Integumentary – Pressure Ulcer: Prevention SECTION: 4.14 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

PURPOSE: Active Support Surface: A powered support surface, with To identify patients at risk for the development of the capability to change its load distribution properties, pressure ulcers and define early interventions. with or without applied load. Integrated Bed System: A bed frame and support CONSIDERATIONS: surface that are combined into a single unit whereby the 1. Patients at increased risk for development of surface is unable to function separately. pressure ulcers are those who are chairfast or Non-powered: Any support surface not requiring or bedfast. using external sources of energy. 2. The following characteristics further increase the Powered: Any support surface requiring or using risk for pressure ulcer development: external sources of energy to operate. a. Advanced age. b. Chronic illness that requires bed rest; poor Overlay: An additional support surface designed to be circulation. placed directly on top of an existing surface. c. Dehydration, malnutrition, significant obesity Mattress: A support surface designed to be placed on and thinness. the existing bed frame d. Diabetes mellitus. Skin Protectants/Emollients and Sprays: e. Incontinence, excessive perspiration, wound  Lotion drainage.  Ointment f. Diminished pain awareness.  Moisture-barrier creams g. Fractures, trauma, paralyses.  Transparent film h. Corticosteroid therapy, immunosuppression. i. Mental impairment, possibly related to coma, Comfort Aids (does not reduce pressure but aids in altered level of consciousness, sedation and/or comfort): confusion.  Pillows 3. Rating scales, such as the Braden (SeeAppendix A-  Heel and elbow protectors Braden Scale), Gosnell and Norton are the most common risk assessment tools used by clinicians to PROCEDURE: identify the patients at greatest risk for pressure 1. Adhere to Standard Precautions. ulcers. 2. Explain procedure to patient. 4. Early intervention refers to treatment prescribed for those patients determined to be at high risk for Risk Assessment Tools and Risk Factors developing pressure ulcers. These include: 1. Assess all patients on admission to homecare and adequate pressure redistribution, frequent reassess every visit for risk factors related to repositioning, attention to nutritional status, pressure ulcers, using a validated risk assessment aggressive and gentle perineal care, protective tool, i.e., Braden, Grosnell or Norton Scale. devices that lift the heels off the bed and padding for 2. Assess bed- and chair-bound patients for additional ankles and knees. risk factors such as, incontinence, altered level of 5. Recommendations for an effective prevention consciousness and impaired nutritional status. program include four goals: 3. Document assessment of all risk factors. a. Identifying at-risk individuals who need Skin Care and Early Treatment prevention and the specific factors placing them 1. Inspect the skin at each visit and instruct at risk. patient/caregiver to do so on a daily basis, paying b. Maintaining and improving tissue tolerance to particular attention to bony prominences. pressure in order to prevent injury. 2. Individualize and teach frequency of skin cleansing c. Protecting against the adverse effects of according to need and/or patient preference. During pressure, friction, and shear. the cleansing process, use minimal force and d. Reducing the incidence of pressure ulcers friction on the skin. through educational programs. 3. Avoid hot water and use a mild cleansing agent that minimizes irritation and dryness of the skin, then EQUIPMENT: apply moisturizers and a barrier cream. Pressure Redistribution (as defined by the National 4. Minimize environmental factors leading to dry skin, Pressure Ulcer Advisory Panel, 2007) Support Surfaces: such as low humidity (less than 40%) and exposure Reactive support surface: A powered or non-powered to the cold. Treat dry skin with moisturizers. support surface with the capability to change its load 5. Avoid massaging over bony prominences. distribution properties only in response to applied load. 6. Minimize skin exposure to moisture due to incontinence, perspiration or wound drainage. When sources of moisture cannot be controlled, be sure to use a Moisture Barrier to protect the skin Integumentary – Pressure Ulcer: Prevention SECTION: 4.14 Strength of Evidence Level: 3 __RN__LPN/LVN__HHA

and use linen-saver pads or briefs made of b. Risk assessment tools and their application. materials that absorb moisture and present a quick- c. Skin assessment. drying surface to the skin. d. Selection and/or use of support surfaces. 7. Use proper positioning,transferring and turning e. Development and implementation of an techniques to lessen skin injury due to friction and individualized program of skin care. shearing. To reduce additional friction injuries, use f. Demonstration of positioning to decrease risk of lubricants, protective dressings, and protective tissue breakdown. padding. g. Instruction of accurate documentation of 8. Ensure adequate nutrition and hydration that pertinent data. includes adequate intake of protein, calories, vitamins, minerals and fluids. A plan of nutritional AFTER CARE: support and/or supplementation may need to be 1. Document in patient’s record: implemented for those patients who are nutritionally a. Assessment of risk and risk factors identified. compromised. Dietitian referral may be indicated. b. Instructions given to patient/caregiver. 9. Keep the patient as active as possible. Use active c. Patient’s/caregiver’s ability to demonstrate and passive exercise including range of motion. teaching instructions. Physical therapy referral may be indicated. REFERENCES: Mechanical Loading and Pressure Redistribution Support Surfaces Keast, D., Parslow, N., Houghton, P., Norton, L., & Patient confined to bed: Fraser, C. (2007). Best practice recommendations for 1. Initiate a written, systematic turning and the prevention and treatment of pressure ulcers: Update repositioning schedule that repositions the patient at 2006. Advances in Skin and Wound Care. 20:8. P. 447- least every 2 hours. 460. 2. Protect bony prominences, such as ankles and knees, from contact with each other with pillows or Stoelting, J., Mckenna, L., Taggart, E. Mottar, R., foam wedges. For a completely immobile patient, Jeffers, B., & Wendler, C. (2007). Prevention of use devices that totally relieve pressure on the nococomial pressure ulcers: A Process improvement heels. DO NOT use donut-type devices. project. Journal of Wound, Ostomy and Continence 3. Avoid positioning the patient directly on the Nursing. 34: 4. P. 382-388. trochanter, when the side-lying position is used. 4. Maintain the head of the bed at the lowest degree of American National Pressure Ulcer Advisory Panel elevation possible < 30 degrees. Limit the amount of (NPUAP). & European Pressure Ulcer Advisory Panel time it is elevated. (EPUAP). (2009). International Guideline: Pressure 5. Use lifting devices during transfers and position ulcer prevention: A Quick reference guide. Retrieved changes. February 10, 2010 from www.npuap.org 6. Place at-risk patients on a pressure-reducing device, such as foam, static air, alternating gel or water mattress. Patient confined to chair: 1. Initiate a systematic schedule for repositioning that shifts the points under pressure at least every hour. If able, have patient shift weight every 15 minutes. A written plan may be helpful. 2. Use a pressure-reducing device, such as those made of foam, gel, air or a combination, as indicated. DO NOT use donut-type devices. 3. Consider postural alignment, distribution of weight, balance and stability and pressure relief when positioning patient. Education 1. The keystones to prevention are educational programs that are structured, organized and comprehensive. These programs must be directed at all levels of healthcare providers, patients, families and caregivers. 2. Educational programs should include information on the following items: a. Etiology of and risk factors for pressure ulcers.