Journal of Gerontological Nursing

Clinical Practice Guidelines: PREDICTION AND PREVENTION OF PRESSURE ULCERS

Brenda Bergman-Evans, PhD, RN, CS; Janet Cuddigan, MSN, RN; Nancy Bergstrom, PHD, RN, FAAN

Abstract

Whether at home in the hospital or in a nursing home, a patient confined to a bed or chair is vulnerable to a potentially dangerous complication: pressure ulcers. Fortunately, most pressure ulcers can be prevented and stage I ulcers (nonblanchable erythema of intact skin) need not worsen. Prevention, as well as effective early treatment and intervention, provides an opportunity for both reducing financial costs and improving the quality of life for the patients involved. Therefore, the Public Health Service's Agency for Health Care Policy and Research (AHCPR) identified the prevention and treatment of pressure ulcers as a priority topic for the development of clinical practice guidelines.

AHCPR had defined the term guidelines as "systematically developed statements to assist practitioner and patient decision-making about appropriate health care for specific clinical circumstances." Clinical circumstances or conditions for which guidelines were to be developed were based on established priorities. These criteria included the following:

* A significant number of individuals are affected by the condition;

* Significant variations occur in clinical practice;

* Significant variations occur in the outcomes of care;

* The condition is amenable to prevention; and

* An adequate scientific base of evidence exists to support the guidelines.

Additionally, the specific needs of the Medicare and Medicaid populations and costs of providing care are considered.

An interdisciplinary non-Federal panel of experts and consumers was convened by the AHCPR's Office of the Forum for Quality and Effectiveness in Health Care to develop the Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guidelines, Number 3, pursuant to the Forum's mandate in Section 911 of the Omnibus Budget Reconciliation Act of 1989. With the support of the Forum, the panel conducted a comprehensive review of the literature on the treatment and prevention of pressure ulcers, including both scientific evidence and expert/professional opinion.

Whenever possible, research evidence was used as the basis for guideline formulation. The panel also considered the clinical benefits and harms of potential interventions as well as relevant health policy issues, such as cost constraints and feasibility. Traditionally, guideline development by professional organizations has been focused to meet specific needs of a given discipline and formulated more on the basis of professional opinion and clinical practice than on empirical research.

The Guidelines make specific recommendations regarding at-risk adults as well as those with stage I pressure ulcers. The Guidelines may not be appropriate for every at-risk adult, however, and should be adapted to the overall goals for the individual. The guidelines are not intended for infants and children; individuals with stage ?, ??, or W pressure ulcers; or individuals who are fully mobile.

Recommendations target four overall goals:

* Identify at-risk individuals who need prevention and the specific factors that place them at risk;

* Maintain and improve tissue tolerance to pressure in order to prevent injury;

* Protect against the adverse effects of external mechanical forces (pressure, friction, shear); and

* Reduce the incidence of pressure ulcers through educational programs.

The guidelines are outlined below in italics; each recommendation is accompanied by a summary of the rationale behind it.

GUIDELINES FOR RISK ASSESSMENT TOOLS AND RISK FACTORS

Bed- and chair-bound individuals or those with impaired ability to reposition should be assessed for additional factors that increase the risk of developing pressure ulcers. These factors include immobility, incontinence, and nutritional factors, such as inadequate dietary intake and impaired nutritional status, and altered level of consciousness. Individuals should be assessed on admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities. A systematic risk assessment can be accomplished by using a validated risk assessment…

Whether at home in the hospital or in a nursing home, a patient confined to a bed or chair is vulnerable to a potentially dangerous complication: pressure ulcers. Fortunately, most pressure ulcers can be prevented and stage I ulcers (nonblanchable erythema of intact skin) need not worsen. Prevention, as well as effective early treatment and intervention, provides an opportunity for both reducing financial costs and improving the quality of life for the patients involved. Therefore, the Public Health Service's Agency for Health Care Policy and Research (AHCPR) identified the prevention and treatment of pressure ulcers as a priority topic for the development of clinical practice guidelines.

AHCPR had defined the term guidelines as "systematically developed statements to assist practitioner and patient decision-making about appropriate health care for specific clinical circumstances." Clinical circumstances or conditions for which guidelines were to be developed were based on established priorities. These criteria included the following:

* A significant number of individuals are affected by the condition;

* Significant variations occur in clinical practice;

* Significant variations occur in the outcomes of care;

* The condition is amenable to prevention; and

* An adequate scientific base of evidence exists to support the guidelines.

Additionally, the specific needs of the Medicare and Medicaid populations and costs of providing care are considered.

An interdisciplinary non-Federal panel of experts and consumers was convened by the AHCPR's Office of the Forum for Quality and Effectiveness in Health Care to develop the Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guidelines, Number 3, pursuant to the Forum's mandate in Section 911 of the Omnibus Budget Reconciliation Act of 1989. With the support of the Forum, the panel conducted a comprehensive review of the literature on the treatment and prevention of pressure ulcers, including both scientific evidence and expert/professional opinion.

Whenever possible, research evidence was used as the basis for guideline formulation. The panel also considered the clinical benefits and harms of potential interventions as well as relevant health policy issues, such as cost constraints and feasibility. Traditionally, guideline development by professional organizations has been focused to meet specific needs of a given discipline and formulated more on the basis of professional opinion and clinical practice than on empirical research.

The Guidelines make specific recommendations regarding at-risk adults as well as those with stage I pressure ulcers. The Guidelines may not be appropriate for every at-risk adult, however, and should be adapted to the overall goals for the individual. The guidelines are not intended for infants and children; individuals with stage ?, ??, or W pressure ulcers; or individuals who are fully mobile.

Recommendations target four overall goals:

* Identify at-risk individuals who need prevention and the specific factors that place them at risk;

* Maintain and improve tissue tolerance to pressure in order to prevent injury;

* Protect against the adverse effects of external mechanical forces (pressure, friction, shear); and

* Reduce the incidence of pressure ulcers through educational programs.

The guidelines are outlined below in italics; each recommendation is accompanied by a summary of the rationale behind it.

GUIDELINES FOR RISK ASSESSMENT TOOLS AND RISK FACTORS

Bed- and chair-bound individuals or those with impaired ability to reposition should be assessed for additional factors that increase the risk of developing pressure ulcers. These factors include immobility, incontinence, and nutritional factors, such as inadequate dietary intake and impaired nutritional status, and altered level of consciousness. Individuals should be assessed on admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities. A systematic risk assessment can be accomplished by using a validated risk assessment tool, such as the Braden Scale or the Norton Scale. Pressure ulcer risk should be reassessed at periodic intervals. All assessments of risk should be documented.

If pressure ulcers are to be prevented, the identification of individuals at risk is imperative. Assessment should occur on admission to a health care facility or at the initiation of a home care program (Bergstrom, 1992). In addition, because the condition of any individual changes over time, routine reassessment of risk is needed (Andersen, 1983). Accurate and complete written documentation of risk also is necessary to ensure both continuity of care and the execution of a suitable skin care plan.

The risk factors of immobility and limited activity levels are primary factors (Exton-Smith, 1961). Other factors such as incontinence, altered levels of consciousness, and inadequate dietary intake or impaired nutritional status also should be assessed (Allman, 1991; Bergstrom, 1992; Berlowitz, 1989; Lowthian, 1976).

Although numerous risk assessment tools exist, only the Braden (1989) and Norton (1989) scales have been tested extensively. The conceptual subscales for the Braden Scale are sensory perception, skin moisture, activity, mobility, nutrition, friction and shear. The five components of the Norton Scale are physical condition, mental state, activity, mobility, and incontinence (this scale was later modified to include nutrition [Ek, 1987; Stotts, 1988]). Although all tools have limitations, there is no evidence that any other method does a better job of predicting risk than the overall scores obtained by these tools.

GUIDEUNES FOR SKIN CARE ANDEARLYTREAJMENT

1. AU individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the bony prominences. Results of skin inspection should be documented.

Routine skin inspection is customarily included in any skin care program. It provides essential information in formulating and evaluating skin care plans. A head-to-toe skin assessment with special attention to bony prominences should be performed at least once daily. Results of all assessments should be recorded.

2. Sun cleansing should occur at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or patient preference. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin. During the cleansing process, care should be used to minimize the force and friction applied to the skin.

Metabolic wastes (including urine and feces) and environmental contaminants that result from daily activities are potential irritants, and should be removed promptly and frequently. By the use of warm rather than hot water when bathing, skin damage caused by excess thermal energy should be rninimized. When the skin's "natural barrier" has been removed, the skin is drier and more susceptible to irritants. By using a mild cleansing agent, the removal of the skin's "natural barrier" is minimized. Frequency of skin cleansing should be based not only on the patient's skin condition, but also on the patient's preference.

3. Minimize environmental factors leading to skin drying, such as low humidity (under 40%) and exposure to cold. Dry skin should be treated with moisturizers.

Decreased ambient air temperature and relative humidity are causes of clinically dry skin (Dotz, 1983; Kligman, 1978; Spencer, 1975). Preliminary research indicated a weak association between dry, flaky, or scaling skin and the development of pressure ulcers (Guralnik, 1988).

Decreased skin hydration results in reduced pliability, and sometimes fissuring and cracking, of the stratum corneum. Adequate hydration appears to help protect the stratum corneum against mechanical insult (Wildnauer, 1971). The application of topical moisturizing agents improves skin hydration; however, the efficacy of a specific agent has not been established. In addition, although maintenance of relative temperature and humidity have not been linked directly to the prevention of pressure ulcers, adoption of these procedures appears to be prudent.

4. Avoid massage over bony prominences.

Massage has been used for decades to stimulate circulation, contribute to a sense of patient comfort, and supposedly help prevent pressure ulcers. Preliminary evidence now suggests, however, not only that the purported benefit of such massage cannot be documented, but also that the practice may be harmful (Dyson, 1978; Ek, 1985). Back rubs are useful for promoting relaxation, but areas over bony prominences should be avoided.

5. Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, underpads or briefs can be used that are made of materials that absorb moisture and present a quickdrying surface to the skin. For information about assessing and managing urinary incontinence, refer to Urinary Incontinence in Adults: Clinical Practice Guidelines (available from AHCPR Pubtications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; or call 800-358-9295). Topical agents mat act as barriers to moisture also can be used.

Moisture alone can make the skin more susceptible to injury (Leyden, 1977, 1984; Zimmer, 1986). Urine, stool, perspiration, and wound drainage also may contain substances other than moisture that irritate the skin; therefore, it is important to keep skin exposure to mese sources of moisture to a rrunimum.

The first line of attack should be management of incontinence (Urinary Incontinence, 1992). When sources of moisture cannot be controlled, evidence indicates that underpads or briefs specifically designed to absorb moisture and present a quick-drying surface result in improvement of the skin condition (Campbell, 1987; Davis, 1989). The inclusion of the recommendation to use topical agents as moisture barriers is in accord with the current clinical practice trends (Hibbs, 1985; Kramer, 1988).

6. SJdn injury due to friction and shear forces should be minimized by proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricants (such as cornstarch and creams), protective films (such as transparent him dressings and skin sealants), protective dressings (such as hydrocolloids), and protective padding.

Shear (when the skin remains stationary and the underlying tissue shifts) and friction (when the skin moves across a coarse surface, such as bed linens) predispose the skin to pressure-induced injuries. Most shear injuries can be eliminated with proper positioning. Cornstarch, emollient cream, barrier dressings, and heel and elbow pads also have been promoted as approaches to help reduce friction injuries, although none has been subjected to systematic research as it relates to preventing pressure ulcers (Leyden, 1984; Norton, 1962).

7. When apparently well-nourished individuals develop an inadequate dietary intake of protein or calories, caregivers fìrst should attempt to discover the factors compromising intake and offer support with eating. Other nutritional supplements or support may be needed. If dietary intake remains inadequate, and if consistent with overall goals of therapy, more aggressive nutritional interventions, such as enteral or parenteral feedings, should be considered.

For nutritionally compromised individuals, a plan of nutritional support and /or supplementation should be implemented that meets individual needs and is consistent with the overall goals of therapy.

Pressure ulcer development has been found to be related to impaired dietary intake among chronic care patients (Berlowitz, 1989). More specifically, Bergstrom and Braden (1992) found that dietary intake below the recommended daily allowances for calories, protein, and zinc in elderly nursing home patients was a predictor of pressure ulcer development.

To address the problem of impaired dietary intake, assistance with eating or nutritional supplements may be sufficient for the apparently well-nourished individual (Goode, 1989; Kaminski, 1989; Lidowski, 1988). For the nutritionally compromised patient, a more aggressive nutritional intervention, such as parenteral feedings, should be instituted (if it is congruent with the patient's overall plan of care).

8. If potential for improving mobility and activity status exists, rehabilitation efforts should be instituted if consistent with overall goals of therapy. Maintaining current activity level, mobility, and range of motion is an appropriate goal for most individuals.

Immobility and inactivity are associated not only with the development of pressure ulcers, but also with the development of larger ulcers (Abildgaard, 1979). Active and passive range of motion exercises reduce the deleterious effects of pressure on the tissues (Colbum, 1987; Dimant, 1988). Encouraging ambulation, introducing physiotherapy and supporting exercises that improve strength, flexibility, coordination and range of motion are examples of other types of physical rehabilitation that may help to prevent pressure ulcers (Droessler, 1979; Fugill, 1980; Levine, 1989).

9. Interventions and outcomes should be monitored and documented.

Detailed information regarding interventions including type, extent, and outcomes should be individualized and readily available in written form. To ensure continuity of care, the plan of care should be periodically re-evaluated by the multidisciplinary team.

GUIDEUNES FOR MECHANICAL IQADING AND SUPPORT SURfACES

1. Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours if consistent with overall patient goals. A written schedule for systematically turning and repositioning the patient should be used.

Elderly bedridden patients who do not reposition themselves have a higher incidence of pressure ulcers (Exton-Smith, 1961). Two clinical trials investigated the effects of repositioning immobilized patients. Norton and associates (1962) reported a lower incidence of pressure ulcers in at-risk patients who were turned every 2 to 3 hours; however, statistical teste of significance were not performed. In a randomized controlled trial involving 19 long-term facility residents, unscheduled small shifts in body position (in addition to turning every 2 hours) did not lower the incidence of pressure (Smith, 1990).

Although the supporting evidence could be stronger, the panel believes that there is sufficient data to support a recommendation for turning bedridden patients at least every 2 hours. The goal of repositioning is to allow tissue reperfusion before the tissue becomes ischemic. Repositioning should involve a sustained relief of pressure, not merely a temporary shift.

2. For individuals in bed, positioning devices, such as pillows or foam wedges, should be used to keep bony prominences (eg, knees or ankles) from direct contact with one another, according to a written plan.

Extremities should be supported in all positions (American Nurses' Association, 1985). The establishment and execution of written plans for repositioning have been endorsed in the usual care literature and by standards for professional organizations (International Association, 1988; VanEtten, 1990). An example of a positioning chart was developed and presented by Abruzzese (1985).

3. Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Do not use donuttype devices.

Because of the small surface area, it is difficult to redistribute pressure under the heels (Parish, 1980). The use of pillows under the lower length of the leg (but not under the knee), suspending the heels, is one effective method. Ring cushions (donuts), however, have been found more likely to cause than to prevent pressure ulcers and should not be used (Crewe, 1987).

4. When the side-lying position is used in bed, avoid positioning directly on the trochanter.

Studies have indicated that interface pressures are higher and transcutaneous oxygen tension is lower when individuals are positioned directly on their trochanters (Garber, 1982; Seiler, 1986). Patients should be positioned off the trochanter, ideally at a 30° angle (Braden, 1990; Low, 1990; Seiler, 1985).

5. Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated.

When the head of the bed is elevated, the skin and superficial fascia remain fixed against the bed linens, while the deep fascia and skeleton slide down toward the foot of the bed (shear injury). This also is true when sitting individuals slide down in their chairs. Blood vessels in the sacral area are likely to twist and distort, and tissue may become ischemic and necrotic (Reichel, 1958). In order to prevent shear injury from semi-Fowler positioning, the head of the bed should not be elevated more than 30°. When this is not possible, positioning techniques and devices that help individuals maintain their position in the bed or chair should be used.

6. Use a lifting device, such as trapeze or bed linen, to move (rather than drag) individuals in bed who cannot assist during transfer and position changes.

Although friction is most commonly associated with blisters and abrasions, it also can lead to more extensive injury. In addition, friction decreases the amount of pressure required to produce a pressure ulcer (Dinsdale, 1974). When transferring patients, care should be taken not to slide or drag the skin across the support surface (King, 1990; Maklebust, 1987). The patient also may help to prevent friction injuries by taking an active role and using the trapeze in the turning and repositioning process (Maklebust, 1987; Messner, 1987).

7. Any individual assessed to be at risk for developing pressure ulcers should be placed, when lying in bed, on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattresses.

Several studies have produced evidence that pressure-reducing devices can decrease the incidence of pressure ulcers when compared with standard hospital beds (Andersen, 1983; Goldstone, 1982). There is no evidence to recommend one type of device over another, however (Andersen, 1983; Daeschel, 1985; Whitney, 1984). For many patients, 4-inch convoluted foam overlays may be sufficient. More research is required to determine the pressure-reducing device most appropriate given the patient's level of risk.

8. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if this is consistent with overall patient management goals. Individuals who are able to reposition themselves should be taught to shiñ weight every 15 minutes.

Prolonged and uninterrupted mechanical loading of the tissue results in tissue breakdown (Kosiak, 1959; Reswick, 1976). Relief of interface pressure during sitting is required at least every hour and preferably more frequently. King and French (1990) suggested that patients shift their weight every 15 minutes for at least a 10-second duration.

9. For chair-bound individuals, the use of a pressure-reducing device, such as those made of foam, gel, air or a combination, is indicated. Do not use donut-type devices.

Through the use of a pressurereducing device, mechanical loading on tissue is reduced and the risk of pressure ulcers is in turn diminished (DeLateur, 1976; Ferguson-Pell, 1986; Garber, 1978). To ensure effectiveness, the device should be individually prescribed for the user so that it does not interfere with other aspects of mobility or personal autonomy (Cooney, 1984).

10. Positioning of chair-bound individuals in chairs or wheelchairs should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief.

Proper postural alignment reduces the risk of deformities that could impair respiratory function and selfcare activity. Distribution of weight influences the person's ability to transfer from the seat and defines the magnitude and location of maximum pressure. Balance and stability directly influence mobility, energy expenditure, and function performance. Use of pressure-reducing devices and positioning should be considered in conjunction with all these factors to ensure that the individual has maximum autonomy as well as protection from the possibility of pressure ulcers.

11. A written plan for the use of positioning devices and schedules may be helpful for chair-bound individuals.

Written plans are important to document the use of positioning devices and ensure continuity of care for the patient confined to a chair or wheelchair.

GUIDEUNES FOR EDUCATION IN PRESSURE ULCER PREVENTION AND EARLY INTERVENTION

1. Educational programs for the prevention of pressure ulcers should be structured, organized, and comprehensive and directed at all levels of health care providers, patients, and family or caregivers.

Effective pressure ulcer prevention depends on the coordinated effort of health care professionals in hospital settings and continued implementation of preventive interventions by family and the patient at home. A multidisciplinary approach that includes all caregivers is important and effective (Hamilton, 1989; Levine, 1989). The multidisciplinary approach may be operationalized in the form of a pressure ulcer clinic, tissue management program, tissue team, skin care team/task force, or pressure ulcer committee. When appropriate and possible, the patient and family should be involved (Colbum, 1987).

2. The educational program fer prevenfion of pressure ulcers should include information on the following items:

* Etiology and risk factors for pressure ulcers;

* Risk assessment tools and their application;

* Skin assessment;

* Selection and/or use of support surfaces;

* Development and implementation of an individualized program of skin care;

* Demonstration of positioning to decrease the risk of tissue breakdown; and

* Instruction on accurate documentation of pertinent data.

Moody (1988) has shown that educational programs decrease the incidence of pressure ulcers. A consensus exists that such programs should include the seven essential components noted in the guidelines (King, 1977; Kroskop, 1983; Moody, 1988).

3. The educational program should identify those responsible for pressure ulcer prevention, describe each person's role, and be appropriate to the audience in terms of level of information presented and expected participation. The educational program should be updated on a regular basis to incorporate new and existing techniques or technologies.

More continuity of care is reported when team approaches are used and each member has identified responsibilities (Dimant, 1988; Frye, 1986; Khun, 1984). The education program should be designed to meet the needs of the learner. Written and illustrated guides are helpful for those who must position patients, including family members (DiDomenico, 1989; King, 1977; Lovett, 1986; Morison, 1989). Coordinated, ongoing programs that provide consistent and accurate information are effective (Andberg, 1983; Dimant, 1988). It is imperative to update the content of educational programs as new information becomes available.

4. Educational programs should be developed, implemented, and evaluated using principles of adult learning.

The primary purpose of pressure ulcer prevention programs is to reduce the occurrence of ulcers, and such programs must have a built-in evaluation mechanism that considers baseline data and compliance with quality assurance standards.

CONCUJSION

The purpose of these guidelines is to assist practicing professionals in the field, as well as consumers, in the prevention and early treatment of pressure ulcers. For more information or copies of the full guidelines, contact AHCPR Publications Clearinghouse, PO Box 8547, Silver Spring, MD 20907; 800-358-9295 (voice), 301-589-3014 (fax).

AHCPR Disclaimer: This product is the work of a panel of experts and consumers convened by AHCPR pursuant to Federal Law. It does not necessarily represent the position of the US Department of Health and Human Services.

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