European Pressure Ulcer Advisory Panel

Epidemiological research has increased considerably in recent years, providing a better understanding of risk factors important in the development of pressure ulcers and this literature needs to underpin risk assessment practice. However, one must be careful with interpreting the results of these epidemiological research studies, as the results may depend on which risk factors are included in the multi-variable model.

1. Establish a risk assessment policy in all health care settings. (Strength of Evidence = C)

   Each health care setting should have a policy in place including recommendations for the structured approach to risk assessment relevant to the health care setting, targeted clinical areas, the timing of risk assessment and reassessment, clear recommendations for documentation of risk assessment and communication to the wider healthcare team.

2. Educate healthcare professionals on how to achieve an accurate and reliable risk assessment. (Strength of Evidence = B)
3. Document all risk assessments. (Strength of Evidence = C)

   Documentation of risk assessments are required to ensure communication within the multidisciplinary team, confer evidence that care planning is appropriate and provide a benchmark to monitor the progress of the individual.

4. Use a structured approach to risk assessment to identify individuals at risk of pressure ulcer development. (Strength of Evidence = C)

   A structured approach may be achieved through the use of a risk assessment scale in conjunction with a comprehensive skin assessment and clinical judgment.

   Despite the fact there are some limitations of risk assessment scales, their widespread utilization would suggest this is indicative of the value professionals place on them. Evidence suggests that their introduction in conjunction with the establishment of skin care teams, education programs and care protocols may reduce the incidence of pressure ulcers. Better than clinical judgement.

5. Use a structured approach to risk assessment which includes assessment of activity and mobility. (Strength of evidence = C)
   • 5.1 Consider individuals who are bedfast and/or chairfast to be at risk of pressure ulcer development.
6. Use a structured approach to risk assessment which includes a comprehensive skin assessment including alterations to intact skin. (Strength of evidence = C)
   • 6.1 Consider individuals with alterations to intact skin to be at risk of pressure ulcer development.

     Alteration in skin condition include dry skin, erythema and other alterations. The presence of non-blanching erythema also increases the risk of further pressure ulcer development.

7. Use a structured approach to risk assessment which is refined by using clinical judgment informed by knowledge of key risk factors. (Strength of Evidence = C)
8. Consider the impact of the following risk factors on an individual’s risk of pressure ulcer development.
   1. Nutritional indicators

      Nutritional indicators include hemoglobin, anemia, and serum albumin, measures of nutritional intake, and weight.

   2. Factors affecting perfusion and oxygenation

      Factors affecting perfusion include diabetes, cardiovascular instability/nor epinephrine use, low blood pressure, ankle brachial index and oxygen use.

   3. Skin moisture
   4. Increased age
9. Consider the potential impact of the following risk factors on an individual’s risk of pressure ulcer development.
   1. Friction and shear (Subscale Braden Scale)
   2. Sensory perception (Subscale Braden Scale)
   3. General health status
   4. Body temperature
10. Conduct a structured risk assessment on admission, and repeat as regularly and as frequently as required by patient acuity. Reassessment should also be undertaken if there is any change in patient condition. (Strength of Evidence = C)
11. Develop and implement a prevention plan when individuals have been identified as being at risk of pressure ulcer development. (Strength of Evidence = C)

1. Ensure that a complete skin assessment is included in the risk assessment screening policy in place in all health care settings. (Strength of Evidence = C)

   Each health care setting should have a policy in place including recommendations for the structured approach to skin assessment relevant to the setting, targeted clinical areas, the timing of assessment and reassessment. It should have clear recommendations for documentation of skin assessment and communication to the wider healthcare team.

2. Educate the professional on how to undertake a comprehensive skin assessment that includes the techniques in identifying blanching response, localized heat, oedema and induration (hardness). (Strength of Evidence = B)

   These additional assessment techniques can be used for all individuals. However, there is evidence that Category I pressure ulcers are underdetected in individuals with darkly pigmented skin because areas of redness are not as easily seen.

3. Inspect skin regularly for signs of redness in individuals identified as being at risk of pressure ulceration. The frequency of inspection may need to be increased in response to any deterioration in overall condition. (Strength of Evidence = B)

   Ongoing assessment of the skin is necessary to detect early signs of pressure damage.

4. Skin inspection should include assessment for localized heat, oedema or induration (hardness), especially in individuals with darkly pigmented skin. (Strength of Evidence = C)

   Localized heat, oedema and induration have all been identified as warning signs for pressure ulcer development. As it is not always possible to see signs of redness on darkly pigmented skin these additional signs should be used for assessment.

5. Ask individuals to identify any areas of discomfort or pain that could be attributed to pressure damage. (Strength of Evidence = C)

   A number of studies have identified pain as a major factor for individuals with pressure ulcers. In several studies there is also some indication that pain over the site was a precursor to tissue breakdown.

6. Observe the skin for pressure damage due to medical devices. (Strength of Evidence = C)

   Many different types of medical devices have been reported as causing pressure damage (e.g., catheters, oxygen tubing, ventilator tubing, semirigid cervical collars, etc.).

7. Document all skin assessments including details of any pain possibly related to pressure damage. (Strength of Evidence = C)

   Accurate documentation is essential to monitor the progress of the individual and to aid communication between professionals.

8. Do not turn the individual onto a body surface that is still reddened from a previous episode of pressure loading whenever possible. (Strength of Evidence = C)

   Redness indicates that the body has not recovered from the previous loading and requires further respite from repeated loading (See Etiology).

9. Do not use massage for pressure ulcer prevention (Strength of Evidence = B)

   Massage is contra-indicated in the presence of acute inflammation and where there is the possibility of damaged blood vessels or fragile skin. Massage could not be recommended as a strategy for pressure ulcer prevention.

10. Do not vigorously rub skin at risk for pressure ulceration. (Strength of Evidence = C)

    As well as being painful, rubbing the skin can also cause mild tissue destruction or provoke an inflammatory reaction, particularly in the frail elderly.

11. Use skin emollients to hydrate dry skin in order to reduce risk of skin damage. (Strength of Evidence = B)

    Dry skin seems to be a significant and independent risk factor of pressure ulcer development.

12. Protect the skin from exposure to excessive moisture with a barrier product in order to reduce the risk of pressure damage. (Strength of Evidence = C)

    The mechanical properties of the stratum corneum are changed by the presence of moisture and as a function of temperature.

1. Screen and assess nutritional status for every individual at risk of pressure ulcers in each health care setting. (Strength of Evidence = C)

   Since under-nutrition is a reversible risk factor for pressure ulcer development, early identification and management of under-nutrition is very important. Individuals at risk of pressure ulcer development may also be at risk of under-nutrition and so should be screened for nutritional status.

   • 1.1 Use a valid, reliable and practical tool for nutritional screening that is quick and easy to use and acceptable to both the individual and health care worker. (Strength of Evidence = C)

     It is important that the screening tool is validated, reliable and relevant to the patient group it is assessing. It is also important that the same tool can be used in different care settings to encourage continuity of care.

   • 1.2 Have a nutritional screening policy in place in all health care settings, along with recommended frequency of screening for implementation. (Strength of Evidence = C)

     Each health care setting should have a policy about nutritional screening. Results of screening, especially when action is required, should be communicated from one care setting to another.

2. Refer each individual with nutritional risk and pressure ulcer risk to a registered dietitian and also, if needed to a multidisciplinary nutritional team including a registered dietitian, a nurse specialized in nutrition, physician, speech and language therapist, occupational therapist and/or dentist. (Strength of Evidence = C)

   If the nutritional screening identifies individuals prone to develop pressure ulcers, to be malnourished or at nutritional risk, then a more comprehensive nutritional assessment should be undertaken by a registered dietitian or a multidisciplinary nutritional team.

   • 2.1 Provide nutritional support to each individual with nutritional risk and pressure ulcer risk, following the nutritional cycle. This should include:
     • Nutritional assessment
     • Estimation of nutritional requirements
     • Comparison of nutrient intake with estimated requirements
     • Provide appropriate nutrition intervention, based on appropriate feeding route
     • Monitoring and evaluation of nutritional outcome, with reassessment of nutritional status at frequent intervals while an individual is at risk.
     (Strength of Evidence = C)

     Individuals may need different forms of nutritional management during the course of their illness.

   • 2.2 Follow relevant and evidence based guidelines on enteral nutrition and hydration for individuals at risk of pressure ulcers, who show nutritional risks or nutritional problems. (Strength of Evidence = C)

     It is clear that other and more detailed clinical guidelines on nutrition and hydration exist and should be available and that this guideline’s guidance on nutrition and pressure ulcers should be considered within the context of general guidelines on nutritional management.

1. Offer high protein mixed oral nutritional supplements and/or tube feeding, in addition to the usual diet, to individuals with nutritional risk and pressure ulcer risk because of acute or chronic diseases, or following a surgical intervention. (Strength of Evidence = A)

   Oral nutrition (via normal feeding and/or with additional sip feeding) is the preferred route for nutrition and should be supported whenever possible.

   Oral nutritional supplements are of value because many pressure ulcer prone patients often cannot meet their nutritional requirements via normal oral food intake. Moreover, oral nutritional supplementation seems to be associated with a significant reduction in pressure ulcer development compared to routine care.

   Enteral (tube feeding) and parenteral nutrition may be necessary when oral nutrition is inadequate or not possible based on the individual’s condition and goals.

   • 1.1 Administer oral nutritional supplements (ONS) and/or tube feeding (TF) in between the regular meals, to avoid reduction of normal food and fluid intake during regular mealtimes. (Strength of Evidence = C)

1. The use of repositioning should be considered in all at-risk individuals.
   • 1.1 Repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body. (Strength of Evidence = A)

     High pressures, over bony prominences, for a short period of time, and low pressures, over bony prominences, for a long period of time are equally damaging. In order to lessen the individual’s risk of pressure ulcer development, it is important to reduce the time and the amount of pressure they are exposed to.

   • 1.2 The use of repositioning as a prevention strategy must take into consideration the condition of the patient and the support surface in use. (Strength of Evidence = C)

2. Repositioning frequency will be influenced by the individual (Strength of Evidence = C) and the support surface in use (Strength of Evidence = A).
   • 2.1 Repositioning frequency will be determined by the individual’s tissue tolerance, their level of activity and mobility, their general medical condition, the overall treatment objectives and an assessment of the individual’s skin condition. (Strength of Evidence = C)
   • 2.2 Assess the individual’s skin and general comfort. If the individual is not responding as expected to the repositioning regime, reconsider the frequency and method of repositioning. (Strength of Evidence = C)
   • 2.3 Repositioning frequency will be influenced by the support surface used. (Strength of Evidence = A)

   An individual should be repositioned with greater frequency on a on a non-pressure-redistributing mattress than on a visco-elastic foam mattresses. The repositioning frequency depends on the pressure redistributing features of the support surface.

3. Repositioning will maintain the individual’s comfort, dignity and functional ability. (Strength of Evidence = C)
   • 3.1 Reposition the individual in such a way that pressure is relieved or redistributed. (Strength of Evidence = C)
   • 3.2 Avoid subjecting the skin to pressure and shear forces. (Strength of Evidence = C)
   • 3.3 Use transfer aids to reduce friction and shear. Lift, don’t drag the individual while repositioning. (Strength of Evidence = C)
   • 3.4 Avoid positioning the individual directly onto medical devices, such as tubes or drainage systems. (Strength of Evidence = C)
   • 3.5 Avoid positioning the individual on bony prominences with existing non-blanchable erythema. (Strength of Evidence = C)
   • 3.6 Repositioning should be undertaken using the 30 degree semi Fowler position or the prone position and the 30 degree-tilted side lying position (alternately right side, back, left side) if the individual can tolerate this position and the medical condition allows. Avoid postures that increase pressure, such as the Fowler’s over 30 degree or the 90 degree side lying position, or the semi-recumbent position. (Strength of Evidence = C)
   • 3.7 If sitting in bed is necessary, avoid head of bed elevation and a slouched position that places pressure and shear on the sacrum and coccyx. (Strength of Evidence = C)

4. Position the individual so as to maintain their full range of activities. (Strength of Evidence = C)

   This may be a complex process, for example, in an armchair which tilts back, the use of a foot rest with the heels offloaded may be a suitable position in terms of pressure redistribution but may impede transfer to and from the chair.

   • 4.1 Select a posture that is acceptable for the individual and minimizes the pressures and shear exerted on the skin and soft tissues. (Strength of Evidence = C)
   • 4.2 Place the feet of the individual on a foot stool or foot rest when the feet do not reach the floor. (Strength of Evidence = C)

     When the feet do not rest on the floor, the body slides forward out of the chair. Foot rest height should be chosen to slightly flex the pelvis forward by positioning the thighs slightly less than horizontal.

   • 4.3 Limit the time an individual spends seated in a chair without pressure relief. (Strength of Evidence = B)

     When an individual is seated in a chair, the weight of the body causes the greatest exposure to pressure to occur over the ischial tuberosities. As the loaded area is relatively small, the pressure will be high, therefore, without pressure relief, a pressure ulcer will occur very quickly.

5. Record repositioning regimes, specifying the frequency, position adopted and the evaluation of the outcome of the repositioning regime. (Strength of Evidence = C)

6. Education in the role of repositioning in pressure ulcer prevention should be offered to all persons involved in the care of individuals at risk of pressure ulcer development, including the individual and significant others (where possible). (Strength of Evidence = C)
   • 6.1 Training in the correct methods of repositioning and use of equipment should be offered to all persons involved in the care of individuals at risk of pressure ulcer development, including the individual and significant others (where possible and appropriate). (Strength of Evidence = C)

1. General Statements
   • 1.1 Prevention in individuals at risk should be provided on a continuous basis during the time that they are at risk. (Strength of Evidence = C)
   • 1.2 Do not base the selection of a support surface solely on the perceived level of risk or the Category of pressure ulcer. (Strength of Evidence = C)

     Selection of an appropriate support surface should also take into consideration factors such as the individual’s level of mobility within the bed, comfort, need for microclimate control and the place and circumstances of care provision.

   • 1.3 Do not use either the perceived level of risk or Category of pressure ulcer to select a support surface. (Strength of Evidence = C)
   • 1.4 Choose a support surface compatible with the care setting. (Strength of Evidence = C)

     Not all support surfaces are compatible with every care setting. Support surface use in a home setting requires consideration of the weight of the bed and structure of the home, width of doors, and availability of uninterrupted electrical power and promoting ventilation of heat from the motor.

   • 1.5 Examine the appropriateness and functionality of the support surfaces on every encounter. (Strength of Evidence = C)
   • 1.6 Verify that the support surface is within its functional life span, through the specific manufacturer’s recommended test method (or other industry recognized test method) before use of the support surface. (Strength of Evidence = C)
2. Mattress and Bed Use in Pressure Ulcer Prevention
   • 2.1 Use a higher specification foam mattresses rather than standard hospital foam mattresses for all individuals assessed as at risk for pressure ulcer development. (Strength of Evidence = A)

     Higher specification foam mattresses seem to be more effective in preventing pressure ulcers than standard hospital foam mattresses.

   • 2.2 There is no evidence of the superiority of one high specification foam mattress over alternative high specification foam mattresses. (Strength of Evidence = A)

     There seems to be no clear difference in the effectiveness of high specification foam mattresses.

   • 2.3 Use an active support surface (overlay or mattress) for patients at higher risk of pressure ulcer development where frequent manual repositioning is not possible. (Strength of evidence = B)

     When high risk patients cannot be repositioned manually, active support surfaces are needed as they can change their load distribution properties.

   • 2.4 Overlay or mattress replacement alternating pressure active support surfaces have a similar efficacy in terms of pressure ulcer incidence. (Strength of Evidence = A)
   • 2.5 Do not use small cell alternating pressure air mattresses or overlays. (Strength of Evidence = C)

     Alternating pressure air mattresses with small air cells (diameter <10cm) cannot be sufficiently inflated to ensure pressure relief over the deflated air cells. Internal sensors are being utilised in models currently under development that may resolve this problem.

   • Continue to turn and reposition where possible all individuals at risk of pressure ulcers. (Strength of Evidence = C)
3. The use of support surfaces to prevent heel pressure ulcers
   • 3.1 Ensure that heels are free of the surface of the bed. (Strength of Evidence = C)
   • 3.2 Heel protection devices should elevate the heel completely (off load) in such a way as to distribute the weight of the leg along the calf without putting pressure on the Achilles tendon. The knee should be in slight flexion. (Strength of Evidence = C)

     Hyperextension of the knee may cause obstruction of the popliteal vein and this could predispose to deep vein thrombosis.

   • 3.3 Use a pillow under the calves to elevate the heels (floating heels). (Strength of Evidence = B)

     Using a pillow under the calves elevates the heels from the mattress.

   • 3.4 Inspect the skin of the heels regularly. (Strength of Evidence = C)
4. Use of support surfaces to prevent pressure ulcers while seated
   • 4.1 Use a pressure-redistributing seat cushion for individuals sitting in a chair whose mobility is reduced and who are thus at risk of pressure ulcer development. (Strength of Evidence = B)

     Different studies show that the use of a pressure redistributing seat cushion prevents the development of pressure ulcers.

   • 4.2 Limit the time an individual spends seated in a chair without pressure relief (Strength of Evidence = B)
   • 4.3 Give special attention to individuals with spinal cord injury. (Strength of Evidence = C)
5. The use of other support surfaces in pressure ulcer prevention
   • 5.1 Avoid use of synthetic sheepskin; cut-out, ring or donut type devices; and water-filled gloves. (Strength of Evidence = C)
   • 5.2 Natural sheepskin might assist the prevention of pressure ulcers. (Strength of Evidence = B)

     Some studies show that the use of natural sheepskin might help in the prevention of pressure ulcers.

Operating Room Patients

1. Refine risk assessment of individuals undergoing surgery by examining other factors which are likely to occur and will increase risk of pressure ulcer development including:
   1. Length of the operation
   2. Increased hypotensive episodes intra-operatively
   3. Low core temperature during surgery
   4. Reduced mobility on day 1 post-operatively
2. Use a pressure-redistributing mattress on the operating table for all individuals identified as being at risk of pressure ulcer development. (Strength of Evidence = B)

   Several operating room support surfaces have been developed to redistribute pressure.

3. Position of the patient in such a way as to reduce the risk of pressure ulcer development during surgery. (Strength of Evidence = C)
4. Elevate the heel completely (off load) in such a way as to distribute the weight of the leg along the calf without putting all the pressure on the Achilles tendon. The knee should be in slight flexion. (Strength of Evidence = C)

   Hyperextension of the knee may cause obstruction of the popliteal vein and this could predispose to deep vein thrombosis.

5. Elevate the individual’s heels during surgery to reduce the risk of pressure ulcer occurrence on the heel. (Strength of Evidence = C)
6. Pay attention to pressure redistribution prior to and after surgery. (Strength of Evidence = C)
   • 6.1 Place individuals on a pressure-redistributing mattress both prior to and after surgery. (Strength of Evidence = C)
   • 6.2 Position the individual in a different posture preoperatively and postoperatively to the posture during surgery. (Strength of Evidence = C)