Geriatric Quick Consult      Pressure Ulcers      Do #6

Assess need for special support surface.

Knowledge Action
Goals are to

  • decrease pressure

  • avoid friction and shear

  • maintain optimum level of moisture for wound healing
    • too much moisture: maceration
    • too little moisture: drying and delayed healing
  • Develop plan for pressure relief.
Positioning: In bed, avoid positioning on the pressure ulcer.

If patient has, or is at risk of, a heel ulcer , position heels off the mattress. One way is to place a pillow under the calf, "floating the heels".

Avoid positioning directly on trochanters.

Prevent shear (patient sliding down) by keeping the head of the bed at its lowest level of elevation consistent with other medical conditions.

Be sure patient is lifted and not dragged across bed surface when being pulled up in bed.

General recommendation for turning is every 2 hours in bed.

For high risk patients, more frequent position changes may be needed.

Sitting patients should be repositioned at least every hour and should shift weight every 15 minutes.

If hourly repositioning is not possible, the patient may need to return to bed.
  • Turn patient at least every two hours.


  • Float the heels.


  • Keep the patient's weight off "trouble spots".


  • Lift, don't pull to move patients.


  • Reposition seated patients every hour.
Support Surfaces: for sitting patients, individually-prescribed seat cushions should be used.

Avoid donut-type cushions.

Pressure-reducing surfaces should be used for individuals at risk of additional ulcers.

Use a static support surface (air or water) if the individual can assume a variety of positions without putting pressure on the ulcer.

Use dynamic support surface (low air loss, air-fluidized) if the patient is unable to assume a variety of positions, or if no healing is evident in the expected time, or if multiple stage 3 or 4 ulcers1.
  • Use special flat cushions.


  • Avoid donut cushions.
"Egg crate" mattresses compress and do not relieve pressure on skin.

There are a variety of other technologies that do help, including "low air loss", gel, and "air-fluidized" cushions.

A special support surface can relieve pressure and promote healing.

No mattress is sufficient by itself.

There is some evidence2 that patients in acute care settings who have large pressure ulcers may benefit from the use of air-fluidized beds.

These devices are very costly:$50 to $100 per day.

Studies have shown that patients who use devices that significantly lower skin interface pressure are likely to heal faster than patients whose devices reduce pressure only modestly3.

"Whether the more expensive devices are truly cost effective remains to be shown4." See Note.
  • Ask an expert before ordering air fluidized bed.

References:

  1. Bergstrom N, Bennett A, Carlson CE, et al. Clinical Practice Guidelines Number 15: Treatment of pressure ulcers.
  2. Allman RM, Waller JM, Hart MK, Laprade CA, Noel LB, Smith CR. Air-fluidized beds or conventional therapy for pressure sores: a randomized trial. Ann Intern Med. 1987;107(5): 641-8.
  3. Ferrell BA, Osterweil D, Christenson P. A randomized trial of low air-loss beds for treatment of pressure ulcers. JAMA 1993; 269(4):494.
  4. Ferrell, BA. Pressure ulcers. In Ham RJ, Sloane PD, Warshaw GA (eds): Primary Care Geriatrics 4th ed, St. Louis: Mosby, 2002.
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