CLINICAL

Overview

This topic provides a systematic approach to identifying patients at risk for developing pressure ulcers/injuries (PUs/PIs) and  developing specific care plans , primarily based on the latest evidence-based clinical guidelines by the National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (NPIAP/EPUAP/PPPI), Wound, Ostomy and Continence Nurses (WOCN) Society, the National Institute for Health and Care Excellence, and the Canadian Best Practice Guidelines for the Prevention and Management of Pressure Ulcers in People with Spinal Cord Injury, and the American College of Physicians. [5][6][7][8][9]  For a list of guidelines and quality measures related to PU/PI, see topic " Pressure Ulcers/Injuries - Overview ". For an introduction and assessment of PU/PI including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see " Pressure Ulcers/Injuries - Introduction and Assessment ". For management of PU/PI, see topic " Pressure Ulcers/Injuries - Treatment". For best practices in care coordination, see " Pressure Ulcers/Injuries -Coordination of Care".

Background

• Definition: A pressure ulcer (PU), also known as pressure injury (PI), pressure sore, decubitus ulcer or bed sore, is an area of localized injury to the skin and/or underlying tissue, usually over a bony prominence or related to a medical or other device. A pressure ulcer/injury (PU/PI) can present as intact skin and/or ulcer and may be painful. It occurs as a result of pressure, or pressure in combination with shear. [5]
• Relevance: PUs/PIs pose a large burden to affected individuals, caregivers and healthcare systems. As in any illness or injury, preventing PUs/PIs is better than treating them. From a patient's perspective, PUs/PIs can significantly impact quality of life of affected individuals and caregivers. From a healthcare system's perspective, PUs/PIs treatment is onerous, with estimated costs in the U.S. ranging between $9.1-11.6 billion a year. [1] In addition, PUs/PIs have been identified by the Centers for Medicare and Medicaid Services (CMS) as one of the 14 hospital-acquired conditions (HACs) that are reasonably preventable using evidence-based guidelines. [2] Along with the many recent CMS “value-based purchasing” initiatives, starting in 2008 CMS decided not to reimburse hospitals for hospital-acquired Stage 3 and 4 PU/PI and other preventable HACs. [10] 
• Increasing clinicians' knowledge and attitude toward PU/PI prevention can improve their practice toward prevention of PU/PI. [11] Coordination of care is critical to decrease incidence and severity of PUs/PIs. See topic " Pressure Ulcers/Injuries - Coordination of Care"

Best Practices/ Recommendations for PU/PI Prevention 

The 'Bundle' Concept

A care bundle can be defined as a group of best practices/recommendations derived from evidence-based clinical guidelines that if done in combination are likely to lead to better outcomes. [12] Bundles are meant to organize these best practices and recommendations and tie them in a systematic way that facilitates their implementation by clinicians, patients and caregivers in a practical manner.  This topic outlines a PU/PI prevention bundle that incorporates the main components in PU/PI prevention [5] : 

• Structured PU/PI risk assessment 
• Comprehensive skin assessment
• Development/implementation of a personalized care plan that includes preventative interventions related to pressure redistribution, repositioning, mobility and activity, nutrition, management of moisture and shear, lifestyle/psychological interventions,  measures to prevent medical device-related PU/PI, patient and caregiver education

Bundles are often customized according to care settings and facilities. Acronyms may help facilitate dissemination of care bundles for PU/PI within healthcare systems. Examples are illustrated in Table 1. 

Table 1. Care bundles for PU/PI prevention

Best Practices/ Recommendations - In a Nutshell

Table 2 summarizes the best practices/ recommendations for PU/PI presented in this topic. For more details, see specific sections on each preventive intervention. Best practices/ recommendations shown in Table 2 apply to all care settings (e.g. acute care, long-term acute care hospitals, long-term care (skilled nursing facilities), home health, community, etc). However each care setting presents specific barriers and needs that require clinicians to adapt these general best practices/ recommendations. For instance: 

• Acute care: treatment goals in acute care settings may conflict with recommendations for PU/PI prevention. As an example, patients with respiratory issues may need to have head-of-bed elevated more than the 30 degrees angle recommended by clinical guidelines. 
• Long-term acute care hospitals: patient hand-off may result in gaps of information that preclude adequate fulfillment of a patient's care plan. A wound care team may not always be available or easily accessible. [15] It may be difficult for clinicians who receive the patient to identify all players accountable for wound care [e.g, physical therapy (PT), occupational therapy (OT), etc] from prior care settings. 
• Home health/community settings: each individual's daily life is permeated with an unique constellation of circumstances, some of which may turn out to be disruptive events that culminate in a PU/PI risk episode. These circumstances need to be factored in when developing/monitoring an individualized prevention plan. [16][17][18][19] To illustrate this point, please refer to case "How 20 minutes of fun can cost 4 months of disruption".
• Outpatient wound clinics: commuting to/from the wound clinic for an office visit can be a major event for the patient/caregiver. If adequate transfer equipment/methods are not employed, the act of coming for an office visit itself can pose a PU/PI risk episode. 

Given the above, for each preventative intervention described in this topic, authors strive to provide examples of how it has been successfully adapted in specific care settings. In addition, because PU/PI patients are often treated by distinct healthcare professionals across the continuum of care, care coordination is paramount for a successful prevention program. For more information, refer to the topic " Pressure Ulcers/Injuries - Coordination of Care". In addition, the editable " Provider-to-Provider Communication Form" can help ensure no information gaps are created upon transition of care. 

Table 2. Summary of Best Practices/ Recommendations for Prevention of PU/PI  [5]  

Structured Risk and Skin Assessment

Structured Risk Assessment 

Validated tools for children 

Those include:

• Braden Q Scale  is a validated, adjusted version for children under 8 years of age. [32]  
• Braden QD scale: revised, simplified version is the "Braden QD Scale", for immobility-related and device-related pressure injuries in the pediatric acute care environment. [4]

structured risk assessment across different care settings:

The general recommendations/best practices described above apply to all care settings. Table 4 highlights how those have been adapted to some specific care settings:

Table 4. Structured Risk Assessment Across Different Care Settings

Comprehensive Skin Assessment

• For all individuals being admitted to a care setting, clinical guideline and expert consensus recommend conducting a  comprehensive skin assessment whenever a PU/PI risk assessment is conducted (Grade 1C). [5] [12]
  
• A nurse or healthcare professional trained to complete the skin assessment should perform a comprehensive, head-to-toe skin assessment, ensuring special attention is given to the skin overlying bony prominences (e.g., sacrum, ischium, trochanters, heels, etc) and areas in contact with medical devices. [5] [12] Table 5 below provides a sample checklist that may be adapted to each healthcare facility.

Table 5. Checklist for comprehensive head-to-toe skin assessment by healthcare professionals

Figure 1. Tools for objective assessment of skin tone. Fitzpatrick Classification Scale (left) and  Munsell color chart (right). By  Tânia Santos, RN, MSc

Skin ASSESSMENT across DIFFERENT CARE SETTINGS:

The general recommendations/best practices described above apply to all care settings. Table 6 highlights how these general recommendations/best practices are adapted to some specific care settings:

Table 6. Skin Assessment Across Different Care Settings

Customized Care Plan - Preventative Interventions

• For all individuals at risk for PU/PI, we recommend clinicians develop and implement an individualized risk-based prevention plan. [5] [12]
  
• Most patients do not fit into a "routine" care plan, and need a personalized prevention plan that addresses the needs identified through a structured risk assessment. [12] A proper prevention plan includes interventions that aim at stabilizing, reducing or removing underlying risk factors. 
• To facilitate implementation of customized care plans, facilities might opt to have preset order sets that can be customized for each individual, based on structured risk and skin assessments. To expedite implementation of preventive measures, many healthcare facilities allow nurses to place order sets for PU/PI prevention, without the need to wait for a prescribing provider to sign them off. 
• Computerized decision support systems have been shown to reduce incidence of PU/PI in long-term care facilities for older people. In a study, the system chose residents' skin care products, absorbent briefs and mattresses based on resident's assessment and PU/PI risk. [36] [37]
  
• A sample care plan with examples of interventions that may be considered for each specific Braden subscale scores is listed on the AHRQ.gov website. [38]Nurses and certified nurse assistants should tailor these interventions to meet the needs of each patient. 

Pressure redistribution

Pressure redistribution with support surfaces is one of the key interventions for PU/PI prevention. Support surfaces redistribute pressure by either increasing the body surface in contact with the support surface and thereby reducing interface pressure, or by mechanically altering the parts of the body that bear load, thereby reducing the duration of the applied pressure on any given anatomical site.[5][39][40]  See definition and types of support surfaces in section ' Pressure Redistribution' in "Pressure Ulcers/Injuries - Treatment"

• Mattress and bed support surfaces: 1B To prevent PUs/PIs among individuals at risk for PU/PI, clinical guidelines recommend use of a high-specification reactive foam mattress as opposed to a non-high specification reactive foam mattress. (Grade 1B)  [5] [6] [8] [9]
• Rationale: there is moderate certainty evidence supporting use of high specification foam mattress to prevent PU/PI among individuals at risk of developing PU/PI. [41] When used in the operating room, these support surfaces are also associated with a reduction of postoperative PU/PI. Clinical guidelines recommend usage of high specification foam mattresses compared with any other type of mattress at home or at healthcare facilities, to prevent PU/PI in people at risk of PU/PI. [5] [6] [8] [9] There is no evidence justifying superiority of one higher specification foam mattress over any other higher specification foam mattress.
• Coverage: Medicare covers high specification foam mattresses (Group 1 support surface) for beneficiaries who are completely immobile or are partially immobile and meet at least one of the following: A. impaired nutritional status, B. Fecal or urinary incontinence, C. Altered sensory perception, D.Compromised circulatory status. [42]
• Selection: To help identify the appropriate support surface (i.e., overlay, mattress, integrated bed system) for adults (≥16 years of age) and bariatric patients in care settings where the length of stay is 24 hours or more, clinicians can use the  WOCN Society's Evidence-and Consensus-Based Support Surface Algorithm.  [43] [44] 
• Seating support surfaces: For individuals at risk for PU/PI using wheelchairs or who sit for prolonged periods, clinicians might opt for a high-specification foam pressure redistributing cushion. [8]
• Rationale: Adequate pressure redistribution support surfaces and repositioning are crucial for prevention of PU/PI as it is estimated that more than half of PU/PI occurring among individuals in community settings happen as a result of pressure while sitting. [7] [45] 
• Coverage: Medicare covers adjustable skin protection seat cushions (HCPCS E2622, E2623) for patients with a wheelchair and current or past history of PU/PI, or with absent or impaired sensation in the area of contact with the seating surface, or inability to carry out a functional weight shift. [46]

pressure redistribution ACROSS DIFFERENT CARE SETTINGS:

The general recommendations/best practices described above apply to all care settings. Below we highlight how these general recommendations/best practices are adapted to some specific care settings:

Acute care

• For patients at risk for PU/PI who cannot turn themselves or cannot be turned, consider a reactive support surface (overlay or mattress). [5]
• For all individuals with or at risk of PU/PI who are undergoing surgery, use a pressure redistribution support surface on the operating table. [5]
  

Home health and community

• For home health patients at risk for PU/PI: it is important that home health clinicians  assist the patient in obtaining a high-specification foam pressure redistribution mattress/chair surface. Clinicians can help patients and caregivers procure support surfaces by identifying most adequate model/brand and suppliers. [14]
• For home health patients and community individuals at risk for PU/PI:
• Mattresses and bed support surface: 
• These support surfaces need to be professionally reassessed at least every 4 years or  sooner if the person’s medical condition changes. [7] Some clinicians may recommend reassessment of the support surface every 2 years.
• Seating support surfaces:
• For people with mobility issues (e.g. spinal cord injury): it is recommended that specialized seating professionals (OT/PT) assist with initial fit assessment and recommendation of wheelchairs and other sitting support surfaces including toilet, shower bench, seating for recreational activities .  [7] [16]
• Individuals at risk for PU/PI should sit on their prescribed seating system: If sitting on another surface is needed (e.g., on a padded toilet seat), weight shifts/repositioning should be done more frequently than every 15 minutes. [16]
• Maintenance: many new and recurrent PUs/PIs occur due to worn equipment that has not been replaced. Clinical guideline recommends teaching the individual and caregiver to care and maintain the seating support surface according to manufacturer's instructions, to frequently monitor signs of wear, to set up cushion correctly and monitor bottoming out, to replace cushion as soon as signs of wear and tear are identified, and to avoid placing additional layers on top of the cushion. Scheduled reassessments should be done at least every 2 years or sooner if medical, living conditions change or if equipment wears. [7]

(Re)Positioning

Repositioning (i.e, changing the patient's position on a bed or seating surface) allows for relief of pressure on an existing PU/PI and on areas where PU/PI can develop.   Frequency of repositioning is tailored to each individual.   For patients who can reposition themselves, reminders (e.g., alarm clocks, apps) to prompt them to reposition can be helpful. Patients who cannot reposition themselves need assistance from trained healthcare professionals and caregivers. Repositioning/turning systems have been developed to help clinicians reposition patients more easily. Clinicians should avoid positioning patients on their ulcers and bony prominences. 

See details on repositioning frequency and techniques in section ' (Re)Positioning' in topic "Pressure Ulcers/Injuries - Treatment" .  In summary, for patients at risk for PU/PI, guidelines recommend  [5] [20] [47] : 

• All patients at risk for PU/PI should be repositioned, unless contra-indicated.
• For patients who cannot be repositioned due to medical reasons, PU/PI prevention plans should rely on alternative prevention strategies (e.g., pressure redistribution support surfaces)
• Frequency of repositioning is tailored to each individual and care setting, taking into consideration the patient's general medical condition, overall treatment objectives, comfort and pain. Generally, the following are starting points that can be adjusted:
• For seated individuals: at least every 1 hour while sitting, with weight shifts every 15-30 minutes 
• For individuals in bed: turn according to individualized tissue tolerance, which can be as often as every 1-4 hours, unless they can reposition themselves. Inspect areas at risk at every turn.
• Repositioning techniques to prevent PU/PI in individuals at risk for PU/PI [5]:
• Repositioning in bed: 
• Use the 30° tilted side-lying position (alternate right side, back, left side) or the prone position if the individual can tolerate this and her/his medical condition allows. Avoid extended use of prone positioning unless required for management of the individual’s medical condition.
• Head-of-bed elevation:  keep the head of bed as flat as possible. Limit head-of-bed elevation to 30° and avoid prolonged elevation unless medical conditions require otherwise 
• Heels: 'float the heels' off the bed, that is, ensure heels are free of the surface of the bed. For long term use (e.g, for patients with spinal cord injury) use heel suspension devices and ensure heels are not touching the surface of the bed. To redistribute pressure, it is important that the weight of the leg is redistributed along the entire length of the calf without placing pressure on a single, small area of the leg (e.g., Achilles tendon).  See " Heel Protectors". 
  
• Upon each turn/rotation, inspect skin subject to increased pressure for any signs of impending PU/PI (e.g., erythema, pain)
• Repositioning seated individuals: 
• Goal is to maintain comfort and minimize pressure/shear on areas in contact with seating surface.
• Provide adequate seat tilt to prevent sliding forward in the wheelchair or chair. 
• Select a reclined seated position with the individual’s legs elevated. If reclining is not appropriate or possible, feet should be properly supported on the floor, on a footstool or on footrests. 
• Check hamstring length. If individual cannot extend legs completely, use of elevating leg rests is not recommended, as individual would be pulled into a sacral sitting posture, causing increased pressure on the coccyx and/or sacrum. 
• Teach and encourage individuals who spend prolonged durations in a seated position to perform pressure relieving maneuvers.
  
• Positioning devices or pillows can be helpful in maintaining positions. To offload the occiput, clinicians might opt for fluidized positioning devices. [48]
• Technology-guided repositioning: clinical guidelines suggest the use of continuous bedside pressure mapping as a visual cue to guide repositioning. [5]
  

REPOSITIONING ACROSS DIFFERENT CARE SETTINGS

The general recommendations/best practices described above apply to all care settings. Table 7 highlights how these general recommendations/best practices are adapted to some specific care settings:

Table 7. Repositioning Across Different Care Settings

Mobility, Activity

Limited mobility is one of the most important risk factors for PU/PI development and delayed ulcer healing. [49] 

• For individuals at risk for PU/PI, guidelines recommend early implementation of a mobility and/or activity program so that the patient can increase mobility and activity as rapidly as tolerated. [5]
• Depending on the level of immobility, PT/OT should be included if possible. Therapists will evaluate patients' range of motion and individual needs, and develop a plan for sitting and ambulation as rapidly as patients can tolerate. [5] [25]

mobility/activity care ACROSS DIFFERENT CARE SETTINGS

The general recommendations/best practices described above apply to all care settings. Below we highlight how these general recommendations/best practices are adapted to some specific care settings:

Home health

For all patients at risk for PU/PI  [34]:

• Collaborate with patient and caregivers to establish, monitor and encourage patients to engage in a program for improving patient activity/mobility.
• Offer PT referral to review plan and improve activity level and/or mobility

Community

For individuals with mobility impairment (e.g. spinal cord injury)  [7]

• Mobility assessment and training sessions conducted by PT/OT are recommended:
• A comprehensive assessment of mobility includes: evaluation of physical impairments, gross motor skills, and movement quality, and additional risk for PU/PI. This assessment should be repeated every time gross motor skills decline or if a PU/PI develops 
• Gross motor skills training includes: bed mobility, transfers, wheelchair mobility, and ambulation as appropriate
• Exercises for PU/PI prevention: a PT/OT can guide in the development of a regular exercise program to optimize muscle strength and endurance, encourage postural alignment, improve cardiovascular endurance, and prevent fatigue and deconditioning. 
• Periodic re-education: postural management, positioning, and pressure-redistributing movements are central to PU/PI prevention. Initial good habits can deteriorate over time; periodic re-education is beneficial. [7]

Nutrition

Nutritional optimization is critical in healing and prevention of PUs/PIs.

• For all patients with PU/PI or at risk for PU/PI, clinical guidelines recommend screening of nutritional status upon admission to a healthcare setting, at each significant change in clinical condition and/or if progress towards healing of PU/PI is not observed.  [5] [7] [6]
• Screening of nutritional status may be performed by any healthcare team member upon admission to a healthcare facility or at first visit in community settings. Its goal is to identify individuals at risk for malnutrition so that they can undergo a comprehensive nutrition assessment by a registered dietitian. [5]
• Validated tools such as the " Nestlé MNA" and "Self-MNA®" can be used to facilitate initial screening and follow up.
•   Medicare Quality Payment Program, Quality Measure:
• "Process Measure: Nutritional Screening and Intervention Plan in Patients with Chronic Wounds and Ulcers" 
• "Patient Reported Nutritional Assessment and Intervention Plan in Patients with Wounds and Ulcers"
• "Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up"
• For individuals at risk for malnutrition, referral to a registered dietitian is recommended. Care plan should be individualized to each person. See nutritional optimization plan for individuals at risk for PU/PI and malnutrition in section ' Nutrition' in topic "Pressure Ulcers/Injuries - Treatment".

nutrition ACROSS DIFFERENT CARE SETTINGS

The general recommendations/best practices described above apply to all care settings. Below we highlight how these general recommendations/best practices have been adapted to some specific care settings:

Acute care, long-term care facilities:

•  Dehydration is a common problem predisposing patients to PU/PI. Care plans may suggest offering a sip of a beverage each time a clinician enters the room. [12]
  

Health care and community

For individuals at risk for PU/PI  [34]: 

• Assess nutritional risk using a validated screening tool. If patient is at risk for malnutrition, consult dietitian/nutritionist (a phone/ home visit may be a viable option).
• Teach/monitor patient and caregivers regarding daily dietary needs and fluid intake.
• Secure provider order for nutrition supplements/support as needed and assist patient in obtaining supplements. Of note, oral nutrition supplements are not typically covered by Medicare.

Management of moisture and shear 

Excessive moisture is a risk factor for development of PU/PI and for infection of existing PU/PI. [25]   Moisture and shear can lead to the superficial breakdown of fragile skin of older individuals, contributing to the development of PU/PI.  Excess moisture in the sacral area may occur due to sweat (i.e. non-breathable support surfaces), but most frequently is a result of fecal or urinary incontinen ce. [25]

Microclimate management:

• For all patients at risk for PU/PI, clinical guideline recommends keeping the skin clean and appropriately hydrated. [5]
• Rationale: Changes in the skin microclimate (temperature, humidity and airflow next to the skin surface) can alter tissue deformation response upon pressure and indirectly increase risk for PU/PI development. [50]
• Manage/address excessive skin moisture  [5]:
• Limit layers under the patient to only one and keep it wrinkle free. More layers can alter properties of the support surface, increase interface pressure and/or cause skin to sweat. Check with manufacturers for individual recommendations.
• Protect the skin from exposure to excessive moisture with  moisture barrier products in order to reduce the risk of pressure damage. Current evidence suggests that creams with fatty acid (e.g. Mepentol, not available in the U.S.) versus a control compound (a cream that does not include fatty acid) may reduce the incidence of PU/PI. [51]
  
• If possible, select support surfaces and support surface covers that allow control of skin temperature and moisture (microclimate control).
• Avoid skin contact with heated surfaces (e.g. heating pads, bed warmers, hot water bottles, heated car seats). Heat increases the skin metabolic rate, induces sweating and decreases the tolerance of the tissue for pressure. [5] 
• Avoiding use of alkaline soaps and cleansers. [5] 

For individuals with fecal and urinary incontinence:

• Cleanse the skin promptly  [5], apply moisture barrier products with emollients and  skin protectants (e.g., made with zinc, silicone, dimethicone, cyanoacrylate) on perineal skin to protect skin from excessive moisture. Use high absorbency incontinence products to protect the skin. Fecal/urine containment devices/garments may be used.  See management of fecal and urinary incontinence in section ' Excessive moisture and shear' in topic "Pressure Ulcers/Injuries - Treatment".

Prophylactic dressings:

• 2C For individuals at risk for PU/PI, clinical guidelines suggest use of prophylactic dressings to minimize skin shear on areas subject to higher pressure (e.g., bony prominences such as sacrum, heels) and prevent PU/PI (Grade 2C)  [5] [6]
• Rationale: Current evidence (level C, low certainty) indicates that compared with no dressing, prophylactic silicone/polyurethane 5-layer foam dressings (e.g., Mepilex Border, Allevyn Life), may reduce PU/PI incidence among patients at risk for PU/PI when used with other preventative measures. Other types of dressings have not been shown to reduce PU/PI incidence. [51] Use of prophylactic polyurethane 5 layer foam dressings has been shown to be cost-effective in preventing PU/PI in Australian acute care settings, but this result may not be applicable to other settings/countries. [52]
• Coverage: for Medicare beneficiaries in acute care, home health, long-term care facilities, cost of prophylactic dressings are included in the reimbursement for episode of care. For patients at home (outpatient) without home health services, prophylactic dressings are not a covered benefit. [53]
• When selecting prophylactic dressings, clinicians might opt to consider the following factors  [5]:
• Ability of the dressing to manage microclimate
• Ease of application and removal
• Ability to regularly assess the skin: design should facilitate regular skin assessment (e.g. soft silicone borders that are easy to lift and place back)
• Anatomical location where the dressing will be applied
• The correct dressing size
• It is important to follow manufacturers' recommendations. A prophylactic dressing should be replaced if it becomes damaged, displaced, loosened or excessively moist. 

Transfers and transitions to various surfaces:

• For individuals with limited mobility, ensure transfers at the patient's environment are smooth and free of harmful pressure and shear. [25][16]
• Consider using textiles with low friction coefficients. [5]
  

Moisture and shear management ACROSS DIFFERENT CARE SETTINGS

The general recommendations/best practices described above apply to all care settings. Below we highlight how these general recommendations/best practices have been adapted to some specific care settings:

Acute care setting 

• In operating rooms, if patients need to be in prone position during surgery, consider placing  prophylactic dressings on areas subject to increased pressure (e.g. face, chin, and chest) to protect and minimize skin shear.
  

Home health and community settings:

To manage moisture excess among patients at risk for PU/PI:

• Skin care  [5] [34]:
• Educate patients and caregivers on the importance to keep skin clean and dry, and how to cleanse the skin using plain warm water and mild, non-deodorant, non-scented soap. 
• Teach how to apply a moisture barrier to protect skin from moisture, assist patients and caregivers with purchase of skin care products. 
• Encourage use of absorbent underpads and adult diapers to keep moisture away from skin.

To minimize skin and tissue shear among patients at risk for PU/PI:

• Transfers:
• Teach patient and caregivers the use of draw sheets and other transfer techniques.
• Assist patient to obtain a transfer device. 
• A PT/OT can help select and train individuals in transfer techniques from/to different surfaces to ensure safe repositioning and minimize skin shear during transfer. Path/objects between transfer surfaces should also be assessed for barriers impeding safe transfer. [7] [34]

Lifestyle/psychosocial Interventions

• For individuals at risk for PU/PI, guidelines suggest clinicians confirm presence of healthy lifestyle choices and a supportive social network prior to discharging the individual from a facility. [5] [7]
• Daily life after discharge from a healthcare facility may pose additional risk factors for development of a new/recurrent PU/PI. Major depression can lead to recurrence of PU/PI, as it has been associated with inactivity, self-neglect and poor adherence to care plan. [16] For any change in the patient’s routine, patients, caregivers, and clinicians should assess presence of increased risk for pressure injuries (see case " How 20 minutes of fun can turn into 4 months of disruption"). If potential lifestyle/psychological factors that increase risk of PU/PI are identified, clinicians should consider referring the individual to appropriate resources for problem resolution including PT, OT, rehabilitation services, peer counseling and support groups, formal psychotherapy/counseling. [7] [19]

Preventative Measures for Medical Device-related PU/PI

• The NPIAP clinical guideline recommend clinicians consider patients with medical devices to be at risk for development of PU/PI. [5]
• The pressure and shear caused by medical devices can result in the development or aggravation of an existing PU/PI. Thus, it is important that clinicians follow manufacturer's safety recommendations, choose devices with proper fit and size, and ensure devices are properly secured to prevent dislodgment. [5]
• Medical-device related PI should be staged using the International NPIAP/EPUAP Pressure Ulcer Classification System, unless the injury is on mucosa. [5] See topic " Pressure Ulcers/Injuries - Classification/Staging"
• Retrospective analysis of a large group of patients showed that  [54]: 
• Medical device-related PU/PI forms faster than non-medical device related PU/PI, thus timely proactive assessment and prevention interventions are critical
• Most medical device-related PU/PI occur on the ears (e.g, oxygen tubing secured over the ears), and feet 
• By stage, most medical device-related PU/PI are superficial (58% were Stage 1 or 2) 
• The most common devices linked with medical device-related PU/PI were oxygen tubing and masks, and casts/splints
• The NPIAP has created posters based on the best practices below to prevent medical device-related PU/PI  [5]:
•  Choose the correct size of medical device(s) to fit the individual
• ✔ Cushion and protect the skin with prophylactic dressings in high risk areas (e.g., nasal bridge)
• ✔ Remove or move removable devices to assess skin at least daily
• ✔ Avoid placement of device(s) over sites of prior, or existing pressure injury
• ✔ Educate staff on correct application, use and securement of devices and prevention of skin breakdown
• ✔ Be aware of edema under device(s) and potential for skin breakdown
• ✔ Confirm that devices are not placed directly under an individual who is bedridden or immobile 
• Table 8 below illustrates examples of medical devices, and specific best practices to prevent PU/PI. [55]

Table 8. Prevention of Medical Device-related Pressure Injuries

PATIENT EDUCATION (for clinicians)

Patient education

• Clinical guidelines recommend clinicians provide or facilitate access to PU/PI prevention education for the individual and caregivers upon discharge from a healthcare facility, on an ongoing basis, and every time health or lifestyle/psychosocial conditions change. [5] [7]
• Topics for education should be individualized and at minimum include  [7]:
• Potential causes and risks of pressure ulcer development
• Methods of self-monitoring
• Reduction of pressure ulcer risks 
• A personalized prevention plan, developed with the patient's input and agreement, needs to be explained and understood by the patient and caregiver. The plan includes interventions for positioning in bed and chair, support surfaces, activity, nutrition, skin care, lifestyle changes

Resources:

• Patient education brochures
• Digital content (websites, web-apps):
• Mobile App: VA Pressure Ulcer Resource (VA PUR) App, designed to help Veterans and their Caregivers learn about preventing and taking care of existing pressure ulcers/injuries. Includes tools such as reminders to move, location of nearby facilities, etc. 

APPENDIX

Summary of Evidence (SOE)

SOE - Pressure Redistribution

( back to text)

Clinical Guidelines

[5] [6] [8] [9]