What are WOCN guidelines for the prevention of pressure injuries (pressure ulcers)?

Updated: Mar 26, 2020
  • Author: Christian N Kirman, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Answer

In 2016, the Wound, Ostomy and Continence Nurses Society (WOCN) issued guidelines on the prevention and management of pressure ulcers (injuries). [168] Recommendations for prevention included the following:

  • Implement measures to reduce the risk of developing pressure ulcers: minimize/eliminate pressure, friction, and shear. 
  • Minimize/eliminate pressure from medical devices such as oxygen tubing, catheters, cervical collars, casts, and restraints.
  • Maintain the head-of-bed elevation at/or below 30°, or at the lowest degree of elevation consistent with the patient's medical condition to prevent shear-related injury, and use a 30° side-lying position.
  • Schedule regular repositioning and turning for bedbound and chairbound individuals, taking into consideration the condition of the patient and the pressure redistribution support surface in determining the repositioning strategy.
  • Position sitting patients with special attention to the individual's anatomy, postural alignment, distribution of weight, and support of the feet.
  • Consider prophylactic dressings to prevent sacral and heel ulcers in at-risk patients.
  • Use heel suspension devices for patients who are at risk for pressure ulcers that elevate (float) and offload the heel completely, and redistribute the weight of the leg along the calf without putting pressure on the Achilles tendon.
  • Utilize support surfaces (on beds and chairs) to redistribute pressure. Pressure redistribution devices should serve as adjuncts and not replacements for repositioning protocols.
  • Place individuals who are at risk for pressure ulcers on a pressure redistribution surface.
  • Consider using the WOCN Evidence- and Consensus-Based Support Surface Algorithm (http://algorithm.wocn.org) to identify the appropriate support surface (overlay, mattress, or integrated bed system) for adults (≥16 years) and bariatric patients in care settings where the length of stay is 24 hours or more.
  • Use a high-specification reactive or alternating pressure support surface in the operating room for individuals at high risk for developing pressure ulcers.
  • Avoid foam rings, foam cut-outs, or donut-type devices for pressure redistribution because they concentrate pressure on the surrounding tissue.
  • Use incontinence skin barriers such as creams, ointments, pastes, and film-forming skin protectants as needed to protect and maintain intact skin in individuals who are incontinent and at risk for pressure ulcers.
  • Offer individuals with nutritional and pressure ulcer risks a minimum of 30-35 kcal/kg body weight per day, 1.25-1.5 g of protein/kg body weight per day, and 1 ml of fluid intake/kcal per day.
  • Educate the patient/caregiver(s) about the causes and risk factors for developing pressure ulcers and ways to minimize the risk.

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