Primary prevention

Many pressure ulcers are avoidable through the use of appropriate preventive measures.

Successful preventive programs result in better patient outcomes and are cost-effective.[26] Effective prevention strategies include at least two primary components: identification of at-risk individuals, and actively addressing identified risk factors through the use of appropriate interventions.[17][27]

Identification of at-risk individuals

All patients should be assessed for their risk of pressure ulcer development on admission and periodically thereafter.[28] Risk assessment tools to assist in evaluating a patient's need for pressure ulcer prevention include the Norton, Waterlow, Braden, Ramstaidus scales, and the interRAI Pressure Ulcer Risk Scale.[29][30][31][32][33] [ Norton Scale to Stratify Risk of Pressure Sores Opens in new window ] Prevention Plus: Braden scale for predicting pressure sore risk Opens in new window There is insufficient evidence to show the effect of these tools in preventing pressure ulcers.[34] [ Cochrane Clinical Answers logo ] One systematic review found that, although there was no decrease in pressure ulcer incidence, both the Braden and Norton scales were more accurate than nurses’ clinical judgement in predicting pressure ulcer risk.[35]

  • Norton scale: assesses a patient’s risk of developing a pressure ulcer by examining physical and mental condition, activity, mobility, and incontinence.

  • Waterlow tool: scores build/weight for height, skin type/visual risk areas, sex and age, malnutrition screening tool, continence, mobility, and further risks.

  • Braden scale: comprises sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

  • InterRAI Pressure Ulcer Risk scale: comprises bed mobility, walk in room, bowel continence, weight change, history of resolved pressure ulcers, pain symptoms, and shortness of breath.

  • Ramstadius tool: uses an algorithm to assess specific risk factors instead of a scoring system.

Comprehensive risk assessment involves more than the use of one of these prediction tools. The scales only examine a few domains and many important factors that place a patient at increased risk of pressure ulcers are not considered. All such factors should be identified.

Interventions to prevent pressure ulcers

These should be tailored to the unique needs of each individual patient and should address areas identified using the comprehensive risk assessment.[17][36]

Pressure relief through repositioning patients, and use of an appropriate support surface, is critical.[37][38] A 2011 RCT demonstrated that turning patients every 3 hours prevented the development of pressure ulcers.[39] Guidelines recommend that repositioning frequency should be determined with consideration to the individual's level of activity, mobility and ability to independently reposition.[17] In many institutions, repositioning every 2 hours is the standard of care for at-risk individuals. This may, however, be difficult to achieve in a busy clinical setting, and use of prompting systems to encourage scheduled repositioning should be encouraged.[40]

Specialised support surfaces are better than standard hospital mattresses at preventing pressure ulcers.[17][41][36][42] [ Cochrane Clinical Answers logo ] However, evidence for the superiority of one specialised support surface over another is more limited. In one randomised clinical trial of 1972 hospitalised patients with limited mobility, no differences in pressure ulcer incidence were seen with an alternating pressure mattress versus an alternating pressure overlay.[43] Another study of 2029 patients at 42 UK hospitals found no difference in the time to development of a category 2 or higher pressure ulcer for patients treated with an alternating pressure mattress when compared with a high specification foam mattress.[44] Among nursing home wheelchair users, a skin protection cushion was superior to a segmented foam cushion in preventing sacral and ischial tuberosity ulcers.[45] In patients with hip fracture, a heel elevation device, in addition to a support surface to redistribute pressure, reduces the incidence of heel ulcers.[46]

Monitoring devices that provide continuous feedback on pressures help with repositioning and the prevention of pressure ulcers.[47] Other interventions include nutritional support, and use of emollients to maintain skin barrier, particularly over the sacrum.[48] [ Cochrane Clinical Answers logo ] While multi-layer foam dressings over bony prominences might help prevent pressure ulcers, evidence from trials is modest.[49][50][51]

Successful efforts at implementing a preventive program require a multidisciplinary team to identify best practices for an organisation.[52] AHRQ: preventing pressure ulcers in hospitals: a toolkit for improving quality of care Opens in new window Key components include standardisation of interventions and documentation, designation of 'skin champions', use of audit and feedback, and staff education.

Secondary prevention

Preventing pressure damage depends on regular skin inspection of all patients who are judged to be potentially at risk and the timely use of pressure-reducing aids when early signs of damage are present or suspected. Risk assessment tools to evaluate patients' need for pressure ulcer prevention are available, but there is no evidence to suggest that they reduce the incidence of pressure ulcers.[101][36][34] [ Cochrane Clinical Answers logo ] Relatively minor changes in a patient's physical or mental health can have major implications for their predisposition to pressure damage, so regular inspection is essential if this occurs. Patients who have experienced pressure injuries previously are at particular risk. Attention should be paid to the positioning of tubes and catheters, particularly in infants, as these can cause localised tissue damage in areas not generally at risk of developing pressure injuries.

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