• Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults: prediction and prevention. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, AHCPR; 1992 May. 63 p. (Clinical practice guideline; no. 3). [127 references]

The strength of evidence definitions are provided at the end of the "Major Recommendations" field.

Risk Assessment Tools and Risk Factors

Identify at-risk individuals needing prevention and the specific factors placing them at risk.

1. Bed- and Chair-Bound Individuals

   Bed- and chair-bound individuals or those with impaired ability to reposition should be assessed for additional factors that increase risk for developing pressure ulcers. These factors include immobility, incontinence, nutritional factors such as inadequate dietary intake and impaired nutritional status, and altered level of consciousness. Individuals should be assessed on admission to acute care and rehabilitation hospitals, nursing homes, home care programs, and other health care facilities. A systematic risk assessment can be accomplished by using a validated risk assessment tool such as the Braden Scale or Norton Scale. Pressure ulcer risk should be reassessed at periodic intervals. (Strength of Evidence = A.) All assessments of risk should be documented. (Strength of Evidence = C.)

Skin Care and Early Treatment

Maintain and improve tissue tolerance to pressure in order to prevent injury.

1. Skin Inspection

   All individuals at risk should have a systematic skin inspection at least once a day, paying particular attention to the bony prominences. Results of skin inspection should be documented. (Strength of Evidence = C.)

2. Skin Cleansing

   Skin cleansing should occur at the time of soiling and at routine intervals. The frequency of skin cleansing should be individualized according to need and/or patient preference. Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness of the skin. During the cleansing process, care should be utilized to minimize the force and friction applied to the skin. (Strength of Evidence = C.)

3. Dry Skin

   Minimize environmental factors leading to skin drying, such as low humidity (less than 40 percent) and exposure to cold. Dry skin should be treated with moisturizers. (Strength of Evidence = C.)

4. Massage

   Avoid massage over bony prominences. (Strength of Evidence=B.)

5. Exposure to Moisture

   Minimize skin exposure to moisture due to incontinence, perspiration, or wound drainage. When these sources of moisture cannot be controlled, underpads or briefs can be used that are made of materials that absorb moisture and present a quick-drying surface to the skin. Topical agents that act as barriers to moisture can also be used. (Strength of Evidence = C.)

6. Friction and Shear Injuries

   Skin injury due to friction and shear forces should be minimized through proper positioning, transferring, and turning techniques. In addition, friction injuries may be reduced by the use of lubricants (such as corn starch, and creams), protective films (such as transparent film dressings, and skin sealants), protective dressings (such as hydrocolloids), and protective padding. (Strength of Evidence = C.)

7. Nutrition

   When apparently well-nourished individuals develop an inadequate dietary intake of protein or calories, caregivers should first attempt to discover the factors compromising intake and offer support with eating. Other nutritional supplements or support may be needed. If dietary intake remains inadequate and if consistent with overall goals of therapy, more aggressive nutritional intervention such as enteral or parenteral feedings should be considered. (Strength of Evidence = C.)

   For nutritionally compromised individuals, a plan of nutritional support and/or supplementation should be implemented that meets individual needs and is consistent with the overall goals of therapy. (Strength of Evidence = C.)

8. Mobility and Activity

   If potential for improving mobility and activity status exists, rehabilitation efforts should be instituted if consistent with the overall goals of therapy. Maintaining current activity level, mobility, and range of motion is an appropriate goal for most individuals. (Strength of Evidence = C.)

9. Documentation

   Interventions and outcomes should be monitored and documented. (Strength of Evidence = C.)

Mechanical Loading and Support Surfaces

Protect against the adverse effects of external mechanical forces: pressure, friction, and shear.

1. Repositioning

   Any individual in bed who is assessed to be at risk for developing pressure ulcers should be repositioned at least every 2 hours if consistent with overall patient goals. A written schedule for systematically turning and repositioning the individual should be used. (Strength of Evidence = B.)

2. Positioning Devices

   For individuals in bed, positioning devices such as pillows or foam wedges should be used to keep bony prominences (for example, knees or ankles) from direct contact with one another, according to a written plan. (Strength of Evidence = C.)

3. Pressure Relief for the Heels

   Individuals in bed who are completely immobile should have a care plan that includes the use of devices that totally relieve pressure on the heels, most commonly by raising the heels off the bed. Do not use donut-type devices. (Strength of Evidence = C.)

4. Side-lying Positions

   When the side-lying position is used in bed, avoid positioning directly on the trochanter. (Strength of Evidence = C.)

5. Bed Positioning

   Maintain the head of the bed at the lowest degree of elevation consistent with medical conditions and other restrictions. Limit the amount of time the head of the bed is elevated. (Strength of Evidence=C.)

6. Lifting Devices

   Use lifting devices such as a trapeze or bed linen to move (rather than drag) individuals in bed who cannot assist during transfers and position changes. (Strength of Evidence = C.)

7. Pressure-Reducing Devices for Beds

   Any individual assessed to be at risk for developing pressure ulcers should be placed when lying in bed on a pressure-reducing device, such as foam, static air, alternating air, gel, or water mattresses. (Strength of Evidence = B.)

8. Pressure from Sitting

   Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in a chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every hour or be put back to bed if consistent with overall patient management goals. Individuals who are able should be taught to shift weight every 15 minutes. (Strength of Evidence = C.)

9. Pressure-Reducing Devices for Chairs

   For chair-bound individuals, the use of a pressure-reducing device such as those made of foam, gel, air, or a combination is indicated. Do not use donut-type devices. (Strength of Evidence = C.)

10. Postural Alignment

    Positioning of chair-bound individuals in chairs or wheelchairs should include consideration of postural alignment, distribution of weight, balance and stability, and pressure relief. (Strength of Evidence = C.)

11. Plans and Scheduling

    A written plan for the use of positioning devices and schedules may be helpful for chair-bound individuals. (Strength of Evidence=C.)

Education

Reduce the incidence of pressure ulcers through educational programs.

1. Scope

   Educational programs for the prevention of pressure ulcers should be structured, organized, and comprehensive and directed at all levels of health care providers, patients, and family or caregivers. (Strength of Evidence = A.)

2. Topics

   The educational program for prevention of pressure ulcers should include information on the following items (Strength of Evidence = B):

   • Etiology and risk factors for pressure ulcers.
   • Risk assessment tools and their application.
   • Skin assessment.
   • Selection and/or use of support surfaces.
   • Development and implementation of an individualized program of skin care.
   • Demonstration of positioning to decrease risk of tissue breakdown.
   • Instruction on accurate documentation of pertinent data.
3. Roles and Presentation

   The educational program should identify those responsible for pressure ulcer prevention, describe each person's role, and be appropriate to the audience in terms of level of information presented and expected participation. The educational program should be updated on a regular basis to incorporate new and existing techniques or technologies. (Strength of Evidence = C.)

4. Program Development

   Educational programs should be developed, implemented, and evaluated using principles of adult learning. (Strength of Evidence=C.)

Definitions

The panel assigned each recommendation of rating of A, B, or C to indicate the strength of the evidence supporting the recommendation. The ratings were based on the following criteria:

A: Results of two or more randomized controlled clinical trials on pressure ulcers in humans provide support.

B: Results of two or more controlled clinical trials on pressure ulcers in humans provide support, or when appropriate, results of two or more controlled trials in an animal model provide indirect support.

C: This rating requires one or more of the following: (1) results of one controlled trial; (2) results of at least two case series/descriptive studies on pressure ulcers in humans; or (3) expert opinion.

A clinical algorithm is presented for pressure ulcer prediction and prevention.

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Agency for Health Care Policy and Research (AHCPR). Pressure ulcers in adults: prediction and prevention. Rockville (MD): U.S. Department of Health and Human Services, Public Health Service, AHCPR; 1992 May. 63 p. (Clinical practice guideline; no. 3). [127 references]

Not applicable: The guideline was not adapted from another source.

1992 (reviewed 2000)

Agency for Healthcare Research and Quality - Federal Government Agency [U.S.]

United States Government

Panel for the Prediction and Prevention of Pressure Ulcers in Adults

The panel consisted of three physicians (family practice, dermatology, and gerontology), five nurses (rehabilitation, aging, acute care, enterostomal therapy, oncology, and management), one occupational therapist (rehabilitation), one basic scientist (plastic surgery research), one biomedical engineer (rehabilitation), and one consumer representative.

Names of Committee Members: Nancy Bergstrom, PhD, RN, FAAN (Chair); Richard M. Allman, MD; Carolyn E. Carlson, PhD, RN; William Eaglstein, MD; Rita A. Frantz, PhD, RN, FAAN; Susan L. Garber, MA, OTR, FAOTA; Davina Gosnell, PhD, RN, FAAN; Bettie S. Jackson, EdD, MBA, FAAN; William Eaglstein, MD; Davina Gosnell, PhD, RN, FAAN; Mildred G. Kemp, PhD, RN, CETN, FAAN; Thomas A. Krouskop, PhD; Elena M. Marvel, MSN, MA, RN; George T. Rodeheaver, PhD; George C. Xakellis, MD.

Not stated

This summary was completed by ECRI on May 1, 2001. Per a recent Evidence-based Practice Center (EPC) report commissioned by the Agency for Healthcare Research and Quality (AHRQ) (formerly the Agency for Health Care Policy and Research [AHCPR]) in 2000, the guideline is considered, in whole or in part, to still be current.