Prevention and Management of Pressure Ulcers

Prevention and Management of Pressure Ulcers

Introduction

·        Pressure ulcers, also known as pressure injuries, decubitus ulcers, or bedsores, are localized injuries to the skin and/or underlying tissues, usually over a bony prominence, as a result of prolonged pressure, shear, or friction.

·        They are a major concern in hospitals, nursing homes, and long-term care facilities due to their association with increased morbidity, longer hospital stays, higher healthcare costs, and reduced quality of life.

·        Prevention and management of pressure ulcers require a comprehensive approach, focusing on early identification of at-risk patients, implementation of evidence-based preventive strategies, and timely intervention to minimize complications.

Risk Assessment in Pressure Ulcers

·        Risk assessment is the foundation of effective prevention.

·        It involves identifying individuals at high risk of developing pressure ulcers through standardized tools and clinical evaluation.

A. Risk Factors

1. Patient-related factors:
• Immobility (bedridden, wheelchair-bound, post-surgery, coma).
• Advanced age (fragile skin, reduced healing capacity).
• Malnutrition, dehydration.
• Chronic diseases (diabetes, peripheral vascular disease, neurological disorders).
• Incontinence (urinary/fecal) → skin maceration.
• Sensory impairment (spinal cord injury, neuropathy).
2. External factors:
• Prolonged pressure on bony prominences (sacrum, heels, hips, elbows).
• Friction (rubbing against bed sheets).
• Shear (sliding down in bed or chair).
• Moisture (sweating, incontinence, wound exudate).

B. Risk Assessment Tools

Widely used validated scales include:

1. Braden Scale
• Assesses 6 domains: sensory perception, moisture, activity, mobility, nutrition, friction/shear.
• Scores range 6–23 (lower scores = higher risk).
2. Norton Scale
• Assesses 5 domains: physical condition, mental condition, activity, mobility, incontinence.
• Score ≤14 indicates risk.
3. Waterlow Scale
• Includes build/weight, skin type, mobility, continence, age, appetite, medications, neurological deficits.
• Higher scores indicate greater risk.
4. Clinical Judgment
• Even with tools, professional clinical assessment is vital to account for unique patient conditions.

Preventive Interventions

·        Prevention is more effective and less costly than treatment.

·        Preventive strategies should be multifactorial, individualized, and continuous.

A. General Preventive Strategies

1. Regular Repositioning
• Turn bedridden patients every 2 hours (supine, lateral, prone alternately).
• Reposition wheelchair users every 15–30 minutes.
• Use of repositioning schedules and turning charts.
2. Support Surfaces
• Pressure-redistributing mattresses, overlays, and cushions (foam, gel, air, water).
• Alternating pressure mattresses for high-risk patients.
• Heel protectors and cushions to offload bony prominences.
3. Skin Care
• Daily skin inspection (especially over bony prominences).
• Keep skin clean and dry.
• Use pH-balanced cleansers instead of harsh soaps.
• Moisturizers to prevent dryness and cracking.
• Barrier creams for incontinent patients to protect from moisture.
4. Nutrition and Hydration
• Adequate protein, calorie, vitamin (especially Vitamin C, A, Zinc), and fluid intake.
• Nutritional supplements for malnourished patients.
• Dietitian consultation for high-risk or undernourished patients.
5. Moisture and Incontinence Management
• Prompt cleaning after episodes of incontinence.
• Use absorbent pads or briefs.
• Consider indwelling catheters (only if medically necessary).
• Frequent perineal care.

B. Specific Preventive Interventions

1. Education and Training
• Training of nurses, caregivers, and family in pressure ulcer prevention.
• Patient and family education about skin care, repositioning, and nutrition.
2. Mobility Promotion
• Encourage early mobilization and physical therapy.
• Range-of-motion exercises for immobile patients.
• Use mechanical lifts to reduce friction/shear during transfers.
3. Risk-Specific Strategies
• For spinal cord injury patients → use pressure-relieving cushions.
• For surgical patients → minimize operation time, use pressure-relieving pads during surgery.
• For ICU patients → frequent repositioning despite medical equipment.

Management of Early Pressure Ulcers (Stage I & II)

• Stage I (non-blanchable erythema):
• Relieve pressure immediately.
• Protect with transparent film or protective dressing.
• Optimize nutrition and hydration.
• Stage II (partial-thickness skin loss):
• Clean with normal saline, apply moist wound dressings (hydrocolloids, hydrogels, foams).
• Avoid antiseptics that damage granulation tissue.
• Prevent infection with barrier protection.

Integration of Risk Assessment & Prevention in Care Plans

• Incorporate risk assessment tools on admission and at regular intervals.
• Document skin condition and interventions.
• Interdisciplinary approach (nursing, nutrition, physiotherapy, wound care specialists).
• Audit and monitoring of pressure ulcer incidence rates in hospitals.

Video Description

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