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Three major components contribute to pressure ulcer development: pressure duration and pressure intensity, for
which you can intervene, and tissue tolerance (more on this
later).
Repositioning the patients body reduces the duration
of pressure and using support surfaces reduces the intensity
of pressure. Use these interventions to take the load off body
pressure points.
To reduce pressure and sacral shear, elevate the head of
the patients bed no higher than 30 degrees. If she cant lie
flat because of cardiopulmonary conditions or enteral tube
feedings, keep the head of the bed at the lowest possible angle. When you reposition her side to side, support her in a
30-degree lateral position rather than on her trochanter at
a 90-degree angle. Using a 30-degree side-lying position
avoids putting pressure on the sacrum and the trochanter
simultaneously.
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Use pillows or foam wedges to separate bony prominences, such as knees and ankles, and place pillows under
the patients lower legs to lift her heels off the bed.
Neither time nor pressure alone causes tissue ischemia.
Weve been taught to reposition patients at least every 2
hours because of the inverse relationship between pressure
and time: A person can endure a great amount of pressure
for a short amount of time without sustaining tissue damage; a ballet dancer standing on her toes is a good example.
Long periods of low pressure cause more tissue damage than
short periods of high pressure. Also, repeated pressure insults to the same area before it has a chance to recover may
cause cumulative tissue damage, which can lead to a pressure ulcer.
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Getting specific
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tients body to float on the surface and minimizing pressure, shear, and moisture. A Group 3 surface is indicated
for patients with Stage III or Stage IV pressure ulcers that
havent improved on a Group 2 surface over the last month,
even with comprehensive care.
See Characteristics to Consider When Choosing a Support Surface for more tips on evaluating support surfaces
for patient use.
Support surfaces are no substitute for careful nursing
care and educating the patient and family about wound
care. Comprehensive care includes a nutrition plan to optimize wound healing, managing incontinence or moisture, good local wound care (including treating wound
infection), repositioning your patient every 2 hours, and
assessing her skin and pressure points for potential problems each time you turn her. If you find persistent pressure areas indicating tissue intolerance, consult a wound
specialist for alternative pressure-reducing devices. He may
recommend a different type of support surface to take the
load off.
With proper care, your patients pressure ulcer should
show signs of healing in 2 to 4 weeks. If you dont see signs
of improvement, reassess your interventions for pressure
reduction, adequate nutrition, and good local wound care.
All three areas are key to healing your patient.
SELECTED REFERENCES
Brienza, D., et al.: Seating, Positioning, and Support Surfaces, in
Wound Care Essentials: Practice Principles, S. Baranoski and E.
Ayello (eds). Philadelphia, Pa., Lippincott Williams & Wilkins,
2004.
Cuddigan, J., and Ayello, E.: Treating Severe Pressure Ulcers in
the Home Setting: Faster Healing and Lower Cost with AirFluidized Therapy, The Remington Report. 12(3):6-10, May/June
2004.
Cullum, N., et al.: Beds, Mattresses, and Cushions for Pressure
Sore Prevention and Treatment (Cochrane Review), Chichester,
United Kingdom, The Cochrane Library, John Wiley and Sons,
Issue 2, 2004.
National Pressure Ulcer Advisory Panel: Pressure Ulcers in
America: Prevalence, Incidence and Implications for the Future.
Reston, Va., National Pressure Ulcer Advisory Panel, 2001.
JoAnn Maklebust is a wound care clinical nurse specialist and a
nurse practitioner in the department of surgery at Barbara Ann
Karmanos Cancer Institute at Detroit Medical Center and associate
clinical professor of nursing at Wayne State University, both in
Detroit, Mich.
Fall 2004
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