- Prevention is the key to management of pressure ulcers. Measures include:
- Risk factor assessment, include immobility, limited activity, incontinence, impaired nutritional status, impaired circulation, and altered level of consciousness
- Skin care, including daily inspection with particular attention to bony prominences and minimizing exposure to moisture from incontinence, perspiration, or wound drainage.
- Interventions aimed at relieving or redistributing pressure, including frequent repositioning (minimum of every 2 hours, or every 1 hour for wheelchair-bound patients), pillows or foam wedges between bony prominences, maintenance of the head of the bed at the lowest degree of elevation, and use of lifting devices when moving patients.
- Pressure-reducing devices (foam, dynamic air mattresses) and pressure-relieving devices (low-air-loss, air-fluidized beds) can also be used.
- The National Pressure Ulcer Task Force classifies ulcers as follows:
- Stage I (nonblanchable erythema; intact skin)
- Stage II (extension through epidermis, shallow crater)
- Stage III (full thickness without extension through fascia)
- Stage IV (full thickness with destruction of underlying tissue, muscle, and/or bone)
- Initial interventions include use of pressure-relieving devices, occlusivedressings, pain control, normal saline for cleansing, use of topical agents that promote wound healing (DuoDERM, silver sulfadiazine [Silvadene], bacitracin zinc, Neosporin, Polysporin), avoidance of agents that delay healing (antiseptic agents, such as Dakin solution, hydrogen peroxide; wet-to-dry gauze), and removal of necrotic debris.
- Adequate nutrition with particular attention to protein intake (1.25-1.50 g protein/kg/d), vitamin C (500 mg PO daily) and zinc sulfate (220 mg PO daily) supplementation in the presence of deficiencies may also facilitate healing.
- For clean pressure ulcers that continue to produce exudate or are not healing after 2-4 weeks of therapy, consider a 2-week trial of topical antibiotic (e.g., silver sulfadiazine, double antibiotic).
- Other adjunctive therapies for nonhealing ulcers include electrical stimulation, radiant heat, negative pressure therapy, and surgical intervention.
- Fall precautions should be written for patients who have a history of falls or are at high risk of a fall (i.e., those with dementia, syncope, orthostatic hypotension).
- Falls are the most common accident in hospitalized patients, frequently leading to injury.
- Seizure precautions should be considered for patients with a history of seizures or those at risk of seizing. Precautions include padded bed rails and an oral airway at the bedside.
- Restraint orders are written for patients who are at risk of injuring themselves or interfering with their treatment due to disruptive or dangerous behaviors.
- Restraint orders must be reviewed and renewed every 24 hours. Physical restraints may exacerbate agitation. Bed alarms or sitters are alternatives in appropriate settings.
Adverse Drug Reactions
- Adverse drug reactions occur frequently, and the rate increases in proportion to the number of drugs taken. Adverse reactions may be allergic, idiosyncratic, or dose-related magnification of known effects.
- Prevention. Following the principles below may decrease the incidence of adverse drug reactions.Allergy and Immunology.
- Record a careful history of previous drug reactions, including the drug involved and the specific reaction, clearly on the chart.
- Minimize number of drugs used.
- Consider drug interactions. New medications should be added only after careful consideration of the current medical regimen.
- Consider the metabolism, route of excretion, and major adverse effects associated with each drug used. Individualize dosages according to the patient's age, weight, and kidney and liver function.
- Report unusual drug reactions to the U.S. Food and Drug Administration. The MEDWATCH program provides an easy method for voluntary reporting of adverse drug reactions
- Discharge planning begins at the time of admission. Assessment of the patient's social situation and potential discharge needs should be made.
- Early coordination with nursing, social work, and case coordinators/managers facilitates efficient discharge and a complete postdischarge plan.
- Patient education should occur regarding changes in medications and other new therapies.
- Prescriptions should include the name of the patient, date, name of the drug, dosage, route of administration, amount dispensed, dosage schedule instructions, and signature of the physician. The number of refills should be limited, especially for patients who appear to be self-injurious. For narcotics, write out all numbers in parentheses (e.g., dispense 30 [thirty], refills 2 [two]).
- Communication with physicians who will be resuming care of the patient after discharge is important for optimal follow-up care.