Note from the National Guideline Clearinghouse (NGC) and the Institute for Clinical Systems Improvement (ICSI): For a description of what has changed since the previous version of this protocol, refer to Summary of Changes Report– March 2007.

The recommendations for risk assessment and prevention of pressure ulcers are presented in the form of a protocol accompanied by 6 detailed footnotes. Clinical highlights and the footnotes follow.

Class of evidence (A-D, M, R, X) definitions are provided at the end of the "Major Recommendations" field.

Clinical Highlights

• Risk assessment should be performed in both the outpatient and inpatient settings. For outpatient, a set of questions answering yes or no should be used. For inpatient, use of a standardized risk assessment tool is recommended. The work group recommends the Braden Scale. (Footnote #1)
• A head-to-toe skin inspection should be done on every patient within six hours of admission, and reinspection should occur every 8 to 24 hours, depending on the status of the patient. (Footnote #2)
• The skin safety plan should include interventions that minimize or eliminate friction and shear, minimize pressure, manage moisture, and maintain adequate nutrition/hydration. (Footnote #3)
• Document all risk assessments, skin inspection findings and skin safety plans. Utilize a consistent documentation format. (Footnote #4)
• Communication of pressure ulcer development, risk assessment and skin inspection results should be done consistently. Any change in skin condition should be communicated as soon as observed. (Footnote #5)

Special Considerations

Pressure ulcer prevention should be provided for all patients at risk of pressure ulcer development and those individuals who have a pressure ulcer. There may be some patient conditions that may impede interventions from this protocol being implemented. Individualize the interventions as appropriate for these patients.

Risk assessment should be provided for all patients. The frequency and extent of this assessment varies based on the patient's risk factors.

The risk assessment and skin inspection must be documented in the patient record and "Not Assessed" should be written if not completed. The skin safety plan must be documented in the patient record and "Not Applicable" written if patient is not at risk. The other communication and education steps of the protocol still apply.

All personnel involved in the process must take an active role in this protocol. If at any time, a particular section of the protocol cannot be performed (e.g., maintain nutrition), the other assessment, verifications, and consent steps still apply.

Supporting evidence is of class: M

Footnotes

1. Risk Assessment: Outpatients and Inpatient

   Outpatient

   Assess risk of pressure ulcer development for all patients receiving care in areas such as outpatient, ambulatory care, less than 24-hour stay, same-day surgery, emergency room, catheter lab or similar settings.

   Increases in population age, severity of illness and comorbidities result in outpatient areas providing care for more patients at risk of pressure ulcer development. Health care services and triage processes may immobilize patients for two or more hours and place the patient at risk of pressure ulcer development.

   Assess patient using the following questions:

   • Is the patient bed- or wheelchair-bound, or does he/she require assistance to transfer?
   • Will the patient be immobile or sedated for more than two hours?
   • Is the patient incontinent of urine and/or stool?
   • Does the patient have existing pressure ulcers, history of pressure ulcers or comorbidities?
   • Is the patient under 5 years of age or over 65 years of age?
   • Does the patient have poor nutritional status (i.e., malnutrition)?
   • Does the patient have hemodynamic instability?

   In addition, for young children, assess risk of pressure ulcer development by checking:

   Is the baby/child:

   • Moving extremities and/or body inappropriately for developmental age?
   • Responding to discomfort in developmentally inappropriate manner?
   • Demonstrating inadequate tissue perfusion with evidence of skin breakdown?

   For a "Yes" response to any question above, initiate Skin Safety Plan. See Footnote #3, "Skin Safety Plan," below and Appendix D, "Skin Safety Plan," in the original guideline document.

   Although research has identified those younger than 5 years and older than 65 years of age as being at high risk for developing pressure ulcers, those in between these ages should not be automatically excluded from evaluation. The existence of comorbid conditions such as cardiovascular and endocrine diseases may contribute to increased vulnerability for the development of pressure ulcers.

   Individuals who undergo operative procedures may be at increased risk for pressure ulcers. This risk may be related to length of time on the operating room/procedure table, hypotension or to the type of procedure.

   Inpatient

   Full risk assessment includes determining a person's risk for pressure ulcer development and inspection of skin condition, particularly of pressure points.

   For all inpatients, assess risk of pressure ulcer development at time of admission using a validated risk assessment tool. The literature and work group recommend the Braden Scale for Predicting Pressure Score Risk© (Braden Scale) and the Braden Q Scale©.

   There are several tools available for risk assessment of pressure ulcer prevention. The Braden Scale for Predicting Pressure Score Risk (Braden Scale) is the most commonly used validated tool for predicting patients at risk for pressure ulcer development. Although the sensitivity and specificity for predicting pressure ulcer risk is high for the Braden scale, it serves as an adjunct to clinical judgment regarding each individual. It is important for the health care team to use the Braden score as a guideline in planning interventions aimed at prevention. Other tools available include the Norton Scale and Waterlow Scale.

   The Braden Scale was developed and tested for the adult population. The Braden Q modified the Braden Scale for use in pediatrics. The Braden Q is made up of seven subscales: mobility, activity, sensory perception, skin moisture, friction and sheer, nutrition and tissue perfusion/oxygenation. The Braden Q was tested in a cohort study with children ages 21 days to 8 years in three sites.

   Re-evaluate the risk of pressure ulcer development daily and with any change in condition such as surgery, change in nutritional status or level of mobility.

   See Appendix A, "Braden Scale for Predicting Pressure Score Risk© (Braden Scale)," Appendix B, "Braden Q Scale©," and Appendix C, "Risk Assessment Plan," in the original guideline document.

   Patients at Increased Risk

   It is important for members of the health care team to become familiar with patient populations at increased risk for pressure ulcer development. High-risk diagnoses may include but are not limited to:

   • Peripheral vascular disease
   • Myocardial infarction
   • Stroke
   • Multiple trauma
   • Musculoskeletal disorders/fractures
   • Gastrointestinal (GI) bleed
   • Spinal cord injury
   • Neurological disorders (e.g., Guillain Barré, multiple sclerosis)
   • Unstable and/or chronic medical conditions (e.g., diabetes, renal disease, cancer, chronic obstructive pulmonary disease [COPD], congestive heart failure [CHF], dementia)
   • History of previous pressure ulcer
   • Preterm neonates
   • Dementia

   Patients 75 years of age or greater and/or patients with multiple high-risk diagnoses should be advanced to the next level of risk.

   Individuals who undergo operative procedures may be at increased risk for pressure ulcers. This risk may be related to length of time on the operating room/procedure table, hypotension or to the type of procedure.

   Supporting evidence is of classes: B, C, D, M, R

2. Inpatient Skin Inspection

   A head-to-toe skin inspection should be done on every patient upon admission to the hospital; palpate particularly over pressure points.

   The condition of the skin is an indicator of the general health of the patient. A head-to-toe skin inspection should be done on every patient within six hours of admission to the hospital.

   • For all patients regardless of skin pigmentation, inspect and palpate for:
     • Alteration in skin moisture
     • Change in texture, turgor
     • Change in temperature compared to surrounding skin (warmer or cooler)
     • Color changes, such as pale, red or purplish hues
     • Non-blanchable erythema
     • Consistency, such as bogginess (soft) or induration (hard)
     • Edema
     • Open areas, blisters, rash, drainage
   • In addition, for darkly pigmented skin, look for purplish/bluish localized areas and/or localized warm areas that become cool.

   Skin should be observed in good lighting and any areas of discoloration or redness should be palpated for change in temperature compared to surrounding skin, or feeling of bogginess (soft) or induration (hard). Pay particular attention to areas over bony prominences. Blanching erythema is an early indicator of the need to redistribute pressure, non-blanching erythema is suggestive that tissue damage has already occurred or is imminent, and indurated or boggy skin is a sign that deep tissue damage has likely occurred.

   Ask the patient about:

   • Areas with lack of sensation
   • Areas of pain
   • Location of current or previous ulcers
   • Fragile skin, easy bruising
   • Medications or medical condition putting at higher risk for breakdown

   Re-inspect and palpate skin of all patients every 8 to 24 hours, depending on status of patient. Patients at high risk of breakdown, as determined by either Braden Scale score, may need to be assessed every eight hours or more frequently as condition changes.

   The head-to-toe inspection can be performed at the same time as other assessments. Start at the top and work downward. A full body skin inspection doesn't have to be visualizing all aspects of the patient in the same time period.

   • When applying oxygen, check the ears for pressure areas from the tubing.
   • If on bedrest, don't forget to look at the back of the head during repositioning.
   • When auscultating lung sounds or turning the patient, inspect the shoulders, back and sacral/coccyx region.
   • When checking bowel sounds, look into skin folds.
   • When positioning pillows under calves, check the heels and feet (using a hand-held mirror makes this easy).
   • When checking intravenous (IV) sites, check the arms and elbows.
   • Examine the skin under equipment with routine removal (i.e., teds, restraints, splints, etc).
   • Each time you get a patient up or provide care, be looking at the exposed skin, especially on bony prominences.
   • Pay special attention to areas patient lacks sensation to feel pain and/or has had a breakdown in the past.

   Supporting evidence is of class: R

3. Skin Safety Plan

   The skin safety plan for prevention of pressure ulcers incorporates the interventions below:

   • Minimize or eliminate friction and shear
   • Minimize pressure
   • Manage moisture
   • Maintain adequate nutrition/hydration

   The interventions and information presented are to be utilized for prevention of pressure ulcer development. See Appendix D, "Skin Safety Plan," in the original guideline document.

   Minimize or Eliminate Friction and Shear

   Concepts for minimizing:

   • Utilize transfer or assistive devices to reduce friction and/or shear
   • Use lift sheets or devices to turn, reposition or transfer patients, etc
   • Maintain head of bed at, or below, 30 degrees, or lowest possible level based on medical condition. Match knee angle with angle of head of bed (use knee gatch).
   • Keep skin clean and dry
   • Use trapeze when not contraindicated

   The effect of pressure on underlying structures and tissue is magnified when shear forces are added. Shear forces occur when patients are positioned in such a way that they tend to slide, for example, when the head of the bed is elevated without elevating the feet as well. Shear forces plus pressure cause stretching and kinking of capillaries and tissue, resulting in more tissue ischemia than would have occurred with pressure alone.

   Friction affects only the outermost skin layers by movement of the epidermis against an external surface. Clinically, friction presents as a superficial abrasion or blister (i.e., heel rubbing on sheets). Shear and friction often go hand in hand.

   Actions:

   • Lift body off the bed/chair rather than dragging as the patient is moved up in bed/chair
   • Avoid elevating head of the bed more than 30 degrees unless contraindicated. Sitting at a 90-degree angle when in the chair decreases shear/friction
   • Use transfer devices such as mechanical lifts, hover surgical mattress, slider boards and surgical slip-sheets
   • Pad between skin surfaces that may rub together
   • Heel and elbow pads reduce friction but not pressure
   • Frequent use of hypoallergenic lubricating oils, creams or lotions lowers the surface tension on the skin and reduces friction
   • Use transparent film, hydrocolloid dressings or skin sealants on bony prominences (such as elbows) to decrease friction
   • Keep skin well hydrated and moisturized
   • Lubricate or powder bedpans prior to placing under patient. Roll patients to place bedpan rather than pushing and pulling it in and out
   • Protect skin from moisture. Excessive moisture weakens dermal integrity and destroys the outer lipid layer. Therefore, less mechanical force is needed to wound the skin and cause a physical opening

   Minimize Pressure

   Immobility is the most significant risk factor for pressure ulcer development. Patients who have any degree of immobility should be closely monitored for pressure ulcer development.

   Patients in bed:

   • Make frequent, small position changes
   • Use pillows or wedges to reduce pressure on bony prominences
   • At a minimum, turn every two hours
   • When the patient is lying on one side, do not position directly on trochanter (hip)
   • Use pressure redistribution mattresses/surfaces

   Patients in sitting position:

   • Encourage patients to weight shift every 15 minutes (i.e., chair push ups, if able to reposition self; have patient stand and reseat self if able; make small shift changes such as elevating legs)
   • Reposition every hour if patient unable to reposition self
   • Utilize chair cushions for pressure redistribution

   All patients:

   • Use pressure support surfaces to redistribute pressure as indicated for beds and chairs
   • Consider patient's weight in bed selection. For patients over 300 pounds, evaluate need for bariatric bed/appropriate size support surface
   • Use pressure support surfaces as indicated. Free-float heels by elevating calves on pillows and keeping heels free of all surfaces
   • Minimize/eliminate pressure from medical devices such as oxygen masks and tubing, catheters, cervical collars, casts, IV tubing and restraints
   • Limit the number of layers between the support surface and patient
   • Maintain or enhance patient's level of activity

   Patients have greater intensity of pressure over the bony prominences when sitting in a chair, as there is less distribution of weight. Along with increased weight over the bony prominences, there is a tendency for the body to slide in a downward motion, causing shearing and destruction of the soft tissue over the bony prominences. A sitting position includes sitting in bed greater than 30 degrees, a cardiac chair, recliner or wheelchair. When in this position, it is important for the patient to shift weight every 15 minutes if he/she is able to do so independently. This includes "small shifts of weight" such as pushing up on their arms, raising or lowering head slightly to redistribute the weight or lifting from side to side. If the patient is unable to shift weight independently, his/her position should be changed by care providers on an hourly basis. Remember to utilize chair cushions and consult Physical Therapy/Occupational Therapy for assistance with seating and positioning.

   Manage Moisture

   Concepts for managing moisture:

   • Implement toileting schedule or bowel/bladder program as appropriate
   • Communicate incontinent episodes to primary care giver/team
   • Cleanse skin gently with pH-balanced cleansers and apply moisture barrier
   • Contain urine and stool
   • Contain wound drainage
   • Prevent accumulation of moisture, specifically in skin folds

   Management of moisture from perspiration, wound drainage and incontinence are important factors in pressure ulcer prevention. Moisture from incontinence may be a precursor to pressure ulcer development by macerating the skin and increasing friction.  Fecal incontinence is a greater risk factor for pressure ulcer development than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin. In the presence of both urinary and fecal incontinence, fecal enzymes convert urea to ammonia, raising the skin pH. With a more alkaline skin pH, the skin becomes more permeable to other irritants.

   Actions:

   • Evaluate type of incontinence - urinary, fecal or both
   • Check for incontinence a minimum of every two hours, and as needed
   • Cleanse skin gently at each time of soiling with water or pH-balanced cleanser. Avoid excessive friction and scrubbing, which can further traumatize the skin. Cleansers with nonionic surfactants are gentler to the skin than are anionic surfactants in typical soaps
   • Use incontinence skin barriers (e.g., creams, ointments, film-forming skin protectants) as needed to protect and maintain intact skin, or to treat non-intact skin
   • Consider use of stool containment devices (e.g., fecal pouch, Flexi-seal, Zassi). Assess the fecal incontinence: quantity, frequency and the effectiveness of the above actions before initiation of devices. Be sure to initiate before skin breakdown occurs. If a fecal pouch is ineffective, begin use a Flex-seal or Zassi device. Note these products require prior training to use. Rectal tubes are not recommended, due to risk of injury or perforation

     Be aware that tube feedings and antibiotics may exacerbate the incidence of diarrhea

   • Assess for candidiasis and treat as appropriate
   • Prolonged exposure to moisture is a risk factor, as well as antibiotic therapy over one week, diabetes, obesity, anemia and immunosuppression. Prevention relies on reduction or elimination of moisture. Examples include separation of skin folds, use of a skin sealant, frequent changing of dressings, incontinence containment products, and use of moisture-absorbing topical products
   • Select absorbent underpads and briefs to wick incontinence moisture away from the skin versus trapping moisture against the skin, causing maceration
   • Frequent linen change for excessive perspiration

   Maintain Adequate Nutrition/Hydration

   Concepts for maintaining nutrition/hydration

   • Provide nutrition compatible with individual's wishes or condition
   • Alert caregiver/unit when nourishment is delayed, or promptly provide food and fluids following a procedure in which nutrition has been withheld
   • Consult/refer to Nutrition Therapy when nutrition score on either Braden Scale or patient's condition indicates
   • Advance diet providing and encouraging intake of supplements/fluids as medically indicated

   Patients who are malnourished and/or dehydrated are at greater risk for developing pressure ulcers. Encouraging hydration, as well as high-protein, high-calorie supplements are suggested for the patient who presents with multiple risk factors for developing pressure ulcers.

   Lab values may not reflect current risk of pressure ulcer development. Low serum albumin levels may reflect a chronic disease state versus overall poor nutritional status. Serum albumin is not a sensitive measure of the effects of intervention due to its 20-day half-life. Pre-albumin is a more current reflection of protein stores. Serum pre-albumin levels in malnutrition can be interpreted by the following:

   • Less than 5 mg/dL predicts a poor prognosis
   • Less than 11 mg/dL predicts high risk and requires aggressive nutritional supplementation
   • Less than 15 mg/dL predicts an increased risk of malnutrition, and monitoring twice weekly is recommended

   Supporting evidence is of class: R

4. Documentation

   Document risk assessment, skin inspection and skin safety plan in the patient record. Utilize a consistent documentation format to support care provision, communication and measurement.

   "Not assessed" should be written if the risk assessment and skin inspection is delayed or not completed. "Not applicable" should be written for the Skin Safety Plan if the patient is not at risk. Define a procedure for documentation of a patient refusal of skin inspection. The communication and education steps of the protocol apply even if skin inspection is refused by the patient.

   A paper checklist or process within an electronic medical record system could be a tool to support documentation of risk assessment and skin inspection.

   All personnel involved in the process must take an active role in this protocol. If at any time, a particular section of the protocol cannot be implemented (e.g., maintain nutrition), the other interventions still apply. A defined procedure should be in place for documentation of patient refusal of skin safety strategy.

5. Communication

   All health care team members need to be aware of patients who are at risk for pressure ulcers and those with active safety plans. Communicate skin status and safety plan interventions when transferring care to another provider such as change of shifts, transporting between departments and patient transfer to another facility or unit. Develop a method to communicate skin care concerns to all members of the health care team. Use consistent methods for communication, such as identifying the Braden score and skin inspection results on the interdisciplinary transfer form.

6. Patient Education

   Educate staff, patients, family members, and caregivers about risk assessment, skin inspection techniques, and skin safety interventions. Discuss current status of pressure ulcer risk, skin inspection findings and planned interventions. Involve patients, family members, and caregivers in care planning.

Definitions:

Classes of Research Reports:

1. Primary Reports of New Data Collection

   Class A:

   • Randomized, controlled trial

   Class B:

   • Cohort study

   Class C:

   • Non-randomized trial with concurrent or historical controls
   • Case-control study
   • Study of sensitivity and specificity of a diagnostic test
   • Population-based descriptive study

   Class D:

   • Cross-sectional study
   • Case series
   • Case report

2. Reports that Synthesize or Reflect upon Collections of Primary Reports

   Class M:

   • Meta-analysis
   • Systematic review
   • Decision analysis
   • Cost-effectiveness analysis

   Class R:

   • Consensus statement
   • Consensus report
   • Narrative review

   Class X:

   • Medical opinion

ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; e-mail: icsi.info@icsi.org; Web site: www.icsi.org.

ICSI's conflict of interest policy and procedures are available for review on ICSI's Web site at http://www.icsi.org.

Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

• Development and revision process for guidelines, order sets, and protocols. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2007 Jun. 5 p. Electronic copies: Available from the Institute for Clinical Systems Improvement (ICSI) Web site.

Print copies: Available from ICSI, 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; telephone, (952) 814-7060; fax, (952) 858-9675; Web site: www.icsi.org; e-mail: icsi.info@icsi.org.

Also, the appendices of the original guideline document contain scales for predicting pressure score risk.

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