What is the best strategy for preventing pressure ulcers in an elderly female with cachexia and a history of stroke, aside from consistent repositioning?

Best Strategy for Pressure Ulcer Prevention Beyond Repositioning

Apply prophylactic multilayer foam dressings to the sacrum and heels immediately, as this is the single most effective additional intervention for high-risk patients like this elderly cachectic stroke survivor. 1

Primary Prevention Strategy: Prophylactic Dressings

Multilayer foam dressings placed over high-risk bony prominences (sacrum and heels) represent the best evidence-based intervention beyond repositioning for this patient population. 1 This recommendation comes from the most recent 2025 guidelines specifically addressing high-risk patients, and is particularly relevant given this patient's multiple risk factors (cachexia, immobility from stroke, elderly age). 1

• Prophylactic dressings are explicitly recommended as a key component of bundled prevention protocols for patients with high-risk profiles. 1
• These dressings work by redistributing pressure and reducing friction/shear forces at vulnerable sites. 1

Advanced Support Surface Selection

Use an advanced static air mattress or overlay immediately—this is strongly recommended over standard hospital mattresses and provides equivalent outcomes to more expensive alternating-air systems. 2

• Advanced static mattresses show moderate-quality evidence for lower ulcer rates compared to standard mattresses. 2
• Avoid alternating-air mattresses—they provide no clear benefit over advanced static surfaces while costing significantly more without improving outcomes. 2
• Air-fluidized beds are superior to other support surfaces for patients who already have large ulcers (>7 cm), but for prevention, advanced static surfaces are the evidence-based choice. 3, 4

Nutritional Intervention

Provide high-protein oral nutritional supplementation immediately, as this directly addresses the cachexia and reduces pressure ulcer risk. 2

• The European Society for Clinical Nutrition and Metabolism demonstrates significant reduction in ulcer development with high-protein supplementation (OR 0.75; 95% CI 0.62-0.89). 2
• Protein or amino acid supplementation reduces wound size in patients who develop ulcers despite prevention efforts. 3
• This intervention is particularly critical for malnourished patients like this cachectic individual. 2
• Note the caveat: Vitamin C supplementation shows no benefit and should not be prioritized. 3

Heel Protection Protocol

Implement dedicated heel pressure-relieving devices, as heels are the second most common site for pressure ulcers after the sacrum. 1

• Heel protection with pressure-relieving devices is essential for high-risk patients. 1
• This is particularly important in stroke patients who may have sensory impairment and cannot feel developing pressure damage. 5

Positioning Considerations for Stroke Patients

Keep the head of bed at the lowest safe angle (15-20°) that maintains airway protection and aspiration prevention, as elevation ≥30° increases sacral pressure ulcer risk. 1

• Head elevation ≥30° increases pressure ulcer risk in dependent areas, particularly the sacrum. 1
• The 2024 guidelines note that 45° elevation increases decubitus ulcer risk compared with 30° elevation. 1
• Critical pitfall: Balance aspiration risk (common in stroke patients) against pressure ulcer risk—use the minimum elevation needed for safe swallowing. 1
• When repositioning is performed, use 30° lateral tilt position rather than 90° lateral or flat supine to reduce pressure on bony prominences. 1

Daily Skin Assessment Protocol

Perform visual and tactile examination of sacrum, heels, ischium, and occiput at least once daily. 1

• This allows early detection of stage 1 pressure injuries (non-blanchable erythema) before progression. 1
• Stroke patients may have sensory deficits preventing them from reporting discomfort, making systematic assessment critical. 5

Moisture Management

Keep skin clean and dry with prompt management of any incontinence, as moisture increases tissue vulnerability. 1

• Urinary and fecal incontinence are established risk factors for pressure ulcer development. 2
• This is particularly relevant in stroke patients who may have neurogenic bladder or bowel dysfunction. 5

Interventions to Explicitly Avoid

Never use donut cushions—they are contraindicated as they concentrate pressure around the perimeter, creating a tourniquet effect that impairs circulation to central tissue. 1

• There is no quality evidence supporting donut cushion use for pressure ulcer prevention. 1
• This is a common error in clinical practice that actually increases ulcer risk. 1

Implementation as Bundled Care

These interventions should be implemented simultaneously as a standardized bundle, not sequentially, as multicomponent interventions show superior outcomes to single interventions. 2

• Bundled care practices with moderate-quality evidence show improved outcomes in both acute and long-term care settings. 2
• One 2-hospital system reported $11.5 million annual savings from reduced ulcer prevalence using multicomponent prevention programs. 2