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Nursing:
doi: 10.1097/01.NURSE.0000368818.35594.6a
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Taking steps to prevent pressure ulcers

Blaney, Wendy D. RN

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Wendy D. Blaney is a registered nurse in the progressive-care unit at Mercy General Hospital in Sacramento, Calif. This article received an honorable mention in the Nursing2009 clinical writing contest.

Here's how one hospital is putting evidence-based practices to work to keep patients' skin intact.

EACH YEAR in the United States, thousands of patients die from complications of preventable hospital-acquired pressure ulcers.1 Psychologically and physically devastating for patients, pressure ulcers also cost billions of dollars in treatment and litigation and put a strain on an already burdened healthcare system.

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Implementing evidence-based practices and effective prevention policies and procedures can help hospitals prevent pressure ulcers and comply with Centers for Medicare & Medicaid Services (CMS) regulations, which no longer reimburse hospitals for Stage III and Stage IV pressure ulcers acquired while patients are hospitalized.2 (For assessment guidelines, see Staging pressure ulcers.)

Many patients in my facility's cardiovascular progressive care unit are at high risk for acquiring pressure ulcers because of cardiovascular disease, older age, compromised circulatory status, immobility, and comorbidities, such as obesity and diabetes (see Who's at risk for pressure ulcers?). To prevent pressure ulcers, our unit implemented several practices based on current research and recommendations from the National Pressure Ulcer Advisory Panel. These recommendations can be used by all clinicians, whether working in an acute care facility, the home, or a long-term-care setting.

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Step 1: Identify and evaluate risk

At admission, assess the patient's skin from head to toe. The skin is an indicator of the patient's general health. Inspect and palpate for changes in skin integrity, texture, turgor, temperature, consistency (such as bogginess or induration) and moisture, color changes, non-blanchable erythema, and edema. Blanchable erythema is an early indicator that pressure needs to be redistributed; non-blanchable erythema suggests that tissue damage has already occurred.

Take the patient's history related to pressure ulcers. Ask about areas with lack of sensation, areas of pain, location of current or previous pressure ulcers, location of fragile skin or easy bruising, and any medications or medical conditions that raise the risk of skin breakdown.

Next, perform a pressure ulcer risk assessment using a tool such as the Braden Scale, which assesses six indicators: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The maximum score is 23; a score of 18 or less indicates that the patient is at risk for developing a pressure ulcer. Once you've identified your patient's pressure ulcer risk level, you and your colleagues can implement a plan of prevention and take appropriate steps to prevent skin breakdown.

Document your assessment findings, including any existing pressure-related injuries. The CMS will reimburse if it can be demonstrated that the pressure ulcer didn't develop while the patient was in your facility. Document your skin assessment and care plan. Our unit also photographs patient pressure ulcers when they're identified, and then weekly or whenever the patient's skin condition changes. This lets the clinical team track the pressure ulcer's progress. (Patient consent for this photography is obtained at admission.)

Reassess skin integrity and level of risk every shift or whenever the patient's condition changes. Remember that you can do this while you do your regular assessments, working from head to toe—you don't have to perform the full body assessment all at once. For example, when auscultating lung sounds, inspect the back and sacral and coccyx area; when checking I.V. sites, also check the patient's elbows.

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Step 2: Put evidence-based practices in place

Start by minimizing pressure. Encourage patients to move if they can. Most patients who've recently had coronary artery bypass graft surgery are very reluctant to move because of pain. To promote movement, make sure pain is under control and teach patients how to splint the chest incision to minimize pain when they move. Getting out of bed not only reduces the incidence of pressure ulcers but can also reduce the risk of other complications of immobility, such as atelectasis, pneumonia, and venous thromboembolism.

Implement a turning schedule (typically every 2 hours) for patients who are immobile, have difficulty moving, or have impaired sensory perception. Our unit has placards that are posted outside patients' rooms to remind us to turn the patient every 2 hours. Bear in mind, however, that in order to take pressure off of one area you may be increasing pressure on another. Use pillows or wedges between the knees and elsewhere as needed to reduce pressure on bony prominences. Free-float heels by elevating the patient's calves on pillows and keeping heels free of all surfaces.

Medical devices are another potential source of pressure. These include such everyday equipment as urinary drainage catheters, I.V. tubing, and oxygen masks and tubing. Pad these devices if possible. When positioning patients, make sure they're not lying on any of these devices or anything else that may have inadvertently been left in the bed.

Depending on your patient's level of pressure ulcer risk, use pressure support surfaces, such as a low-air-loss mattress, to redistribute pressure. Keep in mind, however, that these pressure-relieving devices don't replace the need to reposition an immobile patient at least every 2 hours.

Next, maintain adequate nutrition and hydration. Encourage a high-protein, high-calorie diet. Postsurgical patients are often anorexic. Consult a dietitian as indicated. Offering small, frequent meals or letting the patient's family bring favorite foods from home can help stimulate the patient's appetite. To maintain hydration and ease discomfort from endotracheal intubation, offer sugar-free ice pops and frequent sips of water.

Minimize and manage moisture. Moisture macerates the skin. Sources of moisture include urine, feces, diaphoresis, and wound drainage. If your patient is incontinent, clean the skin at the time of soiling using a mild soap and apply a commercial moisture barrier to protect the skin. Place the patient on a moisture-control pad that provides a quick drying surface for the skin. Implement a toileting schedule or bowel or bladder program as appropriate. Contain urine, stool, and wound drainage, and prevent moisture from accumulating in skin folds.

Minimize friction and shear. Elevate the head of the bed no more than 30 degrees, unless contraindicated. (After surgery, immobile patients can be at risk for pulmonary complications, so the head of the bed should be elevated more than 30 degrees in those cases.) Because sliding down in bed causes friction and shear, encourage patients to reposition themselves by lifting instead of sliding, and to use a trapeze when indicated. Protect the patient's elbows and heels from friction. Our unit recently started using slip sheets to move patients up in bed or for transfer. This is extremely helpful when repositioning an obese patient. Not only does it reduce the strain on the nurse's back but also friction and shear on the patient's skin. Use lift sheets if slip sheets aren't available.

Educate your patients and families. The more patients and families know about the risk factors involved in developing pressure ulcers, the more they can help you prevent problems. With your patient's consent, discuss with them the patient's particular risk factors and involve the patient and caregivers in the plan of care, as appropriate.

Communicate with colleagues in your unit and when transferring the patient to another facility or unit. Communication between shifts and unit managers should be consistently maintained. Any changes in a patient's clinical status should be documented and communicated immediately to everyone directly involved in the patient's care.

Pressure ulcers are costly to patients and hospitals. Following these steps can help minimize those costs and improve patient care.

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Staging pressure ulcers

Pressure ulcers are staged according to the National Pressure Ulcer Advisory Panel's system:

* Suspected deep tissue injury—a purple or maroon localized area of discolored intact skin or blood-filled blister, caused by damage to the underlying soft tissue from pressure or shear. The area may be painful, firm, mushy, boggy, warmer, or cooler compared with adjacent tissue.

* Stage I pressure ulcer—intact skin with non-blanchable redness of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared with adjacent tissue. This stage may be difficult to detect in patients with dark skin.

* Stage II pressure ulcer—partial-thickness loss of dermis presenting as a shiny or dry, shallow, open ulcer with a red-pink wound bed, without slough or bruising. (Note that bruising indicates suspected deep tissue injury.) May also present as an intact or open or ruptured serum-filled blister. Stage II shouldn't be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

* Stage III pressure ulcer—full-thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, and muscle aren't exposed. Slough may be present but doesn't obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies depending on its anatomic location. On the bridge of the nose, ear, occiput, and malleolus, which lacks subcutaneous tissue, these ulcers are shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone or tendon isn't visible or is directly palpable.

* Stage IV pressure ulcer—full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. As with Stage III pressure ulcers, Stage IV pressure ulcers vary in depth depending on their location. Because these ulcers can extend into muscle and supporting structures, the patient also is at risk for osteomyelitis. Exposed bone or tendon is visible or directly palpable.

* Unstageable pressure ulcer—full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar (tan, brown, or black). The true depth and stage of the ulcer can't be determined until enough slough and eschar are removed. Stable eschar (defined as dry, adherent, or intact without erythema or fluctuance) on the heels provides a natural biologic cover and shouldn't be removed.

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Who's at risk for pressure ulcers?

These factors increase a patient's pressure ulcer risk:

* peripheral vascular disease

* myocardial infarction

* stroke

* multiple trauma

* musculoskeletal disorders or fractures

* gastrointestinal bleeding

* spinal cord injury

* neurological disorders, such as Guillain-Barré syndrome or multiple sclerosis

* unstable or chronic medical conditions, such as diabetes, renal disease, cancer, chronic obstructive pulmonary disease, heart failure, and dementia

* history of a previous pressure ulcer.

Patients age 75 or older and/or patients with multiple high-risk diagnoses should be advanced to the next level of risk.

Patients who undergo invasive procedures may be at increased risk for pressure ulcers. This risk may be related to length of time on the operating or procedure table, hypotension, or type of procedure.

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REFERENCES

1. National Pressure Ulcer Advisory Panel. The role of nutrition in pressure ulcer prevention and treatment: National Pressure Ulcer Advisory Panel white paper. http://npuap.org/Nutrition%20White%20Paper%20Website%20Version.pdf.

2. Centers for Medicare and Medicaid Services. Hospital-acquired conditions in acute inpatient prospective payment system hospitals. http://www.cms.hhs.gov/HospitalAcqCond.

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RESOURCES
Agency for Healthcare Research and Quality. Prevention of pressure ulcers in older patients. http://www.ahrq.gov/clinic/ptsafety/chapter27.htm.

Ayello EA, Lyder CH. Preventing pressure ulcers. Nursing. 2007;37(10):36–41.

Institute for Clinical Systems Improvement. Skin safety protocol: risk assessment and prevention of pressure ulcers. Health care protocol. Bloomington, MN, Institute for Clinical Systems Improvement, 2007.

© 2010 Lippincott Williams & Wilkins, Inc.

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