A 24-year-old man with hypoxic-ischemic brain injury is sent to the hospital from a nursing facility for evaluation of a skin ulcer. The patient has a history of injection drug use, and 6 months ago he was found unresponsive at home with agonal respirations and pulseless electrical activity. He required cardiopulmonary resuscitation, endotracheal intubation, and mechanical ventilation. Since then, the patient's neurocognitive functions have not improved, and he receives mechanical ventilation through a tracheostomy and feeding through a gastrostomy tube. Several days ago, the staff noticed a small ulceration over the patient's right heel, which has not healed. Temperature is 37 C (98.6 F), blood pressure is 110/70 mm Hg, and pulse is 68/min. He moans to painful stimuli but does not follow any instructions. Corneal and gag reflexes are present. Heart sounds are normal. Bilateral breath sounds are equal with no added sounds. The abdomen is soft and nontender. Skin examination shows an area of nonblanchable erythema overlying the sacral region. On the posterior aspect of the right heel, there is a skin ulcer that is 2 cm x 1 cm with exposed dermis. Which of the following would have been most effective in preventing this patient's skin lesions?
This patient has an extended nursing facility stay with decreased mobility and evidence of significant neurologic injury, and now has a stage II pressure ulcer at the heel and a stage I lesion at the sacrum. Besides reduced mobility, risk factors for pressure ulcers include malnutrition, abnormal mental status (eg, dementia), decreased skin perfusion, and reduced sensation.
Standard interventions to prevent pressure ulcers in high-risk patients include:
Patients at risk for pressure ulcers should be cared for on beds with features that provide pressure redistribution and reduce focal pressure. Effective modifications include air-fluidized beds, pressure-relieving overlays (eg, sheepskin), higher-specification foam mattresses, and active repositioning systems or alternating pressure supports. In addition, patients should be repositioned by the nursing staff at regular intervals (eg, every 2 hours), although there is less evidence to support this intervention.
(Choice A) Aspirin and statins are effective in reducing the risk of acute coronary events in patients with symptomatic atherosclerotic arterial disease. They do not prevent pressure ulcers.
(Choice B) Compression stockings are useful in the prevention and management of venous insufficiency ulcers, which usually occur in the setting of venous stasis dermatitis. They are not beneficial for prevention of pressure ulcers.
(Choice C) Elevation of the head of the bed to >30 degrees can cause the patient to slide in the bed, causing skin friction and increasing the risk for pressure ulcers.
(Choice D) Tissue overlying bony prominences is particularly susceptible to pressure ulcer formation. Massaging bony prominences is not recommended as it may further increase tension on the overlying skin.
(Choice E) Malnutrition is associated with an increased risk for pressure ulcers. In patients with otherwise normal nutritional status, however, specialized feedings and nutritional supplements have not been shown to reduce the risk for pressure ulcers.
(Choice F) Intermittent pneumatic compression devices are used to prevent deep venous thrombosis in patients with contraindications to anticoagulant therapy. They do not decrease the risk of pressure ulcers.
Educational objective:
Risk factors for pressure ulcers include decreased mobility, malnutrition, abnormal mental status, decreased skin perfusion, and reduced sensation. Interventions that can prevent pressure ulcers include proper positioning for pressure redistribution, mobilization, careful skin care, moisture control, and maintenance of nutrition.