The expert of the week, Karen S. Clay, RN, BSN, CWCN, is president of Clay & Associates and has more than 30 years experience in healthcare and specializes in wound management, risk management, and clinical program development.
To create an effective program for pressure ulcer prevention, first conduct a risk assessment to identify risk factors, and then focus on your prevention program on minimizing their negative effects. When addressing pressure ulcers as a risk-management problem, prevention is the number one solution. It alleviates needless patient suffering, unnecessary healthcare costs, and associated litigation. This focus will include management of pressure, friction, shear, moisture, and any other individual factors.
When deciding which prevention method is best for your facility, here are a few things to consider:
Positioning: Frequent positioning of the patient can help prevent capillary occlusion, which leads to tissue ischemia and pressure ulcers. The Agency for Healthcare Research and Quality recommends at least every two hours. However, the frequency of repositioning required to prevent ischemia depends on capillary-closing pressures, which vary by person and pressure point. No matter what the staffing circumstances, use the "rule of 30" when repositioning patients. This rule indicates that you should elevate the head of the bed to 30 degrees or less and that the body, when repositioned to either side, should be placed in a 30-degree laterally inclined position.
Contractures: Contractures, which cause shortened and flexed positions of the affected area, develop in predictable patterns, so splinting, range-of-motion exercises, and proper positioning can help prevent their occurrence. Such prevention is necessary not only because contractures cause the loss of strength and function, but also because they may compromise positioning and hygiene. Although a contracture may not necessarily result in a pressure ulcer, healing of any pressure ulcer that does erupt will be complicated by the poor perfusion of the limb.
Repositioning clocks: Some hospitals use repositioning clocks to monitor repositioning schedules. The basic concept is that a clock placed at the bedside prescribes a particular position at a specific time. Theoretically, it is easier for supervisors to detect whether a patient's repositioning schedule is being followed if they see that at 10:00 all at-risk patients will be positioned on their left sides.
Heels: Heels pose a significant risk for pressure ulcer development. Beyond regularly scheduled pressure risk assessments, assess a patient's potential for heel-ulcer formation when he or she has an acute change in status. Most support surfaces cannot adequately reduce the interface pressure under the heels. Thus, there are a few types of "zero pressure" three-cell alternating-therapy support surfaces that will eliminate heel pressure in 7 ½-minute cycles.
Bed linens: Assess bed linens for their impact on pressure ulcer development. Even if you don't make foot pleats, relieve pressure on the feet by loosening the sheets at the foot of the bed when assisting a patient back to bed or by using a foot cradle. Another important area one should not overlook is the patient's gown and the underpads and lift sheets. If wrinkles occur under the patient and the patient is not moved, these folds will cause pressure on the skin and will result in the beginnings of a pressure ulcer.
Karen S. Clay, RN, BSN, CWCN