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

Nursing Best Practice GuidelineDiscussion of EvidencePressure is the major causative factor in pressure ulcer formation. Therefore, pressure ulcers will not healif the etiology of pressure, shearing and friction are not addressed. For clients at risk of developingpressure ulcers, or for those with existing pressure ulcers, institute the recommendations related to riskassessment and prevention described in the RNAO Nursing Best Practice Guideline Risk Assessment andPrevention of Pressure Ulcers (Revised) (2005), available at www.rnao.org/bestpractices. Appendix Cprovides a sample of the Braden Scale for Predicting Pressure Sore Risk.Support surfaces can be classified as active, a powered support surface with the capability to change itsload distribution properties with or without applied load (NPUAP, 2006), or reactive, a powered or nonpoweredsupport surface with the capability to change its load distributions properties only in response toapplied load (NPUAP, 2006). These terms replace the traditionally used terms static and dynamic. In theirsystematic review Cullum et al. (2004) concluded that although high specification foam alternatives to thestandard hospital foam mattress can reduce the incidence of pressure ulcers in people at risk, the relativemerits of such devices are unclear, specifically related to poor reporting of the particular support surfacesevaluated in the literature. Eight randomized controlled trials comparing the various constant low pressuredevices and alternating pressure devices were pooled with no significant difference detected in pressureulcer incidence (Cullum et al., 2004). Furthermore, one case study (Russell & Longsdon, 2003) explored the role ofskin assessment and a positioning schedule on clients on rotational surfaces. In this case study,manufacturer guidelines advising not to turn the patients on these rotational beds did not appear toprotect the patient against pressure ulcer development. In fact, more than 50% of reported pressure ulcers inthe facility during a six month period occurred in patients using lateral rotation beds (Russell & Longsdon, 2003).Therefore, the panel suggests that when choosing support surfaces, these decisions should be made to fitappropriately with the overall plan of care. Appendix F outlines support surface considerations.Importantly, the panel recognizes that the use of support surfaces may be limited by the availability ofresources. As there are many factors which may result in the poor healing of pressure ulcers, the panelsuggests an exploration of alternative measures to support healing prior to proceeding to a poweredsupport surface (e.g., nutrition, transferring strategies).Heels are at particular risk of skin breakdown due to the relatively lower resting blood profusion level andhigh amount of surface pressure when under load (Mayrovitz, Sims, Taylor, & Dribin, 2003). Citing severalcomparison studies Wong and Stotts (2003) indicate that special support surfaces reduce heel pressurebetter than do standard hospital mattresses, however caution that the interface pressure of heels on thesesurfaces remain greater than that of the buttock and trochanter, and in some cases these surfaces offer nosignificant reduction on heel pressure at all. Despite the availability of various heel-protective devices, noone product has been identified as the most effective (Cullum et al., 2004; Cullum & Petherick, 2006; Gilcreast,Warren, Yoder, Clark, Wilson, & Mays, 2005; Wong & Stotts, 2003). For example, in one quasi-experimental study of338 moderate-risk to high-risk patients, Gilcreast et al. (2005) compared three different heel ulcerpreventiondevices and found no statistical difference in heel pressure ulcer development. It is suggestedthat keeping the heels off the bed with pillows is the best documented approach (Wong & Stotts, 2003).All surfaces should be checked to ensure they are not “bottoming out”. The condition of “bottoming out”occurs when a mattress overlay, support or wheelchair cushion is compressed by high pressure. Asubjective estimate of the amount of compression can be achieved by palpation of the support thickness31