Pressure Ulcer Prevention – Avoiding Bedsores

What Is Pressure Ulcer Prevention?

Pressure ulcer prevention (also known as decubitus prophylaxis) refers to all nursing, medical, and technical measures designed to prevent the development of a pressure ulcer – also called a bedsore or pressure injury. A pressure ulcer forms when sustained pressure on the skin and underlying tissue interrupts blood flow, leading to tissue damage and, if untreated, tissue death.

People who are bedridden or spend long periods in a wheelchair due to illness, disability, or advanced age are particularly at risk.

Why Is Pressure Ulcer Prevention Important?

Pressure ulcers can be extremely painful, heal slowly, and significantly increase the risk of serious complications such as infections or sepsis. Consistent prevention protects the quality of life of those affected, shortens hospital stays, and substantially reduces treatment costs.

Risk Groups

The following groups are at increased risk of developing pressure ulcers:

• Bedridden and immobile patients
• Wheelchair users
• Older adults with limited mobility
• Individuals with circulatory disorders or diabetes mellitus
• Malnourished or dehydrated persons
• Patients with impaired pain perception (e.g., due to spinal cord injury)

Risk Assessment

Standardized scales are used to systematically assess pressure ulcer risk. The most commonly used include:

• Braden Scale: Evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear forces.
• Norton Scale: Assesses general condition, mental status, activity, mobility, and continence.
• Waterlow Scale: Additionally considers factors such as body build, sex, and special risk factors.

Prevention Measures

Repositioning and Position Changes

Regular repositioning is the most important measure in pressure ulcer prevention. Bedridden individuals should change position at least every two hours, while wheelchair users should shift their weight at least every 15 to 30 minutes to redistribute pressure from vulnerable body areas. The 30-degree tilt position, in which the body is slightly angled to one side, has proven particularly effective.

Pressure-Relieving Devices

Specialized positioning aids and anti-decubitus mattresses (alternating pressure mattresses, foam mattresses) reduce pressure on at-risk areas such as the sacrum, heels, and shoulder blades. Pressure-relief seat cushions for wheelchairs are also an important preventive tool.

Skin Care and Skin Monitoring

Daily skin inspection – particularly at bony prominences such as the heels, sacrum, hips, and ankles – allows early detection of redness (Grade I) as the first sign of a pressure ulcer. The skin should be regularly cleansed, thoroughly dried, and moisturized with appropriate skin care products. Moisture from incontinence increases pressure ulcer risk and should be minimized using suitable continence care products.

Nutrition and Hydration

Adequate protein and calorie intake is essential for tissue integrity. Malnutrition and dehydration weaken the skin and delay wound healing. In at-risk individuals, nutritional status should be regularly assessed and optimized through dietary counseling or nutritional supplements when needed.

Mobilization and Activation

Where medically possible, patients should be encouraged to engage in active movement and to get up and about. Physiotherapy and targeted exercise promote circulation and reduce the risk of pressure ulcer development.

Education and Training

Educating patients, residents, and their families about risks, warning signs, and prevention strategies is a central component of pressure ulcer prophylaxis. Nursing staff should receive regular training in evidence-based prevention practices.

Classification of Pressure Ulcers

Despite all preventive efforts, pressure ulcers can still develop. Severity is classified internationally using the EPUAP/NPIAP system (European Pressure Ulcer Advisory Panel / National Pressure Injury Advisory Panel) into four categories:

• Category I: Non-blanchable redness of intact skin
• Category II: Partial-thickness skin loss involving the epidermis or dermis
• Category III: Full-thickness skin loss with damage to subcutaneous tissue
• Category IV: Full-thickness tissue loss with exposure of bone, tendon, or muscle

Guidelines and Standards

Pressure ulcer prevention is regulated by national and international guidelines in many countries. Internationally, the clinical practice guidelines published by the EPUAP, the National Pressure Injury Advisory Panel (NPIAP), and the Pan Pacific Pressure Injury Alliance (PPPIA) serve as the leading evidence-based reference. In clinical practice, adherence to these guidelines is considered the standard of care.

References

1. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Injury Advisory Panel (NPIAP), Pan Pacific Pressure Injury Alliance (PPPIA): Prevention and Treatment of Pressure Ulcers/Injuries – Clinical Practice Guideline, 3rd Edition, 2019.
2. Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (DNQP): Expertenstandard Dekubitusprophylaxe in der Pflege, 2nd Update 2017. Fachhochschule Osnabrück.
3. Lyder CH, Ayello EA: Pressure ulcers – a patient safety issue. In: Hughes RG (ed.): Patient Safety and Quality – An Evidence-Based Handbook for Nurses. Agency for Healthcare Research and Quality, Rockville 2008.