Rationale

To prevent pressure ulcers, individuals at risk must be identified so that risk factors can be reduced through intervention. The primary risk factors for pressure ulcers are immobility and limited activity levels (Allman, compiled 1991; Berlowitz, and Wilking, 1989; Norton, McLaren, and Exton-Smith, 1975; Okamato, Lamers, and Shurtleff, 1983). Therefore, persons with impaired ability to reposition themselves or those whose activity is limited to bed or any chair should be assessed for their risk of developing a pressure ulcer. To determine the magnitude of risk, the degree to which mobility and activity levels are limited can be quantified. Both the Norton Scale (Norton, McLaren, and Exton-Smith, 1975) and the Braden Scale (Braden, and Bergstrom, 1987; Bergstrom, Braden, Laguzza, et al., 1987) assess these factors. Instructions on use of both scales are available (Norton Scale, Braden Scale for Predicting Sore Risk). (Norton, 1989; Braden, 1989).

Table

Norton Scale.

Table

Braden Scale for Predicting Pressure Sore Risk (table format).

Box

Braden Scale for Predicting Pressure Sore Risk (list format). [Note: The presentation format of this scale was modified for online viewing.]

Patient's Name __________________________
Evaluator's Name ________________________ (more...)

Other risk factors for pressure ulcer development include incontinence, impaired nutritional status, and altered level of consciousness. Incontinence is assessed by the Moisture subscale of the Braden Scale (Braden, and Bergstrom, 1987) and the Incontinence component of the Norton Scale (Norton, McLaren, and Exton-Smith, 1975). Nutritional factors are considered indirectly in the General Condition component of the Norton Scale (Norton, 1989) and the Nutritional Status subscale of the Braden Scale (Bergstrom, Braden, Laguzza, et al., 1987). Altered level of consciousness is assessed by the Norton Scale's Mental Condition subscale and the Braden Scale's Sensory Perception subscale.

Numerous risk assessment tools exist; however, only the Braden Scale and the Norton Scale (original, and modified) have been tested extensively. The Braden Scale has been evaluated in diverse sites that include medical-surgical units, intensive care units, and nursing homes. The Norton Scale has been tested with elderly subjects in hospital settings.

The reported sensitivity and specificity of these risk assessment tools have varied greatly. This variability probably reflects differences in study settings, populations, and outcome measures. Some studies have included Stage I ulcers as an outcome with inconsistent definitions of these lesions. The degree to which preventive interventions have been implemented in response to the findings of the risk assessments in these studies may have also contributed to the variability in their reported performance. Good interrater reliability for the Braden Scale has been reported (Bergstrom, Braden, Laguzza, et al., 1987). Reliability data are not available for the Norton Scale, and the original version did not include definitions for its subscales (Norton, McLaren, and Exton-Smith, 1975). Modifications of the Norton Scale have included such definitions (Norton, 1989).

Despite the limitations of the Norton and Braden scales, their use ensures systematic evaluation of individual risk factors. No information is currently available to suggest that adaptations of these risk assessment tools or the assessment of any single risk factor or a combination of risk factors predict risk as well as the overall scores obtained by the tools.

The condition of an individual admitted to a health care facility is not static; consequently, pressure ulcer risk requires routine re-examination. The frequency with which such re-evaluations need to be done is unknown. However, if an individual becomes bed- or chair-bound or develops difficulty with repositioning, pressure ulcer risk needs to be assessed. Accurate and complete documentation of all risk assessments ensures continuity of care and may be used as a foundation for the skin care plan.

Rationale

It is customary practice to include procedures for inspecting skin in an overall skin care program that also includes interventions. As a result, the exact role that a systematic, comprehensive, and routine skin inspection plays in decreasing the incidence of pressure ulcers has not been identified. For this guideline, it was deemed sufficient that health care professionals advocate skin inspection as fundamental to any plan for preventing pressure ulcers. Skin inspection provides the information essential for designing interventions to reduce risk and for evaluating the outcomes of those interventions.

Rationale

Daily activities result in metabolic wastes and environmental contaminants accumulating on the skin. For maximum skin vitality, these potentially irritating substances should be removed frequently. If unexpected contamination occurs, such as fecal or urinary incontinence, the skin should be cleansed as soon as possible to limit chemical irritation. As a person ages, the frequency of routine skin cleansing may decrease because there is less sebum and perspiration. This reduced frequency of cleansing lessens the magnitude of trauma experienced by the more sensitive skin.

Skin injury due to excess thermal energy or the accelerated metabolic activity induced by elevated temperature should be minimized by only using wash water that is comfortable (slightly warm) to the skin.

During the cleansing process, some of the skin's natural barrier is removed. The more the barrier is removed, the drier the skin becomes and the more susceptible it becomes to external irritants. Under most conditions, the individual's skin is minimally soiled and can be properly cleansed with a very mild cleansing agent that does not disrupt the natural barrier.

Rationale

Preliminary research evidence suggests that a weak association may exist between dry, flaky, or scaling skin and an increased incidence of pressure ulcer development (Guralnik, Harris, White, et al., 1988). It also appears that adequate hydration of the stratum corneum helps protect against mechanical insult. The level of stratum corneum hydration decreases with decreasing ambient air temperature, particularly when the relative humidity of the ambient air is low. Further, the development of clinically dry skin may result from a decreased level of relative humidity in the ambient air.

Decreased skin hydration results in reduced pliability, and severely dry skin is associated with fissuring and cracking of the stratum corneum. Also, a number of studies have shown that both the clinical picture of dry skin and measures of stratum corneum hydration generally improve with the application of various topical moisturizing agents (Wehr, Krochmal, Whitmore, et al., 1986; Kantor, Ballinger, and Savin, 1982; Kligman, 1978). Although efficacy of any specific moisturizing agent has not been established, it would appear prudent to treat clinical signs and symptoms of dry skin with a topical moisturizer. Further, although there is no direct evidence to support efficacy in preventing pressure ulcers, maintenance of ambient environmental conditions (relative humidity, and temperature) appears to be prudent to facilitate stratum corneum hydration and minimize the incidence of dry skin.

Rationale

Massage over a bony prominence has been used for decades to stimulate circulation, contribute to a sense of patient comfort and well-being, and assist in prevention of pressure ulcers. However, the scientific evidence for using massage to stimulate blood and lymph flow and avert pressure ulcer formation is not well established, whereas there is preliminary evidence suggesting that it may lead to deep tissue trauma.

Ek, Gustavsson, and Lewis (1985) found that 10 of 15 subjects with skin discoloration over their bony prominences demonstrated a lower skin blood flow after massage than before it was initiated. Additionally, all 15 subjects showed a significant decrease in skin temperature after massage (p<.01). The potentially deleterious effects of massage on human tissue were documented by Dyson (1978), who on postmortem biopsies found macerated, degenerated tissue in the areas exposed to massage, while non-massaged individuals showed no evidence of tissue tearing.

From these studies it would appear that the purported benefit of massage on circulation cannot be documented. However, there is evidence to suggest that massage over bony prominences may be harmful.

Rationale

An individual's skin may be exposed to a variety of substances that are moist: urine, stool, perspiration, or wound drainage. Although these substances may contain factors other than moisture that irritate the skin, moisture alone can make skin more susceptible to injury (Leyden, 1984; Leyden, Katz, Stewart, et al., 1977; Zimmerer, Lawson, and Calvert, 1986). Underpads and briefs are often used to protect the skin of individuals who are incontinent of urine or stool. Because these products are designed to reduce injury attributed to the moisture associated with urinary and fecal incontinence, it is not unreasonable to assume they would serve a similar function in those instances where the source of moisture is perspiration or wound drainage.

The panel reviewed 22 studies that examined the effects of underpads or briefs on the skin condition of either incontinent adults or infants. An initial screening of these studies showed that some form of control or comparison group was used in 10 of the 14 studies involving incontinent adults and in all 8 studies of infants. Less scientific rigor was evident when the panel looked at the number of investigators who tested findings for statistical significance. In 4 of the 14 studies involving incontinent adults, testing for statistical significance was done (Grant, 1982; Hu, Kaltreider, and Igou, 1990; Keller, Sinkovic, and Miles, 1990; Williams, Foerster, Proctor, et al., 1981). By contrast, inferential statistical tests were used to analyze the data in all eight studies involving infants (Campbell, Seymour, Stone, et al., 1987; Campbell, Bartlett, Sarbaugh, et al., 1988; Davis, Leyden, Grove, et al., 1989; Lane, Rehder, and Helm, 1990; Seymour, Keswick, Hanifan, et al., 1987; Stein, 1982; Zimmerer, Lawson, and Calvert, 1986).

Of the 12 studies tested for statistical significance, 4 articles conveyed enough information for the panel to determine that the investigators were comparing cloth products with products designed to absorb moisture and present a quick-drying interface with the skin. In all four of these studies, investigators reported either a significant improvement in skin condition or a significantly lower incidence of skin rashes for subjects who used products specifically designed to absorb moisture, when compared with subjects who used products made of cloth. It is important to note that the key feature evaluated was not whether the product was disposable but whether the product was specifically designed to absorb moisture and present a quick-drying surface to the skin. There are several reusable products made of fabric that have been so designed.

The guideline for using moisture barriers to protect the skin from the injurious effects of moisture is derived from usual practice and standards that professional organizations have developed. Three studies were reviewed (Kramer, and Honig, 1988; Shipes, and Stanley, 1981, 1983). Although each study included some type of comparison group, no investigators tested their findings for statistical significance. Furthermore, the diversity of products tested, the lack of replication for specific categories of products, and a variety of methodological problems further limit the extent to which these studies can be presented as research-based evidence.

Rationale

Shear injury occurs when the skin remains stationary and the underlying tissue shifts. This shift diminishes blood supply to the skin and soon results in ischemia and tissue damage. Most shear injuries can be eliminated by proper positioning.

Friction injuries to the skin occur when it moves across a coarse surface such as bed linens. Most friction injuries can be avoided by using appropriate techniques when moving individuals so that their skin is never dragged across the linens.

Voluntary and involuntary movements by the individuals themselves can lead to friction injuries, especially on elbows and heels. Any agent that eliminates this contact or decreases the friction between the skin and the linens will reduce the potential for injury.

Rationale

While the published studies provide evidence for the role of nutrition in the development of pressure ulcers and to a lesser degree for the healing of ulcers, the practice of supplementation is supported by clinical experts (Goode, and Allman, 1989; Kaminski, Pinchofsky-Devin, and Williams, 1989; Lidowski, 1988). These authorities recommend supplementing or supporting intake of protein, calories, Vitamin C, and zinc in particular.

Although data to support expert opinion on nutritional supplementation are scanty, two cohort prospective studies (Berlowitz, and Wilking, 1989; Bergstrom, and Braden, forthcoming) document the role of poor diet intake in the development of pressure ulcers, particularly the intake of inadequate calories, protein, and iron. For this reason, assessment of nutritional intake and nutritional support is suggested to maintain skin integrity and prevent pressure ulcers.

Rationale

Frequent turning, repositioning, and mobility are reported to be essential in reducing the risk of pressure ulcers (Alexander, 1979; Antypas, 1980; Berecek, 1975; Blom, 1985; Braden and Bryant, 1990). Immobility and inactivity have been associated with larger ulcers (Abildgaard, and Daugaard, 1979), and bed- and chair-bound persons were more likely to develop ulcers (Berlowitz and Wilking, 1989).

Several investigators have reported the use of active and passive range-of-motion exercises as mechanisms to promote activity and reduce the effects of pressure on tissue (Colburn, 1987; Dimant, and Francis, 1988). Encouraging ambulation (Fugill, 1980) and introducing physiotherapy for bedridden individuals are also strongly recommended to reduce the risk of ulcers (Droessler, and Maibusch, 1979). Other aspects of rehabilitation practice have also been suggested. These include physical training and exercise (Griffin, 1982); proper positioning, active exercise and ambulation, and weight shifts for those in wheelchairs (Hamilton, Quek, Lew, et al., 1989); and exercise to improve strength, flexibility, coordination, and range of motion (Levine, Simpson, and McDonald, 1989). All programs should be individualized for each person (Lowthian, 1976, 1977, 1979; Braden, and Bryant, 1990).

Rationale

Interventions - with specific details on who should provide the care, how often, what supplies and equipment are needed, and how the care should be undertaken - should be individualized, written, and readily available. Furthermore, results of the interventions and the care being rendered, and adjustment in the interventions as indicated by the outcomes, should be documented.

To ensure continuity of care through a comprehensive, structured, multidisciplinary approach, documentation of the plan of care must be clear, concise, and accessible to every caregiver. Multidisciplinary collaboration includes physicians, nurses, physical and occupational therapists, and dietitians. The plan of care should be periodically re-evaluated.

Rationale

There are data supporting a negative relationship between the number of spontaneous movements that bedfast, elderly individuals make and the incidence of pressure ulcers (Exton-Smith and Sherwin, 1961). The panel reviewed two clinical trials in which investigators manipulated the repositioning schedule and measured the effect on the incidence of pressure ulcers in at-risk elderly individuals. In one of these trials, patients who developed fewer pressure ulcers were those who were turned every 2-3 hours when their risk for developing pressure ulcers increased (Norton, McLaren, and Exton-Smith, 1975). In the absence of a suitable control group and statistical testing of outcomes, these results must be viewed tentatively. In the one randomized, controlled trial that the panel reviewed, unscheduled, small shifts in body positioning had no significant effect on the incidence of pressure ulcers in 19 residents of a long-term care facility (Smith, and Malone, 1990). However, patients in both the experimental and control groups were turned every 2 hours. The beneficial effects of these significant changes in patients' positioning may have overshadowed any beneficial effects derived from the smaller shifts in body position that constituted the experimental intervention.

Rationale

This guideline is based on usual practice and standards that professional organizations have developed. Written plans for repositioning are endorsed by VanEtten, Sexton, and Smith (1990) and the International Association for Enterostomal Therapy (IAET, 1988). Abruzzese (1985) has developed a positioning chart.

Rationale

Because of the small surface area, it is difficult to redistribute pressure under the heels. Investigators who have measured interface pressure between heels and support surfaces consistently report high pressures in this area. Difficulty in redistributing pressure under the heels and reports of new pressure ulcers on the heels of patients cared for on pressure-reducing devices (Parish, and Witkowski, 1980) suggest the heels need extra protection. This is especially likely in individuals who are unable to reposition their lower extremities. Suspension of the heel is the best remedy. The use of pillows under the length of the lower leg, suspending the heels, will accomplish the goal. Standards of professional organizations and clinical articles promote devices that totally relieve pressure on the heels.

Although ring cushions (donuts) are known to cause venous congestion and edema, few studies have documented their deleterious effects. In a study of at-risk patients, Crewe (1987) found that ring cushions are more likely to cause pressure ulcers than to prevent them.

Rationale

Studies that have measured the effect of various side-lying positions on interface pressures and transcutaneous oxygen tension report higher interface pressures and lower transcutaneous oxygen tension when subjects are positioned directly on their trochanters than when positioned off at an angle (Garber, Campion, and Krouskop, 1982; Seiler, Allen, and Stahelin, 1986).

Rationale

Shearing forces are produced when adjacent surfaces slide across one another. Clinically, shear is exerted on the body when the head of the bed is elevated. In this position, the skin and superficial fascia remain fixed against the bed linens while the deep fascia and skeleton slide down toward the foot of the bed. Shear forces are also generated when individuals sitting in a chair slide down in the chair. As a result of shear, blood vessels in the sacral area are likely to become twisted and distorted and tissue may become ischemic and necrotic (Reichel, 1958). Shear forces have been suggested as contributing to the undermining seen in some sacral ulcers. Standards of professional organizations and clinical articles advocate using positioning techniques and devices to help individuals maintain their position in bed or chair.

Rationale

Friction occurs when the skin moves against the support surface. Friction is common in individuals who cannot lift sufficiently during a position change or transfer to avoid dragging their skin over the rough surface of bed linens. While friction is most commonly associated with the superficial injuries seen in blisters and abrasions, it may also contribute to more extensive injury. It has been demonstrated that friction decreases the amount of external pressure required to produce a pressure ulcer (Dinsdale, 1974). Standards of professional organizations and clinical articles promote using devices that help either patients or their caregivers lift them off support surfaces during repositioning and transferring.

Rationale

Numerous investigators have measured characteristics and properties of a variety of support surfaces. Although the majority of investigators used tissue interface pressure as the basis for comparing these products, a few also compared changes in transcutaneous oxygen tension and capillary blood flow. Most often the subjects have been healthy volunteers, although some investigators have taken their measurements on people with spinal cord injuries, geriatric patients, and patients in acute care settings and hospice settings. Characteristically, the investigators have not included skin condition as an outcome.

The panel reviewed 13 clinical studies that examined the effects of a variety of pressure-reducing devices on the incidence of pressure ulcers in at-risk patients. Six studies were controlled trials without randomization. In several of these studies, either the investigators did not submit their data to statistical testing or there was evidence suggesting that assumptions underlying the statistical tests computed were violated. Most of these studies used patients cared for on a hospital mattress according to a standardized protocol as the control group. In these cases, the incidence and severity of pressure ulcers were consistently lower for patients cared for on the pressure-reducing device. In the one randomized, controlled trial that compared patients cared for on a hospital mattress with patients cared for on either an air or a water mattress, the incidence of pressure ulcers in patients cared for on the hospital mattress was significantly greater (Andersen, Jensen, Kvorning, et al., 1983).

Panel members reviewed three randomized, controlled trials; in each trial two types of pressure-reducing devices were compared. In one study, an air mattress was compared with a water mattress (Andersen, Jensen, Kvorning, et al., 1983). In the second, an alternating pressure pad was compared with a silacore mattress overlay (Daechsel, and Conine, 1985). In the third study, the investigators compared a 4-inch, convoluted foam overlay with an alternating pressure mattress (Whitney, Fellows, and Larson, 1984). The results were similar for all three studies -- no significant difference in the incidence and severity of pressure ulcers. Although there is evidence that pressure-reducing devices can decrease the incidence of pressure ulcers, there is no evidence to suggest that one type of pressure-reducing device is more effective than another in preventing pressure ulcers.

Rationale

The findings of researchers of the etiology of pressure ulcers indicated that prolonged, uninterrupted mechanical loading of the tissue results in breakdown of the tissue (Kosiak, 1959; Reddy, and Cochran, 1979). On the basis of the pressure time curve developed by Brand (1976), relief from the level of interface pressure produced during sitting is needed at least every hour and preferably at shorter intervals. Clinical practitioners who work with spinal cord-injured patients report that weight shifts are an effective means of reducing the risk of pressure ulcer formation (Krouskop, Noble, Garber, et al., 1983).

Rationale

Based on the results of animal experiments in pressure ulcer formation (Reddy, and Cochran, 1979; Lindan, 1961), the risk of developing a pressure ulcer can be diminished by reducing the mechanical loading on the tissue; this can be accomplished by using pressure-reducing devices (Garber, Krouskop, and Carter, 1978; DeLateur, Berni, Hangladarom, et al., 1976; Ferguson-Pell, Cochran, Cardi, et al., 1986). For the device to be effective, it must be individually prescribed for the user to ensure that the device is effective for the person and that the device does not interfere with other aspects of mobility and personal autonomy. The use of pressure-reducing devices allows the user increased latitude when pressure relief must be provided (for example, when push-ups must be done) and also allows more latitude in the timing of nursing care schedules.

Although ring cushions (donuts) are known to cause venous congestion and edema, few studies have documented their deleterious effects. Crewe (1987), in a study of at-risk patients, found that ring cushions are more likely to cause pressure ulcers than to prevent them.

Rationale

Participation in activities of daily living, leisure, and personal interactions requires that a seat provide more than pressure relief. If the seating surface interferes with a person engaging in activities, the device is often not used, and the protection necessary for maintaining healthy skin is not provided. Seating considerations that promote maximum personal autonomy and healthy life styles include postural alignment, distribution of weight, balance and stability, and pressure relief. Postural alignment is important to reduce the risk of deformities developing that could compromise respiratory function as well as self-care activities. Distribution of a person's weight over the seating surface both influences the person's ability to transfer from the seat and defines the magnitude and location of maximum pressure. By proper distribution of a person's weight over the seating surface, it is possible to transfer the load to the areas that are better able to tolerate the mechanical loading. Balance and stability directly influence mobility, energy expenditure, and function performance.

Rationale

Written plans for repositioning are endorsed by VanEtten, Sexton, and Smith (1990) and the International Association of Enterostomal Therapy (IAET, 1988). The use of positioning devices for wheelchair-bound patients is described by several authors (Hamilton, Quek, Lew, et al., 1989; King, and French, 1990).

Rationale

Effective pressure ulcer prevention depends on the coordinated efforts of health care professionals in hospital settings and continued implementation of preventive interventions by family and the patient in the home (Dimant, and Francis, 1988; Frye, 1986). These efforts have been described in the context of multidisciplinary teams and include an organized program of education and clinical practice (Green, 1976; Khun, and Wygonoski, 1984; Levine, Simpson, and McDonald, 1989; Nickel, Waters, and Klein, 1982).

Despite a lack of outcome data, Levine, Simpson, and McDonald (1989) and Hamilton, Quek, Lew, et al. (1989) describe the importance of the interdisciplinary team in pressure ulcer prevention and treatment. While lacking a rigorous research framework, a quality assurance approach (VanNess, 1989; Droessler and Maibusch, 1979) and involvement of individuals and their families (Andberg, Rudolph, and Anderson, 1983) have resulted in increased awareness of pressure ulcer risk factors, assessment, prevention, and early treatment. Programs established in spinal cord injury centers often served as models for subsequent pressure ulcer prevention educational programs (Krouskop, Noble, Garber, et al., 1983; Andberg, Rudolph, and Anderson, 1983; Noble, 1981; King, Boyink, and Keenan, 1977; Nickel, Waters, and Klein, 1982; Rothery, 1989; Stover, and Fine, 1986). They have been called pressure ulcer clinics, tissue pressure management programs, tissue teams, skin care teams (Tenpas, 1990), task forces (Walsh, 1989), and pressure ulcer committees. Regardless of their names, they all endorse the multidisciplinary, coordinated, structured, comprehensive approach to prevention. With regard to patient and family education, Barnes (1987), Sebern (1987), and Andberg, Rudolph, and Anderson (1983) believe that, when appropriate, the patient and family are integral to prevention and management of pressure ulcers.

Rationale

There seems to be a consensus among investigators regarding the essential information that must be included in an effective pressure ulcer prevention program. The seven essential components of a program are listed above. They are reported to be the core of the prevention programs in spinal cord injury and rehabilitation centers (Krouskop, Noble, Garber, et al., 1983; King, Boyink, and Keenan, 1977; Ozer, Lappin, Courtney, et al., 1989); nursing homes (Blom, 1985; California State Department of Health, 1978; Di Domenico, and Ziegler, 1989; Dimant and Francis, 1988; Hamilton, Quek, Lew, et al., 1989; McIntyre, and Welch, 1987; Reed, 1981); and hospitals (Frye, 1986; Green, 1976; Levine, Simpson, and McDonald, 1989; Moody, Fanale, Thompson, et al., 1988; Morison, 1989; Osborne, 1987; Sater, Takano-Stone, Umeh, et al., 1987; Somers, and Drake, 1989; Starling, 1990). The most frequently cited topics to be taught include skin monitoring, followed by devices, risk assessment/risk factors, and prevention.

Moody, Fanale, Thompson, et al. (1988) tested the hypothesis that an educational program, without the introduction of new technology, could result in higher quality care and cost savings. After an intensive educational program for nurses and physicians that covered pathogenesis, staging, prevention, and treatment of ulcers, there was a 63 percent decrease in the development of pressure ulcers among elderly hospitalized patient populations. LaMantia, Hirschwald, Goodman, et al. (1987) focused on 42 individuals with spinal cord injury through a didactic program resulting in specific behavioral outcomes. Success, measured as intact skin as a result of the program, was high when measured at 3 months and 1 year.

Rationale

More continuity of care is reported when team approaches are used and each person on the team has specific, identified responsibilities (Khun, and Wygonoski, 1984; Dimant, and Francis, 1988; Frye, 1986). A variety of techniques for presenting material enhances learning (Simpson, 1988). Lecture and demonstration are the most frequently employed educational methods (Krouskop, Noble, Garber, et al., 1983; LaMantia, Hirschwald, Goodman, et al., 1987; Irvine, and Black, 1990; Morley, 1973). Written guides with illustrations are also very appropriate for use by staff who must position and transfer patients and dress wounds (King, Boyink, and Keenan, 1977; California State Department of Health, 1978; Di Domenico, and Ziegler, 1989) and for patients or families to use at home (Lovett and Bridle, 1986; Morison, 1989).

Educational programs evaluated by staff and modified to incorporate new approaches are effective in reducing the severity of pressure ulcers (McIntyre, and Welch, 1987). Coordinated ongoing programs are successful in reducing the risk of developing pressure ulcers and in preventing progression of ulcers from mild to severe (Van Ness, 1989; Tenpas, 1990; VanEtten, Sexton, and Smith, 1990; Oot-Giromini, Bidwell, Heller, et al., 1989). Systematic ongoing programs are effective if they present accurate and consistent information (Andberg, Rudolph, and Anderson, 1983; Dimant, and Francis, 1988).

Rationale

The primary purpose of pressure ulcer prevention educational programs is to reduce the occurrence of ulcers. Educational programs must have a built-in mechanism to evaluate their effectiveness in achieving this outcome. Baseline audits establish the incidence of ulcers in a particular facility. Establishing baseline data on pressure ulcer occurrence in a facility (hospital, nursing home, rehabilitation center) enables that facility to develop quality assurance standards (Droessler and Maibusch, 1979; Irvine, and Black, 1990). Quality assurance standards are reviewed regularly, especially by facilities that must meet accreditation standards (Commission on Accreditation of Rehabilitation Facilities, Joint Commission on Accreditation of Healthcare Organizations); documentation of compliance reflects changes in outcomes (reduction in number or severity of ulcers). From this point, with the educational program in place, effectiveness based on reduced occurrence or a decrease in severity can be determined (Blom, 1985; Van Ness, 1989). It has been suggested that a pre-education test and a posteducation test be given to evaluate effectiveness of the educational process (Moody, Fanale, Thompson, et al., 1988). However, educational programs must be consistent, comprehensive, and ongoing (Oot-Giromini, Bidwell, Heller, et al., 1989). Evaluation by the patient of the educational program is also recommended when appropriate (Ozer, Lappin, Courtney, et al., 1989).