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Prevention of Complications in Hospitalized Patients Part V: Pressure Ulcers
Author: Nasim Afsar-manesh, M.D., and Michael S. Galindo, M.D.
Last Revised: Wed, 14-May-2008
Article Size: 12.64 KB

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Prevention of Complications in Hospitalized Patients
Part V: Pressure Ulcers

Nasim Afsar-manesh, M.D., and Michael S. Galindo, M.D.

The Clinical Scenario

A 74-year-old woman was admitted to the hospital with pneumonia. Due to her respiratory distress, she was bed-bound. Despite an initial response to antibi-otics, her white blood cell count began to increase on the sixth day of hospitalization. After a negative infectious work-up, an erythematous and draining decubitus ulcer was noted on her sacrum. What measures could have been taken to prevent this complication?


Pressure ulcers affect millions of Americans each year, leading to significant morbidity and mortality.1,2 They often result in decreased functional capacity, cause discomfort and pain, and may lead to chronic infections. The incidence of pressure ulcers has been estimated to be as high as 38% in hospitalized patients in the acute care setting. In long-term facilities, rates can vary from 2% to 24%.3 An estimated 2.5 million pressure ulcers are treated each year.4 Aside from increased morbidity and mortality, treatment of each pressure ulcer can cost up to $70,000. It has been esti-mated that the United States spends as much as $11 billion per year for treatment of ulcers.5,6 Therefore, it is critical to recognize patients at high risk for development of pressure ulcers and actively imple-ment measures to help prevent this debilitating and costly complication.


Healthy individuals, when recumbent, frequently change position on their own. This activity is impaired in ill patients, resulting in prolonged periods in a single position. Uninterrupted pressure from the weight of the patient's body against a surface leads to compression of the skin vasculature and decreased tissue perfusion. This can lead to tissue hypoxia, causing skin necrosis. Sustained pressure on a single site for greater than 2 hours can be significant enough to cause tissue injury. Shear forces as well as friction can further aggravate the damaged tissue.

Risk Factors

The first step in prevention of pressure ulcers is risk stratification. Two different scales have been proposed for this purpose: the Braden and Norton Scales. The Braden Scale predicts the risk of devel-oping pressure ulcers by evaluating the patient based on 6 criteria: sensory perception, skin moisture, activity level, mobility, friction and shear, and nutri-tional status (Table 1). The Norton Scale assesses the patient's physical and mental activity, the level of activity, mobility and degree of incontinence (Table 2). Based on this evaluation, patients with higher risk scores for developing ulcers (scores greater than 16 and 14 on the Braden and Norton scales, respectively) should receive more aggressive skin care and preven-tative measures.

Preventive Strategies

There are a number of measures that have been implemented for the prevention of pressure ulcers. The clinician's efforts should start with recognition of dry skin, as it is a risk factor for the development of ulcers.7 If dry skin is noted, hyperoxygenated fatty acid preparations should be applied to prevent against friction and skin damage. This intervention was illus-trated to reduce the incidence of pressure ulcers from 17% to 7%.8

A variety of bedding and support surfaces have been utilized to decrease the amount of pressure on the skin. These surfaces can be either static or dynamic. Dynamic surfaces use varying and alternating degrees of pressure, while static surfaces such as support mattresses and overlays contain materials composed of air, water, gel, foam or combinations thereof. The efficacy of support surfaces was evaluated in a randomized controlled trial of patients in the oper-ating room (OR), demonstrating a lower incidence of post-operative ulcers with the use of foam mattress overlays on the OR table.9 Multiple studies have illustrated that overlays composed of specialized foam and sheepskin consistently lower the incidence of pressure ulcers when compared to standard hospital mattresses.1-3 While studies show a decreased incidence of pressure ulcers with a variety of support surfaces, one trial did not show a difference when comparing dynamic and static surfaces.13,14 Beds which rotate and turn to decrease the amount of pressure on the body were not shown to decrease the incidence of pressure ulcers.15

Manual repositioning patients in bed has also been utilized to decrease the incidence of ulcers. Most nursing protocols recommend turning bed-bound patient every 2 hours. One study did not find a signif-icant difference between placing the patient in a 30 degree tilt (pillows placed under buttock and legs, so sacrum and heels are not in contact with the support surface) versus 90 degree tilt (patient lying on side).16 Patients in wheelchairs should be turned every hour. These patients can also benefit greatly from leaning forward to relieve pressure on the ischial tuberosities, one of the sites most prone to developing pressure ulcers. Positioning of the feet and heels are critical, as they account for 10% to 20% of all ulcers. Heel elevation and pads can be utilized for support.

Better nutrition has been proposed as a means of prevention of pressure ulcers. In a comparison between a standard diet versus the standard plus an additional 2 oral nutritional supplements, the control group had a relative risk increase of 1.57 for the development of pressure ulcers17; however, other studies have not been able to demonstrate the benefits of improved nutritional status.

Incontinence can often lead to skin inflammation and damage; however, a study comparing the effects of exercise and incontinence care for 2 hours per day for 32 weeks to usual care did not reveal a reduction in the incidence of pressure ulcers.18


Pressure ulcers are a costly yet preventable consequence of immobilization in hospitalized patients. The implementation of simple measures can help decrease morbidity and mortality in inpatient medicine wards.

Resolution of Clinical Scenario

The patient received a short course of antibiotic therapy, aggressive local care for her wound, was assisted in walking twice a day, and was encourage to sit in a chair as much as possible. When in bed, frequent turning was emphasized. Her pressure ulcer healed without sequelae.

Summary of Recommendations for the Prevention of Pressure Ulcers

1) Clinicians should routinely assess each patient'srisk for the development of pressure ulcers, using

the Braden or Norton Scales.

2) Dry skin should be recognized promptly and treated aggressively with moisturizers.

3) Patients at risk for developing pressure ulcers should be provided with appropriate support surfaces and mattresses, including specialized foam and sheepskin overlays.

4) High-risk patients should be repositioned at 30 to 90 degrees every 2 hours, and every hour if the patient is in a wheelchair.

5) Appropriate heel and foot protection should be provided in selected patients.

6) Clinicians should strive to improve patients' nutritional status using dietary supplements.


  1. Berlowitz DR, Brandeis GH, Anderson J, Du W, Brand H. Effect of pressure ulcers on the survival of long-term care residents. J Gerontol A Biol Sci Med Sci. 1997 Mar;52(2):M106-10.

  2. Thomas DR, Goode PS, Tarquine PH, Allman RM. Hospital-acquired pressure ulcers and risk of death. J Am Geriatr Soc. 1996 Dec;44(12):1435-40.

  3. Lyder CH. Pressure ulcer prevention and management. JAMA. 2003 Jan 8;289(2):223-6.

  4. Staas WE Jr, Cioschi HM. Pressure sores--a multifaceted approach to prevention and treatment. West J Med. 1991 May;154(5):539-44.

  5. Gordon MD, Gottschlich MM, Helvig EI, Marvin JA, Richard RL. Review of evidenced-based practice for the prevention of pressure sores in burn patients. J Burn Care Rehabil. 2004 Sep-Oct;25(5):388-410.

  6. Kuhn BA, Coulter SJ. Balancing the pressure ulcer cost and quality equation. Nurs Econ. 1992 Sep-Oct;10(5):353-9.

  7. Allman RM, Goode PS, Patrick MM, Burst N, Bartolucci AA. Pressure ulcer risk factors among hospitalized patients with activity limitation. JAMA. 1995 Mar 15;273(11):865-70.

  8. Torra i Bou JE, Segovia Gómez T, Verdú Soriano J, Nolasco Bonmatí A, Rueda López J, Arboix i Perejamo M. The effective-ness of a hyperoxygenated fatty acid compound in preventing pressure ulcers. J Wound Care. 2005 Mar;14(3):117-21.

  9. Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomised controlled trial comparing a dry visco-elastic polymer pad and standard operating table mattress in the prevention of post-opera-tive pressure sores. Int J Nurs Stud. 1998 Aug;35(4):193-203.

  10. Jolley DJ, Wright R, McGowan S, Hickey MB, Campbell DA, Sinclair RD, Montgomery KC. Preventing pressure ulcers with the Australian Medical Sheepskin: an open-label randomised controlled trial. Med J Aust. 2004 Apr 5;180(7):324-7.

  11. Russell LJ, Reynolds TM, Park C, Rithalia S, Gonsalkorale M, Birch J, Torgerson D, Iglesias C; PPUS-1 Study Group. Randomized clinical trial comparing 2 support surfaces: results of the Prevention of Pressure Ulcers Study. Adv Skin Wound Care. 2003 Nov;16(6):317-27.
  12. Gray DG, Smith M. Comparison of a new foam mattress with the standard hospital mattress. J Wound Care. 2000 Jan;9(1):29-31.

  13. Vanderwee K, Grypdonck MH, Defloor T. Effectiveness of an alternating pressure air mattress for the prevention of pressure ulcers. Age Ageing. 2005 May;34(3):261-7. Epub 2005 Mar 11.

  14. Andersen KE, Jensen O, Kvorning SA, Bach E. Decubitus prophy-laxis: a prospective trial on the efficiency of alternating-pressure air-mattresses and water-mattresses. Acta Derm Venereol. 1983;63(3):227-30.

  15. Keogh A, Dealey C. Profiling beds versus standard hospital beds: effects on pressure ulcer incidence outcomes. J Wound Care. 2001 Feb;10(2):15-9.

  16. Young T. The 30 degree tilt position vs the 90 degree lateral and supine positions in reducing the incidence of non-blanching erythema in a hospital inpatient population: a randomised controlled trial. J Tissue Viability. 2004 Jul;14(3):88, 90, 92-6.

  17. Bourdel-Marchasson I, Barateau M, Rondeau V, Dequae-Merchadou L, Salles-Montaudon N, Emeriau JP, Manciet G, Dartigues JF. A multi-center trial of the effects of oral nutritional supplementation in critically ill older inpatients. GAGE Group. Groupe Aquitain Geriatrique d'Evaluation. Nutrition. 2000 Jan;16(1):1-5.

  18. Bates-Jensen BM, Alessi CA, Al-Samarrai NR, Schnelle JF. The effects of an exercise and incontinence intervention on skin health outcomes in nursing home residents. J Am Geriatr Soc. 2003 Mar;51(3):348-55.

Submitted on December 26, 2007

Prevention of Complications in Hospitalized Patients Part V: Pressure Ulcers
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