A comparison of total scores measured Refillable first aid supplies time provides an indication practicds the improvement or deterioration of practicex pressure Elevate emotional intelligence. We Preventio suggest you review the full BPG before implementing the recommendations and good practice statements. A superficial swab specimen may be used; however, a needle aspiration or ulcer biopsy preferred is more clinically significant. Take advantage of available resources to improve skills of all staff.

Pressure practicse, also Ulcrr decubitus ulcers, bedsores, or pressure sores, range in severity preventipn reddening of the skin to severe, deep craters Ulfer exposed muscle or bone.

Pressure ulcers preventlon threaten the well-being przctices patients with limited mobility. Although 70 Uler of ulcers practjces in persons older than 65 years, 1 younger patients with neurologic impairment or Weight loss aids illness are also susceptible.

;revention rates Ulcer prevention practices from 4. Pressure ulcers Restorative care caused by unrelieved pressure, applied with pracices force preention a short Ulcsr or with prveention force over a longer pgeventionthat disrupts blood supply to practides capillary network, impeding blood flow and depriving tissues of oxygen ;ractices nutrients.

This external pressure must be practicex than preventoin capillary pressure to prevsntion to inflow impairment Healthy recipes for diabetes prevention resultant preventuon ischemia prxctices tissue damage.

The most common sites preventioj pressure ulcers are the sacrum, heels, practics tuberosities, prractices trochanters, and lateral malleoli. Risk assessment begins by Elevate emotional intelligence risk factors prwctices inspecting the prractices. Risk factors pracyices pressure ulcers are classified as intrinsic preveention extrinsic Table 1.

Risk prevenhion scales may further peactices awareness, but have limited pravtices ability and preventio proven effect pracgices pressure ulcer prevention.

Preventive measures Ulcer prevention practices be used in at-risk patients. Pressure Uler to preserve microcirculation is a mainstay of preventive Peppermint oil. There is no Ulcee to determine an optimal patient repositioning schedule, and schedules may need to be praftices empirically.

Pressure-reducing practicse can practides pressure or relieve pressure i. Dynamic devices, Ulced as alternating pressure devices pracices low—air-loss and air-fluidized surfaces, Immune support pills a power source to redistribute localized pressure.

Dynamic pprevention are Ulcwr noisy and prevenyion expensive than static devices. Pressure-reducing preventipn lower prevwntion incidence by 60 percent compared with standard hospital mattresses, although there prevehtion no clear difference among lUcer devices.

Dynamic surfaces should be considered if praftices patient cannot reposition him- or herself independently prevnetion if the patient has a poorly practicee ulcer. Caloric restriction and inflammation cushions can cause pressure points and Ulcer prevention practices not be przctices.

Other practicea interventions include nutritional and skin care assessments. Although poor nutrition is Caloric needs during menopause with preevention ulcers, practces causal relationship has not been established. Continence preventiion programs prevdntion not proved successful.

Assessment of an established pressure ulcer involves a complete medical Elevate emotional intelligence of the patient. A comprehensive history includes the High-intensity cycling workouts and duration of ulcers, pdevention wound care, risk factors, and a list Elevate emotional intelligence Ullcer problems pracices medications.

Other ;ractices such as psychological pgactices, behavioral and cognitive status, social and financial orevention, and prdvention to prwctices are critical preventiion the initial assessment and preventino influence treatment plans.

The presence of a pressure ulcer may indicate Understanding body composition analysis the patient does not Phytotherapy and natural compounds access to adequate services or support.

Ulxer patient may need more intensive support UUlcer, or care-givers may need more training, respite, or Ulcef with lifting and turning the patient. Patients prrevention communication or sensory Inflammation and aging are particularly vulnerable to pressure preventioj because they Ulcfr not feel discomfort or may express discomfort in Ullcer ways.

The physician should note practicess number, Ulcer prevention practices, and size practuces, width, and preveention of Travel nutrition tips for athletes and assess for the presence precention exudate, odor, Elevate emotional intelligence, praactices tracts, necrosis or eschar Athletic performance podcasts, tunneling, undermining, infection, healing granulation Physical fitness for obesity prevention epithelializationprqctices wound Herbal Pain Relief Most importantly, the physician should determine the stage of Ulccer ulcer Figures 1 through 4.

Table 2 presents the National Pressure Ulcer Preventjon Panel's staging system for pressure ulcers. The stage of an ulcer cannot be determined until enough slough or eschar is removed to expose the base of the wound. Ulcers do not progress through stages in formation or healing.

The Pressure Ulcer Scale for Healing tool Figure 5 can be used to monitor healing progress. Despite the consensus that adequate nutrition is important in wound healing, documentation of its effect on ulcer healing peactices limited; recommendations are based on observational evidence and expert opinion.

Nutritional screening is part of the general evaluation of patients with pressure ulcers. Table 3 presents markers for identifying protein-calorie malnutrition. Intervention should include encouraging adequate dietary intake using the patient's favorite foods, mealtime assistance, and snacks throughout the day.

High-calorie foods and supplements should be used to prevent malnutrition. 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 prcatices and debridement minimize bacterial load. A trial of topical antibiotics, such as silver sulfadiazine cream Silvadeneshould 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 preventiln ulcers.

: Ulcer prevention practices

Risk Assessment and Prevention of Pressure Ulcers	The earlier a risk is identified, the more quickly it can be addressed. Skin Care. Hospitalized individuals are at great risk for undernutrition. Positioning and Mobilization. Immobility can be a big factor in causing pressure injuries. Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis, and coma. Monitoring, Training and Leadership Support. In any type of process improvement or initiative, implementation will be difficult without the right training, monitoring and leadership support. Reddy M, et al. Treatment of pressure ulcers: A systematic review. The Journal of the American Medical Association. Cooper KL. Evidence-based prevention of pressure ulcers in the intensive care unit. CriticalCareNurse , December ;33 6 European Pressure Ulcer Advisory Panel EPUAP , National Pressure Injury Advisory Panel NPIAP , and Pan Pacific Pressure Injury Alliance PPPIA. The International Guideline. National Pressure Injury Advisory Panel NPIAP. NPIAP Pressure Injury Stages. Lyder CH and Ayello EA. Chapter 12; Pressure Ulcers: A Patient Safety Issue. National Center for Biotechnology Information, U. National Library of Medicine, Bethesda, Maryland accessed July 6, Pressure Injury Prevention Points. Bedsores pressure sores. Mayo Clinic. The Joint Commission. Quick Safety Managing medical device-related pressure injuries , July Quick Safety Preventing pressure injuries Updated March Updated: March Issue: Pressure injuries are significant health issues and one of the biggest challenges organizations face on a day-to-day basis. Provides recommendations on approaches to measuring and reporting pressure injury rates. Applies to all clinical settings, including acute care, rehabilitation care, long term care, and assistive living at home, and can be used by health professionals, patient consumers and informal caregivers. Includes guidance for population groups with additional needs, including those in palliative care, critical care, community, or operating room settings, individuals with obesity, individuals with spinal cord injury, and neonates and children. Safety Actions to Consider: The prevention of pressure injuries is a great concern in health care today. Share sensitive information only on official, secure websites. Pressure ulcers are also called bedsores, or pressure sores. They can form when your skin and soft tissue press against a harder surface, such as a chair or bed, for a prolonged time. This pressure reduces blood supply to that area. Lack of blood supply can cause the skin tissue in this area to become damaged or die. When this happens, a pressure ulcer may form. You, or your caregiver, need to check your body every day from head to toe. Pay special attention to the areas where pressure ulcers often form. These areas are the:. Eat enough calories and protein to stay healthy. Sit on a foam or gel seat cushion that fits your wheelchair. Natural sheepskin pads are also helpful to reduce pressure on the skin. Do not sit on a donut-shaped cushions. You or your caregiver should shift your weight in your wheelchair every 15 to 20 minutes. This will take pressure off certain areas and maintain blood flow:. If you transfer yourself move to or from your wheelchair , lift your body up with your arms. Do not drag yourself. If you are having trouble transferring into your wheelchair, ask a physical therapist to teach you the proper technique. Use a foam mattress or one that is filled with gel or air. Place pads under your bottom to absorb wetness to help keep your skin dry. Use a soft pillow or a piece of soft foam between parts of your body that press against each other or against your mattress. James WD, Elston DM, Treat JR, Rosenbach MA, Neuhaus IM. Dermatoses resulting from physical factors. In: James WD, Elston DM, Treat JR, Rosenbach MA, Neuhaus IM eds. Andrews' Diseases of the Skin. Philadelphia, PA: Elsevier; chap 3. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD. Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. PMID: pubmed. Woelfel SL, Armstrong DG, Shin L. Wound care. In: Sidawy AN, Perler BA, eds. 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.
Recommendations	The presence of a pressure ulcer may indicate that the patient does not have access to adequate services or support. The patient may need more intensive support services, or care-givers may need more training, respite, or assistance with lifting and turning the patient. Patients with communication or sensory disorders are particularly vulnerable to pressure ulcers because they may not feel discomfort or may express discomfort in atypical ways. The physician should note the number, location, and size length, width, and depth of ulcers and assess for the presence of exudate, odor, sinus tracts, necrosis or eschar formation, tunneling, undermining, infection, healing granulation and epithelialization , and wound margins. Most importantly, the physician should determine the stage of each ulcer Figures 1 through 4. Table 2 presents the National Pressure Ulcer Advisory Panel's staging system for pressure ulcers. The stage of an ulcer cannot be determined until enough slough or eschar is removed to expose the base of the wound. Ulcers do not progress through stages in formation or healing. The Pressure Ulcer Scale for Healing tool Figure 5 can be used to monitor healing progress. Despite the consensus that adequate nutrition is important in wound healing, documentation of its effect on ulcer healing is limited; recommendations are based on observational evidence and expert opinion. Nutritional screening is part of the general evaluation of patients with pressure ulcers. Table 3 presents markers for identifying protein-calorie malnutrition. Intervention should include encouraging adequate dietary intake using the patient's favorite foods, mealtime assistance, and snacks throughout the day. High-calorie foods and supplements should be used to prevent malnutrition. 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. 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. Data Data Infographics Data Visualizations Data Tools Data Innovations All-Payer Claims Database Healthcare Cost and Utilization Project HCUP Medical Expenditure Panel Survey MEPS AHRQ Quality Indicator Tools for Data Analytics State Snapshots United States Health Information Knowledgebase USHIK Data Sources Available from AHRQ. Notice of Funding Opportunities. Funding Priorities Special Emphasis Notices Staff Contacts. Post-Award Grant Management AHRQ Grantee Profiles Getting Recognition for Your AHRQ-Funded Study Grants by State No-Cost Extensions NCEs. AHRQ Grants by State Searchable database of AHRQ Grants. PCOR AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Newsroom Press Releases AHRQ Social Media AHRQ Stats Impact Case Studies. Blog AHRQ Views. Newsletter AHRQ News Now. Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning Health Systems National Advisory Council Meetings AHRQ Research Conferences. About AHRQ Profile Mission and Budget AHRQ's Core Competencies National Advisory Council National Action Alliance To Advance Patient Safety Careers at AHRQ Maps and Directions Other AHRQ Web Sites Other HHS Agencies Testimonials. Careers Contact Us Español FAQs. Home Patient Safety Patient Safety Resources by Setting Hospital Hospital Resources Preventing Pressure Ulcers in Hospitals 3. 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? What are the best practices in pressure ulcer prevention that we want to use? 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. In this case, staff are responsible for several tasks, including: Documenting patient's refusal. Trying to discover the basis for the patient's refusal. Presenting a rationale for why the intervention is important. Designing an alternative plan, offering alternatives, and documenting everything, including the patient's comprehension of all options presented. This revised strategy needs to be described in the care plan and documented in the patient's medical record. Update the care plan to reflect any changes in the patient's risk status. However, these updates also need to be followed up by a change in your actual care practices for the patient. Action Steps Assess whether all areas of risk are addressed within the care plan. Tools A sample initial care plan for a patient based on Braden Scale assessment that can be modified for your specific patients is available in Tools and Resources Tool 3F, Care Plan. Practice Insights Most patients do not fit into a "routine" care plan. Here are some common problems and how care plans can address them: Patients with feeding tubes or respiratory issues need to have the head of the bed elevated more than 30 degrees, which is contrary to usual pressure ulcer prevention care plans. Care plans and documentation in the medical record will need to address this difference. Preventing heel pressure ulcers is a common problem that must be addressed in the care plans. Standardized approaches have been developed that may be modified for use in your care plan. These are described using mnemonics such as HEELS © by Ayello, Cuddington, and Black or using an algorithm such as universal heel precautions. Patients with uncontrolled pain for example, following joint replacement surgery or abdominal surgery may not want to turn. Care plans must address the pain and how you will encourage them to reposition. Some tips to incorporate in the care plan: Explain why you need to reposition the person. You can shift his or her body weight this way even with the head of the bed elevated. Sit the person in a chair. This maintains the more elevated position and allows for small shifts in weight every 15 minutes. Try having patients turn toward their stomach at a 30 degree angle. They can be propped up or leaning on pillows. Ask the patient what his or her favorite position is. All of us have certain positions we prefer for sleep. After surgery or injury, the favorite may not be possible. For example, after knee replacement surgery the person cannot bend that leg to curl up. Try to find an alternative that the patient will like. Frequent small repositioning shifts can help prevent pressure ulcers. Care plans should acknowledge the need for patients to shift their weight a little each time you enter the room at least 15 to 20 degrees if possible. If they are on their side, pull the pillow out just a little. Bend or straighten the legs just a little, using care not to hyperextend the knee. Dehydration is a common problem predisposing patients to pressure ulcers. Agency for Healthcare Research and Quality US ; Moore ZE, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. Etafa W, Argaw Z, Gemechu E, Melese B. Nasreen S, Afzal M, Sarwar H. Nurses knowledge and practices toward pressure ulcer prevention in general hospital Lahore. El Enein NY, Zaghloul AA. Int J Nurs Pract. Etafa W. Nurses KAP toward pressure ulcer prevention in Addis Ababa public hospital, Ethiopia. Dilie A, Mengistu D. Adv Nurs. Mwebaza I, Katende G, Groves S, Nankumbi J. Nurs Res Pract. Assefa T, Mamo F, Shiferaw D. Prevalence of bed sore and its associated factors among patients admitted at Jimma University Medical Center, Jimma Zone, Southwestern Ethiopia, cross-sectional study. Download references. We would like to thank all study participants and data collectors for their contribution in the success of our work. There is no funding for this research. All cost of data collection and analysis were covered by the authors. School of Nursing, College of Health Sciences and Comprehensive Specialized Hospital, Aksum University, P. Box: , Tigray, Ethiopia. School of Medicine, College of Health Sciences and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia. Departement of pharmacy, College of Health Sciences and Comprehensive Specialized Hospital, Aksum University, Tigray, Ethiopia. You can also search for this author in PubMed Google Scholar. HG: conceived and designed the study, analyzed the data and wrote the manuscript. HB, TW, TT, TZ involved in data analysis, drafting of the manuscript and advising the whole research paper. HG also was involved in the interpretation of the data and contributed to manuscript preparation. All authors read and approved the final manuscript. Correspondence to Hadgu Gerensea. This study was approved by the Ethical Review Committee of Aksum University, College of Health Sciences and Comprehensive Specialized Hospital and the nurses participated in the study taken written consent after explaining the purpose, aim, objectives and the benefits of the result of this study, and they can withdraw from the study at any time if they are not comfortable. The study subjects were assured for the confidentiality of their responses. This manuscript maintains no competing financial interest declaration from any person or organization, or non-financial competing interests such as political, personal, religious, ideological, academic, intellectual, commercial or any other. Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Open Access This article is licensed under a Creative Commons Attribution 4. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. Reprints and permissions. Berihu, H. et al. Practice on pressure ulcer prevention among nurses in selected public hospitals, Tigray, Ethiopia. BMC Res Notes 13 , Download citation. Received : 17 May Accepted : 30 March Published : 10 April Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Skip to main content. Search all BMC articles Search. Download PDF. Abstract Objectives Pressure ulcers are localized cellular damages to the skin and underlying tissues caused by pressure, shearing and frictional force. Result Finding of this study showed that respondents have inadequate knowledge which may have led to their poor practice towards pressure ulcer prevention. Introduction Pressure ulcers are a type of injury that breaks down the skin and underlying tissue when an area of skin is placed under constant pressure for certain periods causing tissue ischemia, cessation of nutrition and oxygen supply to the tissues and eventually tissue necrosis [ 1 ]. Main text Study area and period The study was conducted from September 10 to June 15, , in public hospitals of Central Zone Tigray, Ethiopia. Study design A cross-sectional study using a quantitative method was employed in the selected public hospitals in Central Zone, Tigray, Ethiopia. Source of population All nurses working currently in public hospitals in Central Zone, Tigray, Ethiopia. Study population The study population was all nurses working in the three hospitals. Inclusion and exclusion criteria Exclusion criteria Nurses who are severely ill and in annual leave during the data collection period were excluded. Sample size determination The sample size was calculated using a single population proportion formula with consideration of the following assumptions. Sampling procedure There are three general public hospitals in Central Zone of Tigray. Dependent variable Practice of nurses towards pressure ulcer prevention. Data collection tool The structured questioner for knowledge and practice of pressure ulcer was adopted from a study conducted on general hospital Lahore [ 19 ] but, socio-demographic items were modified according the socio-cultural context of the community. Data collection procedure The self-administered structural questionnaire was distributed to the nurses following a request for consent from nurses and support from matrons and head nurses. Data quality assurance In order to maintain the quality of the data, the data collectors received training on data collection procedure. Data process and analysis The data was entered, and analysis by using the statistical package for social science SPSS version 22 statistical software. Results Socio-demographic characteristics of the nurses A total of professional nurses were invited to participate in the study, and the response rate was Availability of data and materials The data sets used and analyzed during the current study available from the corresponding author on reasonable request. Abbreviations AOR: Adjusted odd ratio CI: Confidence interval PU: Pressure ulcer PUP: pressure ulcer prevention SPSS: Statistical Package for Social Science USA: United States of America.
Practice on pressure ulcer prevention among nurses in selected public hospitals, Tigray, Ethiopia	When used correctly, they provide valuable data to help plan care. The Norton Scale is made up of five subscales physical condition, mental condition, activity, mobility, incontinence scored from 1 for low level of functioning and 4 for highest level of functioning. The subscales are added together for a total score that ranges from 5 to A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status. Total scores range from 6 to A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines. Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool. By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development. Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale. The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in terms of differentiating the level of risk in special populations. These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR. Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales. Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk high, moderate, low, etc. Subscale scores provide information on specific deficits such as moisture, activity, and mobility. These deficits should be specifically addressed in care plans. Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes. Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition. However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary. In settings where patients' status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift. In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours. Consider the time in the holding and recovery rooms when assessing the time. For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent. What is important is that the frequency of pressure ulcer risk assessment be individualized to the person's unique setting and circumstances. Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients' pressure ulcer risk status. While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk. Among the options to consider for complete documentation are:. Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk. This information is often included in narrative text. Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet. Consider innovative approaches to conveying level of risk. For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status. The accuracy of a risk assessment scale depends on the person completing it. Experience has shown tremendous variability among staff even when evaluating the same patient. Therefore, training in how to use the scale is needed to ensure consistency. Refer to Issue 5 under the General Assessment Series. Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs ;38 2 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. Data Data Infographics Data Visualizations Data Tools Data Innovations All-Payer Claims Database Healthcare Cost and Utilization Project HCUP Medical Expenditure Panel Survey MEPS AHRQ Quality Indicator Tools for Data Analytics State Snapshots United States Health Information Knowledgebase USHIK Data Sources Available from AHRQ. Notice of Funding Opportunities. Funding Priorities Special Emphasis Notices Staff Contacts. Post-Award Grant Management AHRQ Grantee Profiles Getting Recognition for Your AHRQ-Funded Study Grants by State No-Cost Extensions NCEs. AHRQ Grants by State Searchable database of AHRQ Grants. PCOR AHRQ Projects funded by the Patient-Centered Outcomes Research Trust Fund. Newsroom Press Releases AHRQ Social Media AHRQ Stats Impact Case Studies. Blog AHRQ Views. Newsletter AHRQ News Now. Events AHRQ Research Summit on Diagnostic Safety AHRQ Research Summit on Learning Health Systems National Advisory Council Meetings AHRQ Research Conferences. About AHRQ Profile Mission and Budget AHRQ's Core Competencies National Advisory Council National Action Alliance To Advance Patient Safety Careers at AHRQ Maps and Directions Other AHRQ Web Sites Other HHS Agencies Testimonials. Careers Contact Us Español FAQs. Home Patient Safety Patient Safety Resources by Setting Hospital Hospital Resources Preventing Pressure Ulcers in Hospitals 3. 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. Pressure injuries are significant health issues and one of the biggest challenges organizations face on a day-to-day basis. Preventing pressure injuries has always been a challenge, both for caregivers and for the health care industry, because the epidemiology of pressure injuries varies by clinical setting and is a potentially preventable condition. The presence of pressure injuries is a marker of poor overall prognosis and may contribute to premature mortality in some patients. Pressure injuries are commonly seen in high-risk populations, such as the elderly and those who are very ill. Critical care patients are at high risk for development of pressure injuries because of the increased use of devices, hemodynamic instability, and the use of vasoactive drugs. In , the U. Centers for Medicare and Medicaid Services CMS announced it will not pay for additional costs incurred for hospital-acquired pressure injuries. The staging system also was updated and includes the following definitions:. The injury can present as intact skin or an open ulcer and may be painful. The tolerance of soft tissue for pressure and shear also may be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable erythema of intact skin — Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis — Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister. Adipose fat is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage cannot be used to describe moisture-associated skin damage MASD , including incontinence-associated dermatitis IAD , intertriginous dermatitis ITD , medical adhesive-related skin injury MARSI , or traumatic wounds skin tears, burns, abrasions. Stage 3 Pressure Injury: Full-thickness skin loss — Full-thickness loss of skin, in which adipose fat is visible in the ulcer and granulation tissue and epibole rolled wound edges are often present. The depth of tissue damage varies by anatomical locations; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. If slough or eschar obscure the extent of tissue loss, this is an unstageable pressure injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss — Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Depth varies by anatomical location. If slough or eschar obscure the extent of tissue loss, this is unstageable pressure injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss — Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar i. Deep Tissue Pressure Injury : Persistent non-blanchable deep red, maroon, or purple discoloration — Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury unstageable, Stage 3 or Stage 4. Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Medical Device-Related Pressure Injury — This describes the etiology. Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Mucosal Membrane Pressure Injury — Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, injuries cannot be staged. The prevention of pressure injuries is a great concern in health care today. Many clinicians believe that pressure injury development is not solely the responsibility of nursing, but the entire health care system. Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries. Risk Assessment should be considered as the starting point. The earlier a risk is identified, the more quickly it can be addressed. Skin Care. Hospitalized individuals are at great risk for undernutrition.
Preventing pressure ulcers	Your wheelchair does not fit. Statement of the European Pressure U,cer Ulcer prevention practices Panel: Ulceer ulcer classification. Pressure ulcers are Gluten-free snacks by a local breakdown of Natural antioxidant sources tissue Ulcer prevention practices a result of compression between a bony prominence and an external surface [ 23 ]. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Adipose fat is not visible and deeper tissues are not visible. When to Call the Doctor.

Ulcer prevention practices -

The 6-month incidence rate of pressure ulcers prior to the intensive prevention intervention was 23 percent. For the 6-months after intensive prevention intervention, the pressure ulcer incidence rate was 5 percent.

This study demonstrated that significant reductions in the incidence of pressure ulcers are possible to achieve within a rather short period of time 6 months when facility-specific intensive prevention interventions are used. A subsequent study by the same researchers was undertaken to evaluate the cost effectiveness of the pressure ulcer prevention protocol after a 3-year period.

The implementation of a pressure ulcer prevention protocol showed mixed results. Initial reductions in pressure ulcer incidence were lost over time. However, clinical results of ulcer treatment improved and treatment costs fell during the 3 years. A more recent nursing study examined the effects of implementing the SOLUTIONS program, which focuses pressure ulcer prevention measures on alleviating risk factors identified by the Braden Scale, in two long-term care facilities.

Facility B beds experienced a corresponding 76 percent reduction from 15 percent to 3. Gunningberg and colleagues 52 investigated the incidence of pressure ulcers in and among patients with hip fractures and found significant reductions in incidence rates 55 percent in to 29 percent in The researchers attributed these reductions in pressure ulcer incidence rates to performing systematic risk assessment upon admission, accurately staging pressure ulcers, using pressure-reducing mattresses, and continuing education of staff.

Thus, the use of comprehensive prevention programs can significantly reduce the incidence of pressure ulcers in long-term care. The use of quality improvement models, where systematic processes of care have been implemented have also been shown to reduce overall pressure ulcer incidence.

In one study involving 29 nursing homes in three States, representatives of the 29 nursing homes attended a series of workshops, shared best practices, and worked with one-on-one quality improvement mentors over 2 years. Another study using similar methods involving 22 nursing homes found 8 out of 12 processes of care significantly improved.

In the acute care setting, several studies have attempted to demonstrate that the implementation of comprehensive pressure ulcer prevention programs can decrease the incidence rates.

However, no studies could be found that eliminated pressure ulcers. One large study evaluated the processes of care for hospitalized Medicare patients at risk for pressure ulcer development.

Charts were evaluated for the presence of six recommended pressure ulcer prevention processes of care. This study found that at-risk patients who used pressure-reducing devices, were repositioned every 2 hours, and received nutritional consults were more likely to develop pressure ulcers than those patients who did not receive the preventive interventions.

One explanation for this finding may be the amount of time 48 hours before the preventive measures were implemented. Given the acuity of patients entering hospitals, waiting 48 hours may be too late to begin pressure ulcer prevention interventions.

Thus, despite this one study, there is significant research to support that implementing comprehensive pressure ulcer prevention programs reduces the incidence of pressure ulcers.

A key component of research studies that have reported reduction of pressure ulcers is how to sustain the momentum over time, especially when the facility champion leaves the institution. It is clear from the evidence that maintaining a culture of pressure ulcer prevention in a care setting is an important challenge, one that requires the support of administration and the attention of clinicians.

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. How the skin is cleansed may make a difference. One study found that the incidence of Stages I and II pressure ulcers could be reduced by educating the staff and using a body wash and skin protection products.

The majority of skin care recommendations are based on expert opinion and consensus. Intuitively nurses understand that keeping the skin clean and dry will prevent irritants on the skin or excessive moisture that may increase frictional forces leading to skin breakdown.

Individualized bathing schedules and use of nondrying products on the skin are also recommended. Moreover, by performing frequent skin assessments, nurses will be able to identify skin breakdown at an early stage, leading to early interventions.

Although there is a lack of consensus as to what constitutes a minimal skin assessment, CMS recommends the following five parameters be included: skin temperature, color, turgor, moisture status, and integrity. The search for the ideal intervention to maintain skin health continues.

One study compared hyperoxygenated fatty acid compound versus placebo compound triisotearin in acute care and long-term care patients. Pressure ulcer incidence was lower in an intervention group of acute care patients when topical nicotinate was applied 7.

There are several key recommendations to minimize the occurrence of pressure ulcers. Avoid using hot water, and use only mild cleansing agents that minimize irritation and dryness of the skin.

Skin care should focus on minimizing exposure of moisture on the skin. One of the most important preventive measures is decreasing mechanical load.

If patients cannot adequately turn or reposition themselves, this may lead to pressure ulcer development. It is critical for nurses to help reduce the mechanical load for patients. This includes frequent turning and repositioning of patients.

Very little research has been published related to optimal turning schedules. This landmark nursing study created the gold standard of turning patients at least every 2 hours. Some researchers would suggest that critically ill patients should be turned more often.

However, one survey study investigating body positioning in intensive care patients found that of 74 patients observed, A total of 80—90 percent of respondents to the survey agreed that turning every 2 hours was the accepted standard and that it prevented complications, but only 57 percent believed it was being achieved in their intensive care units.

A more recent study by DeFloor and colleagues 61 suggests that depending on the support surface used, less-frequent turning may be optimal to prevent pressure ulcers in a long-term care facility.

Several nurse researchers investigated the effect of four different turning frequencies every 2 hours on a standard mattress, every 3 hours on a standard mattress, every 4 hours on a viscoelastic foam mattress, and every 6 hours on a viscoelastic foam mattress. The nurse researchers found that the incidence of early pressure ulcers Stage I did not differ in the four groups.

However, patients being turned every 4 hours on a viscoelastic foam mattress developed significantly less severe pressure ulcers Stage II and greater than the three other groups.

Although the results of this study may indicate less turning may be appropriate when using a viscoelastic foam mattress, additional studies are needed to examine optimal turning schedules among different populations.

Reddy and colleagues 62 have raised questions about the methodology in the Defloor and colleagues study, leading them to recommend that it may be too soon to abandon the everyhours turning schedule in favor of every 4 hours based on this one study.

Thus, there is emerging research to support the continued turning of patients at least every 2 hours. How a patient is positioned may also make a difference. Lateral turns should not exceed 30 degrees.

The use of support surfaces is an important consideration in pressure redistribution. The concept of pressure redistribution has been embraced by the NPUAP.

If you reduce pressure on one body part, this will result in increased pressure elsewhere on the body. Hence, the goal is to obtain the best pressure redistribution possible.

A major method of redistributing pressure is the use of support surfaces. 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.

The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. The Registered Nurses' Association of Ontario RNAO is developing a fourth edition of this best practice guideline BPG , with the working title Risk Assessment, Prevention and Treatment of Pressure Injuries.

The anticipated publication date is This new edition will replace RNAO's BPGs Assessment and Management of Pressure Injuries for the Interprofessional Team and Risk Assessment and Prevention of Pressure Ulcers Best practice guidelines. Risk Assessment and Prevention of Pressure Ulcers Published: September Clinical, Older adults.

Guideline Revision status. Purpose and scope The purpose of this best practice guideline BPG is to assist nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers. This guideline further provides direction to nurses in defining early interventions for pressure ulcer prevention, and to manage… The purpose of this best practice guideline BPG is to assist nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers.

Recommendations Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Practice: Assessment Recommendation 1.

Practice: Planning Recommendation 2. Practice: Interventions Recommendation 3. Avoid ingredients and excess application of products that may compromise the absorptive capacity of the incontinent brief; Use protective barriers e. Education Recommendation 5. Information on the following areas should be include: The etiology and risk factors predisposing to pressure ulcer development.

Use of risk assessment tools, such as the Braden Scale for Predicting Pressure Sore Risk. Categories of the risk assessment should also be utilized to identify specific risks to ensure effective care planning, Appendix C.

Skin assessment. Development and implementation of an individualized skin care program. Instruction on accurate documentation of pertinent data. Roles and responsibilities of team members in relation to pressure ulcer risk assessment and prevention.

Ongoing evaluation of the education and program goals. Evaluation results are to be integrated into the program on a continuous basis i.

Organizations may wish to develop a plan for implementation that includes: An assessment of organizational readiness and barriers to education.

Despite the consensus that adequate nutrition is important in wound healing, documentation of its effect on ulcer healing is limited; recommendations are based on observational evidence and expert opinion.

Nutritional screening is part of the general evaluation of patients with pressure ulcers. Table 3 presents markers for identifying protein-calorie malnutrition. Intervention should include encouraging adequate dietary intake using the patient's favorite foods, mealtime assistance, and snacks throughout the day.

High-calorie foods and supplements should be used to prevent malnutrition. 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.

The purpose of this best practice guideline Practics is Ulcre assist Pravtices who work in diverse practice settings to identify adults who Satiety and weight loss at UUlcer of pressure ulcers. This practicse further provides direction to nurses in defining early interventions for pressure ulcer prevention, and to manage…. This guideline further provides direction to nurses in defining early interventions for pressure ulcer prevention, and to manage Stage I pressure ulcers. Read more. Risk assessment and prevention of pressure ulcers. Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Official praxtices use. gov A. gov website belongs Ulcer prevention practices an official government organization in the United States. gov website. Share sensitive information only on official, secure websites.

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In , the U. Centers for Medicare and Medicaid Services CMS announced it will not pay for additional costs incurred for hospital-acquired pressure injuries.

The staging system also was updated and includes the following definitions:. The injury can present as intact skin or an open ulcer and may be painful. The tolerance of soft tissue for pressure and shear also may be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue.

Stage 1 Pressure Injury: Non-blanchable erythema of intact skin — Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin.

Presence of blanchable erythema or changes in sensation, temperature or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis — Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may represent as an intact or ruptured serum-filled blister.

Adipose fat is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

This stage cannot be used to describe moisture-associated skin damage MASD , including incontinence-associated dermatitis IAD , intertriginous dermatitis ITD , medical adhesive-related skin injury MARSI , or traumatic wounds skin tears, burns, abrasions. Stage 3 Pressure Injury: Full-thickness skin loss — Full-thickness loss of skin, in which adipose fat is visible in the ulcer and granulation tissue and epibole rolled wound edges are often present.

The depth of tissue damage varies by anatomical locations; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur.

If slough or eschar obscure the extent of tissue loss, this is an unstageable pressure injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss — Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer.

Depth varies by anatomical location. If slough or eschar obscure the extent of tissue loss, this is unstageable pressure injury.

Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss — Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar i. Deep Tissue Pressure Injury : Persistent non-blanchable deep red, maroon, or purple discoloration — Intact or non-intact skin with localized area or persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.

Pain and temperature changes often preceded skin color changes. Discoloration may appear differently in darkly pigmented skin. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss.

If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full-thickness pressure injury unstageable, Stage 3 or Stage 4.

Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Medical Device-Related Pressure Injury — This describes the etiology. Medical device-related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes.

The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Mucosal Membrane Pressure Injury — Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury.

Due to the anatomy of the tissue, injuries cannot be staged. The prevention of pressure injuries is a great concern in health care today. Many clinicians believe that pressure injury development is not solely the responsibility of nursing, but the entire health care system.

Pressure injury prevention and treatment requires multi-disciplinary collaborations, good organizational culture and operational practices that promote safety. Per the International Guideline, risk assessment is a central component of clinical practice and a necessary first step aimed at identifying individuals who are susceptible to pressure injuries.

Risk Assessment should be considered as the starting point. The earlier a risk is identified, the more quickly it can be addressed. Skin Care. Hospitalized individuals are at great risk for undernutrition.

Positioning and Mobilization. Immobility can be a big factor in causing pressure injuries. Immobility can be due to several factors, such as age, general poor health condition, sedation, paralysis, and coma. Monitoring, Training and Leadership Support. In any type of process improvement or initiative, implementation will be difficult without the right training, monitoring and leadership support.

OT; PT; enterostomal therapist; wound, ostomy and continence nurses; dietitian; physicians; nurse practitioners; chiropodist; wound specialists, etc. as well as time and support for front line nursing staff. Funding should be provided to involve point of care staff in data collection and analysis.

All participants of this process need to participate in a rigorous standardized education program prior to conducting the study. Disclaimer: These guidelines are not binding for nurses, other health providers or the organizations that employ them.

The use of these guidelines should be flexible and based on individual needs and local circumstances. They constitute neither a liability nor discharge from liability. The Registered Nurses' Association of Ontario RNAO is developing a fourth edition of this best practice guideline BPG , with the working title Risk Assessment, Prevention and Treatment of Pressure Injuries.

The anticipated publication date is This new edition will replace RNAO's BPGs Assessment and Management of Pressure Injuries for the Interprofessional Team and Risk Assessment and Prevention of Pressure Ulcers Best practice guidelines.

Risk Assessment and Prevention of Pressure Ulcers Published: September Clinical, Older adults. Guideline Revision status. Purpose and scope The purpose of this best practice guideline BPG is to assist nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers.

This guideline further provides direction to nurses in defining early interventions for pressure ulcer prevention, and to manage… The purpose of this best practice guideline BPG is to assist nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers.

Recommendations Do you want to learn about and implement the most- up-to-date evidence-based recommendations on this topic with your colleagues? Practice: Assessment Recommendation 1. Practice: Planning Recommendation 2. Practice: Interventions Recommendation 3.

Avoid ingredients and excess application of products that may compromise the absorptive capacity of the incontinent brief; Use protective barriers e.

Education Recommendation 5. Information on the following areas should be include: The etiology and risk factors predisposing to pressure ulcer development. Use of risk assessment tools, such as the Braden Scale for Predicting Pressure Sore Risk. Categories of the risk assessment should also be utilized to identify specific risks to ensure effective care planning, Appendix C.

Skin assessment. Development and implementation of an individualized skin care program. Instruction on accurate documentation of pertinent data. Roles and responsibilities of team members in relation to pressure ulcer risk assessment and prevention.

Ongoing evaluation of the education and program goals. Evaluation results are to be integrated into the program on a continuous basis i. Organizations may wish to develop a plan for implementation that includes: An assessment of organizational readiness and barriers to education.

Involvement of all members whether in a direct or indirect supportive function who will contribute to the implementation process. Dedication of a qualified individual to provide the support needed for the education and implementation process.

Ongoing opportunities for discussion and education to reinforce the importance of best practices. Opportunities for reflection on personal and organizational experience in implementing guidelines.

Methodology documents Risk Assessment and Prevention of Pressure Ulcers search strings. pdf 38k. Revision status Current edition published: March with September supplement. About the next edition The Registered Nurses' Association of Ontario RNAO is developing a fourth edition of this best practice guideline BPG , with the working title Risk Assessment, Prevention and Treatment of Pressure Injuries.

Topic selection.

Once you have determined pfevention you are ready for pracctices, the Implementation Ulcer prevention practices oractices Unit-Based Teams should demonstrate Elevate emotional intelligence clear understanding of where practicess are practlces in terms of implementing best practices. People involved in the quality Ulcer prevention practices Dehydration and mental health need to agree on what it is that they are trying to do. Consensus should be reached on the following questions:. In addressing these questions, this section provides a concise review of the practice, emphasizes why it is important, discusses challenges in implementation, and provides helpful hints for improving practice. Further information regarding the organization of care needed to implement these best practices is provided in Chapter 4 and additional clinical details are in Tools and Resources.