Decubitus Ulcer Prevention

Aka: Decubitus Ulcer Prevention, Pressure Sore Prevention, Pressure Sore Positioning, Pressure Injury Prevention

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II. Indications

  1. See Decubitus Ulcer for Risk Factors

III. Prevention: General Measures

  1. Perform comprehensive skin assessments in patients at high risk of Pressure Injury
    1. See Comprehensive Skin Integrity Assessment
    2. Perform on inpatient or facility admission
    3. Perform at periodic intervals, adjusted for acuity of illness and clinical status changes
    4. Focus on bony prominence regions and areas of medical device contact (see Decubitus Ulcer)
  2. Frequent patient repositioning (every 2 hours)
    1. Pressure Ulcers may develop within 2-4 hours
    2. Encourage small shifts in weight every 15 minutes
    3. Do not drag patient!
  3. Daily skin care (maintain clean and hydrated skin)
    1. Use balanced skin cleansers (pH 5.5) instead of typical alkaline soaps (pH >9)
    2. Apply topical moisture barriers
  4. Reduce excessive moisture exposure
  5. Correct Malnutrition
    1. See Subjective Global Assessment of Nutritional Status
    2. Maintain adequate nutrition
    3. Avoid Feeding Tubes (decrease mobility further, as well as other complications)
  6. Recognize early Pressure Injury with intact skin before Pressure Ulcer formation
    1. Nonblanchable erythema or pinkness of skin
  7. Protect areas at risk from devices
    1. Use a Tegaderm or similar at sites of skin contact (e.g. BiPAP Mask, splint)
    2. Use a Foam Dressing (e.g. Allevyn) over Sacrum and posterior heel in regions of increased friction

IV. Prevention: Tissue loads while SUPINE

  1. Positioning in bed
    1. Avoid positioning patient on ulcer
    2. Use positioning device to keep ulcer off surface
    3. Avoid donut-type devices (may limit Blood Flow and cause ulcers)
    4. Written repositioning schedules every 2 hours
      1. Often more frequent than 2 hour turning is required
  2. Prevention for patients at risk
    1. Avoid positioning immobile patients on trochanters
    2. Use pillows and foam wedges
      1. Relieve heel pressure
      2. Relieve bony prominence pressure (knee and ankle)
      3. Sheepskin does not relieve pressure
    3. Maintain head of bed at lowest appropriate level
      1. Limit time head of bed is elevated
      2. Higher head of bed causes patient to slide down
        1. Sliding leads to shear forces
        2. Sacral ulcers may result

V. Prevention: Tissue loads while SITTING

  1. Avoid pressure on ulcer while sitting
  2. Properly position
    1. Consider patient weight
    2. Consider balance
    3. Consider patient stability
  3. Reposition so pressure points shifted once per hour
    1. Return to bed if this schedule can not be met
    2. Attempt to teach patient to shift weight every 15 min
  4. Appropriate seat cushion
    1. Avoid donut-type cushions (decreases Blood Flow to the area and may worsen ulcers)
  5. Wheelchair related Pressure Ulcers
    1. Consider Wheelchair mapping (computerized pressure readings) at Wheelchair clinic

VI. Prevention: Bed Types

  1. Static Surfaces
    1. Surface types
      1. High specification foam mattress
      2. Medical grade sheepskin
      3. Gel-infused memory foam mattresses of overlays
      4. Static floatation
    2. Indications
      1. Patient in many positions without loading ulcer
      2. No bottoming out of patient
      3. Fully compresses surface to <1" at injury site
  2. Dynamic Surfaces
    1. Provide intermittent off-loading (not found in static surfaces)
    2. Surface types
      1. Air-fluid (costs $100 per day)
      2. Low-air (costs $65 per day)
      3. Alternate air
    3. Indications for all dynamic surfaces
      1. Stage 3 or 4 Decubitus Ulcers
      2. Conditions not met for static surface bed
      3. Pressure Ulcer not healing by 2 to 4 weeks
    4. Additional indications for air-fluid or low-air bed
      1. Large Stage 3 to 4 Ulcers
      2. Ulcers on multiple turning surfaces
      3. Ulcer fails to heal on dynamic overlay

VII. Resources: Risk Assessment Tools

  1. Pressure Scale Assessment Tools (AHRQ)
    1. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/pu7b.html
  2. Braden Scale for Predicting Pressure Sore Risk
    1. https://www.mdcalc.com/calc/10038/braden-score-pressure-ulcers

VIII. References

  1. (2022) Presc Lett 29(5):28-29
  2. Habif (1996) Clinical Derm, Mosby, p. 810-13
  3. Krasner (1995) Prevention Management Pressure Ulcers
  4. Lewis (1996) Med-Surg Nursing, Mosby, p. 199-200
  5. Lueckenotte (1996) Gerontologic Nurs., Mosby, p. 800-7
  6. PUGP (1994) Pressure Ulcer Treatment, AHCPR 95-0653
  7. Way (1991) Current Surgical, Lange, p.95-108
  8. (1995) Am Fam Physician 51(5):1207-22 [PubMed]
  9. Bello (2000) JAMA 283(6): 716-8 [PubMed]
  10. Degreef (1998) Dermatol Clin 16(2): 365-75 [PubMed]
  11. Findlay (1996) Am Fam Physician 54(5): 1519-28 [PubMed]
  12. Knapp (1999) Pediatr Clin North Am 46(6):1201-13 [PubMed]
  13. Raetz (2015) Am Fam Physician 92(10): 888-94 [PubMed]
  14. Visconti (2023) Am Fam Physician 108(2): 166-74 [PubMed]

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