A review of guidelines.

Anumber of prevention guidelines exist for planning care for people who are at risk for pressure ulcers.1-5 To identify the major themes in preventive care, we reviewed guidelines established by the University of Iowa; the Registered Nurses' Association of Ontario; the Wound, Ostomy, and Continence Nurses Society; and the Institute for Healthcare Improvement (IHI). Each of the following recommendations appeared in at least two of these guidelines.

Pressure Relief

* Reposition patients who aren't using pressure-relieving devices every two hours.1, 4, 5 Those using pressurerelieving devices should be repositioned every two to four hours.2

* Implement a positioning schedule.1, 4

* Use pillows or foam to prevent surfaces from coming into contact with bony prominences.1,4

* Keep the head of the bed elevated to 30[degrees] or less2, 4, 5 and position the patient on her or his side at a 30[degrees] angle from supine.4, 5

* Avoid massaging bony prominences.2, 4, 5

* Those who are confined to a wheelchair and can reposition themselves should do so every 15 minutes,2,5 or the provider should change the patient's position every hour.2, 4

* Don't use ring devices.2,4, 5

* Relieve pressure on heels.1, 2, 4

* Use a turn or lift sheet to turn or transfer the patient.2, 4, 5

* Ensure that chairbound patients maintain proper spinal alignment.2, 4

Pressure-Relieving Surface

* Place a pressure-relieving surface on beds and chairs.1, 2, 4, 5

* Use pressure-relieving devices in the operating room.1, 2, 4

Skin Moisture

* Keep the skin dry and well lubricated.1,4, 5

* Cleanse the skin when the patient is incontinent.1, 2, 4

* Use moisture barriers.1,2

* Establish bowel and bladder programs for continence.2, 4

* Use skin barriers with incontinent patients.1, 2, 4Other

* Educate patients and caregivers.2, 4, 5

* Supplement nutrition.1,2, 4

The IHI recommends flagging patient records with a particular color or a sticker to remind caregivers to do pressure ulcer risk and skin assessment on admission. It also recommends reorganizing data collection forms to include a checklist for assessing pressure ulcer risk and skin, designating a pressure ulcer "champion" on each unit, dividing the institution's population into risk groups and addressing those at high risk first, and playing music over the public-address system at two-hour intervals to remind staff to turn patients.1

Nancy A. Stotts, EdD, RN, FAAN

Lena Gunningberg, PhD, RN

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