RNAO BPG Pressure Ulcers Stage I to IV - Faculty of Health ...

Nursing Best Practice GuidelineRecommendation 1.8Assess all patients with EXISTING PRESSURE ULCERS to determine their risk for developingadditional pressure ulcers using the “Braden Scale for Predicting Pressure Sore Risk”.Level of Evidence – IVRecommendation 1.9If the patient remains at risk for other pressure ulcers, a high specification foam mattress instead of astandard hospital mattress should be used to prevent pressure ulcers in moderate to high risk patients.Level of Evidence – IaClients identified at risk of developing a pressure ulcer should receive care on a low interface pressuremattress. Cullum, McInnes, Bell-Syer and Legood (2005) identified seven randomized controlled trials thatindicated that the use of foam alternatives to the standard hospital mattress can reduce the incidence ofulcers in at-risk patients, including patients with a fracture of the neck or femur. However, the authors wereunable to make specific recommendations regarding types of low interface pressure mattresses based onthe methodological flaws of the studies. The most clear conclusion from this review is that the standardhospital mattress is out performed by a range of foam based, low pressure mattresses and overlays, and alsoby “higher tech” pressure-relieving beds and mattresses in the prevention of pressure sores (NHS Centre forReviews and Dissemination, 1995).The panel recognizes that the definition of a “standard hospital mattress” can differ between organizations.The definition for standard mattress used by the panel is “a non-pressure reducing institutional mattressusually constructed of cold foam with 10-20% of the body being supported” (Defloor, de Bacquer, & Grypdonck,2005, p.31). Given the need to balance equipment recommendations with available resources, it is suggestedthat decisions regarding mattress purchasing be made in collaboration between purchasing departmentsand the interdisciplinary health care team. Characteristics to consider when choosing a mattress include:weight capacity, pressure management properties, and ease of use by caregivers.Even when using a high specification foam mattress, other pressure management devices, such as overlays,can be used in combination as needed. Importantly, despite the use of any pressure management device,repositioning should also be used to prevent further pressure ulcers (Defloor et al., 2005). Additionalstrategies, particularly for special needs pediatric and geriatric populations, can be designed inconsultation with the interdisciplinary team.For further discussion of prevention strategies, the reader is encouraged to consult the RNAO Nursing BestPractice Guideline Risk Assessment and Prevention of Pressure Ulcers (Revised) (2005).Recommendation 1.10Vascular assessment (e.g., clinical assessment, palpable pedal pulses, capillary refill, ankle/brachialpressure index and toe pressure) is recommended for ulcers in lower extremities to rule out vascularcompromise.Level of Evidence – IV29