Interventions To Prevent Pressure Ulcers

Single And Multicomponent Interventions

A number of standalone interventions to prevent pressure ulcers have been evaluated in high quality systematic reviews. These reviews have found convincing evidence of effectiveness for high-specification foam mattresses,7 but not for standalone nutritional interventions8 or for the application of topical agents over bony prominences.9 While both risk assessment and repositioning of patients are likely to be worthwhile practices, there is currently no clear evidence to favour one particular pressure ulcer risk assessment tool,10 or a particular frequency or position for repositioning.11

In practice, multicomponent interventions or care bundles are generally recommended over standalone interventions for the prevention of pressure ulcers. Recently, an NHS Stop the Pressure campaign was rolled out nationally to support a 50% reduction in pressure ulcer prevalence throughout winter 2013/14.2 As well as providing educational resources, the campaign promotes the SSKIN care bundle that emphasises the need for a bundle of practices, incorporating appropriate pressure-relieving surfaces, skin inspections, repositioning of patients, incontinence/moisture management, and where necessary nutrition/hydration support.

Purpose Of Systematic Review

Knowledge is translated from research into clinical practice based on the evidence reported by systematic reviews . Yet, there has not been a systematic review of the intensive care literature published since 2002 for HAPU prevention strategies incorporating the Braden scale , and none focused on care bundles. The purpose of this systematic review was to evaluate the effectiveness of care bundles incorporating the Braden scale for risk assessment in reducing the HAPU prevalence in older adults hospitalized in the ICU.

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Is 2 Hourly Repositioning Abuse

Two-hour repositioning is abuse It interrupts natural sleep patterns, causing constant tiredness, which the research say can trigger the person to acting out their feelings of frustration. In addition, patients with dementia are often not able to give their consent to the practice, the researchers say.

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Risk Assessment And Prevention Of Pressure Ulcers

About this Guideline

Define early interventions for pressure ulcer prevention, and to manage Stage I pressure ulcers.

This best practice guideline assists nurses who work in diverse practice settings to identify adults who are at risk of pressure ulcers. This guideline focuses its recommendations on:

• Practice Recommendations including assessment, planning, intervention and discharge/transfer of care
• Educational Recommendations for supporting the skills required for nurses working with adults at risk for pressure ulcers
• Organization & Policy Recommendations addressing the importance of a supportive practice environment as an enabling factor for providing high quality nursing care, which includes ongoing evaluation of guideline implementation.

Revised: 2011

Nancy Parslow RN, CETN, MClSc Wound Healing – Team LeaderKaren Campbell RN, MScN, PhDChris Fraser HBSc, RDConnie Harris RN, ET, IIWCC, MScKathryn Kozell RN, BA, MScN, APN, CETNJanet Kuhnke RN, BA, BScN, MS, ET, PhDKimberly LeBlanc RN, BScN, MN, CETNSusan Mills Zorzes RN, BScN, MDE, CWOCN, CETNLinda Norton OTReg., MScCHLyndsay Orr PT, MCLSc Wound HealingFruan Tabamo RN, BPh, BTh, MCLScLaura Teague RN, MN, NP-AdultKevin Woo RN, PhD, GNC, FAPWCAFrederick Go, RN, MNBa Pham MSc, PhD – Advisory Panel Member

Fran MacLeod, RN, MScN – Team LeaderPatti Barton, RN, PHN, ETKaren Campbell, RN, MSN

Who Is At Risk For Developing Pressure Injuries

• People with a limited amount of mobility or a total inability to move. Those in wheelchairs or bedridden are at particular risk and need to be moved or turned regularly.
• Those with prosthetic limbs. If the device does not fit properly, the skin can be irritated and a pressure injury can develop.
• People with a loss of sensation. They are at risk because they may not feel the pressure being applied to the skin. As a result, they may not move, which could worsen the damage.
• Those with malnutrition. Wound healing is slowed when nutritional needs are not met.
• The elderly. As people age, the skin naturally becomes thinner and more easily damaged.

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Pressure Injury Prevention & Management

Implementing an evidence-based best practice system for pressure injury prevention and management can reduce the potential for pressure injury development and promote healing of existing pressure injuries.

Each person should be assessed for pressure injury risk factors on admission and receive an in-depth assessment of any existing pressure injuries. The assessment process drives the development of person-centered goals and interventions to prevent or heal pressure injuries.

The care plan should reflect the persons preferences, values and needs and identify the interventions necessary to meet his/her goals for treatment. The care plan should also include guidelines for reassessment to evaluate the effectiveness of the care provided and to prompt changes in treatment as needed. The use of any particular intervention should be based on the strength of the evidence provided by existing clinical trials or literature reviews.

Evaluation and monitoring outcomes are vital components of any program for managing pressure injury risk and treating existing pressure injuries. An effective system includes reassessment of the persons risk for developing a pressure injury. The frequency of reassessment will depend on a variety of factors, with more frequent assessments for people with existing pressure injuries, those who are at high risk for developing pressure injuries, or those who have experienced a significant change of condition.

Adherence With The Clinical Interventions

The reported all-or-none adherence to the bundle was 16%, although this varied throughout the 9 weeks . The reported adherence to the individual elements also varied: adherence was 75% to the repositioning element 22% to the support surfaces element and 21% to the skin inspection element. The reasons for non-completion were rarely documented.

Figure 1

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How Should A Comprehensive Skin Assessment Be Conducted

The first step in our clinical pathway is the performance of a comprehensive skin assessment. Prevention should start with this seemingly easy task. However, as with most aspects of pressure ulcer prevention, the consistent correct performance of this task may prove quite difficult.

3.2.1 What is a comprehensive skin assessment?

Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking andtouching the skin from head to toe, with a particular emphasis over bony prominences.

As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. 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 .
• 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:

3.2.2 How is a comprehensive skin assessment performed?

• Temperature.

Relevance To Clinical Practice

Nursing interventions should consist of evidence-based âbundlesâ and be adapted to patientsâ needs. To prevent pressure injuries among critically ill patients, nurses must be competent and highly educated and ensure fundamental strategies are routinely implemented to improve mobility and offload pressure.

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What This Paper Adds

• A pressure ulcer prevention bundle for nursing homes is acceptable and has the potential to improve care.
• Nursing home staff believed their care became more comprehensive when using the bundle and they felt accountable for the care provided due to the inclusion of staff signatures on the bundle documentation sheet.
• We identified the following issues to be addressed by future studies: recruitment and retention collection of care and outcome data staff adherence.

If You Use A Wheelchair

Make sure your wheelchair is the right size for you.

• Have your doctor or physical therapist check the fit once or twice a year.
• If you gain weight, ask your doctor or physical therapist to check how you fit your wheelchair.
• If you feel pressure anywhere, have your doctor or physical therapist check your wheelchair.

Sit on a foam or gel seat cushion that fits your wheelchair. Natural sheepskin pads are also helpful to reduce pressure on the skin. DO NOT sit on a donut-shaped cushions.

You or your caregiver should shift your weight in your wheelchair every 15 to 20 minutes. This will take pressure off certain areas and maintain blood flow:

• Lean forward
• Lean to one side, then lean to the other side

If you transfer yourself , lift your body up with your arms. DO NOT drag yourself. If you are having trouble transferring into your wheelchair, ask a physical therapist to teach you the proper technique.

If your caregiver transfers you, make sure they know the proper way to move you.

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Risk Factors For Pressure Sores

A pressure sore is caused by constant pressure applied to the skin over a period of time. The skin of older people tends to be thinner and more delicate, which means an older person has an increased risk of developing a pressure sore during a prolonged stay in bed.

Other risk factors for pressure sores include:

• immobility and paralysis for example due to a stroke or a severe head injury
• being restricted to either sitting or lying down
• impaired sensation or impaired ability to respond to pain or discomfort. For example, people with diabetes who experience nerve damage are at increased risk of pressure sores
• urinary and faecal incontinence skin exposed to urine or faeces is more susceptible to irritation and damage
• malnutrition can lead to skin thinning and poor blood supply, meaning that skin is more fragile
• obesity being overweight in combination with, for example, immobility or being restricted to sitting or lying down can place extra pressure on capillaries. This then reduces blood flow to the skin
• circulation disorders leading to reduced blood flow to the skin in some areas
• smoking reduces blood flow to the skin and, in combination with reduced mobility, can lead to pressure sores. The healing of pressure sores is also a slower process for people who smoke.

If youre bedridden, pressure sores can occur in a number of areas, including:

• back or sides of the head
• rims of the ears
• backs or sides of the knees
• heels, ankles and toes.

Systematic Reviews Of Interventions For The Prevention And Treatment Of Pus: Search Of The Cochrane Library

A range of Cochrane systematic reviews has been undertaken to summarise the current evidence from RCTs of interventions for the prevention and treatment of PUs. A search of The Cochrane Library up to July 2017 revealed 50 results , 27 of which are relevant to this review . Of these, 23 reviews evaluate interventions specifically relating to PUs, and 4 relate to several types of chronic or complex wound including PUs. Twenty-one reviews found trials, which were eligible for inclusion, whilst five were empty reviews and another, whilst including various types of wound, did not include any patients with PUs. Of the 50 retrieved results from the search, 23 reviews were not relevant to this overview .

Fig. 1

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Culture Of Preventive Care

Nurses working in clinical units balance the acute actual needs of the patient with the available time to address prevention goals. There is no question that early intervention to prevent pressure injury is required, but the interventions must be integrated into the workflow process. Support surfaces must be present at the time of admission, because moving the unstable critically ill patient is often not possible. Preventive dressings must be available and placed quickly during movement of the patient. However, none of these interventions are completed if the nurse lacks the knowledge of best practice guidelines for pressure injury prevention or lacks the attitude about their significance. Implementation depends on experienced knowledge about HAPI prevention and attitude that compliance with prevention will achieve measurable improvements.

How Often Is Repositioning Necessary

Even though it’s often recommended that people be repositioned every two hours, there’s no single recommendation that works for everyone. Some people can lie in the same position for quite a long time without getting ulcers, while others need to switch much more often. Research has not yet found out how often someone should change position to get the best preventive effect.

Unnecessarily moving someone too much for no good reason can also have disadvantages. For instance, repositioning every two hours at night may wake the person each time and keep them from getting a good nights sleep. Changing position can also be very painful for people who have wounds or joint conditions. Frequent repositioning is physically demanding for caregivers or family members too. It’s therefore important to observe how often someones position really needs to be shifted. It can then help to make a note every time they are repositioned.

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Management Of The Residents Possessions On The Beds

It was not at all easy to manage the clutter on the residents beds. Due to insufficient space, it was impossible to give additional bedside cabinets to each resident. The in-charge of each nursing home explained to the family members how these belongings, which occupied much of the bed, affected the care provided to the residents. The family members were strongly advised to avoid buying unnecessary items for the residents. In the meantime, the PCWs cleared and tidied the beds every day and the existing bedside cabinets at least once a week in order to create more space to store as many of the belongings that had been placed on the beds as possible.

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What Is The Concept Of Repositioning

The term, “repositioning,” refers to the process of changing a target market’s understanding or perception of a product or service. A product’s positioning involves what customers think about its features and how they compare it to competing products. … Companies choose to reposition products for a variety of reasons.

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Description Of The Condition

A pressure ulcer is a localised injury to skin or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear . PUs occur when the soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time.

PU classification systems provide an accurate and consistent means by which the severity and level of tissue injury of a PU can be described and documented .The words stage , grade, and category are used interchangeably to describe the levels of softtissue injury. The original staging system includes Stages 1 to 4. Stage 1 reflects persistent nonblanching erythema of the skin . Stage 2 involves partialthickness skin loss . Stage 3 reflects fullthickness skin loss involving damage, or necrosis, of subcutaneous tissue, whereas in Stage 4 the damage extends to the underlying bone, tendon or joint capsule. However, more recently, two additional classifications have been identified, namely: unclassified/unstageable and deep tissue injury . PUs are associated with pain, an increased risk of infection and sepsis, longer hospital stays, higher hospitalisation costs and mortality .

Interventions For Pu Prevention And Treatment

A wide range of interventions is used in the prevention and treatment of PUs. Key preventative interventions include those which aim to redistribute pressure at the interface between the skin and the support surface . Key treatment interventions include support surfaces and also wound dressings. The UK National Institute for Health and Care Excellence commissioned the National Clinical Guideline Centre to produce a detailed clinical guideline for the prevention and management of PUs in primary and secondary care, which contains a list of interventions used in clinical practice . The main types of intervention are summarised in Box .

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Pressure Ulcers: Prevention Evaluation And Management

DANIEL BLUESTEIN, MD, MS, Eastern Virginia Medical School, Norfolk, Virginia

ASHKAN JAVAHERI, MD, Stanford University School of Medicine, Stanford, California, and Veterans Affairs Palo, Alto Health Care System, Palo Alto, California

Am Fam Physician. 2008 Nov 15 78:1186-1194.

• References

Pressure ulcers, also called decubitus ulcers, bedsores, or pressure sores, range in severity from reddening of the skin to severe, deep craters with exposed muscle or bone. Pressure ulcers significantly threaten the well-being of patients with limited mobility. Although 70 percent of ulcers occur in persons older than 65 years,1 younger patients with neurologic impairment or severe illness are also susceptible. Prevalence rates range from 4.7 to 32.1 percent in hospital settings2 and from 8.5 to 22 percent in nursing homes.3

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Compared with standard hospital mattresses, pressure-reducing devices decrease the incidence of pressure ulcers.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

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How Can Pressure Injuries Be Prevented

Ways to prevent pressure injuries include:

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How Are Pressure Injuries Treated

Pressure injuries can be treated in many ways depending on the stage. Once the stage and severity of the wound is determined, it must be cleaned, usually with a saline solution. After the wound is cleaned, it needs to be kept clean, moist, and covered with an appropriate bandage. There are several different types of bandages your doctor may use to dress the wound. These include:

• Water-based gel with a dry dressing
• Foam dressing
• Hydrocolloid dressing
• Alginate dressing

Sometimes debridement is needed. This is a process of ridding the wound of dead tissue. Debridement is an important part of the healing process. It changes the wound from a long-lasting one to a short-term wound. There are several types of debridement. These methods include:

• Ultrasound: Using sound waves to remove the dead tissue.
• Irrigation: Using fluid to wash away dead tissue.
• Laser: Using focused light beams to remove the dead tissue.
• Biosurgery: Using maggots to eliminate bacteria from the wound.
• Surgery: Using surgery to remove the dead tissue and close the wound.
• Topical: Medical-grade honey or enzyme ointments.