1. Elizabeth Ciyou-Allee BA, RN, CLNC, CHPN. ELNEC-PEDS, TNCC
When Pressure Persists: Prevention of Pressure Ulcers for Those at Risk
By:
Elizabeth Ciyou-Allee
BA, RN, CLNC, CHPN. ELNEC-PEDS, TNCC

2. When Pressure Persists: Learning Objectives
Direct Care Staff will be able to:
Identify the risk factors for pressure ulcers
Discuss common reasons for pressure ulcers
Discuss strategies to prevent these wounds
Describe a team approach to pressure ulcer prevention and care
Describe a pressure ulcer prevention program
Objectives are included in the participant handout and include the detail for the last objective:
Describe a pressure ulcer prevention program for a nursing home, including:
Education of residents, staff and residents’ families
Routine assessment of skin
Proper skin care
Prompt response to early signs of pressure ulcers
Frequent movement of residents
Toileting schedule for incontinent residents
Staff observation and reporting of risks and signs of pressure ulcers

3. Pressure Ulcer: Definition
A pressure ulcer is any change in color or break in the skin caused by too much pressure on the skin for too long a period of time.
Pressure ulcers are areas of skin death. When the tissue is exposed to prolonged pressure it does not get enough
nutrients and cells die.
In its earliest stage, the ulcer shows up as persistent redness in light-colored skin. In dark-colored skin the area may
appear red, blue or purplish.
Muscle cells may die before pressure is visible on the skin. Body tissues have different resistance to pressure. Muscle is
more sensitive than skin. By the time pressure is evident on the skin, muscle cells may have already died.

4. Pressure Ulcers Occur commonly in older people
Can be prevented in many residents
Can be painful, lead to infection, and are a marker for increased risk of death
Cost more than $6,000 each to treat
As people age, the skin becomes drier, thinner and more fragile. The fatty layer under the skin becomes thin, resulting
in more prominent bony structures.
The goal is to prevent ulcers whenever possible. Many, but not all, pressure ulcers are preventable. Those that are not
preventable are often due to poor nutrition or chronic disease. Pressure ulcers can be painful and may result in complications. Residents with pressure ulcers are likely to die sooner than those without them.
Treatment of a single pressure ulcer exceeds $6000. The overall cost in terms of pain and suffering, bad survey citations, law suits, etc., can not be determined but is surely much higher.

5. What Causes Skin Injury?
Pressure – reduces blood flow to skin
Friction – repeated rubbing causes a break in the skin
Shear – sideways pulling on the skin layers until it breaks
Pressure is seldom the only cause of pressure ulcers. More often the cause is
a combination of pressure, friction, and shear.
Pressure, the amount of force exerted on an area, is measured in millimeters of mercury (mm of Hg). When external pressure is greater than 32 mm Hg,
blood flow to the area is reduced. The area may not get enough oxygen and
nutrients. Metabolic toxins may build up. Cells may die. There is
a relationship between time and pressure. Lower levels of pressure for
long periods of time are as damaging as high pressure for short periods of
time.
Friction occurs when two substances rub together. Pulling an older person across the bed linen may rub away the outer skin layer. When the interface
between the body and the bedding is moist, the force of friction is greater.
Think about the friction associated with pulling on a wet, as compared to a
dry, bathing suit.
Shear is a mechanical force that is parallel rather than perpendicular to the
area. When we elevate the head of the bed, the body skeleton actually slides
down in relation to the skin. This especially affects the sacrum. Shear force
is greatest when we drag a person up in bed.

6. Who’s at Risk? Individuals who are: bed or chair-bound
unable to sense discomfort
incontinent
poorly nourished or dehydrated
feverish, have diabetes, or low
blood pressure
Many factors contribute to the risk for pressure ulcers:
Immobility is probably the greatest threat of all. Individuals who are unable to move independently in bed and to get in and out of bed must depend on those caring for them to change their position.
Loss of discomfort from pressure. Normally, when pressure on the skin reduces blood flow to an area a sensation of discomfort causes one to shift a little and relieve the pressure. Those who are unable to sense the discomfort will be at greater risk. This may include individuals who had a stroke, but also those who are sedated or restrained.
Incontinence increases the risk because it causes excessively moist skin and chemical irritation. Of the two types of incontinence, fecal incontinence makes a greater contribution to pressure ulcer risk – probably because stool contains bacteria while urine is normally sterile.
Underweight and loss of weight. Adequate protein, calories, and fluids are essential to prevent skin injury. Individuals who are underweight or who are losing weight are at higher risk. Various acute and chronic illnesses may increase the risk for pressure injury.

7. Pressure Points Back of the head Back of shoulders Elbows Hip Buttocks
Contractures
Heels
Pressure ulcers occur over bony prominences.
Common sites of pressure ulcers include the:
the back of the head
back of shoulders (scapula)
ischium
trochanter
sacrum
malleolus
lateral edge of the foot and
heels
Areas of skin-to-skin contact are susceptible, especially in residents with muscle contractures. Most pressure ulcers
occur in the lower half of the body.
(Overhead is in participant handout as a full-page illustration)

8. A Team Approach to Prevention
Identify at-risk individuals
Maintain and improve skin condition
Protect against pressure and injury
Assure adequate nutrition and hydration
Encourage activity and mobility
Educate older adults, families, and care providers
Early identification of skin injury
Preventing pressure ulcers requires a team approach.
The nurse identifies “at risk” residents on admission using an assessment tool. Most facilities use the Braden Scale, although some use the Norton Scale.
The dietician assesses the nutritional status of each resident and
prescribes a diet that will assure adequate protein, calories, and fluid to
maintain skin health.
The physical or occupational therapist assists with mobility and positioning devices. The activity therapist conducts activities that encourage movement.
Despite the efforts of all of these providers, it is the direct care staff who provide the first line of defense in protecting older persons from pressure ulcers.
What you do for prevention:
􀂄 maintain the skin in good condition,
􀂄 protect against pressure and injury,
􀂄 assure that the resident consumes adequate food and fluids,
􀂄 encourage participation in activities, and
􀂄 inspect the skin to identify early signs of skin injury.

9. Clean and Dry Clean gently with warm water
Prevent incontinence by maintaining toileting schedule
Help resident off the bed pan or toilet promptly
Clean skin at time of soiling
Absorbent underpads or briefs
Moisture barriers
The thin, fragile skin of older people needs special care. Gentle cleaning with warm water alone is generally sufficient for daily bathing. During cleaning and drying, use a soft towel and pat the skin dry. Do not rub the skin.
Make every effort to prevent incontinence by toileting individuals promptly as needed. Older adults should not be left sitting on the bedpan or toilet for more than 10 minutes.
Clean the skin whenever it becomes soiled. Diapers and underpads do not replace the need for awareness and immediate cleaning.
For incontinence, absorbent briefs, (adult diapers) may be used. Briefs should be made of materials that absorb moisture and present a quick-drying surface to the skin. There is little good reason for wearing briefs in bed. When you use “specialty surfaces,” place a single layer of fabric between the individual and the surface.
Do not place the patient directly on plastic or paper linen savers because they hold moisture and irritate skin.
Topical moisture barriers may be used to protect the skin from moisture. Protective films may also help to reduce friction injuries.

10. Beyond Clean and Dry Look for and report any changes
Clean skin and keep it well lubricated
Minimize dryness and avoid excessive moisture
Clean and dry is not enough!
Lubrication of skin is important.
Apply lotions or creams to areas of dry, flaky skin.
Skin that is water-logged (macerated) is easily eroded by friction, more easily irritable, and more readily colonized by germs than normal skin.

11. Skin Checks Check all surfaces at least once a day
Remove clothing and position for visibility
Check pressure points with every position change
If you note a reddened area, reassess in 15 minutes
The easiest times to do a skin check are when getting the person up and returning him/her to bed. Be sure to inspect all surfaces. Look for redness, dryness, rashes or other breaks in skin integrity. Feel for changes in skin temperature– damaged areas may feel warm to the touch.
Pay special attention to areas that remain reddened after position change. By definition an area that is still red after 15 minutes is a Stage I pressure ulcer. Never position a resident on a reddened area (or on a pressure ulcer).
Never massage over bony prominences or reddened areas. Massage may rupture capillaries and damage underlying tissues.
If you notice:
a rash or break, then wash the area with plain warm water (no soap).
an area of red but intact skin, then position the resident to relieve pressure.
In either case, tell the nurse– describe what you saw, felt and did.
Ask him or her if he/she would like to see the area.

12. Abnormal Skin Changes Note location, size and degree of:
Areas of redness or warmth in fair skin
Areas of duskiness or darkness and warmth in dark skin
Areas of pain or discomfort
Blisters – fluid-filled or broken
Weeping or drainage
Examine the skin for signs of pressure change (redness, change in color, temperature, or texture), moisture or dryness, and presence of rashes or skin breaks. Report any changes promptly to the nurse. Describe the area including color, temperature, location, and size. Recheck the area 15 minutes after the resident is repositioned; note any change.
Check for temperature changes by placing the back of your hand against the area. Compare findings with the temperature of other skin surface areas.
Investigate and report complaints of pain or discomfort. When sensation is intact, residents may complain of pain associated with being in one position for too long. Established pressure ulcers may be painful – especially if pressure is sustained, and during dressing changes.
Blisters, fluid-filled or broken, may be Stage II pressure ulcers. Friction usually causes blisters. If an area is weeping or draining, notice and report the color, amount and odor of the drainage.

13. Reducing Pressure in Bed
Turn at least every two hours
Prevent skin- to- skin contact
Complete pressure relief for heels
Elevate head of bed as little as possible
Use lift sheets or trapeze
Do not position directly on hip bone
Do not rub or massage reddened areas
Remember the time– pressure relationship. Less pressure for more time is as dangerous as more pressure for shorter time. Some older adults may need to be turned or repositioned more frequently than every two hours. No one should ever lie on skin that is already reddened by pressure. Heels are especially vulnerable and should be lifted completely off the bed with pillows. Heels should be elevated even when the resident is on a specialty surface.
The head of the bed should not be elevated more than 30o so that the person does not slide down in bed. If the head of the bed must be elevated to minimize risk for aspiration, monitor the skin in the sacral region carefully.
Lift sheets or a trapeze may enhance mobility and reduce friction and shear. When an older adult is lying on the side, weight should never be directly on the hip bone (greater trochanter of the femur). A 30o laterally inclined position relieves sacral pressure and prevents trochanteric pressure. (Shown on next slide). Historically, nurses were taught to massage reddened tissue over bony prominences. However, massage of reddened tissue may break small blood vessels, and result in more ischemic injury.

14. 30° Laterally Inclined Position
Weight not on sacrum or trochanter
Support with pillows or foam wedge
Use pillows to protect vulnerable areas
Head of bed as low as possible
Turning and repositioning is essential even if the person is on a pressure-reducing surface.
In the 30° laterally inclined position, weight is on the fleshy buttock muscle, suspended between the sacrum and the trochanter (hip bone). Bending the knees further reduces pressure on the trochanter.
A pillow between the legs prevents skin-to-skin contact and reduces pressure between the knees; one under the lower leg reduces pressure on the ankle bone and outer aspect of the foot.

15. Specialty Mattresses Help decrease pressure ulcer formation
Patients still need frequent skin checks
These mattresses do not replace the need to turn the person
Turn and check the person at least every two to three hours
Sheets and incontinence pads should be crease free
Sheets should be placed loosely on these mattresses and never tucked
With the introduction of many different pressure reduction surfaces the development of pressure ulcers in bedbound and immobile patients has decreased.
These surfaces do not however replace the need for turning the patient on a frequent basis and checking the skin for redness and possible breakdown. Mattresses that rotate and turn patients at a 30-degree angle are mostly used for improving pulmonary function therefore the patient still needs observation and turning.
Studies indicate that patients on specialty mattresses need to be turned every two to three hours at least to eliminate any possibility of pressure on at risk areas.
Incontinence pads and specialty mattress should be used sparingly. The presence of an incontinence pad and a specialty mattress can increase the pressure on at risk area such as the sacrum up to 25% and many manufacturers do not recommend large pads. Pads should always be smoothed as any creases from movement or placement of the pad increases the pressure on the patient’s skin.
For these mattresses to perform at the optimum level sheets should always be kept as loose as possible. If a sheet is tight it can become a barrier to the pressure relieving properties of the mattress.

16. Reducing Pressure in Chairs
Reposition at least every hour
Instruct to shift weight every 15 minutes
Do not use doughnuts or rings
When an older adult is in the chair, more of the body weight is distributed to smaller surface, producing higher pressure. The pressure–time relationship means that those in a chair should be repositioned more frequently than those in bed. Older adults in a chair should be repositioned at least every hour.
Those who are able should be taught and encouraged to make small weight shifts every 15 minutes.
Ring cushions are known to cause venous congestion and edema. In one study, they were found to be more likely to cause than to prevent pressure ulcers.

17. Nutrition Encourage residents to drink enough water
Assist residents to eat enough protein and calories
Older adults need to know that skin breaks down more easily and wounds won’t heal unless nutrition and hydration are adequate.
Primary sources of protein in the diet include milk products (yogurt, cheese, ice cream), meat, poultry, fish, dry beans, and eggs. If individuals are unable to complete their entire meal, these foods are especially important.

18. You can make a make a difference!
Keep your older adults moving
Position immobile or dependent individuals frequently and carefully
Assist with meals and snacks
Provide plenty of clear, cool water
Keep those with incontinence clean and dry
Be alert to changes and report them
Not all pressure ulcers can be prevented, but many can. CNAs provide the first line of protection against pressure ulcers. You can make a difference!The best way to lower the risk of pressure ulcers is to keep older adults moving.
If individuals cannot position themselves, turn and reposition frequently. Those who can change their position may need to be reminded to do so. Don’t forget to help or encourage the person sitting in a chair to change position.
Adequate nutrition and hydration are essential to prevent pressure ulcers. If you notice someone is not eating or drinking enough, report it to the nurse. Some may need vitamins or supplements added to their diet.
Individuals who are incontinent have a five times higher risk of pressure ulcers than those who are continent. Establish a toileting schedule for those who are incontinent. Clean those with incontinence promptly after soiling. Use skin protective barriers.
Always be on the lookout – report redness, investigate complaints of pain or discomfort – you may be the eyes and ears of the nurse, but the voice of the older adult.

19. Objectives Review Identify the risk factors for pressure ulcers?
Discuss common reasons for pressure ulcers?
Discuss strategies to prevent these wounds?
Describe a team approach to pressure ulcer prevention and care?
Describe a pressure ulcer prevention program?
Can you now:
Identify the risk factors for pressure ulcers?
Discuss common reasons for pressure ulcers?
Discuss strategies to prevent these wounds?
Describe a team approach to pressure ulcer prevention and care?
Describe a pressure ulcer prevention

20. References
Bergstrom, N., et al. (2005). The National Pressure Ulcer Long-Term Care Study: outcomes of pressure ulcer treatments in long-term care. Journal of the American Geriatrics society, 53:
Benbow, M (2006) Guidelines for the prevention and treatment of pressure ulcers. Nursing Standard. 20 (52),
Garcia, AD and Thomas, DR. (2006). Assessment and management of chronic pressure ulcers in the elderly. Medical Clinics of North America, 90 (5):
 Thomas, DR. Prevention and treatment of pressure ulcers. Journal of the American Medical Directors Association, 7 (1),