Home CareNotes How To Prevent Pressure Ulcers This material must not be used for commercial purposes, or in any hospital or medical facility. Failure to comply may result in legal action.How To Prevent Pressure Ulcers WHAT YOU NEED TO KNOW: What is a pressure ulcer? A pressure ulcer is an injury to the skin or tissue over a bony area. A pressure ulcer is also called a pressure sore, bedsore, or decubitus ulcer. Pressure ulcers can form over any bony area but are most common on the back, buttocks, hips, and heels. What causes pressure ulcers? Continuous pressure builds when you sit or lie on a bony area for too long. Pressure slows or stops the blood from flowing to the skin. This may hurt the skin and cause tissue damage. Pressure can start to cause damage to your skin and tissue about 2 hours after staying in the same position. Shearing or friction happens when delicate skin is dragged across a surface, such as sheets. This may cause your skin to tear or a blister to form.
Sliding up or down in bed or moving from the bed to a chair may tear your skin. Muscle spasms may cause your arms or legs to jerk and rub the sheets, causing tears in your skin. What increases my risk for a pressure ulcer? Long periods of time without moving Short periods of increased pressure, such as sitting in a wheelchair Not being able to control your urine or bowel movements Dehydration or poor nutrition Poor blood flow to your limbs Age over 65 years What can I do to help prevent a pressure ulcer? Ask your healthcare provider for more information on any of the following: Check your skin several times each day. Check for red skin, or other color changes, over bony areas. Use a mirror if you have trouble seeing certain areas, or ask another person to look. Change wet bedding and clothes right away. The wet material may rub against your skin and cause damage. Change your position often. Change your position every 2 hours if you are in a bed all day.
Change your position every hour if you are in a wheelchair all day. Set an alarm to help remind you when it is time to turn. Keep a written turning schedule to help you remember to turn. If you are helping a person move in bed, lift him. Do not slide him. Keep the head of the bed as low as possible. This may help prevent damage to the skin from sliding down in bed. Protect the skin over bony areas. Use pillows or foam wedges to keep bony areas from touching, and to relieve pressure. For example, put a pillow or foam wedge between your knees to keep them from pressing on one another. Place a pillow or foam wedge under you to keep your hip raised when you lie on your side. Do not rest directly on your hipbone. Put a foam pad or pillow under your legs from calf to ankle when you lie on your back. The pad or pillow should raise your heels so that they are not touching the bed. Use medical equipment and pads. A draw sheet or large pad under you may help others move you up in bed. An overhead trapeze can help you change positions in bed.
Mattresses and overlays made to provide more cushioning may help decrease the risk of pressure ulcers. Examples include a foam mattress pad and air or water mattresses. Ask about equipment that may be right for you and how you use it. Keep your skin clean, dry, and moisturized. Use mild soap and warm water to clean your skin. Do not rub or scrub when you wash. Do not use products that contain alcohol, because they can dry out your skin. Gently pat your skin dry. Do not rub your skin with a towel. Apply lotion or a moisturizer on your skin often. Eat a variety of healthy foods. Healthy foods include fruits, vegetables, whole-grain breads, and fish. Foods that are high in protein may help your pressure ulcer heal. This includes lean meats, beans, milk, yogurt, and cheese. Nutrition shakes may also give you extra calories and protein if you have trouble eating or are underweight. When should I contact my healthcare provider? You have a fever. You see red or purple skin over a bony area.
The above information is an educational aid only. Talk to your doctor, nurse or pharmacist before following any medical regimen to see if it is safe and effective for you.The industry standard for turning and repositioning a patient at risk for pressure ulcers is every two hours. There is, however, limited research to support this standard. As the costliest elements of pressure ulcer prevention are support surfaces and repositioning, a change in this standard would have major economic impact. A research study published in the October 2013 issue of the Journal of the American Geriatrics Society (JAGS) could potentially alter the standard for turning frequency for nursing home residents at risk for pressure ulcers. Bergstrom et al. tested whether there was a difference in pressure ulcer incidence in persons at moderate (Braden score 13-14) or high risk (Braden score 10-12) who were turned at 2, 3, or 4 hour intervals when a high density foam mattress was in use. Persons at very high risk (Braden score 6-9) were excluded.
They studied 942 nursing home residents in 20 facilities in the US and Canada. Subjects were age 65 and older with the most common diagnoses of cardiovascular disease and dementia. All were newly admitted short-stay or long-stay residents of nursing homes, and were followed for three weeks. The researchers found no difference in pressure ulcer incidence between those repositioned at 2, 3, or 4 hour intervals. The surface used was a high density foam mattress as opposed to a spring type mattress. Powered surfaces such as alternating pressure air mattresses (APAMs) or low air-loss mattresses (LAL) were not studied. High density foam is commonly used for sofa cushions, benches, chairs and mattresses, and density reflects how much weight polyurethane foam can handle per cubic foot. There are several considerations for interpretation of these results before they can be applied to the larger population of persons at risk for pressure ulcers. Only 3 of the 20 (17%) nursing facilities included in the study were for-profit, while for-profit facilities are actually 69% of all nursing homes in America.
Data from CMS demonstrates higher prevalence of survey deficiencies and poorer staffing ratios in for-profit homes than non-profit or government run facilities. The data may therefore be skewed to represent higher quality sites with better staffing levels and less staff turnover. Prior data has demonstrated that education alone can decrease the prevalence of pressure ulcers. It may be that higher scrutiny and required documentation inherent in a research protocol may have raised awareness of skin issues resulting in better outcomes independent of variation in turning schedules. The authors acknowledge that vigilant assessment and documentation required by their study may have cued staff and helped reduce pressure ulcer incidence. A key element of this study was accurate scoring on the Braden risk-assessment tool. The study protocol included extra training in 3 hour sessions for the licensed nurses who performed the scoring – training that may not be available in most nursing facilities.
The authors justify why residents at very high risk (Braden < 9) were excluded, stating that they “are often cared for on powered mattresses or alternating-pressure relief overlays.” This statement was not referenced by supportive data and may not be true in many facilities. Finally, this study did not include hospitalized patients who have acute illness or surgery, with concomitant physiologic changes that add to pressure ulcer risk. Whether results from this research paper will alter the “Q2H” standard of care for pressure ulcer prevention remains to be seen, but it certainly opens it up for challenge. The temptation to save money in today’s healthcare climate is great, but these data may not be generalizable to all nursing home residents and certainly not to patients in hospitals. I would urge caution when considering changes in policy that may adversely impact large numbers of persons at risk for the devastating complications of pressure ulceration. * * * * * * * * * * * * * * *