Tips for Keeping it Together
Estella Boger
May 2011
Why Prevent Pressure Ulcers
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Cause Pain
Interfere with ambulation & rehabilitation
Result in Osteomyelitis
Cause cellulitis and septicemia
Result in amputation
Take 2-12+ months to heal
Result in unnecessary healthcare costs – $8.5
billion spent annually on pressure ulcers
Result in litigation
Pressure Ulcer
• A pressure ulcer is a localized injury to the skin
and/or underlying tissue usually over a bony
prominence, as a result of pressure, or pressure
in combination with shear and/or friction.
• Results in vascular insufficiency, tissue anoxia
and cell death
NPUAP definition as of February 2007
Pressure Ulcers
 Possible causes include
- not repositioning the patient
- patient sliding down in bed
- laying on tubing or pieces of equipment
- TEDS, Jobst stockings, tubigrip
Contributing Factors
 Co-morbid condition - Medical diagnoses, pain,
 Patient nutrition
 Mobility status – Immobility is the most
significant risk factor. Patients who can’t
reposition themselves are at high risk
 Incontinence – moisture from incontinence
macerates skin. Fecal incontinence more
important risk factor than urinary incontinence.
Which is the most important risk factor for
pressure ulcers?
A) Fecal incontinence
B) Malnutrition
C) Diabetes
D) Immobility
D) Immobility
Patient profile
 64 year old female
 Co-morbid conditions: Diabetes mellitus,
Fibromyalgia, Osteoarthritis, Spinal stenosis,
Chronic pain, Depression
 Hospitalized due to falls
 Frequently refused to be repositioned due to pain
What
would you call this?
A) Ecchymosis
B) Stage 3 pressure ulcer
C) Suspected deep tissue injury
D) Incontinence associated dermatitis
C) Suspected Deep Tissue Injury
There is also a stage 2 pressure ulcer on the coccyx.
How do we prevent this?
 Start with assessment
 Initial and ongoing
 Several pressure ulcer prediction scales are available –
Braden, Norton
Where to Look - Pressure
 Check pressure points
- Heels
- Ankles, outer and inner
- Hips
- Coccyx/sacrum/buttocks
- Ischial areas
- Spinous processes
Where to Look - Pressure
- Shoulder blades
- Back of head
- Ears, especially the tops if patient has
oxygen by cannula
- Elbows
- Skin on legs and feet of patients with
TED hose, Jobst Stockings or tubigrip
on the lower extremities
Interventions
 Reposition the patient regularly - every 2-4 hours on a
pressure reducing mattress and at least every 2 hours on a
nonpressure reducing mattress. This is the most
important intervention.
 Use of pressure reducing mattresses – this does not replace
repositioning but is an adjunct treatment
 Minimize friction and shear by keeping skin clean and dry,
keeping head of bed below 30 degrees, using lift sheets to
turn patient
Interventions
 Avoid using foam donuts or rings – they
concentrate pressure on the surrounding tissue
 Avoid sheepskin for pressure reduction – it’s
comfortable but doesn’t reduce pressure. The
same can be said for eggcrate cushions and
mattresses
 Maintain adequate nutrition – your facility
dietition can be very helpful with this
What is the most important intervention for
preventing pressure ulcers?
A) Repositioning the patient
B) Special mattress
C) Nutritional supplementation
D) Medication
A) Repositioning the patient
A special mattress could help.
Optimizing nutrition could also help.
If the patient has quite a bit of pain, pre-medication with
an analgesic might be helpful.
References
 Guideline for Prevention and Management of
Pressure Ulcers. WOCN Society. 2003.