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Agency for Health Care Policy and Research (US). AHCPR Quick Reference Guides. Rockville (MD): Agency for Health Care Policy and Research (US); 1992-1996.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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3Pressure Ulcers in Adults: Prediction and Prevention

Quick Reference Guide for Clinicians No. 3

Created: .

Attention Clinicians

The Clinical Practice Guideline on which this Quick Reference Guide for Clinicians is based was developed by an interdisciplinary, non-Federal panel comprised of health care professionals and a consumer representative. Panel members were:

  • Nancy Bergstrom, PhD, RN, FAAN (Chair)
  • Richard M. Allman, MD
  • Carolyn E. Carlson, PhD, RN
  • William Eaglstein, MD
  • Rita A. Frantz, PhD, RN, FAAN
  • Susan L. Garber, MA, OTR
  • Davina Gosnell, PhD, RN, FAAN
  • Bettie S. Jackson, EdD, MBA, FAAN
  • Mildred G. Kemp, PhD, RN, CETN, FAAN
  • Thomas A. Krouskop, PhD
  • Elena M. Marvel, MSN, MA, RN
  • George T. Rodeheaver, PhD
  • George C. Xakellis, MD

For a description of the guideline development process and information about the sponsoring agency (Agency for Health Care Policy and Research), see the Clinical Practice Guideline, Pressure Ulcers in Adults: Prediction and Prevention (AHCPR Publication No. 92-0047), Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services, May 1992. To receive additional copies of the Clinical Practice Guideline, which includes this Quick Reference Guide (AHCPR Publication No. 92-0050), and a patient booklet (AHCPR Publication No. 92-0048), call toll free 1-800-358-9295 or write the AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907.

AHCPR invites comments and suggestions from users for consideration in development and updating of future guidelines. Please send written comments to Director, Office of the Forum for Quality and Effectiveness in Health Care, AHCPR, Executive Office Center, Suite 401, 2101 East Jefferson Street, Rockville, MD 20852.

Note: This Quick Reference Guide for Clinicians contains excerpts from the Clinical Practice Guideline, but users should not rely on these excerpts alone. Clinicians should refer to the complete Clinical Practice Guideline for a more detailed analysis and discussion of the available research, critical evaluation of the assumptions and knowledge of the field, considerations for patients with special needs, and references. The full Guideline Report has a more complete discussion of relevant research, including literature reviews and summary evidence tables.

Purpose and Scope

Pressure ulcers are serious problems that can lead to pain, a longer hospital stay, and a slower recovery. Fortunately, most can be prevented, and Stage I pressure ulcers (nonblanchable erythema of intact skin) that do form need not worsen in most circumstances. However, even the most vigilant nursing care may not prevent the development and worsening of pressure ulcers in some very high-risk individuals. In those cases, intensive therapy must be aimed at reducing risk factors, preventive measures, and treatment.

The purpose of this guideline is to help identify adults at risk of pressure ulcers and to define early interventions for prevention; it may also be used to treat Stage I pressure ulcers. This guideline is not intended as a basis for care of infants and children. The guideline does not apply to individuals with existing Stage II or greater pressure ulcers or to individuals who are fully mobile.

Recommendations target four goals: (1) identifying at-risk individuals who need prevention and the specific factors placing them at risk; (2)maintaining and improving tissue tolerance to pressure in order to prevent injury; (3) protecting against the adverse effects of pressure, friction, and shear; and (4) reducing the incidence of pressure ulcers through educational programs.

A pressure ulcer is defined as any lesion caused by unrelieved pressure that results in damage to underlying tissue. Pressure ulcers usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed. The staging of pressure ulcers recommended for use by this panel is consistent with the recommendations of the National Pressure Ulcer Advisory Panel (NPUAP):

  • Stage I: Nonblanchable erythema of intact skin; the heralding lesion of skin ulceration. Note: Reactive hyperemia can normally be expected to be present for one-half to three-fourths as long as the pressure occluded blood flow to the area; it should not be confused with a Stage I pressure ulcer.
  • Stage II: Partial thickness skin loss involving epidermis and/or dermis. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
  • Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.
  • Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to muscle, bone, or supporting structures (for example, tendon or joint capsule). Note: Undermining and sinus tracts may also be associated with Stage IV pressure ulcers.

Staging definitions recognize these limitations:

  1. Assessment of Stage I pressure ulcers may be difficult in patients with darkly pigmented skin.
  2. When eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided.

The guideline is intended for clinicians who examine and treat persons at risk of developing pressure ulcers. These clinicians include family physicians, internists, geriatricians, dieticians, occupational and physical therapists, nurses, and nurse practitioners working in a variety of health care settings such as acute care, rehabilitation, geriatric care, and home- and community-based settings.

After an extensive review of the scientific literature, the panel used the following criteria to grade the evidence supporting each recommendation:

  • A. There is good research-based evidence to support the recommendation.
  • B. There is fair research-based evidence to support the recommendation.
  • C. The recommendation is based on expert opinion and panel consensus.

Risk Assessment Tools and Risk Factors

Goal: Identify at-risk individuals needing prevention and the specific factors placing them at risk.

Bed- and chair-bound individuals or those with impaired ability to reposition should be assessed for additional factors that increase risk for developing pressure ulcers. These factors include immobility, incontinence, 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 Norton Scale (reproduced here). Pressure ulcer risk should be reassessed periodically. (Strength of Evidence = A.) All assessments of risk should be documented. (Strength of Evidence = C.)

Norton Scale

Physical conditionMental conditionActivityMobilityIncontinentTotal Score
Good 4Alert4Ambulant4Full4Not4
Fair3Apathetic3Walk-help 3Slightly limited 3Occasional 3
Poor 2Confused2Chair-bound 2 Very limited 2 Usually-Urine 2
Very bad1 Stupor 1 Stupor 1 Immobile 1Doubly 1
NameDate

Source: Doreen Norton, Rhoda McLaren, and A.N. Exton-Smith. An investigation of geriatric nursing problems in the hospital. London. National Corporation for the Care of Old People (now the Centre for Policy on Ageing); 1962. Reprinted with permission.

Skin Care and Early Treatment

Goal: Maintain and improve tissue tolerance to pressure in order to prevent injury.

 1. All 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. (Strength of Evidence = C.)

 2. Skin should be cleansed 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. (Strength of Evidence = C.)

 3. Minimize environmental factors leading to skin drying, such as low humidity (less than 40 percent) and exposure to cold. Dry skin should be treated with moisturizers. (Strength of Evidence = C.)

 4. Avoid massage over bony prominences. Current evidence suggests that massage over bony prominences may be harmful. (Strength of Evidence = B.)

 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 quick-drying surface to the skin. For information about assessing and managing urinary incontinence, refer to Urinary Incontinence in Adults: Clinical Practice Guideline (available from AHCPR). Topical agents that act as barriers to moisture can also be used. (Strength of Evidence = C.)

 6. Skin injury due to friction and shear forces should be minimized through proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricants (such as corn starch and creams), protective films (such as transparent film dressings and skin sealants), protective dressings (such as hydrocolloids), and protective padding. (Strength of Evidence = C.)

 7. When apparently well-nourished individuals develop an inadequate dietary intake of protein or calories, caregivers should first 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 intervention such as enteral or parenteral feedings should be considered. (Strength of Evidence = C.)  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. (Strength of Evidence = C.)

 8. If the potential exists for improving the individual's mobility and activity status, rehabilitation efforts should be instituted if consistent with the overall goals of therapy. Maintaining current activity level, mobility, and range of motion is an appropriate goal for most individuals. (Strength of Evidence = C.)

 9. Interventions and outcomes should be monitored and documented. (Strength of Evidence = C.)

Mechanical Loading and Support Surfaces

Goal: Protect against the adverse effects of external mechanical forces: pressure, friction, and shear.

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 individual should be used. (Strength of Evidence = B.)

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

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 donut-type devices. (Strength of Evidence = C.)

4. When the side-lying position is used in bed, avoid positioning directly on the trochanter. (Strength of Evidence = C.)

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. (Strength of Evidence = C.)

6. Use lifting devices such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfers and position changes. (Strength of Evidence = C.)

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. (Strength of Evidence = B.)

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 consistent with overall patient management goals. Individuals who are able should be taught to shift weight every 15minutes. (Strength of Evidence = C.)

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. (Strength of Evidence = C.)

10. Positioning of chair-bound individuals should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief. (Strength of Evidence = C.)

11. A written plan for the use of positioning devices and schedules may be helpful for chair-bound individuals. (Strength of Evidence = C.)

Education

Goal: Reduce the incidence of pressure ulcers through educational programs.

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. (Strength of Evidence = A.)

The educational program for prevention of pressure ulcers should include information on the following items (Strength of Evidence = B):

  • The etiology of 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 risk of tissue breakdown.
  • Instruction on accurate documentation of pertinent data.

3. The educational program should identify those persons 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. (Strength of Evidence = C.)

4. Educational programs should be developed, implemented, and evaluated using principles of adult learning. Programs must have built-in mechanisms such as quality assurance standards and audits to evaluate their effectiveness in preventing pressure ulcers. (Strength of Evidence = C.)

Algorithm

The algorithm that follows was developed as a visual display of the conceptual organization, procedural flow, decision points, and preferred management path discussed in the guideline. It begins at the point of admission to an acute care hospital, rehabilitation hospital, nursing home, home care program, or other health care facility or program. Numbers in the algorithm refer to the annotations that follow.

Pressure Ulcer Prediction and Prevention Algorithm

1. Activity or Mobility Deficit

Bed- or chair-bound individuals or those whose ability to reposition is impaired should be considered at risk for pressure ulcers. Identification of additional risk factors (immobility, moisture/incontinence, and nutritional deficit) should be undertaken to direct specific preventive treatment regimes.

2. Educational Program

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. Refer to Educational Guideline 1-4 (page 11).

3. Reassessment

Active, mobile individuals should be periodically reassessed for changes in activity and mobility status. The frequency of reassessment depends on patient status and institutional policy.

4. Risk Assessment Tools

Clinicians are encouraged to select and use a method of risk assessment that ensures systematic evaluation of individual risk factors. Many risk assessment tools exist, but only the Norton Scale and Braden Scale have been tested extensively.

Risk assessment tools include the following risk factors: mobility/activity impairment, moisture/incontinence, and impaired nutrition. Altered level of consciousness (or altered sensory perception) is also identified as a risk factor in most assessment tools. Identification of individual risk factors (boxes 5-7) is helpful in directing care.

5. Mobility/Activity Deficit

If there is a deficit, see boxes 8 and 9:

Mechanical Loading and Support Surfaces (see page 9)

For bed-bound individuals:

  • Reposition at least every 2 hours.
  • Use pillows or foam wedges to keep bony prominences from direct contact.
  • Use devices that totally relieve pressure on the heels.
  • Avoid positioning directly on the trochanter.
  • Elevate the head of the bed as little and for as short a time as possible.
  • Use lifting devices to move rather than drag individuals during transfers and position changes.
  • Place at-risk individuals on a pressure-reducing mattress. Do not use donut-type devices.

For chair-bound individuals:

  • Reposition at least every hour.
  • Have patient shift weight every 15 minutes if able.
  • Use pressure-reducing devices for seating surfaces. Do not use donut-type devices.
  • Consider postural alignment, distribution of weight, balance and stability, and pressure relief when positioning individuals in chairs or wheelchairs.
  • Use a written plan.

Skin Care and Early Treatment (see Guideline 1-4, 6, 8, 9, pages 7-8)
  • Inspect skin at least once a day.
  • Individualize bathing schedule. Avoid hot water. Use a mild cleansing agent.
  • Minimize environmental factors such as low humidity and cold air. Use moisturizers for dry skin.
  • Avoid massage over bony prominences.
  • Use proper positioning, transferring, and turning techniques.
  • Use lubricants to reduce friction injuries.
  • Institute a rehabilitation program.
  • Monitor and document interventions and outcomes.

6. Moisture/Incontinence

If there is moisture or incontinence, see: Skin Care and Early Treatment (see Guideline 2, 5, page 7)

  • Cleanse skin at time of soiling.
  • Minimize skin exposure to moisture. Assess and treat urinary incontinence. When moisture cannot be controlled, use underpads or briefs that are absorbent and present a quick-drying surface to the skin.

7. Nutritional Deficit

If there is a nutritional deficit, see: Skin Care and Early Treatment (see Guideline 7, pages 7-8)

  • Investigate factors that compromise an apparently well-nourished individual's dietary intake (especially protein or calories) and offer him or her support with eating.
  • Plan and implement a nutritional support and/or supplementation program for nutritionally compromised individuals.

Risk should be periodically reassessed. Care should be modified according to the level of risk. Frequency of reassessment depends on patient status and institutional policy.

Citation Information—Inside Back Cover

This document is in the public domain and may be used and reprinted without special permission, except for those copyrighted materials noted for which further reproduction is prohibited without the specific permission of copyright holders. AHCPR appreciates citation as to source, and the suggested format is provided below: Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Quick Reference Guide for Clinicians. AHCPR Publication No.92-0050. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. May 1992.

AHCPR Pub. No. 92-0050.

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