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Tips for Protecting Critically Ill Patients From Pressure Ulcers
Irene M. Jankowski
Crit Care Nurse. 2010;30: 7-9 doi: 10.4037/ccn2010636
© 2010 American Association of Critical-Care Nurses
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Critical Care Nurse is the official peer-reviewed clinical journal of the American
Association of Critical-Care Nurses, published bi-monthly by The InnoVision Group,
101 Columbia, Aliso Viejo, CA 92656. Telephone: 949-362-2000. Fax:
949-362-2049. Copyright 2010 by AACN. All rights reserved.
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Guidelines Clearinghouse Web site (www.guideline.gov). A
planned repositioning schedule tailored to each individual
patient is recommended in all pressure ulcer prevention guidelines. Recently, the National Pressure Ulcer Advisory Panel, in
collaboration with the European Pressure Ulcer Advisory
Panel, announced updated guidelines for prevention and treatment of pressure ulcers. Each guideline recommendation is
supported by a rigorous review of the literature and a
strength-of-evidence rating.1
The goals in progressive mobility programs, specifically
prevention of complications associated with immobility, are
aligned with recommended interventions for pressure ulcer
prevention. Techniques for progressive mobility can be combined with repositioning techniques recommended for prevention of pressure ulcers.
Mobilizing Bedridden Patients
Tips for Protecting Critically Ill
Patients From Pressure Ulcers
Irene M. Jankowski, RN, MSN, APRN-BC, CWOCN
A
n important focus in critical care units is maintaining circulatory, respiratory, and renal function. Care of critically ill
patients also requires interventions that are designed to prevent
pressure ulcers, an all-too-common complication of immobility,
inadequate nutrition, and illnesses or medications that affect
blood flow and perfusion. Pressure injuries may be avoidable
when consistent attention is given to assessment, nutrition, and
appropriate positioning within appropriate time frames.
At least 10 published guidelines for the prevention and
treatment of pressure ulcers can be found on the National
www.ccnonline.org
Both progressive mobility programs and pressure ulcer
prevention programs involve planned movements with various positioning techniques. With the progressive mobility
program, changes in position for bedridden patients can
include changes in head-of-bed elevation, continuous lateral
rotation, and prone positioning. The patient is then progressed to chair sitting and ambulation. Recommended interventions for preventing pressure ulcers in bedridden patients
taken from guidelines for prevention and treatment of pressure ulcers include maintaining the head of the bed at 30º or
lower2 to prevent shearing injuries, especially to the sacral
area, and complete changes in position using supine positioning and tilted side-lying 30º positions, alternating right, back,
and left to ensure that pressure over bony prominences is
avoided. Friction and shearing can be avoided when positioning patients by using transfer aids such as slide sheets and
slings or by using at least 2 staff members and draw sheets to
lift patients. The frequency of positioning, however, should be
tailored to individual patients. According to the guidelines
from the National and European pressure ulcer advisory panels, patients who are not on pressure redistribution mattresses
require more frequent repositioning. Other considerations
when positioning patients include using padding between the
knees when patients are lying on their side and elevating or
“floating” heels off the mattress to avoid pressure on the heels.
Therapy Beds and Pressure Ulcer Prevention
The idea that all therapy beds prevent pressure ulcers is a
common misconception. Actually, the therapy bed is an
adjunct to repositioning patients and does not decrease the
required frequency of repositioning. The selection of a therapy
bed should be tailored to the specific needs of the patient.
Goals for pressure ulcer prevention require the selection of a
bed that has a pressure redistribution surface such as air bladders, high-density foam, or alternating pressure surfaces. In
addition to pressure redistribution, some surfaces also provide
low air loss for microclimate management. Bed manufacturers
should be able to provide pressure mapping data to aid in
appropriate selection of surfaces.
CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S7
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Certain products may be designed to provide various turning features. Some beds offer only a “turn assist” that tilts the
patient for a short period, thereby helping the caregiver to turn
the patient during bathing or incontinence care. Other therapy
bed products, usually limited to critical care units or pulmonary
care units, may provide turning features that include a preset
automatic turn designed to promote improved pulmonary
outcomes. Various beds are available with a combination of
complications related to pressure ulcer injuries such as sepsis
related to wound care, amputations, and countless surgical
procedures. Skin over bony prominences can be assessed by
taking a quick look while measuring vital signs or performing
incontinence care, making it possible to assess skin even more
often than every 2 hours. If the patient has an existing pressure ulcer, CLRT can be stopped for a time—for example, up
to 30 minutes—so that bolsters, pillows, and positioning
Erythema can be an early sign of pressure ulcer poten-
tial and should trigger a change in the patient’s position.
features that can meet the needs of patients requiring both pulmonary support and pressure ulcer prevention.
DeLaat et al3 described a prospective cohort study conducted
in an intensive care unit that demonstrated a sustained reduction in intensive care unit–acquired pressure ulcers as a result
of the introduction of a pressure ulcer prevention protocol that
was supported by certain nurses who acted as “supporting
innovators” of the project. The strongest significant intervention associated with the decrease in incidence of pressure ulcers
was identified as the use of pressure redistribution mattresses.3
Once an appropriate therapy bed is selected, nurses
should avoid layering sheets, pads, diapers, and other items
between the patient and the specialty bed surface. Such layering will interfere with the effectiveness of the pressure redistribution surface.4
Continuous Lateral Rotation Therapy
Continuous lateral rotation therapy (CLRT) is designed to
support pulmonary toileting; however, not all therapy beds
with this feature provide pressure redistribution surfaces such
as low airloss surfaces. Even when a CLRT bed provides a pressure redistribution surface, CLRT alone (the right and left
rotation of 20º to 40º) may not provide protection from pressure ulcers unless specific interventions for pressure ulcer prevention also are instituted. Even if the CLRT is set for the
maximum rotation, the patient never breaks contact with the
surface. Nurses must be vigilant, assessing patients’ skin frequently, particularly over bony prominences, for early signs of
pressure injuries. Heels must be protected from prolonged
pressure whether by the specialty therapy surface or by the use
of positioning devices, unless the CLRT bed surface is equipped
with air-only bladders designed to prevent heel ulcers.
Frequent skin assessments while the patient is on CLRT
may enable early detection of potential development of pressure ulcers. CLRT can be stopped for short periods to allow for
skin assessments. Erythema can be an early sign of pressure
ulcer potential and should trigger a change in the patient’s
position whenever possible. Blanchable erythema, also known
as reactive hyperemia, can be reversed simply by eliminating
pressure for a short period. Such careful vigilance may save
patients from months to years of wound care treatments and
techniques can be used to offload pressure points and relieve
pressure to injured areas. Bolsters and other positioning
devices should be removed when CLRT is resumed. Keep in
mind that CLRT may be most effective in facilitating optimal
pulmonary outcomes when employed for at least 18 hours in a
24-hour period. It is appropriate to use pillows and other positioning devices during the 6 hours of non-CLRT therapy.5-11
Progression to Chair and Ambulation
Even when the patient has progressed to the full upright
chair position, important nursing interventions are still required
for those patients at risk for pressure ulcers. Clinical guidelines from both the Wound, Ostomy and Continence Nurses
Society and the national and European pressure ulcer advisory
panels recommend encouraging the patient to shift weight frequently while in a chair. Some patients will require assistance
with weight shifting. In addition, assisting a patient to a standing position will help prevent pressure ulcers and meet goals
for progressive mobility. Pressure redistribution chair cushions can also be provided, and measures to protect skin from
incontinence-associated skin breakdown such as moisture barrier ointments and other skin protective products still should
be used. Once the patient is ambulatory, nurses should remain
vigilant. Ambulation may begin with a few tentative steps,
with the patient quickly returning to the bed or bedside chair,
until he or she can tolerate an extended period of mobility.
Conclusion
Careful and frequent skin assessments, frequent repositioning, managing moisture, and maximizing nutritional support are common interventions for prevention of pressure
ulcers. Progressive mobility techniques and repositioning
techniques used to prevent pressure ulcers are designed to
promote the best outcomes while preventing dangerous complications.
©2010 American Association of Critical-Care Nurses
doi: 10.4037/ccn2010636
Financial Disclosures
The author has received grants from Hill-Rom in the past, but not for this
paper.
S8 CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement
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www.ccnonline.org
References
1. National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory
Panel Pressure Ulcer Prevention and Treatment Clinical Practice Guideline.
Washington, DC: National Pressure Ulcer Advisory Panel; 2009.
2. Ratliff CR, Bryant DE. Guideline for Prevention and Management of Pressure Ulcers. Glenview, IL: Wound, Ostomy, and Continence Nurses Society; 2003:1-52.
3. deLaat EH, Pickers P, Schoonhoven L, et al. Guideline implementation
results in a decrease of pressure ulcer incidence in critically ill patients.
Crit Care Med. 2007;35(3):815-820.
4. Williamson R, Sauser FE. Linen Usage Impact on Pressure and Microclimate Management [white paper]. http://www.hillrom.com/usa/PDF
/156445.pdf. Accessed January 19, 2010.
5. Ahrens T, Kollef M, Stewart J, Shannon W. Effect of kinetic therapy on
pulmonary complications. Am J Crit Care. 2004;13:376-383.
6. Delaney A, Gray H, Laupland KB, Zueger DJ. Kinetic bed therapy to
prevent nosocomial pneumonia in mechanically ventilated patients: a
systematic review and meta-analysis. Crit Care. 2006;10:R70. Also available at: http://ccforum.com/content/10/3/R70.
7. Washington GT, Macnee CL. Evaluation of outcomes: the effects of continuous lateral rotational therapy. J Nurs Care Qual. 2005;20(3):273-282.
8. Choi S, Nelson L. Kinetic therapy in critically ill patients: combined
results based on meta-analysis. J Crit Care. 1992;7:57-62.
9. McKay C. Best practices: reducing nosocomial pneumonia. Regis Nurse.
1999;Feb(suppl):3-8.
10. Goldhill DR, Imhoff M, McLean B, Waldmann C. Rotational bed therapy to prevent and treat respiratory complications: a review and metaanalysis. Am J Crit Care. 2007;16:50-62.
11. Swadener-Culpepper L, Skaggs RL, VanGilder CA. The impact of continuous lateral rotation therapy in overall clinical and financial outcomes
of critically ill patients. Crit Care Nurs Q. 2008;31(3):270-279.
www.ccnonline.org
CRITICALCARENURSE Vol 30, No. 2, APRIL 2010 Supplement S9
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CE Test
Test ID C102S: Progressive Mobility in the Critically Ill
Learning objectives: 1. Identify the risks associated with bed rest and immobility in intensive care unit patients 2. Describe the process of progressive
mobility 3. Discuss challenges and barriers to making positioning and mobility of patients a priority of practice in the intensive care unit
1. What is the major long-term complication resulting from the physical
deconditioning that takes place during a patient’s stay in the intensive care
unit (ICU)?
a. Loss of orthostatic tolerance/disturbed equilibrium
b. Onset of depressive mood disorders
c. Diminished quality of life after discharge
d. Increased susceptibility to autoimmune disorders
2. Which of the following is the result of a patient’s developing “gravitational
equilibrium”?
a. Increased orthostatic tolerance
b. Difficulty adapting to a change in position
c. Stabilization of the plasma volume reduction that occurs during the
first few days of bed rest
d. Improved function of the body’s autonomic feedback loop
3. Progressive mobility is defined as a series of planned movements in a
sequential manner with what final goal?
a. Returning to the patient’s baseline level of mobility
b. Achieving 75% of the patient’s pre-ICU activity level
c. Prevention of ventilator- and hospital-acquired pneumonia
d. Patient’s ability to ambulate for a distance of at least 100 feet by the time
of ICU discharge
4. What was the main cause of functional limitations occurring in patients
within 1 year after discharge from the ICU?
a. Heart muscle deconditioning
b. Skin breakdown/delayed wound healing
c. Joint contractures
d. Muscle wasting
5. When do this article’s authors recommend assessing each ICU patient’s
readiness for mobility?
a. During the initial nursing assessment following admission
b. Each time a patient’s condition changes significantly
c. Daily
d. At the time of initiation of a progressive mobility protocol
6. The decreased muscle mass that occurs in critically ill patients is most
pronounced in what area of the body?
a. Upper limbs
b. Lower limbs
c. Diaphragm
d. Abdomen
7. Patients receiving continuous lateral rotation therapy (CLRT) should have the
continuous rotation for how many hours per day?
a. 12
c. 16
b. 14
d. 18
8. Which of the following is a recommendation included in all pressure ulcer
prevention guidelines?
a. Repositioning of patients at least every 2 hours
b. Use of a therapy bed with a low-density foam surface
c. A planned repositioning schedule tailored to each individual patient
d. Use of a sling transfer aid when turning and/or repositioning patients
9. Which of the following statements regarding the use of CLRT is true?
a. CLRT alone—the right and left rotation of 20°-40°—is the only pressure ulcer
prevention therapy necessary if the CLRT bed has a pressure distribution mattress.
b. Bolsters, pillows, and other positioning devices may be used during times when
CLRT is stopped, but they should be removed before use of active CLRT.
c. CLRT is designed specifically for supporting pulmonary toileting, and should not be used
for patients who are at high risk for developing pressure ulcers.
d. Incontinent patients receiving CLRT should have diapers and specially designed pads
placed between them and the surface of the CLRT bed.
10. Which of the following is the definition of the beach chair position?
a. Elevation of the patient’s head of bed to 90° and the foot of bed at a -90° angle
b. Elevation of the patient’s head of bed to 75° and the foot of bed at a -75° angle
c. Elevation of the patient’s head of bed to 70° and the foot of bed at a -75° angle
d. Elevation of the patient’s head of bed to 90° and the foot of bed at a -70° angle
11. Evidence-based practices to facilitate daily delivery of early ICU mobility include
best practices in which of the following areas?
a. Management of sedatives and analgesics; promotion of sleep for ICU patients
b. Using physical therapists to initiate progressive mobility programs; prioritization of
procedures by ICU nurses
c. Use of beds that allow for patients to be positioned with backrest, hips, and knees
angled at 90° without getting out of bed; protocols that include daily passive range of
motion exercises
d. Physician-ordered “out-of-bed” activity (early mobility); staff education regarding the
complications associated with immobility and bed rest
12. The study designed to evaluate staff perceptions of patient readiness for mobility
found that the most common facilitator identified by the nurses who planned out-ofbed activity for their patients was which of the following?
a. “Adequate staffing today”
b. “Physician order”
c. “Patient is cooperative”
d. “New beds make getting the patient out of bed easier”
Test answers: Mark only one box for your answer to each question. You may photocopy this form.
1. ! a
!b
!c
!d
2. ! a
!b
!c
!d
3. ! a
!b
!c
!d
4. ! a
!b
!c
!d
5. ! a
!b
!c
!d
7. ! a
!b
!c
!d
6. ! a
!b
!c
!d
8. ! a
!b
!c
!d
9. ! a
!b
!c
!d
11. ! a
!b
!c
!d
10. ! a
!b
!c
!d
12. ! a
!b
!c
!d
Test ID: C102S Form expires: April 1, 2012 Contact hours: 1.0 Fee: AACN members, $0; nonmembers, $10 Passing score: 9 correct (75%) Category: Synergy CERP A
Test writer: Ann Lystrup, RN, BSN, CEN, CFRN, CCRN
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