Home Health Blogger

Pressure Ulcer Prevention: Nursing Assessment and Patient Teaching

Posted by Melissa Cott on Feb 11, 2020

Any person who is in a bed or chair for 8 hours or longer is at risk for pressure ulcers. Pressure ulcers - also known as bed sores, decubitus ulcers, pressure sores and skin ulcers - often develop in patients with the following conditions: diabetes mellitus, deep venous thrombosis, s/p hip fracture, s/p hip surgery, limb paralysis, dependent edema, cancer, malnutrition, osteoporosis, Parkinson’s disease, rheumatoid arthritis, and urinary tract infections. In addition, patients with Alzheimer’s disease, congestive heart failure, chronic obstructive pulmonary disease, and c/p cerebral vascular accident are at risk for pressure ulcers. 

PRESSURE ULCER RISK ASSESSMENTpressure-ulcer-prevention


A person is at risk for pressure ulcers if s/he...

  • Is in a bed or chair for eight hours or more – excluding sleeping
  • Has urine or fecal incontinence
  • Has a chronic medical condition
  • They already have redness or pain in pressure ulcer areas: such as sacrum, trochanter, scapulae, elbow, heel, inner and outer malleolus, inner and outer knee, back of the head
  • Has trouble getting enough calories or fluids every day
  • Is already under-nourished


PRESSURE ULCER PREVENTION STRATEGIES

img-pressure-ulcerAny patient with reduced mobility should be taught how to prevent pressure ulcers. The following are general but important tips:

  • CHANGE POSITION FREQUENTLY! The patient should move their position no less than every 2 hours, and if chair or bedbound, perform passive or active range of motion exercises while in a chair or in bed.
  • Be vigilant about skincare especially if incontinent of urine or feces.
  • Clean the skin with mild soap and warm water or a no-rinse cleanser. Gently pat dry. Use skin protectant to protect skin vulnerable to excess moisture.
  • Apply lotion to dry skin.
  • Change bedding and clothing frequently.
  • Watch for buttons on the clothing and wrinkles in the bedding that irritate the skin.
  • If not contraindicated make sure the patient is drinking eight (8) 8-oz glasses of water a day and getting a diet with plenty of protein.
  • If not contraindicated make sure the patient adds calories. Some good strategies on increasing calorie intake
    • Add butter or margarine to foods when cooking and put on foods that are already cooked.
    • Add cream sauce or melt cheese over vegetables.
    • Eat peanut butter sandwiches, or put peanut butter on vegetables or fruits, such as carrots or apples.
    • Mix whole milk or half-and-half with canned soups.
    • Add protein supplements to yogurt, milkshakes, fruit smoothies, or pudding.
    • Drink milkshakes between meals.
    • Add honey to juices.
  • Encourage the patient/caregiver to keep a log of dietary and fluid intake and position changes
  • Consider using Pressure-relieving mattresses and support surfaces Special foam mattresses and as alternating pressure mattresses can be used to provide a soft surface. These distribute the pressure over a larger surface area, reducing the pressure on especially vulnerable parts of the body.

PDGM Therapy: is PT Always Indicated for an M1860 Mobility Deficit?

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