Pressure Ulcer - Prevention

Prevention

The most important care for a patient at risk for pressure ulcers and those with bedsores is the redistribution of pressure so that no pressure is applied to the pressure ulcer. In the 1940s Ludwig Guttmann introduced a program of turning paraplegics every two hours thus allowing bedsores to heal. Previously such patients had a two year life-expectancy, normally succumbing to blood and skin infections. Guttmann had learned the technique from the work of Boston physician, Donald Munro.

The NPUAP in conjunction with the European Pressure Ulcer Advisory Panel (EPUAP) published a comprehensive guideline on the prevention and treatment of pressure ulcers in 2009. Nursing homes and hospitals usually set programs in place to avoid the development of pressure ulcers in bedridden patients such as using a routine time frame for turning and repositioning to reduce pressure. The frequency of turning and repositioning depends on the level of risk in the patient. Turning patients every 2 hours has been a long-standing tradition, with little evidence to support its practice. Pressure-redistributive mattresses are used to reduce high values of pressure on prominent or bony areas of the body. There are several important terms used to describe how these support surfaces work. These terms were standardized through the Support Surface Standards Initiative of the NPUAP. See S3I at npuap.org Many support surfaces redistribute pressure by immersing and/or enveloping the body into the surface. Some support surfaces contain multiple air chambers that are alternately pumped. Antidecubitus mattresses and cushions can contain multiple air chambers that are alternately pumped. Methods to standardized the products and evaluate the efficacy of these products have only been developed in recent years through the work of the S3I within NPUAP. For individuals with paralysis, pressure shifting on a regular basis and using a wheelchair cushion featuring pressure relief components can help prevent pressure wounds.

Controlling the heat and moisture levels of the skin surface, known as skin microclimate management, also plays a significant role in the prevention and control of pressure ulcers.

In addition, adequate intake of protein and calories is important. Vitamin C has been shown to reduce the risk of pressure ulcers. People with higher intakes of Vitamin C have a lower frequency of bed sores in bed-ridden patients than those with lower intakes. Vitamin C supplements have also been shown to help the healing of bed sores or pressure sores in a double-blind study. Maintaining proper nutrition in newborns is also used to prevent pressure ulcers. If unable to maintain proper nutrition through protein and calorie intake, it is advised to use supplements to support the proper nutrition levels. Skin care is also important because damaged skin does not tolerate pressure. However, skin that is damaged by exposure to urine or stool is not a pressure ulcer. These skin wounds should be classified as Incontinence Associated Dermatitis.

Maintaining proper nutrition in newborns is also used to prevent pressure ulcers. If unable to maintain proper nutrition through protein and calorie intake, it is advised to use supplements to support the proper nutrition levels.

In the UK the Royal College of Nursing has published guidelines in 'Pressure ulcer risk assessment and prevention'. It is important to identify those who are at risk and to intervene early with strategies for prevention, in the bed, wheelchair or chair, in the bath and on the commode - indeed, it is a requirement within the National Standards for Care Homes (UK) to do so:

"Standard 8.3 Service users are assessed, by a person trained to do so, to identify those service users who have developed, or are at risk of developing, pressure sores and appropriate intervention is recorded in the plan of care. 8.4 The incidence of pressure sores, their treatment and outcome, are recorded in the service user’s individual plan of care and reviewed on a continuing basis. 8.5 Equipment necessary for the promotion of tissue viability and prevention or treatment of pressure sores is provided."

Certain types of patients with risk of pressure ulcers require additional, specialized methods for prevention. One example is bariatric patients. Preventative measures for pressure ulcers in bariatric patients include:

• Holistic assessment: Nurses’ assessments should encompass and identify all high-risk breakdown areas for careful monitoring and include any comorbidities and their effects on the patient.
• Hygiene: Patient’s skin folds must be kept clean and dry to minimize the amount of moisture.
• Specialist equipment and safe manual handling: In order to avoid pressure damage, weight shifting is essential.