Patients at risk for pressure ulceration should be evaluated and a management plan to prevent ulceration should be instituted.
Patients at risk for pressure ulcers:
(1) bed-bound patients
(2) chair-bound patients
(3) patients with impaired ability to reposition themselves
Schedule for reassessment:
(1) if there is no activity or mobility deficit, then reassessment can be periodic
(2) if there is an activity or mobility deficit, then reassessment should be more frequent, depending on the severity of the deficit and the clinical status of the patient
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Management Guidelines
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activity deficit
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mobility deficit
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moisture problem
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incontinence
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nutritional deficit
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|
educational
|
Y
|
Y
|
|
|
|
|
mechanical loading and support surface
|
Y
|
Y
|
|
|
|
|
skin care and early treatment
|
Y
|
Y
|
Y
|
Y
|
Y
|
|
nutritional support
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|
|
|
|
Y
|
Educational guidelines:
(1) structured and comprehensive program
(2) involve patient, family, caregivers and health care personnel
Mechanical loading and support surface guideline:
(1) Reposition the patient periodically based on need.
(2) Use appropriate pressure reducing devices when possible.
(3) Have the patient periodically shift weight if able.
(4) Pay attention to sites prone to ulceration, especially over bony prominences.
Skin care and early treatment guideline:
(1) inspect skin at least once a day
(2) provide bathing with a mild cleansing agent and avoiding hot water
(3) use moisturizers for dry skin
(4) avoid environmental exposures to cold or low humidity
(5) use proper positioning, turning and patient transferring techniques
(6) minimize skin exposure to moisture
(7) cleanse any urine or fecal soilage immediately
Nutritional support:
(1) characterize nutritional deficiencies, especially protein or calorie deficiencies
(2) implement nutritional support and/or supplementation
