Prevention of Decubitus Ulcers

How to Prevent Pressure Sores
A recent US Dept. of Health and Human Services article lists methods to prevent decubitus ulcers in hospital patients and nursing home residents. The government study collected differing studies and isolated the areas of agreement in decubitus ulcer prevention and treatment of decubitus ulcers.

Areas of Agreement Between Differing Researchers

Skin Care and Protection
There is overall agreement that keeping the skin clean, dry and moisturized is an important preventive step. The groups further agree that massage over bony prominences should be avoided, and that dry lubricants or other protective dressings (e.g., transparent films, hydrocolloids) should be used to avoid skin injury from friction/shear during transferring and turning. Both groups recommend use of moisturizers on dry skin.

The groups agree that incontinence-related skin moisture can be a risk factor for pressure ulcer development, and that the etiology of the incontinence should be identified and eliminated, if possible. Both groups recommend that skin be cleansed and dried as soon as possible after each incontinent episode, and that hot water, drying bar soaps, and irritating cleansing agents (e.g., products with fragrance or alcohol) should be avoided. The use of skin protectants/incontinence skin barriers is recommended by both groups, with the Wound, Ostomy, and Continence Nurses Society (WOCN) noting that products with humectants should be avoided. There is further agreement that absorbent underpads/undergarments that wick moisture away from the skin should be used. WOCN also recommends a bowel/bladder management retraining program be established, and consideration of a pouching system or a bowel or fecal containment device to contain excessive stool output and to protect the skin from the effluent. They add that an indwelling catheter may be indicated in situations where the severity of urinary incontinence has contributed to or may contaminate the pressure ulcer. The Hartford Institute for Geriatric Nursing (HIGN) recommends a bedpan or urinal be offered in conjunction with turning schedules.

Positioning and Pressure-Relieving Devices
Both groups recommend the following be implemented to aid in the prevention of pressure ulcers: elevation of the head of the bed to no more than 30 degrees (or at the lowest degree of elevation consistent with the patient’s medical condition); use of a 30-degree lateral lying position; avoidance of placement of the patient directly on his/her trochanter; use of lift sheets/equipment to reposition or transfer patients rather than dragging or pulling; employment of trapeze bars to facilitate the patient who is able to assist with mobility; protection of high-risk areas such as the elbows, heels and sacrum; and use of pillows or wedges to reduce pressure over bony prominences and to keep them from rubbing together. There is further agreement that donut-type devices should not be used for pressure redistribution; WOCN also recommends against foam rings, foam cut-outs, and synthetic sheepskin.

There is further agreement that support surfaces should be used on beds and chairs to redistribute pressure. HIGN cites static air, alternating air, gel, and water mattresses as treatment of bed sores options. WOCN notes that there is insufficient evidence to support the choice of one specific pressure redistribution surface/device over another, adding, however, that it has been reported that at-risk patients should not be placed on an ordinary, standard hospital mattress. WOCN continues to note that compared with standard hospital mattresses, alternating or dynamic mattresses and oscillating air-flotation beds have been associated with a lower incidence of pressure ulcers. They add that high specification foam has been shown to be effective in decreasing the incidence of pressure ulcers in high-risk patients. When choosing a support surface, WOCN states that factors to consider other than interface pressure include skin surface tension, shear force, temperature, humidity, the magnitude and duration of interface pressure, pressure and blood flow distribution, and adult versus pediatric patients.

With regard to heel pressure ulcers, the groups agree that heel protection devices should completely offload (float) the heel. WOCN notes that no specific support surface or heel product has proven superior overall in decreasing pressure at the heel. They recommend against the use of synthetic sheep skin, bunny boots, rigid splints, IV bags, and rolled towels or sheets. WOCN adds that pillows under calves decrease heel interface pressures as well as foam cushions under calves, and that the recommended method is to place the pillow longitudinally underneath the calf with the heel suspended in air.

The groups agree that chair-bound individuals have unique repositioning and pressure redistribution needs. There is agreement that for those who can reposition themselves while sitting, pressure relief using weight shifts or activities (e.g., chair push-ups, standing and re-sitting, elevating the legs or placing the feet on a stool) should be encouraged every 15 minutes. There is further agreement that those who are incapable of performing position changes while sitting should be repositioned at least every hour by a caregiver. The use of a pressure-reducing device (not a donut) is recommended by both groups for chair-bound clients. According to WOCN, selection of appropriate pressure redistributing chair cushions should be done by trained health care professionals who have specific knowledge and expertise in this area; chair cushions have not been adequately evaluated to recommend one over another.

The groups agree that individuals with suspected or identified nutritional deficiencies should be referred to a registered dietician. HIGN recommends protein and calorie intake be increased and A, C, or E vitamin supplements be administered as needed. WOCN recommends maintenance of adequate nutrition that it is compatible with the individual’s wishes or condition, and that individuals with nutritional and pressure ulcer risks be offered a minimum of 30-35 kcal per kg body weight per day with 1.25-1.5 g/kg/day protein and 1 ml of fluid intake per kcal per day. HIGN recommends offering a glass of water with turning and repositioning schedules to keep the patient hydrated. For potential treatment options for pressure sores, click here.

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