Adapted from the PICOT Questions Template; Ellen Fineout-Overholt, 2006. This form may be used for educational & research purposes without permission. Template  for  Asking  PICOT  Questions   INTERVENTION   In  ____________________(P),  how  does  ____________________  (I)  compared  to   ____________________(C)  affect  _____________________(O)  within  ___________(T)?       THERAPY   In  __________________(P),  what  is  the  effect  of  __________________(I)  compared  to   _____________  (C)  on  ________________(O  within  _____________(T)?     PROGNOSIS/PREDICTION   In  ______________  (P),  how  does  ___________________  (I)  compared  to  _____________(C)   influence  __________________  (O)  over  _______________  (T)?   DIAGNOSIS  OR  DIAGNOSTIC  TEST   In  ___________________(P)  are/is  ____________________(I)    compared  with   _______________________(C)  more  accurate  in  diagnosing  _________________(O)?     ETIOLOGY   Are____________________  (P),  who  have  ____________________  (I)  compared  with  those   without  ____________________(C)  at  ____________  risk  for/of   ____________________(O)  over  ________________(T)?       MEANING   How  do  _______________________  (P)  with  _______________________  (I)    perceive   _______________________  (O)  during  ________________(T)?   Adapted from the PICOT Questions Template; Ellen Fineout-Overholt, 2006. This form may be used for educational & research purposes without permission. Short  Definitions  of  Different  Types  of  Questions     Intervention/Therapy:  Questions  addressing  the  treatment  of  an  illness  or  disability.     Etiology:  Questions  addressing  the  causes  or  origins  of  disease  (i.e.,  factors  that  produce  or   predispose  toward  a  certain  disease  or  disorder).     Diagnosis:  Questions  addressing  the  act  or  process  of  identifying  or  determining  the  nature  and   cause  of  a  disease  or  injury  through  evaluation.     Prognosis/Prediction:  Questions  addressing  the  prediction  of  the  course  of  a  disease.     Meaning:  Questions  addressing  how  one  experiences  a  phenomenon.     Sample  Questions:     Intervention:  In  African-­‐American  female  adolescents  with  hepatitis  B  (P),  how  does   acetaminophen  (I)  compared  to  ibuprofen  (C)  affect  liver  function  (O)?     Therapy:  In  children  with  spastic  cerebral  palsy  (P),  what  is  the  effect  of  splinting  and  casting(I)   compa.

1. Adapted from the PICOT Questions Template; Ellen Fineout-
Overholt, 2006. This form may be used for educational &
research purposes without permission.
Template
for
Asking
PICOT
Questions
INTERVENTION
In
____________________(P),
how
does
____________________
(I)
compared
to
____________________(C)
affect
_____________________(O)
within
___________(T)?

2. THERAPY
In
__________________(P),
what
is
the
effect
of
__________________(I)
compared
to
_____________
(C)
on
________________(O
within
_____________(T)?
PROGNOSIS/PREDICTION
In
______________
(P),
how
does
___________________
(I)

3. compared
to
_____________(C)
influence
__________________
(O)
over
_______________
(T)?
DIAGNOSIS
OR
DIAGNOSTIC
TEST
In
___________________(P)
are/is
____________________(I)
compared
with
_______________________(C)
more
accurate
in
diagnosing
_________________(O)?

4. ETIOLOGY
Are____________________
(P),
who
have
____________________
(I)
compared
with
those
without
____________________(C)
at
____________
risk
for/of
____________________(O)
over
________________(T)?
MEANING

5. How
do
_______________________
(P)
with
_______________________
(I)
perceive
_______________________
(O)
during
________________(T)?
Adapted from the PICOT Questions Template; Ellen Fineout-
Overholt, 2006. This form may be used for educational &
research purposes without permission.
Short
Definitions
of
Different
Types
of
Questions

6. Intervention/Therapy:
Questions
addressing
the
treatment
of
an
illness
or
disability.
Etiology:
Questions
addressing
the
causes
or
origins
of
disease
(i.e.,
factors
that
produce
or
predispose
toward
a
certain
disease
or
disorder).

7. Diagnosis:
Questions
addressing
the
act
or
process
of
identifying
or
determining
the
nature
and
cause
of
a
disease
or
injury
through
evaluation.
Prognosis/Prediction:
Questions
addressing
the
prediction
of
the
course

8. of
a
disease.
Meaning:
Questions
addressing
how
one
experiences
a
phenomenon.
Sample
Questions:
Intervention:
In
African-­‐American
female
adolescents
with
hepatitis
B
(P),
how
does
acetaminophen

9. (I)
compared
to
ibuprofen
(C)
affect
liver
function
(O)?
Therapy:
In
children
with
spastic
cerebral
palsy
(P),
what
is
the
effect
of
splinting
and
casting(I)
compared
to
constraint-­‐
induced
therapy
(C)
on

10. two-­‐handed
skill
development
(O)?
Prognosis/Prediction:
1)
For
patients
65
years
and
older
(P),
how
does
the
use
of
an
influenza
vaccine
(I)
compared
to
not
received
the
vaccine
(C)
influence

11. the
risk
of
developing
pneumonia
(O)
during
flu
season
(T)?
2)
In
patients
who
have
experienced
an
acute
myocardial
infarction
(P),
how
does
being
a
smoker
(I)
compared
to
a
non-­‐smoker
(C)

12. influence
death
and
infarction
rates
(O)
during
the
first
5
years
after
the
myocardial
infarction
(T)?
Diagnosis:
In
middle-­‐aged
males
with
suspected
myocardial
infarction
(P),
are
serial
12-­‐lead
ECGs
(I)
compared

13. to
one
initial
12-­‐lead
ECG
(C)
more
accurate
in
diagnosing
an
acute
myocardial
infarction
(O)?
Etiology:
Are
30-­‐
to
50-­‐year-­‐old
women
(P)
who
have
high
blood
pressure
(I)
compared
with
those

14. without
high
blood
pressure
(C)
at
increased
risk
for
an
acute
myocardial
infarction
(O)
during
the
first
year
after
hysterectomy
(T)?
Meaning:
How
do
young
males
(P)
with
a
diagnosis
of
below

15. the
waist
paralysis
(I)
perceive
their
interactions
with
their
romantic
significant
others
(O)
during
the
first
year
after
their
diagnosis
(T)?
EVIDENCE-
BASED CARE
SHEET
ICD-9
707.0
ICD-10

16. L89
Authors
Tanja Schub, BS
Cinahl Information Systems, Glendale, CA
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Reviewers
Eva Beliveau, RN, MSN, CNE
Professor of Nursing, Northern Essex
Community College
Gina DeVesty, BSN, MLS
Cinahl Information Systems, Glendale, CA
Nursing Executive Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Editor
Diane Hanson, MM, BSN, RN, FNAP
August 13, 2021
Published by Cinahl Information Systems, a division of EBSCO
Information Services. Copyright©2021, Cinahl Information
Systems. All rights
reserved. No part of this may be reproduced or utilized in any
form or by any means, electronic or mechanical, including
photocopying, recording, or by
any information storage and retrieval system, without

17. permission in writing from the publisher. Cinahl Information
Systems accepts no liability for advice
or information given herein or errors/omissions in the text. It is
merely intended as a general informational overview of the
subject for the healthcare
professional. Cinahl Information Systems, 1509 Wilson Terrace,
Glendale, CA 91206
Pressure Injuries: Prevention Strategies
What We Know
› Pressure injuries (PIs ; Figure 1 )—referred to as “pressure
ulcers” until the change in
terminology by the National Pressure Ulcer Advisory Panel
(NPUAP; 2016) and also
referred to as decubitus ulcers, pressure sores, or bedsores—are
localized, oftentimes
painful, areas of damaged skin and/or underlying soft tissue
resulting from prolonged or
intense pressure or a combination of pressure and shear. The
skin at the site of a PI can be
intact or the injury can appear as an open ulcer. PIs usually
occur over bony prominences
or in areas where medical or other devices or surfaces exert
prolonged pressure against
the skin. Factors that can potentiate the injurious effects of
pressure and shear include
prolonged skin moisture, poor nutrition, and poor perfusion.(11)
(For details, see Quick
Lesson About … Pressure Injuries: an Overview )
Figure 1: Graphic illustrating four of the eight pressure injury
classifications
established by the National Pressure Ulcer Advisory Panel
(NPUAP).

18. Additional categories include Unstageable, Deep Tissue,
Medical
Device Related, and Mucosal Membrane Pressure Injury.
Copyright©
Nanoxyde, 2008. Licensed under Creative Commons
Attribution-Share
Alike 3.0 Unported, 2.5 Generic, 2.0 Generic and 1.0 Generic
License
• Of note, the majority of current literature does not yet reflect
the NPUAP’s recent
change in terminology; it is expected that the termpressure
injury will gradually replace
pressure ulcer anduse of Arabic numerals to identify PIs
stagesinstead of Roman
numeral,as acknowledgement of the change becomes
widespread(1)
–The European Pressure Ulcer Advisory Panel (EPUAP)
continues to support the
guidelines issued in 2014 and has not yet adopted the new
terminology and pressure
ulcer classification system propounded by NPUAP in April
2016(8)
• PI risk factors include older age, impaired mobility, physical
inactivity, being subject
to friction and shear, moisture, low body mass index (BMI)
and/or poor nutritional
status (especially low protein intake), dehydration,
incontinence, sensory loss, cognitive
impairment, certain medical conditions (e.g., diabetes mellitus,
[DM] peripheral vascular

19. disease [PVD], stroke, and spinal cord injury [SCI]), drugs that
affect wound healing
(e.g., corticosteroids), hip fracture, smoking, and need for
assisted ventilation(4,5,6,10,14)
• PIs are associated with a decrease in quality of life and a 1-
yearmortality rate that approaches40%(14)
• Up to 95% of PIs are thought to be preventable(15)
–As of 2008, the Centers for Medicare & Medicaid Services
(CMS) in the United States no longer reimburses facilities for
treatment of facility-acquired Stage 3 and 4 PIs(2)
› Standard prevention strategies include risk assessment using
standardized PI risk assessment tools (e.g., Braden scale), skin
care, frequently redistributing pressure (particularly over bony
prominences) by frequent repositioning, maintaining good
hygiene, minimizing moisture (especially that caused by
incontinence), management of incontinence by scheduled
toileting
plans, use of mattresses and/or cushions to reduce/relieve
pressure, preventing skin damage through use of topical agents
(e.g., creams, ointments) or dressings, avoiding over-sedation,
and optimizing nutrition(4,5,6,9,10,14,15)
• PI risk assessment scales have low to modest predictive ability
and Cochrane reviewers found no reliable evidence
demonstrating that the use of structured risk assessment tools
reduces the incidence of PIs(13)
• Although the value of regular patient repositioning in reducing
the risk of developing PIs has been confirmed, and clinical
practice guidelines commonly recommend patient repositioning

20. every 2 hours, the optimal frequency for repositioning has
not been established in clinical trials(6)
• Cochrane reviewers analyzed 59 randomized trials and found
evidence that(9)
–constant low-pressure support surfaces reduce the incidence of
PIs compared to standard foam mattresses
–sheepskin mattress overlays reduce the incidence of PIs
–pressure-relieving overlays on the operating table reduce the
incidence of PIs
–alternating pressure mattresses reduce the incidence of PIs
compared to standard foam mattresses
–alternating pressure mattresses and constant low-
pressuresupport surfaces have similar efficacy for reduction of
PIs
–alternating pressure mattresses and alternating pressure
overlays have similar efficacy for reduction of PIs
–addition of a Jay Gel cushion to foam wheelchair cushions
reduces PI risk
• Cochrane reviewers of256 recent studies for the prevention
and treatment of PI report the focus on repositioning, nutrition,
and support surfaces continue to be major recommendations(13)
• Although malnutrition is associated with increased PI risk,
there is insufficient evidence to support the routine use of
vitamin C and zinc supplementation to reduce PI risk(6)
• Authors of a recent systematic review found no evidence
supporting the use of any behavioral or educational
interventions
for PI prevention in adults with SCI(3)
–Researchers in South Korea randomized 47 patients with SCI
to a self-efficacy enhancement program or a control group.

21. Patients in the intervention group had greater improvements in
self-care knowledge, self-efficacy, and self-carebehaviors
for PI prevention. However, there was no significant difference
in incidence of PIs between the groups(7)
› The prevalence of PIs in U.S. facilities has declined over the
last decade(12)
• Researchers who conducted the International Pressure Ulcer
Prevalence Survey, a 10-year study of 918,621 inpatients
in the U.S., observed that the overall prevalence of PIs declined
from 13.5% in 2006 to 9.3% in 2015. The prevalence of
facility-acquired PIs declined from 6.2% in 2006 to 3.1–3.4% in
2013–2015(12)
What We Can Do
› Learn more about PI prevention so you can accurately assess
your patients’ personal characteristics and health education
needs; share this knowledge with your colleagues(5)
› Collaborate with an interdisciplinary healthcare team at your
facility to develop a PI prevention plan to reduce the risk for PI
development
› Assess PI risk and skin condition(6,14)
• On admission, assess for skin compromise, especially at bony
prominences; signs of recent trauma; effects of friction or
shear; immobility and/or functional incapacity; factors that
influence healing (e.g., nutritional status); and incontinence.
Ask about medical history (including previous treatments or
surgeries); and measure body weight(6)
• Reassess risk daily in acute care settings, at each home care
visit, and weekly in long-term care settings

22. –Use a valid risk assessment scale (e.g., Braden Scale for
Predicting PI Risk; the most widely used risk assessment tool
according to facility protocol(6,14)
- Risk assessment tools permit routine organized assessment of
the skin and factors related to skin integrity
› Optimize nutrition and hydration(6)
• Request referral to a registered dietitian for patient evaluation
and recommendation of specific amounts of proteins,
calories, fluids, electrolytes, and micronutrients
–Provide liquid nutritional supplements, enteral nutrition, or
total parenteral nutrition, as prescribed
• Perform ongoing nutritional assessment
–Use of a standardized nutrition assessment tool, such as the
Mini Nutritional Assessment (MNA), can assist in
determining the extent of malnutrition
• Assess body composition (height and weight), and for
alteration in laboratory values (e.g., serum albumin,
prealbumin, and
Hgb), which can indicate malnutrition
› Manage moisture and maintain skin integrity—cleanse and dry
skin after each incontinent event; use noncytotoxic cleansers
to avoid drying or irritating skin; do not rub the skin(14)
• For incontinent patients, use special supplies (e.g., topical
skin barriers, a pouching system, or indwelling catheters) and
frequently inspect skin

23. • For patients with dry skin, use moisturizer frequently because
dry skin is more susceptible to breakdown
› Minimize pressure, friction, and shear(6,14)
• Use heel protective devices (Figure 2) for patients at high-
risk for PIs
• Provide a pressure-redistributing support surface instead of a
standard mattress, per clinician orders or facility protocol
(Figure 3)
Figure 2: The convoluted foam of the heel protector increases
cushioning, promotes air circulation, and
dissipates heat for protection against skin breakdown. Copyright
©2015, EBSCO Information Services
Figure 3: Example of continuous pressure air-suspension
mattress overlay that is utilized to
reduce the risk for pressure injury development. Copyright©
2014, EBSCO Information Services
• Use lift sheets, overhead trapeze bars, and hoists; do not drag
or pull the patient
• Reposition the patient frequently
–Turn the patient every 1–2 hours using a hoist, trapeze, or lift
sheet
–Use pressure-redistributing devices (e.g., pillows, wedges) to
reduce pressure on bony prominences; frequently evaluate
their effectiveness
- Avoid use of donut-type ring cushions as support devices
because they can increase the size of the PI by causing further

24. ischemia rather than reducing risk for PI development
–Do not massage bony prominences (6)
› Educate patient and family about PI etiology, risk factors, and
prevention strategies (e.g., good nutrition, regular inspection
of skin, frequent repositioning), and when to seek medical
attention
Coding Matrix
References are rated using the following codes, listed in order
of strength:
M Published meta-analysis
SR Published systematic or integrative literature review
RCT Published research (randomized controlled trial)
R Published research (not randomized controlled trial)
C Case histories, case studies
G Published guidelines
RV Published review of the literature
RU Published research utilization report
QI Published quality improvement report
L Legislation
PGR Published government report
PFR Published funded report

25. PP Policies, procedures, protocols
X Practice exemplars, stories, opinions
GI General or background information/texts/reports
U Unpublished research, reviews, poster presentations or
other such materials
CP Conference proceedings, abstracts, presentation
References
1. Black, J.M., Goldberg, M., McNichol, L., & Moore, L.
(2016). Revised national pressure ulcer advisory panel pressure
injury staging system: Revised pressure injury staging
system. Journal of wound, ostomy, and continence nursing,
43(6), 585-597. doi:10.1097/WON.0000000000000281 (G)
2. Centers for Medicare & Medicaid Services. (2020, February
11). Hospital-acquired conditions. Retrieved June 15, 2020,
from
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/HospitalAcqCond/Hospital-Acquired_Conditions.html
(GI)
3. Cogan, A. M., Blanchard, J., Garber, S. L., Vigen, C.,
Carlson, M., & Clark, F. A. (2017). Systematic review of
behavioral and educational interventions to prevent pressure
ulcers in adults with spinal cord injury. Clinical Rehabilitation,
31(7), 871-880. doi:10.1177/0269215516660855 (SR)
4. Doh, G., & Heo, C.Y. (2021). Pathogenesis and prevention of
pressure ulcer. Journal of the Korean Medical Association,
64(1), 16-25. doi:10.5124/jkma.2021.64.1.16 (RV)

26. 5. Dunk, A. M., & Carville, K. (2016). The international
clinical practice guidelines for prevention and treatment of
pressure ulcers/injuries. Journal of Advanced Nursing, 72(2),
243-244. doi:10.1111/jan.12614 (G)
6. European Pressure Ulcer Advisory Panel, National Pressure
Ulcer Advisory Panel, & Pan Pacific Pressure Injury
Alliance. (2016). Prevention and treatment of pressure ulcers:
Quick reference guide. Retrieved June 15, 2021, from
http://www.npuap.org/wp-content/uploads/2014/08/Updated-10-
16-14-Quick-Reference-Guide-DIGITAL-NPUAP-EPUAP-
PPPIA-16Oct2014.pdf (G)
7. Kim, J. Y., & Cho, E. (2017). Evaluation of a self-efficacy
enhancement program to prevent pressure ulcers in patients with
a spinal cord injury. Japan Journal of Nursing
Science, 14(1), 76-86. doi:10.1111/jjns.12136 (RCT)
8. Markova, A. (2019). Pressure ulcer terminology. European
Pressure Ulcer Advisory Panel. Retrieved June 15, 2021, from
http://www.epuap.org/news/pressure-ulcer-terminology/ (GI)
9. McInnes, E., Jammali-Blasi, A., Bell-Syer, S. E., Dumville,
J. C., Middleton, V., & Cullum, N. (2015). Support surfaces for
pressure ulcer prevention. Cochrane Database of
Systematic Reviews, Issue 9. Art. No.: CD001735.
doi:10.1002/14651858.CD001735.pub5 (M)
10. National Institute for Health and Care Excellence (NICE).
(2015). Pressure ulcers. Retrieved June 25, 2021, from
https://www.nice.org.uk/guidance/qs89/resources/pressure-
ulcers-pdf-2098916972485 (G)
11. National Pressure Ulcer Advisory Panel. (2016, April 13).

27. National Pressure Ulcer Advisory Panel (NPUAP) announces a
change
in terminology from pressure ulcer to pressure injury and
updates the stages of pressure injury. Retrieved June 15, 2021,
from
http://www.npuap.org/national-pressure-ulcer-advisory-panel-
npuap-announces-a-change-in-terminology-from-pressure-ulcer-
to-pressure-injury-and-updates-the-stages-of-pressure-injury/
(G)
12. VanGilder, C., Lachenbruch, C., Algrim-Boyle, C., &
Meyer, S. (2017). The International Pressure Ulcer
Prevalence™ Survey: 2006-2015: A 10-year pressure injury
prevalence
and demographic trend analysis by care setting. Journal of
Wound, Ostomy, and Continence Nursing, 44(1), 20-28.
doi:10.1097/WON.0000000000000292 (R)
13. Walker, R.M., Gillespie, B.M., Mcinnes, E., Moore, Z.,
Eskes, A.M., Patton, D., & Chaboyer, W. (2020). Prevention
and treatment of pressure injuries: A meta-sythesis of
Cochrane Reviews. Journal of Tissue Viability, 29(4), 227-243.
doi:10.1016/j.jtv.2020.05.004 (M)
14. Welesko, M.-B., & Javier, N. M. (2018). Pressure injury. In
F. F. Ferri (Ed.), 2018 Ferri's clinical advisor: 5 books in 1 (pp.
1056-1058). Philadelphia, PA: Elsevier. (GI)
15. Zack, A. M. (2018). Pressure ulcer. In F. J. Domino (Ed.),
The 5-minute clinical consult 2018 (26th ed., pp. 808-809).
Philadelphia, PA: Wolters Kluwer. (GI)