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Is pressure ulcer prevention alive and well?

September 1, 2007
by Donna McMullen, RN, CWOCN and Carolyn Corazza, RN, CWOCN
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Maintaining skin integrity calls for periodic review of practices and protocols as recommended

Prevention of pressure ulcers is a constant process for long-term care facilities, but vitally important to preserve residents' health and avoid major deficiencies. A prophylactic approach should include three steps: identifying high-risk residents, implementing a prevention plan, and auditing the prevention plan. Armed with this protocol, how can we accomplish prevention? Nursing leaders must empower staff into action.

Identifying High-Risk Residents

Mental status, activity, mobility, nutritional status, and incontinence are all factors that have a direct influence on the risk of a resident developing a pressure ulcer. Use of a recognized risk assessment tool—such as the Norton and Braden scales—is mandated for all residents on admission. Assess on admission and once a week for four weeks, and then quarterly, or with any change in a resident's status.1

Communicate with the resident if his or her mental status allows for participation in the plan and with the resident's physician and/or certified registered nurse practitioner, family member(s), nursing, social worker, dietitian, physical therapist, social worker, discharge planner, and staff caring for the patient, such as geriatric nursing assistants. Communication with the resident (if possible) and family cannot be emphasized enough.

Educate staff on risk assessment and the definitions of friction and shearing with examples of how these occur. Staff should have a solid understanding of comorbidities that place residents at increased risk, such as diabetes, immunosuppression, cardiac and pulmonary issues, smoking or a history of smoking, multiple sclerosis, neurological conditions, weight loss, low albumin, anemia, obesity, and contractures. A prevention plan should be implemented immediately. Documentation of this assessment is essential, and every person responsible for charting should know where to locate this information.

Implementing the Prevention Plan

Define staff members' duties to implement prevention goals, including pressure relief, maintenance of clean intact skin, monitoring of nutritional status, patient movement, and patient family education.

Prevention plan assessment criteria

Identifying High-Risk Residents

Implementing the Prevention Plan

Auditing the Prevention Plan

Risk assessment tool

  • Norton or Braden scales

  • List of high-risk residents

Team members

  • Roles and responsibilities

  • Competencies

Collection of baseline data

  • Prevalence survey

  • Review of policies/protocols

Risk assessment tool behaviors

  • Correlate with the risk assessment tool score

  • MD orders written in chart

Identifi cation of goals

  • Prevalence

  • Incidence

  • Targets set

Goal evaluation

  • Target met or not met

  • Behavior changes

  • Develop incidence monitoring tool

Pressure relief

  • Type of device

  • Policy/protocol

  • TAPS

Education of staff on prevention plan

  • Competencies

  • Self-learning packets

Skin inspection

  • Licensed and non-licensed

  • Documentation tools

Audit tools

  • Chart audit

  • Bedside audit

  • Documentation tools

  • Random and/or spontaneous


  • Policy/protocol

  • Documentation tools

Ongoing monitoring

  • Audit tool development

  • Staff responsibility

  • Care plan updating

Patient movement

  • Physical therapy's role

  • Devices involved

  • Documentation tools


  • Patient, MD, and family

  • Care plan development

  • Document notifi cation

Pressure relief. This is still the “biggie.” Pressure-relieving devices can come in many forms: specialty beds, mattress replacements, overlays, and assistive devices. Choosing the correct device and implementation are pertinent in prevention. A support surface should provide adequate pressure relief or reduction for residents according to their risk level.

The facility prevention plan should include a way for staff to reconcile the resident's risk level with appropriate actions sanctioned by the facility. The plan's steps should be clear and concise and meet regulatory guidelines. When staff understand the connection between the risk score and needed response, they will be more likely to act. Chairs, wheelchairs, and heel protection need to be included in your pressure-relief device plan. Staff may place a wonderful mattress on a resident's bed, yet the resident sits in a sling-seat wheelchair without a cushion for several hours each day. All surfaces on which the resident spends time must be part of the plan. For example, in one facility, staff taught and encouraged a resident to carry his chair cushion to the outdoor patio to use.