removed and the process may be painful. Enzymatic debridement is useful in the long-term care of patients who cannot tolerate sharp debridement; however, it takes longer to be effective and should not be used when infection is present.
Wounds should be cleansed initially and with each dressing change. Use of a mL syringe and gauge angiocatheter provides a degree of force that is effective yet safe; use of normal saline is preferred.
Wound cleansing with antiseptic agents e. Dressings that maintain a moist wound environment facilitate healing and can be used for autolytic debridement.
Transparent films effectively retain moisture, and may be used alone for partial-thickness ulcers or combined with hydrogels or hydrocolloids for full-thickness wounds. Hydrogels can be used for deep wounds with light exudate. Alginates and foams are highly absorbent and are useful for wounds with moderate to heavy exudate.
Hydrocolloids retain moisture and are useful for promoting autolytic debridement. Dressing selection is dictated by clinical judgment and wound characteristics; no moist dressing including saline-moistened gauze is superior.
Because there are numerous dressing options, physicians should be familiar with one or two products in each category or should obtain recommendations from a wound care consultant.
Urinary catheters or rectal tubes may be needed to prevent bacterial infection from feces or urine. Pressure ulcers are invariably colonized with bacteria; however, wound cleansing and debridement minimize bacterial load.
A trial of topical antibiotics, such as silver sulfadiazine cream Silvadene , should be used for up to two weeks for clean ulcers that are not healing properly after two to four weeks of optimal wound care. Quantitative bacteria tissue cultures should be performed for nonhealing ulcers after a trial of topical antibiotics or if there are signs of infection e.
A superficial swab specimen may be used; however, a needle aspiration or ulcer biopsy preferred is more clinically significant. Ulcers are difficult to resolve.
Although more than 70 percent of stage II ulcers heal after six months of appropriate treatment, only 50 percent of stage III ulcers and 30 percent of stage IV ulcers heal within this period.
Surgical consultation should be obtained for patients with clean stage III or IV ulcers that do not respond to optimal patient care or when quality of life would be improved with rapid wound closure. Surgical approaches include direct closure; skin grafts; and skin, musculocutaneous, and free flaps.
However, randomized controlled trials of surgical repair are lacking and recurrence rates are high. Growth factors e. Although noninfectious complications of pressure ulcers occur, systemic infections are the most prevalent. Noninfectious complications include amyloidosis, heterotopic bone formation, perinealurethral fistula, pseudoaneurysm, Marjolin ulcer, and systemic complications of topical treatment.
Infectious complications include bacteremia and sepsis, cellulitis, endocarditis, meningitis, osteomyelitis, septic arthritis, and sinus tracts or abscesses. Magnetic resonance imaging has a 98 percent sensitivity and 89 percent specificity for osteomyelitis in patients with pressure ulcers 38 ; however, needle biopsy of the bone via orthopedic consultation is recommended and can guide antibiotic therapy.
Bacteremia may occur with or without osteomyelitis, causing unexplained fever, tachycardia, hypotension, or altered mental status. Whittington K, Patrick M, Roberts JL.
A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs. Kaltenthaler E, Whitfield MD, Walters SJ, Akehurst RL, Paisley S.
UK, USA and Canada: how do their pressure ulcer prevalence and incidence data compare?. J Wound Care. Coleman EA, Martau JM, Lin MK, Kramer AM. Omnibus Budget Reconciliation Act.
J Am Geriatr Soc. Garcia AD, Thomas DR. Assessment and management of chronic pressure ulcers in the elderly. Med Clin North Am. Schoonhoven L, Haalboom JR, Bousema MT, et al. Prospective cohort study of routine use of risk assessment scales for prediction of pressure ulcers. Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C.
Risk assessment scales for pressure ulcer prevention: a systematic review. J Adv Nurs. Whitney J, Phillips L, Aslam R, et al. Guidelines for the treatment of pressure ulcers. Wound Repair Regen. Agency for Health Care Policy and Research.
Treatment of pressure ulcers. Rockville, Md. Department of Health and Human Services; AHCPR Publication No. Accessed December 17, Thomas DR. Prevention and treatment of pressure ulcers. J Am Med Dir Assoc. Cullum N, McInnes E, Bell-Syer SE, Legood R.
Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: a systematic review. Improving outcome of pressure ulcers with nutritional interventions: a review of the evidence.
Bourdel-Marchasson I, Barateau M, Rondeau V, et al. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Langer G, Schloemer G, Knerr A, Kuss O, Behrens J.
Nutritional interventions for preventing and treating pressure ulcers. 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. National Pressure Ulcer Advisory Panel.
Updated staging system. Stotts NA, Rodeheaver G, Thomas DR, et al. An instrument to measure healing in pressure ulcers: development and validation of the Pressure Ulcer Scale for Healing PUSH.
J Gerontol A Biol Sci Med Sci. Royal College of Nursing. The management of pressure ulcers in primary and secondary care. September Flock P. Pilot study to determine the effectiveness of diamorphine gel to control pressure ulcer pain.
J Pain Symptom Manage. Rosenthal D, Murphy F, Gottschalk R, Baxter M, Lycka B, Nevin K. Using a topical anaesthetic cream to reduce pain during sharp debridement of chronic leg ulcers. Registered Nurses' Association of Ontario. Assessment and management of stage I to IV pressure ulcers. Accessed July 1, Singhal A, Reis ED, Kerstein MD.
Options for nonsurgical debridement of necrotic wounds. Adv Skin Wound Care. Ovington LG. Hanging wet-to-dry dressings out to dry. Home Healthc Nurse. Püllen R, Popp R, Volkers P, Füsgen I. Age Ageing. Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D.
Systematic reviews of wound care management: 2. Dressings and topical agents used in the healing of chronic wounds. Health Technol Assess. Rodeheaver GT.
Pressure ulcer debridement and cleansing: a review of current literature. Ostomy Wound Manage. Kerstein MD, Gemmen E, van Rijswijk L, et al. Cost and cost effectiveness of venous and pressure ulcer protocols of care. Dis Manage Health Outcomes. Bouza C, Saz Z, Muñoz A, Amate JM. Efficacy of advanced dressings in the treatment of pressure ulcers: a systematic review.
Rudensky B, Lipschits M, Isaacsohn M, Sonnenblick M. Infected pressure sores: comparison of methods for bacterial identification. South Med J. The promise of topical growth factors in healing pressure ulcers. Ann Intern Med. Robson MC, Phillips LG, Thomason A, Robson LE, Pierce GF.
Platelet-derived growth factor BB for the treatment of chronic pressure ulcers. Argenta LC, Morykwas MJ.
gov means it's Ulcer prevention measures. Federal government websites measurex end in. gov or. Ulcer prevention measures sharing sensitive information, make sure you're on a federal government site. The site is secure. NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
For the best browsing experience Ulcer prevention measures enable JavaScript. Instructions prvention Microsoft Edge and Internet ExplorerUlcer prevention measures Citrus aurantium supplement. Pressure sores Uocer wounds measrues develop when constant pressure or friction on one area of the body damages the skin. Constant pressure on an area of skin stops blood from flowing normally, so the cells die, and the skin breaks down. We normally move about constantly, even in our sleep.
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