PREVENTION & TREATMENT

Preventing pressure injuries: 6 best practices to improve patient outcomes

Advice from a wound care expert to help guard against skin breakdown.

By Dot Weir, RN, CWON, CWS

Pressure injuries can be worrisome for patients, families and healthcare providers. Patients with pressure injuries often must deal with pain. The pain may be both generalized as well as related to dressing changes, loss of appetite and sleep, and other impacts on their quality of life such as  restrictions related to positioning and their ability to socialize.

Families and other caregivers are concerned about how to keep their loved ones comfortable. Providers and institutions worry about quality of care and risk management, as well as the very real financial and legal implications of a facility-acquired pressure injury.

To help prevent PIs—and ease concerns on all fronts—follow these six evidence-based best practices.

1 | Perform comprehensive skin assessments

Conduct the first detailed and routine skin assessment as soon as possible after a patient is admitted to your care. Be sure to visually assess bony prominences, such as:

  • Sacrum
  • Coccyx
  • Buttocks
  • Heels/feet
  • Ischium (especially for chair-bound individuals)
  • Trochanters
  • Elbows
  • Spine

To determine skin changes in all patients, regardless of age or ethnicity, use adequate lighting and compare the temperature of skin on bony prominences to surrounding tissue. Also check beneath medical devices to help prevent medical device-related pressure injuries. Continue to monitor all these areas closely, especially when non-blanchable redness is noted. If blanchable redness is noted, continue to reassess that area until it is resolved.

Two things to remember:

  • Account for risk factors such as fragile skin, history of pressure injuries or existing pressure injuries, which can all increase a patient’s risk for further skin damage.
  • Document everything. This includes documenting interventions such as turning and repositioning, as well as support surfaces, skin care and preventive measures. In addition, document any non-modifiable factors such as use of medications that may impact perfusion, changes in oxygen levels or hemodynamic changes related to position.

2 | Keep skin healthy with an appropriate skin care routine

Studies show that a structured skin hygiene practice can help prevent pressure injuries.1 Many residents in post-acute care facilities such as skilled nursing facilities may be incontinent and therefore more vulnerable to moisture-associated skin damage. While the MASD is not considered a pressure injury, it can increase the risk of pressure injuries.

To shield high-risk skin from breakdown, promptly cleanse the area after every incontinent episode, moisturize and apply a barrier product. Using pH-balanced skin care has been shown to provide better protection.

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3 | Provide proper support

Regardless of the site of care, consideration must be given to the type of support surface the patient will require. That’s why it’s important to use a support surface that fits a patient’s condition and need for microclimate control and comfort. The effective use of pressure-redistribution components in mattresses, such as air, gel or foam can help prevent tissue deformation and improve tissue perfusion.

An assessment of where the patient spends the majority of their time (for example, a bed or chair) is also important. You can request an assessment of your mattresses to guide the right choices for your patient population.

4 | Set up a schedule for turning and repositioning

All individuals at risk for pressure injury should be turned and repositioned regularly. In the past, the rule of thumb was every two hours. But now, National Pressure Injury Advisory Panel guidelines state that this practice should be tailored to the patient’s medical condition, needs and preferences, as well as existing areas of breakdown and their support surface.2

More tips on turning and repositioning:

  • Use a 30-degree lateral turning position to keep patients off of the sacrum and trochanter.
  • Place a wedge or pillow between the knees in a side-lying position to further protect the area.
  • Offload the heels either using pillows (for prevention, or Stage 1 or 2 pressure injuries) or with appropriate heel offloading devices.
  • Consider silicone foam dressings on patients at high risk for pressure injuries to protect bony prominences.
  • Use products that make it safe and easy to turn and reposition patients.
  • Assist in repositioning individuals in bedside chairs or wheelchairs hourly.
  • Add padding and protection for surgical patients, especially for surgeries expected to last more than four hours.
  • Individuals who cannot turn themselves should be repositioned at appropriate intervals established for that patient, regardless of the surface.
  • Consider non-skin-related factors, such as respiratory, gastrointestinal and genitourinary functions when establishing a turning schedule.
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5 | Make nutrition part of pressure injury prevention

Individuals who are at risk for pressure injuries tend to also be at risk for both undernutrition and malnutrition. Research shows that malnutrition and weight loss can increase the risk of pressure injuries and delayed wound healing.3 That’s why nutrition is a key area of assessment for elderly patients and those whose illnesses cause reduced food intake over time.

Encourage those at risk for pressure injuries to consume adequate fluids and a balanced diet, and assess weight changes over time. Nutritional supplements between meals and oral medications may be recommended. Consult with a nutritionist to help inform your decisions for patients who are at high risk for malnutrition.

6 | Educate patients and families about pressure injuries

Discuss your prevention goals with patients, families and caregivers. When you include patients in their own care, it helps them adhere to care and treatment plans. When you educate families and caregivers, they can help play a role in achieving prevention goals, whether at home or in the healthcare setting.

Remember that pressure injury prevention is a multidisciplinary practice. Educating nursing staff within each care unit helps empower them to do the right thing to help prevent skin damage for vulnerable patients.

Dot Weir, RN, CWON, CWS, is on the Clinical Staff at Saratoga Hospital Center for Wound Healing and Hyperbaric Medicine, Saratoga Springs, NY, and a Medline consultant.

Key takeaway

From the beds patients lie on to their routine skin care to nutrition and even education, preventing pressure injuries takes a holistic approach. When you look at all aspects of a patient’s needs, you can start to reduce the risk—and the worry—for skin breakdown. It’s important to continually assess the skin and modify the care plan to meet each individual’s changing condition.

Learn more about how to improve skin health and prevent breakdown:
Is your PPE putting your skin at risk? Here’s how to help prevent pressure injuries and keep skin safe
Watch the webinar: Building a pressure injury prevention program that works
Perioperative pressure injuries: tips to help reduce the risk and create a culture of skin health

References:

  1. NPIAP Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, pages 84-85
  2. NPIAP Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline, 2019, page 115
  3. Dorner, B., Posthauer, M. E., & Thomas, D. (2009). The Role of Nutrition in Pressure Ulcer Prevention and Treatment. Advances in Skin & Wound Care, 22(5), 212–221. Available at https://doi.org/10.1097/01.asw.0000350838.11854.0a
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