Pressure Ulcer Prevention in CVA Patients in the ICU
Primary Recommendation
For CVA patients in the ICU at high risk for pressure ulcers, implement a multicomponent prevention bundle that includes advanced static air mattresses, prophylactic multilayer foam dressings on the sacrum and heels, repositioning every 2-4 hours at 30-degree tilt, and high-protein nutritional supplementation. 1, 2
Equipment Selection
Support Surfaces (Mattresses)
Use advanced static air mattresses or overlays as the primary support surface for all high-risk CVA patients. 1, 2
- Advanced static mattresses reduce pressure ulcer incidence compared to standard hospital mattresses with moderate-quality evidence 1
- These surfaces are significantly less expensive than alternating-air systems while providing equivalent or superior outcomes 1
- Do NOT use alternating-air mattresses or overlays - they provide no clear benefit over advanced static surfaces, cost substantially more, and add unnecessary noise that disrupts patient care 1, 2, 3
Prophylactic Dressings
Apply multilayer foam dressings prophylactically to the sacrum and heels immediately upon ICU admission. 2
- Prophylactic foam dressings on high-risk areas (sacrum, heels) are explicitly recommended as the best additional preventive strategy beyond repositioning 2
- These dressings provide a protective barrier and redistribute pressure at vulnerable bony prominences 2
Equipment to AVOID
Never use donut cushions - they are explicitly contraindicated as they concentrate pressure around the perimeter, creating a tourniquet effect that impairs circulation to central tissue 2
Positioning Protocol
Repositioning Schedule
Reposition patients every 2-4 hours using a 30-degree tilt position. 1, 2, 4
- The 30-degree tilt reduces pressure on bony prominences more effectively than 90-degree lateral rotation (relative risk 0.62) 2
- Advanced static mattresses allow repositioning intervals up to 4 hours without increased ulcer incidence 2
- Document pressure zone checks at each repositioning 4
Head of Bed Elevation
For hemodynamically stable CVA patients: maintain head elevation at 15-30 degrees. 2
- Head elevation ≥30 degrees is contraindicated in hemodynamically unstable patients as it reduces venous return and worsens hypotension 2
- Elevating the head ≥30 degrees increases pressure ulcer risk in the sacrum 2
- 45-degree elevation significantly increases decubitus ulcer risk compared to 30-degree elevation 2
- Keep the head of bed at the lowest safe angle (15-20 degrees) until hemodynamics stabilize, then gradually increase if tolerated 2
- Avoid flat supine position as it concentrates pressure on vulnerable areas 2
Repositioning in Vasopressor-Dependent Patients
Vasopressor use is NOT a contraindication to repositioning - monitor blood pressure and heart rate during position changes but continue the repositioning protocol 2
Skin Care Protocol
Daily Assessment
Perform visual and tactile skin examination at least once daily, focusing on sacrum, heels, ischium, and occiput. 2, 4
- Document findings at each assessment 1
- Early identification of stage 1 changes allows immediate intervention 4
Moisture Management
Keep skin clean and dry with prompt management of any incontinence. 2
- Urinary and fecal incontinence are major risk factors for pressure ulcer development in CVA patients 1
- Use moisture barriers as needed but avoid massage, which is contraindicated despite being commonly practiced 5
Nutritional Support
Provide high-protein oral nutritional supplementation for all at-risk CVA patients. 2
- High-protein supplementation significantly reduces pressure ulcer risk (odds ratio 0.75,95% CI 0.62-0.89) 2
- Protein or amino acid supplementation also reduces wound size if ulcers develop despite prevention efforts 2
- Do NOT prioritize vitamin C supplementation - it shows no benefit for pressure ulcer prevention 2
Implementation Framework
Multicomponent Bundle Approach
Implement a standardized multicomponent prevention bundle with multidisciplinary team involvement. 1
The American College of Physicians found that multicomponent interventions reduce pressure ulcer rates in both acute and long-term care settings with moderate-quality evidence 1
Key components of successful implementation include:
- Simplification and standardization of pressure ulcer-specific interventions and documentation 1
- Designated skin champions who educate staff about skin care and ulcer prevention 1
- Ongoing staff education including team meetings and motivational campaigns 1, 4
- Sustained audit and feedback with weekly prevalence reports and all-facility meetings 1
- Multidisciplinary team leadership including nursing, nutrition, and physical therapy 1
Cost-Effectiveness
This approach demonstrates substantial cost savings - one 2-hospital system achieved approximately $11.5 million in annual savings through statistically significant reductions in pressure ulcer prevalence 1
A 4-year quality improvement program in critical care units achieved an average estimated cost saving of £2.6 million with a 63% relative rate reduction in pressure ulcers 4
Risk Assessment
Perform initial risk assessment using the Braden Scale or clinical judgment to identify high-risk patients. 1
CVA patients have multiple risk factors including:
- Cognitive impairment and altered mental status 1
- Physical impairments and immobility 1
- Urinary or fecal incontinence 1
- Impaired microcirculation 1
- Malnutrition and hypoalbuminemia 1
The Braden Scale has moderate-quality evidence for predicting pressure ulcer risk, though sensitivity and specificity are low 1
Common Pitfalls to Avoid
Using alternating-air mattresses - these add unnecessary cost without improving outcomes compared to advanced static surfaces 1, 3
Massage of pressure areas - this is contraindicated despite being commonly practiced in ICUs 5
Excessive head elevation in unstable patients - this worsens hemodynamics and increases sacral pressure 2
Delaying prophylactic dressing application - apply foam dressings to sacrum and heels immediately upon ICU admission 2
Withholding repositioning in vasopressor-dependent patients - continue repositioning with hemodynamic monitoring 2