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Pressure Ulcer Prevention Strategies For Bariatric Patients Include

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Acp Clinical Practice Guidelines

Seven Strategies for Pressure Ulcer/Injury Prevention

The 2015 American College of Physicians clinical practice guidelines for risk assessment, prevention, and treatment of pressure ulcers included the following recommendations and statements :

  • Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016 Nov/Dec. 43 :585-597. . .

  • NPIAP pressure injury stages. National Pressure Injury Advisory Panel. Available at . Accessed: April 29, 2022.

  • Woolsey RM, McGarry JD. The cause, prevention, and treatment of pressure sores. Neurol Clin. 1991 Aug. 9:797-808. .

  • Abrussezze RS. Early assessment and prevention of pressure ulcers. Lee BY, ed. Chronic Ulcers of the Skin. New York: McGraw-Hill 1985. 1-9.

  • Schweinberger MH, Roukis TS. Effectiveness of instituting a specific bed protocol in reducing complications associated with bed rest. J Foot Ankle Surg. 2010 Jul-Aug. 49:340-7. .

  • Zhao G, Hiltabidel E, Liu Y, Chen L, Liao Y. A cross-sectional descriptive study of pressure ulcer prevalence in a teaching hospital in China. Ostomy Wound Manage. 2010 Feb 1. 56:38-42. .

  • Pham B, Stern A, Chen W, Sander B, John-Baptiste A, Thein HH, et al. Preventing pressure ulcers in long-term care: a cost-effectiveness analysis. Arch Intern Med. 2011 Nov 14. 171:1839-47. .

  • Keeping The Bariatric Patients Skin Intact

    This CE activity is expired.

    Dr. Black is Associate Professor of Nursing, Department of Adult Health and Illness, University of Nebraska Medical Center, Omaha, Nebraska. Ms. Clark is Instructor of Nursing, Department of Adult Health and Illness, University of Nebraska Medical Center College of Nursing, Omaha, Nebraska

    Financial disclosure: Dr. Black is a consultant for Coloplast Corporation and KCI. Ms. Clark reports no conflicts of interest relevant to the content of this article.

    Funding: This CE-accredited article was supported by an educational grant from KCI.

    Bariatric Times. 2011 8:2023

    AbstractThe authors review skin integrity issues specific to the bariatric patient population. Turning and repositions techniques are reviewed as well as prevention and management techniques. A case example is provided for illustrative purposes.

    IntroductionKeeping the skin of patients intact has always been a goal of healthcare providers for many reasons including pain, risk of infection, increased cost, and increased length of stay. In 2008, a financial reason was added to the list when the Centers for Medicare and Medicaid Services determined that hospitals would not receive payment for specified hospital-acquired conditions, including pressure ulcers. This provision makes it even more important for healthcare providers to take preventive actions to preserve skin integrity.

    Pressure Relief Ankle Foot Orthoses

    In simple terms, the PRAFO® range is perfect for all patients with compromised mobility and at risk of developing pressure sores at the heel.

    The term PRAFO® stands for Pressure Relief Ankle Foot Orthosis – a family of ankle-foot orthotic devices manufactured by Anatomical Concepts Inc and developed since 1995 to be extremely versatile and suitable for many applications.

    We have a version specifically designed to protect the heels of your larger patients whether they are ambulant, in bed or in a chair. .

    The product cradles the heel leaving it suspended so that no pressure or shear can be applied to vulnerable tissue at the heel or malleoli area.

    The product has an Adjustable Posterior Upright design that allows the dorsiflexion/plantarflexion angle to be precisely set. This means any existing deformity can be easily accommodated.

    The upright structure is heavy duty aluminium suitable for ambulant patients of up to 136 kg.

    This metal upright design is unique to the PRAFO range and ensures that no distortion of the structure occurs under normal loading situations. This orthosis will not slip during patient transfers or repositioning on the bed. We feel that this device sets the standard for heel protection for this group

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    Emerging Therapies For Hapus Prevention

    Polarized light

    One study investigated the efficacy of polarized light once a day for 10 minutes in preventing the incidence of HAPUs on the sacral and heel area . The study showed no significant difference in the development of all stages of PUs with the use of polarized light on the sacrum and heels , despite a significant decrease in the incidence of HAPUs when stage I PUs were excluded . However, the control group had more assessed areas of skin at risk for PUs compared to the intervention group . In addition, a small sample size of 23 participants limited the study’s findings.


    Three studies reported the effectiveness of the application of prophylactic silicone foam dressings in decreasing the incidence of sacral HAPUs . The overall effect size across studies was 0.12 , the result indicating that HAPU incidence of sacral area decreased after the application of the dressing .

    Figure 2

    How Should A Comprehensive Skin Assessment Be Conducted

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    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 and touching 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?

    • Skin integrity .


    Detailed instructions for assessing each of these areas are found in Tools and Resources .

    Action Steps

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    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 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.

    What Is Bariatrics About

    Bariatrics describes the area of medicine concerning people who are significantly overweight or morbidly obese with a Body Mass Index of greater than 40. The number of obese people in the UK is growing rapidly and this inevitably means that some will require hospital care. The phenomenon of excess weight gain is not confined to one country obesity is a worldwide public health problem in both developed and less developed countries.

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    Enhanced Care For Compromised Skin

    Enhance the care and protection of fragile skin with specialised support surfaces for plus size patients with compromised skin integrity.

    Due to fluid retention and poor circulation, plus size patients commonly suffer increased skin fragility, making them more vulnerable to pressure injury and skin tears. To help mitigate this risk, the use of appropriate support surfaces are recommended by expert body guidelines such as the European Pressure Ulcer Advisory Panel and the National Pressure Ulcer Advisory Panel .1

    We offer a range of support surfaces and microclimate management solutions to help in the care of plus size patients with compromised skin integrity.


    1. Muir, M, Archer-Heese, G. Essentials of Bariatric Patient Handling Program, OJIN: The Online journal of Issues in Nursing Vol. 14, No. 1.

    Linking Evidence To Action

    Pressure ulcer prevention: A guide for patients, carers and healthcare professionals
    • This review revealed the effectiveness of using silicon foam dressing for preventing sacral HAPUs in ICU settings.
    • RCTs for preventing HAPUs in ICUs that follow standardized criteria for reporting intervention are needed.
    • Future RCTs should include a standard PU definition, staging systems, and intervention and comparative care integrity.

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    Essentials Of A Bariatric Patient Handling Program

    • Email:

      Gail Archer-Heese is an Occupational Therapist who graduated from the University of Manitoba with an undergraduate degree in Medical Rehabilitation. She has been involved in the area of work-related injury and rehabilitation since 1992. Currently she is a Musculoskeletal Specialist in Ergonomics at the Health Sciences Centre Site, which is part of the Winnipeg Regional Health Authority in Manitoba, Canada. She has been responsible in the past for the development of a musculoskeletal injury prevention program at a regional facility and instrumental over the past few years in developing the Patient Handling and Movement Guidelines and the Bariatric Care Guidelines for the Regional Authority. Ms. Archer-Heese has co-authored several journal articles on the topic of bariatric patient handling she continues to provide clinical care on the wards and serve as a consultant in the community.

    Keywords: bariatric patients injury prevention safe patient handling protocols and guidelines risk to healthcare workers

    Bariatric Definitions

    Health Concerns of Bariatric Patients

    Risks for Healthcare Providers

    Components of a Bariatric Patient Handling Program

    • Operational Procedure and Policy

    Each of these components will be discussed in turn below.

    Operational Procedure and Policy

    Patient Assessment Tools

    Communication Tools

    Patient Handling Algorithms and Guidelines

    Space and Environment Considerations

    Equipment Needs

    What Are The Best Practices In Pressure Ulcer Prevention That We Want To Use

    Once you have determined that you are ready for change, the Implementation Team and Unit-Based Teams should demonstrate a clear understanding of where they are headed in terms of implementing best practices. People involved in the quality improvement effort need to agree on what it is that they are trying to do. Consensus should be reached on the following questions:

    In addressing these questions, this section provides a concise review of the practice, emphasizes why it is important, discusses challenges in implementation, and provides helpful hints for improving practice. Further information regarding the organization of care needed to implement these best practices is provided in Chapter 4 and additional clinical details are in Tools and Resources.

    In describing best practices for pressure ulcer prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside is an extremely complex task. Some of the factors that make pressure ulcer prevention so difficult include:

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    Preventive Interventions: Minimizing Linen Layers And Moisture Management

    Linens are routinely used under patients, but they can impact the features on support surfaces such as the ability of the mattress to provide microclimate management by reducing air flow on a low-air-loss system, as well as the ability of the mattress to provide pressure redistribution. Current guidelines recommend limiting linen layers.1 In this sample, a very small percentage were using more than 6 layers of linens and the majority were using 3 or less layers .

    Linen layers in use at time of survey for all acute settings. For each set of linen layers, there were significant differences between all 3 PI stage groups . PI indicates pressure injury.

    Moisture management strategies were implemented in 72% of all patients, including 84% of patients with Stage 1 and 2 HAPIs and 89% of those with the most severe HAPIs .6). Moisture management was reported as unnecessary for 7.8% of patients with no HAPIs, 3.7% of patients with Stage 1 and 2 HAPIs, and only 2.6% of those with the most severe HAPIs .

    Moisture management and nutritional support. For each question there were significant differences between all 3 PI stage groups . PI indicates pressure injury.

    Preventive Interventions: Nutrition Support Heel And Head

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    Assessment for nutritional deficits is strongly recommended in current guidelines.1 A nutritional support consultation or plan was present for 82.7% of patients with severe HAPIs and 71.4% for patients with Stage 1 or 2 HAPIs .6). Nutritional support was not provided for 10.7% of those with the most severe HAPIs .

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    Characteristics Of Included Studies

    Searching identified 675 potentially relevant papers, and after sifting of titles and abstracts according to the above inclusion criteria, 78 papers were selected for retrieval. When the full text versions of the papers were examined, 35 of the 78 retrieved papers were found to fully meet the inclusion criteria. These 35 studies were critically appraised by two independent reviewers using the JBI-MAStARI critical appraisal tools. Only 24 were found to be of sufficient quality to include. The flowchart presents further details of the search results and study selection process.

    Figure 1

    The level of evidence overall was levels II to III-2 according to the National Health and Medical Research Council evidence hierarchy . The majority of included studies were RCT designs . One was a posttest only design with three-group comparisons, three were preâpost experimental studies, and six were two-group quasi-experimental studies. Included studies were conducted worldwide and participants were all intensive care patients . Studies details are described further in Table .

    • aNational Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, & Pan Pacific Pressure Injury Alliance, 2014.

    Preventive Interventions: Repositioning And Support Surfaces For At

    As noted earlier, use of preventive interventions was analyzed for patients with a Braden Scale score of 18 or less. Strategies to prevent pressure injuries that target decreased mobility included repositioning and use of support surfaces data concerning the use of these preventive interventions were acquired from the NDNQI portion of the IPUP data collection. Routine repositioning was reported in 67.9% of patients with no HAPIs, and 79.5% of all at-risk patients with Stage 1 or 2 HAPIs . Repositioning was also reported in 84.8% for at-risk patients with severe PIs .3). Pressure redistribution surfaces were implemented for 74.6% for at-risk patients with no HAPIs, 82.8% for at-risk patients with Stage 1 or 2 HAPIs, and 91.9% for at-risk patients with severe HAPIs . Daily skin assessment was performed for 86% of at-risk patients with a Braden Scale score of 18 or less and with no HAPI present and in 96.8% of those with a severe HAPI, and 95.1% for those with Stage 1 or 2 HAPIs. Further analysis revealed that inpatients without HAPI 0.6% were not assessed as were 1.1 % of those with the severe HAPI .2). Routine repositioning was documented as no in 9.1% to 11% of the groups .

    Prevention practices implemented within the last 24 hours for patients with Braden Scores 18 or less. For each question there were significant differences between all 3 PI stage groups . PI indicates pressure injury.

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    What Bundle Of Best Practices Do We Use

    Given the complexity of pressure ulcer prevention, with many different items that need to be completed, thinking about how to implement best practices may be daunting. One approach that has been successfully used is thinking about a care bundle. A care bundle incorporates those best practices that if done in combination are likely to lead to better outcomes. It is a way of taking best practices and tying them together in a systematic way. These specific care practices are among the ones considered most important in achieving the desired outcomes.

    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.

    Because these aspects of care are so important, we describe them in more detail in the subsequent subsections along with helpful clinical hints. While these three components of a bundle are extremely important, your bundle may stress other aspects of care. It should build on existing practices and may need to be tailored to your specific setting. Whatever bundle of recommended practices you select, you will need to take additional steps. We describe strategies to ensure their successful implementation as described in Chapter 4.

    The challenge to improving care is how to get these key practices completed on a regular basis.


    Additional Information


    Practice Insights

    Why Pressure Ulcer/injury Prevention Is Critical

    EBP project pressure ulcers 2

    Pressure injuries are very common in hospitals and long-term care facilities. In one recent survey, it was found that 26.7% of patients in a hospital had pressure injuries.2 The high rate of pressure injuries equates to significant time and resources spent on care and treatment. Some estimates place the cost of pressure injury treatment in the United States as high as $11.6 billion each year. This makes pressure injuries one of the most costly medical conditions.3 To reduce these costs and improve patient outcomes, it is important for nurses and other health care professionals to take a proactive approach focused on pressure injury prevention.

    Interested in more information on pressure injury prevention?

  • Take initiative The first step to making a facility-wide impact on pressure injury prevention is to work with key staff and stakeholders to develop a prevention initiative. It is important to make sure that all relevant stakeholders, including senior administration and all health care clinicians providing hands-on care, understand the importance of reducing the incidence of pressure injuries and the steps they need to take to prevent them. Circulating risk assessment and best practice literature can help ensure that the staff is well educated and prepared to move forward with the initiative.
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