In addition, patients with lower extremity edema or patients who have had a pressure ulcer in the past are high risk. Therefore, regardless of their Braden score, these patients need a higher level of preventive care: support surface use, dietary consults, and more frequent skin assessments.

Documentation should reflect the increased risk protocols. Read more about how critically ill patients have factors that put them at risk for developing pressure ulcers despite implementation of pressure ulcer prevention bundles: Shanks HT, Kleinhelter P, Baker J.

Skin failure: a retrospective review of patients with hospital-acquired pressure ulcers. World Council Enterostomal Ther J ;29 1 A number of guidelines have been published describing best practices for pressure ulcer prevention.

These guidelines can be important resources to use in improving pressure ulcer care. In addition, the International Pressure Ulcer Guideline released by the National Pressure Ulcer Advisory Panel and the European Pressure Ulcer Advisory Panel is available. A Quick Reference Guide can be downloaded from their Web site at no charge.

Clinical Practice Guideline 3: Pressure ulcers in adults: prediction and prevention. Rockville, MD: Agency for Healthcare Policy and Research; May AHCPR Pub. Pressure ulcer prevention and treatment following spinal cord injury: a clinical practice guideline for health-care professionals.

Consortium for Spinal Cord Medicine Clinical Practice Guidelines. J Spinal Cord Med Spring;24 Suppl 1:S National Pressure Ulcer Advisory Panel NPUAP and European Pressure Ulcer Advisory Panel EPUAP.

American Medical Directors Association: Pressure Ulcers in the Long-Term Care Setting. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline.

Washington, DC: National Pressure Ulcer Advisory Panel; October Wound, Ostomy and Continence Nurses Society. Pressure ulcer assessment: best practices for clinicians. 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.

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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.

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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.

If your loved one is spending a lot of time up in a chair, egg crate chair pads are also available. An egg crate surface helps distribute pressure more evenly, helping minimize the amount of pressure on one area.

A step up from the egg crate mattress is an air mattress overlay. This type of surface is placed on top of a mattress and typically alternates air pressure in various columns. The big guns of pressure-relieving devices are the fluidized air mattresses. These special mattresses contain silicone-coated glass beads that become fluid when the air is pumped through them.

These mattresses do a wonderful job of relieving pressure but they have their downside. The frame of the mattress makes transferring to and from bed difficult. And if the person wants to sit up in bed, a foam wedge would probably need to be used to help support their back. This mattress is really best suited for palliative care patients who are fully bed-bound, have severe pressure ulcers , and are in a lot of pain.

Friction is the rubbing of skin on an external surface, usually bed sheets. Friction to the most commonly affected areas can be reduced with protective devices. Heel and elbow cradles are typically made of egg-crate material and Velcro on.

Use a draw sheet to help you lift your loved one off the bed when you lift and reposition. Shear is created when the deeper fatty tissues and blood vessels are damaged by a combination of friction and gravity.

The best way to avoid this type of injury is to avoid a semi-Fowler and upright position in bed. A semi-Fowler position is where the head is raised less than 30 degrees and upright positions more than 30 degrees. Many patients need to be semi-Fowler to help ease shortness of breath or prevent gastric reflux and all patients need to be in an upright position to eat safely.

To minimize the risk of shear injury in a semi-Fowler or upright position, take precautions to prevent your loved one from sliding down in bed. You can do this by raising the foot of the bed and propping the knees up with pillows. Shear injury can happen in chairs too. To keep your patient from sliding in their chair, use footstools or ottomans to prop their feet and pillows or special devices to keep their hips at a degree angle.

There is a strong correlation between nutrition deficits and pressure ulcer risk. If your loved one has an appetite, try to maintain adequate nutrition with nutrient-rich foods think lean proteins, whole grains, fruits, and vegetables. If their appetite is waning, offer supplements such as Ensure or Boost to help bolster nutrition.

Moisture from sweat, urine, or feces can be damaging to the skin. If a patient accumulates a lot of moisture from sweat, they will need their clothing and possibly sheets changed frequently.

You can make this easy on yourself by using hospital gowns or other clothing that slips on and off easily. Using several layers of sheets can also make this task easy. If your loved has urinary incontinence, they will need frequent changing of their adult diapers or pull-ups. Checking the diaper at least every two hours and changing it as soon as it is soiled is important.

Bedsore Enlarge image Close. Bedsore Bedsores are areas of damaged skin and tissue caused by sustained pressure — often from a bed or wheelchair — that reduces blood circulation to vulnerable areas of the body.

Request an appointment. Thank you for subscribing! Sorry something went wrong with your subscription Please, try again in a couple of minutes Retry. By Mayo Clinic Staff. Show references Pressure ulcers.

Merck Manual Professional Version. Accessed Dec. Berlowitz D. Clinical staging and management of pressure-induced injury. Office of Patient Education. How to prevent pressure injuries. Mayo Clinic; Pressure injury. Ferri FF. Pressure ulcers. In: Ferri's Clinical Advisor Philadelphia, Pa.

How to manage pressure injuries. Rochester, Minn. Prevention of pressure ulcers. Tleyjeh I, et al. Infectious complications of pressure ulcers. Lebwohl MG, et al. Superficial and deep ulcers.

In: Treatment of Skin Disease: Comprehensive Therapeutic Strategies. National Pressure Ulcer Advisory Panel NPUAP announces a change in terminology from pressure ulcer to pressure injury and updates the stages of pressure injury. News release. Accessed April 13, Raetz J, et al. Common questions about pressure ulcers.

American Family Physician. Epidemiology, pathogenesis and risk assessment of pressure ulcers. Gibson LE expert opinion. Mayo Clinic, Rochester, Minn.

Pressure ulcer prevention.

Friction to the most commonly affected areas can be reduced with protective devices. Heel and elbow cradles are typically made of egg-crate material and Velcro on. Use a draw sheet to help you lift your loved one off the bed when you lift and reposition.

Shear is created when the deeper fatty tissues and blood vessels are damaged by a combination of friction and gravity. The best way to avoid this type of injury is to avoid a semi-Fowler and upright position in bed. A semi-Fowler position is where the head is raised less than 30 degrees and upright positions more than 30 degrees.

Many patients need to be semi-Fowler to help ease shortness of breath or prevent gastric reflux and all patients need to be in an upright position to eat safely. To minimize the risk of shear injury in a semi-Fowler or upright position, take precautions to prevent your loved one from sliding down in bed.

You can do this by raising the foot of the bed and propping the knees up with pillows. Shear injury can happen in chairs too. To keep your patient from sliding in their chair, use footstools or ottomans to prop their feet and pillows or special devices to keep their hips at a degree angle.

There is a strong correlation between nutrition deficits and pressure ulcer risk. If your loved one has an appetite, try to maintain adequate nutrition with nutrient-rich foods think lean proteins, whole grains, fruits, and vegetables.

If their appetite is waning, offer supplements such as Ensure or Boost to help bolster nutrition. Moisture from sweat, urine, or feces can be damaging to the skin. If a patient accumulates a lot of moisture from sweat, they will need their clothing and possibly sheets changed frequently.

You can make this easy on yourself by using hospital gowns or other clothing that slips on and off easily. Using several layers of sheets can also make this task easy. If your loved has urinary incontinence, they will need frequent changing of their adult diapers or pull-ups.

Checking the diaper at least every two hours and changing it as soon as it is soiled is important. Using skin barrier creams can help prevent damage from urine. If a pressure ulcer already exists or if there is a high risk of developing one, it may be beneficial to place an indwelling Foley catheter.

A Foley catheter is a small tube that is inserted into the urethra and into the bladder where it remains with the help of an inflated balloon.

Once placed, urine drains out of the tube and into a collection bag, keeping the skin free from urine. A person who has bowel incontinence is at an increased risk of skin breakdown from the bacteria and digestive enzymes found in bowel movements.

They will need to be cleaned and changed as soon as possible after every bowel movement. This can be quite a challenge if your patient suffers from diarrhea or has frequent bowel movements.

But it will be well worth the hard work if it prevents painful skin breakdown. Preventing pressure ulcers can be hard work.

Like most things that require hard work, the payoff is huge. Keeping your loved one free of painful pressure sores will make all the physical labor seem well worth it.

Ferris A, Price A, Harding K. Pressure ulcers in patients receiving palliative care: A systematic review. Palliat Med. Saghaleini SH, Dehghan K, Shadvar K, Sanaie S, Mahmoodpoor A, Ostadi Z. Pressure Ulcer and Nutrition. Indian J Crit Care Med. By Angela Morrow, RN Angela Morrow, RN, BSN, CHPN, is a certified hospice and palliative care nurse.

Use limited data to select advertising. Create profiles for personalised advertising. Use profiles to select personalised advertising. Create profiles to personalise content. Use profiles to select personalised content. Measure advertising performance. Measure content performance.

Understand audiences through statistics or combinations of data from different sources. Develop and improve services. 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.

Workers have a common language by which they describe risk. Action Steps Ask yourself and your team: Do the unit staff understand why they are doing the risk assessment? Are unit staff communicating the risk assessment results to all clinicians who need to know?

Presence of a pressure ulcer: All patients with an existing pressure ulcer should be considered at-risk for an additional ulcer. Prior Stage III or IV pressure ulcers: When Stage III or IV ulcers close through a process of scar tissue formation and eventual epithelialization, the resulting skin is not normal as it lacks its former tensile strength and is very prone to break down again.

Hypoperfusion states: Patients who are not perfusing vital organs as a result of conditions such as sepsis, dehydration, or heart failure are also not adequately perfusing the skin. Minimal amounts of pressure may then cause ulceration.

Peripheral vascular disease: Because of the limited blood supply to the legs, these patients are predisposed to pressure ulcers of the feet, particularly the heels. Diabetes: Patients with diabetes have consistently been shown to be at increased risk of pressure ulcers.

Smoking: Smoking interferes with oxygen delivery. Smoking is associated with recurrence of pressure ulcers postsurgery and likely increases risk of new pressure ulcers. Restraint use: Patients with physical restraints have limited mobility in addition to having pressure applied at the site of the restraints.

Chemical restraints with resulting sedation may lead to rapid decline in mobility. Spinal cord injury: Immobility, incontinence, and impaired sensation may combine to place these patients at exceptionally high risk. The level and completeness of the spinal cord injury is critical in this determination.

Operating room OR and emergency room ER stays: Prolonged time on a hard surface or in one position increases the risk of skin breakdown. This often happens in an OR or ER, with lengthy procedures, or while transporting a patient,.

Always consider the length of time that the patient may need to stay in one position. Patients who undergo a procedure longer than 4 hours are at particularly high risk.

Practice Insights Comprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development. Action Steps Ask yourself and your team: Are we using a risk assessment tool in conjunction with the assessment of additional specific patient risk factors?

When and what kind of training did the staff receive on how to use and interpret the scales? Are risk assessment results being used as a basis for planning care? Tools Copies of the Braden and Norton scales are included in Tools and Resources Tool 3D, Braden Scale , and Tool 3E, Norton Scale.

Resources Consider the following resources for risk assessment in special populations: Palliative Care: Hunters Hill Marie Curie Centre Risk Assessment Tool. Chaplin J, McGill M. Pressure sore prevention. Palliative Care Today ;8 3 Home Care: Braden Scale for Predicting Pressure Sore Risk in Home Care.

Available at: www. Pediatrics: Braden Q 21 days to 8 years. Quigley SM, Curly MAQ. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Spec Pediatr Nurs ;1 1 Glamorgan Scale birth to 18 years.

Willock J, Harris C, Harrison J, et al. Identifying the characteristics of children with pressure ulcers. Nursing Times ; 11 Pediatric Waterlow neonate to 16 years.