Use of Alternating Pressure Mattresses to Preserve Skin Integrity in the ICU

By: Kelsey C. & Amanda R.

Case Exemplar

A patient was admitted to the CVICU following complications during surgery. He had bilateral chest tubes, continuous CR monitoring, CVL, a foley catheter, and was sedated. While admitted, he developed stage III and stage IV pressure ulcers even with repositioning every two hours.

Significance of Quality Issue

-"For the individual patient, the impact can be considerable, leading to physical, psychological and social issues in addition to the financial impact (Gorecki et al, 2009). Pressure ulcers on the heel can result in increased length of hospital stay and even the loss of the limb due to infection, and potential development of osteomyelitis (Burdette-Taylor and Kass, 2002). (Masterson & Younger, 2014)."

-One study found that the use of alternating pressure mattresses or overlay air mattresses in combination with a regular turning/repositioning schedule reduced the onset of pressure ulcers in patients on ventilators in the medical surgical ICU by 48.6%, when compared to patients only on a turning/repositioning schedule (Manzano, F., Perez, A., Colmenero, M., Aguilar, M., Sanchez-Cantalejo, E., Reche, A., & Fernandez-Mondejar, E., 2013).

-The use of the Braden Scale in combination with daily head to toe skin assessments upon admission and monitoring the effect of sedation on patient mobility decreased the occurrence of nosocomial pressure ulcers by 19% (Wolverton, C., Hobbs, L., Beeson, T., Benjamin, M., Campbell, K., Forbes, C., & White, S., 2005).


   Financial- In 2006, the average hospital charge per patient with a pressure ulcer was $48,000 (Brem. H, Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., Golinko, M., Yan, A., Lyder, C., Vladeck, B., 2010).

   Physical- Life threatening consequences such as sepsis and multi-system organ failure may occur as a result from pressure ulcers (Masterson & Younger, 2014).

Organizational Plan

-Complete head to toe skin assessment with 2 RNs upon admission.

-Individualized assessment to identify risk and specialty mattress requirements.

-Continuous monitoring of necessary sedation with adjustments to patient care based on mobility.

-Implementation of Braden score assessment upon admission and every shift.

(Woverton, C., Hobbs, L., Beeson, T., Benjamin, M., Campbell, K., Forbes, C., & White, S., 2005).

SWOT Analysis


-Updated education and knowledge of nursing staff

-Individualized patient-centered care

-Open communication & collaboration within the interdisciplinary team.

-Good patient advocacy


-Inadequate nursing staff to meet patient needs

-Decreased budget allowance

-Staff burnout

-Patient inability to participate in care


-Prompt initial assessment

-Individualized risk reduction strategy

-Education improvement

-Opportunity for staffing involvement in quality improvement committees


-Employee rejection of new strategies

-Available resources

-Adequate funding for staff education

QSEN Competencies

Evidence Based Practice- A combination of a routine turning schedule and use of alternating pressure mattress or mattress overlay led to greater improvement in patient outcomes regarding pressure ulcer formation (Manzano, F. et al, 2013).

Teamwork & Collaboration- Collaboration among all health care disciplines leads to success and planning strategies to prevent, treat, or heal pressure ulcers (Baranoski, 2002).

Nursing Implications


An RN education program was used to address key areas of guideline methods, epidemiology of pressure ulcers, etiology, pathophysiology, risk factor assessment, ulcer staging, preventative equipment and documentation.  The education increased the accurate identification of pressure ulcer risk resulting in improved prevention strategies.  

(Tweed, C., Tweed, M., 2008)


Overwhelming evidence supports the combined use of regular turning and repositioning schedules in conjunction with alternating pressure mattresses or overlay air mattresses has significantly reduced the onset of pressure ulcers in the ICU.

(Manzano, et al., 2013)

Collaboration and consistency among interdisciplinary health care professionals has been shown to improve wound healing in the hospitalized patient by up to 65%.

(Baranoski, S., 2002)


Implementation of admission assessments and Braden score in conjunction with individualized risk assessment to determine patient need and application of specialty mattresses to mobility impaired ICU patients.

(Wolverton & Hobbs, 2005)

Literature Review

Using Alternating Pressure Mattress to Offload Heels in ICU-

This article talks about the anatomy & physiology of the heel specifically and what the different overall risk factors for developing a pressure ulcer are, especially for patients who are critically ill. It evaluates the Nimbus 4 alternating pressure mattress and its effectiveness in preventing heel ulcers. None of the patients who used this bed developed pressure ulcers.

The Pegasus Overture Alternating-Pressure Mattress Overlay-

This article discusses the Pegasus Overture which is an overlay that is put over the existing mattress and how it is successful in preventing pressure ulcers in patients who are deemed to be at medium risk. It also discusses how the mattress is acceptable to patients in terms of comfort, and how nurses say it is easy to use.

High Cost of Stage IV Pressure Ulcers-

This journal discusses the the research study that was conducted in order to calculate and analyze the average cost of stage IV pressure ulcers. This includes the cost of nursing care, dressing changes, medications, malpractice lawsuits, debridement & surgical procedures, office visits, etc. It also mentions what other co-morbidities are associated with pressure ulcers.

Proficare (R): An Alternating Pressure Relieving Mattress-

This article discusses specifically how the Proficare (R) mattress works, and how it can be used for pressure ulcer prevention and treatment. It discusses the research conducted on the mattress and how patients who had established pressure ulcers evaluated the mattress. Before and after pictures and assessments were done, and all of the patients' ulcers demonstrated healing, one even closed completely within the 8 week period.

SMART Criteria

By June 1, 2015, implementation of nursing staff educational seminars on Braden Scale and individual risk factors assessments to identify patient need for specialty mattresses and overlays to prevent pressure ulcer development will take place.  Nursing staff will demonstrate competencies in accurate assessment and implementation of the plan to provide specialty mattresses and overlays to patients according to individual need assessment.  By December 1, 2015 all critical and intensive care nursing staff will apply knowledge from the seminar to identify need for specialty mattresses and utilize the mattresses in combination with frequent repositioning to decrease incidence of pressure ulcers in the ICU.  


Baranoski, S. (2002). Collaborative roles lead to success in wound healing. PubMed, 5(3), 66-68.

Brem, H., Maggi, J., Nierman, D., Rolnitzky, L., Bell, D., Rennert, R., . . . Vladeck, B. (2010). High Cost Of Stage IV Pressure Ulcers. The American Journal of Surgery, 473-477.

Collins, F. (2003). ProfiCare(R): An alternating pressure-relieving mattress. British Journal of Nursing, 12(19), 1156-1161. Retrieved from

Fox, C. (1997). Product focus. The Pegasus Overture alternating-pressure mattress overlay. British Journal Of Nursing, 6(18), 1065-1066.

Manzano, F., Pérez, A., Colmenero, M., Aguilar, M., Sánchez-Cantalejo, E., Reche, A., & ... Fernández-Mondejar, E. (2013). Comparison of alternating pressure mattresses and overlays for prevention of pressure ulcers in ventilated intensive care patients: a quasi-experimental study. Journal of Advanced Nursing, 69(9), 2099-2106.

Masterson, S., & Younger, C. (2014). Using an Alternating Pressure Mattress to Offload Heels in ICU. Retrieved April 10, 2015, from Ebsco Host.

Tweed, C., & Tweed, M. (2008). Intensive care nurses' knowledge of pressure ulcers: development of an assessment tool and effect of an educational program. American Journal of Critical Care, 17(4), 338-347.

Wolverton, C., Hobbs, L., Beeson, T., Benjamin, M., Campbell, K., Forbes, C., & ... White, S. (2005). Nosocomial pressure ulcer rates in critical care: performance improvement project. Journal of Nursing Care Quality, 20(1), 56-62.

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