The document discusses a quality improvement project to reduce atypical pressure ulcers in hospitals. It defines atypical pressure ulcers and describes their causes in different areas of the body compared to common pressure ulcers. A literature review found that careful skin assessments, risk factor identification, and pressure ulcer prevention systems can decrease hospital-acquired ulcers. A staff survey revealed a need for training on prevention systems and atypical ulcer types. Recommendations include additional training, awareness posters, and continued repositioning with prevention therapies.

1. Preventative Measures For
Atypical Pressure Ulcers
Taylor Gray, Halie Gribble, Dani Huss,
Elise Beshlian, Courtney McColley,
Katie Greenlaw, Carolyn Beahr,
University of Nebraska Medical Center: College of Nursing

2. Purpose
• The purpose of our quality improvement project is to increase
awareness of preventative measures to reduce the incidence
of atypical pressure ulcers.
▫ NDNQI data indicates a need to decrease the amount of
hospital acquired pressure ulcers.

3. Definitions
Atypical pressure ulcers are distinguished from common pressure ulcers
with both unusual location and different causes. The causes differs and is
not the usual compression of bony prominence and hard surface while lying
or sitting (Jaul, 2014).
Pressure Ulcer, as defined by the National Pressure Ulcer Advisory Panel
(NPUAP), is a “localized injury to the skin and/or underlying tissue over a
bony prominence, as a result of pressure in combination with shear and/or
friction.” (Peterson, 2013)

4. Research Strategies
• Survey monkey
• NDNQI Pressure Ulcer Report
• Joint Commission
• Faith Regional Statistics
▫ Past protocols
▫ New protocols
▫ Incidence rate of pressure
ulcers
• Databases
▫ EBSCO
▫ PUBMED
▫ COCHRANE
▫ CINAHL
• Search terms
▫ Pressure ulcers
▫ Atypical pressure ulcers
▫ Prevention
▫ Hospital setting
▫ Repositioning
▫ Awareness
▫ Ventilator

5. Literature Synopsis
According to the cohort study by Jaul, atypical wounds were divided into three categories according
to causes: medical devices, severe spasticity, and bony deformities.
Medical Devices - nape of the neck, posterior scalp, & on the chin
Severe Spasticity - medial surface of the knee and elbow, & on the ventral surface of the palm
Bony Deformities - shoulder blades, upper thoracic spine, ears, & the penis
“The prominent role of the multidisciplinary team is primary in identification, prevention and treatment”
(Jaul, 2014).
“Hospital-acquired pressure ulcers are a critical issue for hospitals and patients, given their negative
impact on patient morbidity and mortality” (Padula, 2015).

6. Methods
• Data was collected via an anonymous online survey (Survey Monkey).
▫ Survey questions based in current awareness, implementation,
and utilization of pressure ulcer screening and prevention
methods.
▫ Survey sent to all Medical/Surgical-Orthopedic nurses.
▫ Survey was open from February 16 through March 1, 2015.
• Sample size: 20 Registered Nurses and Certified Nurses Aides
▫ Chosen based on increase of hospital acquired pressure ulcers.

7. Survey Questions
1. How often do you use preventive measures for pressure ulcers?
a. Always
b. Sometimes
c. Never
2. How often do you use the Waffle Heel Elevator System?
a. Always
b. Sometimes
c. Never
3. Do you use the EHOB Waffle Mattress?
a. Yes
b. No
c. Unsure
4. How aware are you of the different types of pressure ulcers i.e.
on the elbow, head, scrotum, face and ears?
a. Very aware
b. Somewhat aware
c. Unaware
5. Have you been trained on the use of EHOB pressure ulcer
prevention systems?
a. Yes
b. No
c. Unsure
6. How aware are you of the facility’s current protocol for
pressure ulcers
a. Yes
b. No
c. Unsure
7. What measures do you usually use on your shift?
8. DO you feel the current measures are effective in
preventing hospital-acquired pressure ulcers?
a. Yes
b. No
c. Suggestions

8. Question 1

9. Question 2

10. Question 3

11. Question 4

12. Question 5

13. Question 6

14. Question 7

15. Question 7 Comments
• “Turn every 2 hrs, make sure no boney prominences are in one spot, pillows under heals, arms,
or hips”
• “Repositioning every two hours, off-loading heels, elevating extremities on pillows”
• “Pillows under all bony prominences if patient is unable to move on their own. Air mattresses if
available. Wash clothes under scrotum if needed. Repositioning every 2 hours.”
• “We are just starting to use the waffle boots and EHOB mattresses, they have been ordered but
not in yet. We also use mepilex, pillows, repositioning, etc”
• “Repo patients Q2, using pillows, rolled up towels, or gel pillows”

16. Question 8

17. Conclusion
• Based on our research and data analysis, we have concluded that the best
tool for prevention of hospital acquired pressure ulcers is the nurse's
critical thinking skills. Critical thinking should be used along with current
prevention methods such as, the Braden Risk scale and EHOB pressure
ulcer prevention systems. With proper practice of detailed skin
assessments, acknowledgement of risk factors, and the use of pressure
ulcer prevention systems, hospital acquired pressure ulcers should
decrease and awareness of atypical pressure ulcers should increase.

18. Recommendations
• After reviewing the literature and our results, we found the need for:
▫ Formal training on EHOB pressure ulcer prevention systems, including
where to find them.
▫ Training on factors that increase risk for pressure ulcers (Gonzales, Pickett,
2011).
▫ Inservice on types of atypical pressure ulcers.
▫ Clarity on what is expected in prevention of atypical pressure ulcers.
▫ Providing informational posters in each patient room to raise awareness
of how to assess and prevent pressure ulcers (Padula, Makic, Mishra, Campbell,
Nair, Wald, & Valuck, 2015).
▫ Continue to turn patients every two hours, combined with additional
therapies (Peterson et. al, 2013).

19. References
Behrendt, R., Ghaznavi, A. M., Mahan, M., Craft, S., & Siddiqui, A. (2014). Continuous bedside pressure mapping and
rates of hospital-associated pressure ulcers in a medical intensive care unit. American Journal
of Critical Care, 2014(23). doi: 10.4037/ajcc2014192
Gillespie, B. M., Chaboyer, W. P., McInnes, E., Kent, B., Whitty, J. A., & Thalib, L. (2014, April 3). Repositioning for
pressure ulcer prevention in adults. Retrieved February 16, 2016, from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009958.pub2/abstract
Gonzales, D., Pickett, R. (2011) Too much pressure. Stanford Nurse, 12-13.
Heywood, N. (2015) A quality improvement programme to reduce pressure ulcers. Art & Science Tissue Variability
Supplement, 29 (46), 62-70.
Jaul, E. (2014). Cohort study of atypical pressure ulcers development. International Wound Journal, 11(6), 696-700.
doi:10.1111/iwj.12033

20. References Continued
Moore, Z. E. (2014). Risk assessment tools for the prevention of pressure ulcers. Retrieved February 16, 2016, from
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006471.pub3/abstract
Padula, W. V., Makic, M. F., Mishra, M. K., Campbell, J. D., Nair, K. V., Wald, H. L., & Valuck, R. J. (2015). Comparative
effectiveness of quality improvement interventions for pressure ulcer prevention in academic medical centers
in the United States. Joint Commission Journal On Quality And Patient Safety / Joint Commission Resources, 41(6),
246-256.
Peterson, M. J., Gravenstein, N., Schwab, W. K., van Oostrom, J. H., & Caruso, L. J. (2013). Patient repositioning and
pressure ulcer risk Monitoring interface pressures of at-risk patients. Journal of Rehabilitation
Research & Development, 2013(50). doi:10.1682/JRRD.2012.03.0040
Raipaul, K., & Acton, C. (2015). The use of smart technology to deliver efficient and effective pressure-damage education.
British Journal Of Nursing (Mark Allen Publishing), 24 Supply 20S4-S12. doi: 10.12968/bjon.2015.24.Sup20.S4
Visscher, M. O., White, C. C., Jones, J. M., Cahill, T., Jones, D. C., & Pan, B. S. (2015). Face masks for noninvasive
ventilation: Fit, excess skin hydration, and pressure ulcers. Respiratory Care, 2015(60). doi: 10.4187/respcare.04036