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Turning Patients Every 2 Hours To Preventing Pressure Ulcers

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What Bundle Of Best Practices Do We Use

Repositioning for pressure injury/ulcer prevention: TEAM-UP trial results

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

What Do The Australian Wound Management Associations Official Guidelines Say

Professor Geoff Sussman, Chairman of Wounds Australia, told HelloCare that the Australian Wound Management Associations Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury give the evidence based and the most widely accepted guidelines in the region for preventing pressure sores.

The key recommendations for prevention of pressure injuries for those who have been assessed as being at risk of developing them include:

  • Add high protein oral nutritional supplements to a regular diet.
  • Use a high specification reactive support foam mattress on beds, or active support mattresses as an alternative.
  • Reposition patients to reduce the duration and magnitude of pressure over vulnerable areas, including bony prominences and heels.
  • Frequency of repositioning will depend on the patients risk of pressure injury development, skin response, comfort, functional level, medical condition, and the support surface used.
  • Position patients using 30° lateral inclination alternating from side to side or a 30° inclined recumbent position. Use the prone position if the patients medical condition precludes other options.
  • When repositioning the patient in any position always check the positioning of heels and other bony prominences.
  • Use a support cushion for patients at risk of pressure injury when seated in a chair or wheelchair. Limit the time a patient spends in seated positions without pressure relief.
  • Select and fit devices for heel pressure injuries.
  • What Do The Pressure Ulcer Guidelines Say About Q2h

    They don’t! The 2014 National Pressure Ulcer Advisory Panel does not recommend a frequency but suggests that we “consider the pressure redistribution surface in use” and also “tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort.” 1 Similarly, the Wound, Ostomy and Continence Nurse Pressure Ulcer guidelines state, “schedule regular repositioning and turning for bedbound and chairbound individuals.”2 The TURN study by Nancy Bergstrom and associates found no difference in pressure ulcer development between “those at moderate and high risk of developing Pressure Ulcers turned at 2-, 3-, or 4-hour intervals…using high-density foam mattresses.”3 There is nothing evidence-based or magic about the two hours of “Q2H” turning!

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    What About Patients Non

    If patients refuse T& P efforts, that is their right . Documentation of refusals becomes crucial!


    • The reason that patients refuse T& P. Use of exact quotes from patients can be very effective. Is it because of pain and the need for a reassessment of their pain regimen? Are they close to end of life and don’t wish to be disturbed? Maybe they just don’t understand the dangers of immobility and the risk for skin breakdown. Sometimes it may be a control issue, understandable when everything else in their life seems out of their own control.
    • What actions you took as a result and the education you provided about the need for adherence.
    • Patients’ reactions to the education. This demonstrates patients’ understanding and, implicitly, patients’ consent, assuming cognition is intact.
    • Be sure to involve all staff in reinforcing the need, so patients are hearing it from multiple providers, and of course educate and involve the family.

    Next up? That all important Risk Assessment…

    About the AuthorHeidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.

    Getting A Patient Ready


    The following steps should be followed when turning a patient from their back to their side or stomach:

    • Explain to the patient what you are planning to do so the person knows what to expect. Encourage the person to help you if possible.
    • Stand on the opposite side of the bed the patient will be turning towards, and lower the bed rail. Move the patient towards you, then put the side rail back up.
    • Step around to the other side of the bed and lower the side rail. Ask the patient to look towards you. This will be the direction in which the person is turning.
    • The patient’s bottom arm should be stretched towards you. Place the person’s top arm across the chest.
    • Cross the patient’s upper ankle over the bottom ankle.

    If you are turning the patient onto the stomach, make sure the person’s bottom hand is above the head first.

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    Classification Of Pressure Ulcers

    Pressure Ulcers would be classified as grade I to IV according to The Pressure Ulcer Advisory Panel Consensus Development Conference 1989, and the National group for the study and counseling in Pressure Ulcers and Chronic Wound-Spain , 2003. We did not use the new pressure ulcer terminology and the updated stages provided by The National Pressure Ulcer Advisory Panel- NPUAP, given that all hospitals in our country follow the Ministry of Health Guidelines according to the primary pressure ulcers classification and also Pus are reported in this way.

    This system, accepted until very recently, establishes four stages for pressure ulcers. The main objective of any classification system is to standardize the collection of information and provide a standard description of the severity of the ulcer for both clinical practice, evaluation, or research purposes.

    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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    Special Devices That Can Help You

    In addition to turning and repositioning frequently, using a special surface to reduce or relieve pressure can help a great deal. The simplest of these is an egg crate mattress. Many hospice and home health agencies provide these free of charge but they are relatively inexpensive at your local department store.

    If your loved one is spending a lot of time up in a chair, egg crate chair pads are also available. An egg crate surface helps distribute pressure more evenly, helping minimize the amount of pressure on one area.

    A step up from the egg crate mattress is an air mattress overlay. This type of surface is placed on top of a mattress and typically alternates air pressure in various columns. When using an egg crate mattress or an air mattress overlay, its still important to maintain the turning schedule. These devices dont replace frequent repositioning.

    The big guns of pressure-relieving devices are the fluidized air mattresses. These special mattresses contain silicone-coated glass beads that become fluid when the air is pumped through them. These mattresses do a wonderful job of relieving pressure but they have their downside.

    The frame of the mattress makes transferring to and from bed difficult. And if the person wants to sit up in bed, a foam wedge would probably need to be used to help support their back. This mattress is really best suited for palliative care patients who are fully bed-bound, have severe pressure ulcers, and are in a lot of pain.

    What Are The Complications Of Bedsores

    Careturner® the innovative solution for the prevention of pressure ulcers

    Once a bedsore develops, it can take days, months, or even years to heal. It can also become infected, causing fever and chills. An infected bedsore can take a long time to clear up. As the infection spreads through your body, it can also cause mental confusion, a fast heartbeat, and generalized weakness.

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    Patient Involvement In Medical Device

    Education relating to medical devices, splints, and casts tends to be from staff on the unit. This education is most often utilized if a patient is on maternity and has a knee brace. Often, it is the patient who is likely to be more familiar with the device than the nurse. Asking the patient should not be viewed as a problem and is preferable to patient repositioning of the device afterward. Medical device procurement must include staff involvement with medical device purchasing so that company rhetoric and cost are not placed above patient comfort and safety or staff experience and expertise.

    How To Prevent Medical Device

    Preventing medical device-related pressure injuries is better than treating these injuries. Prevention saves both patients and health care professionals time, resources, and discomfort. As seen the previous case studies, medical device-related pressure injuries can result in longer hospital stays for patients, not to mention detective work for health care professionals to find the origin of the injury.

    Here are 10 hints and tips to assist in preventing medical device-related pressure injuries:

  • Avoid working from the bed. If it is necessary, use a defined space , so intravenous caps and other equipment do not stray under the covers or the patient.
  • When turning a patient, always check that the sheet is smooth under them this ensures their bed is clear of glasses, dentures, books, crumbs, and intravenous caps.
  • Every time the patient is repositioned, clear the skin. This means all tubes head to toe need to be lifted free from the skin and repositioned optimally for comfort and safety. Tapes and supports for tracheostomy and endotracheal tubes may need to be dried or changed. Staff performing such care need to be confident and competent or work with a more experienced colleague.
  • Oxygen tubing may need to be softer for patients with more delicate skin, and when crossing the ear, soft foam covers can be used or hydrocolloid cheek or face supports can be placed.
  • Urinary catheters should be secured in a way that allows repositioning of the tubing after moving the patient .
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    Implications For Future Research

    In general, there is a lack of studies examining turning frequency and its impact on the development of PU. The limited available studies have limitations in their methodological designs. There is a need for multiple welldesigned RCTs consisting of lesser methodological limitations with a large sample size that compare just the frequency of turning while making other variables constant.Further studies should focus on changing only 1 variable such as turning frequency so that lesser confounding factors exist, yielding more reliable results. This scoping review identified that patients nursed under pressurerelieving devices are less susceptible to PU development. Specifically, repositioning patients coupled with the use of pressurerelieving devices is one of the most promising interventions to implement. However, the challenge is to identify what exactly is the optimal repositioning interval with pressurerelieving devices. Hence, further RCTs need to be conducted to confirm the results from these studies to allow organisations to relook into their intervention guidelines and adopt EBP. Studies should also focus on repositioning intervals on different patient populations to allow for generalisability across different patient populations. This can improve patients quality of life and also relieve nurses of unnecessary workload.

    What Are The Symptoms Of Bedsores


    Bedsores are divided into 4 stages, from least severe to most severe. These are:

    • Stage 1. The area looks red and feels warm to the touch. With darker skin, the area may have a blue or purple tint. The person may also complain that it burns, hurts, or itches.
    • Stage 2. The area looks more damaged and may have an open sore, scrape, or blister. The person complains of significant pain and the skin around the wound may be discolored.
    • Stage 3. The area has a crater-like appearance due to damage below the skin’s surface.
    • Stage 4. The area is severely damaged and a large wound is present. Muscles, tendons, bones, and joints can be involved. Infection is a significant risk at this stage.

    A wound is not assigned a stage when there is full-thickness tissue loss and the base of the ulcer is covered by slough or eschar is found in the wound bed. Slough may be tan, grey, green, brown, or yellow in color. Eschar is usually tan, brown or black.

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    Reviews And Nonexperimental Studies

    One study17 was a prospective cohort study that examined the association between repositioning and PUs in elderly bedbound patients. However, there was no association between repositioning and the incidences of PU among bedbound elderly. The remaining 3 studies were systematic reviews, all of which had inconclusive evidence with regards to the optimal turning frequency to prevent PUs.2, 14, 20 Similarly, the last study, which was a general review, also yielded inconclusive evidence on the frequency of turning among PU incidences and concluded that the frequency of repositioning varies according to each patient’s needs.31

    How To Prevent Pressure Ulcers Or Bed Sores

    Pressure ulcers are a common problem in palliative care patients. Decreased mobility, increased time spent in bed, and altered nutrition make these patients prime targets for skin breakdown. Pressure ulcers are painful. As a caregiver, one of the most important things you can do to keep your patient comfortable is to prevent one from developing.

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    Can Bedsores Be Prevented

    Bedsores can be prevented by inspecting the skin for areas of redness every day with particular attention to bony areas. Other methods of preventing bedsores and preventing existing sores from getting worse include:

    • Turning and repositioning every 2 hours
    • Sitting upright and straight in a wheelchair, changing position every 15 minutes
    • Providing soft padding in wheelchairs and beds to reduce pressure
    • Providing good skin care by keeping the skin clean and dry
    • Providing good nutrition because without enough calories, vitamins, minerals, fluids, and protein, bed sores cant heal, no matter how well you care for the sore

    Implementing A Prevention Plan

    How to Prevent Pressure Ulcers

    Preventing pressure ulcers can be nursing intensive. The challenge is more difficult when there is nursing staff turnover and shortages. Studies have suggested that pressure ulcer development can be directly affected by the number of registered nurses and time spent at the bedside., In contrast, however, one recent study suggested that there was no correlation between increasing the nurse-to-patient ratio and the overall incidence of pressure ulcers. Donaldson and colleagues noted that this particular study was limited by the fact that the researchers could not affirm compliance with ratios per shift and per unit at all times. Given that the cost of treatment has been estimated as 2.5 times that of prevention, implementing a pressure ulcer prevention program remains essential.

    A key component of research studies that have reported reduction of pressure ulcers is how to sustain the momentum over time, especially when the facility champion leaves the institution. It is clear from the evidence that maintaining a culture of pressure ulcer prevention in a care setting is an important challenge, one that requires the support of administration and the attention of clinicians.

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    New Research Challenges Q2h Turning Standard For Pressure Ulcer Prevention

    by Jeffrey M Levine | Oct 28, 2013

    The industry standard for turning and repositioning a patient at risk for pressure ulcers is every two hours. There is, however, limited research to support this standard. As the costliest elements of pressure ulcer prevention are support surfaces and repositioning, a change in this standard would have major economic impact. A research study published in the October 2013 issue of the Journal of the American Geriatrics Society could potentially alter the standard for turning frequency for nursing home residents at risk for pressure ulcers.

    Bergstrom et al. tested whether there was a difference in pressure ulcer incidence in persons at moderate or high risk who were turned at 2, 3, or 4 hour intervals when a high density foam mattress was in use. Persons at very high risk were excluded. They studied 942 nursing home residents in 20 facilities in the US and Canada. Subjects were age 65 and older with the most common diagnoses of cardiovascular disease and dementia. All were newly admitted short-stay or long-stay residents of nursing homes, and were followed for three weeks. The researchers found no difference in pressure ulcer incidence between those repositioned at 2, 3, or 4 hour intervals.

    * * * * * * * * * * * * * * *

    Citation for this research is: Bergstrom et al. Turning for Ulcer ReductioN: A Multisite Randomized Clinical Trial in Nursing Homes. JAGS 61: 1705-1713, 2013.

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