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Pressure Injuries
Module 1
- Pressure injury definition
- Preventive interventions
- Interdisciplinary team
- Tracking and reporting Intended Audience: Interdisciplinary Team, Skin Champions, Administrators, Nurses, Nursing Assistants Approximate time for presentation and post test: : 15 minutes
Learning Objectives
After completing this learning session, the participant will be able to:
- Describe pressure injuries and how they occur
- List pressure injury prevention techniques
- Recall critical members of an interdisciplinary skin safety team
- Recognize pressure injury tracking measures reported by Minnesota Hospitals
Shear
(2)
- When combined with pressure results in
pressure injury
- The skin stays in one place while the body
slides in the opposite direction.
- Blood vessels stretch and angulate, blood flow
is disrupted leading to tissue deformation or
death
- Classic example: head of bed elevation > than
30 degrees
Graphic credit: Bryant Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 5th Edition. St. Louis, Mosby/Elsevier January 2016.
Examples of Pressure Injuries
(2) Stage 1 Pressure Injury Stage 2 Pressure Injury Stage 3 Pressure Injury Deep Tissue Pressure Injury (DTPI ) Mucosal Membrane Pressure Injury Stage 4 Pressure Injury Photo credit: Bryant Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 5th Edition. St. Louis, Mosby/Elsevier January 2016. Unstageable Pressure Injury
I nspect
(1-3)
- Inspect skin and evaluate risk for pressure injury on admission, at least daily and with change in condition
- Include head to toe, under and around all medical devices, between skin fold and buttocks, palpate back of head
- Ensure adequate lighting
- Thoroughly cleanse wounds for accurate assessment and staging
- Communicate findings with team to began a protocol based on skin inspection and risk factors
I
I nspect
Communicate findings with team to began a protocol based on skin inspection and risk factors Example of findings Interventions Excessive moisture or incontinence Initiate an incontinence protocol Apply a moisture barrier product Red, discolored, or open skin near a pressure point Position off open/red skin Evaluate for a high specification mattress Friction/shear Float heels off the bed Prevent sliding in bed or chair
- Keep head of bed <30 degrees unless medically contraindicated
- Slightly raise knee gatch
- Lifting/transfer aids
I
N utrition and Hydration
- Monitor nutrition and hydration
- Offer additional nourishment to help prevent and heal pressure injuries
- Talk with patients and families to determine dietary preferences
- Encourage high protein supplements and fluids if medically appropriate
- Ensure food is set up and accessible
- Facilitate optimal position for eating
N
J ust Move
- Encourage patients to move and to be physically active whenever possible
- Prevent sliding to minimize friction and shear (1-2) o Use positioning aides o Slightly raise the knee gatch on the bed o Float the heels off the bed o Limit head of bed < 30 degrees unless medically contraindicated
J
U U nder and Around Devices
Collaborate with critical team members! Device Critical Team Member Respiratory Respiratory Therapist Cervical Collars, Splints Orthotics Specialist Chairs Physical Therapy Fecal Containment Devices Dietician (nutritional adjustments for diarrhea) EEG Electrodes EEG technician ECMO Cannula ECMO perfusionist
R eposition (in bed)
- Optimal Repositioning (1-3) o Keep heels floating off the bed o Keep head of bed < 30 degrees o Turn 30 degrees side to side at least every 2 hours o Avoid back position (supine) whenever possible
- If optimal positioning can not be achieved or is medically contraindicated o Retrial every 8 hours, discuss barriers with provider and team (3) o Use high specification mattress (1-3) o Conduct at least hourly microshifts, offloads, or slow incremental tilts 10-15 degrees (1-3)
R
R eposition (patient refusal)
Patient Refusal (2-3)
- Discuss barriers to positioning with provider and care team
- Document informed refusal, reason for refusal, & patient/family education
- Frequently, re-evaluate, re-educate & trouble shoot barriers
- Keep trying! Escalate as needed
- Consider use of refusal to turn algorithm
R
Refusal to Turn Algorithm Image retrieved from: Minnesota Hospital Association (MHA) Pressure Injury Roadmap and Tool Kit (2017). Retrieved from: https://www.mnhospitals.org/pressure-ulcers#/videos/list
Y ou Are Important!
- We are all a team
- Patients, families, and caregivers are partners in pressure injury prevention
- Communicate reasons for:
- repositioning the patient every 2 hours o to prevent pressure injuries AND other complications (e.g. pneumonia, loss of strength and mobility, constipation, incontinence, urinary tract infection, contractures)
- looking at their skin daily and while positioning o to identify any early changes in skin condition
- offering additional nutrition o to promote healing and prevention
Y
Interdisciplinary Skin Safety Team
Patient and Caregiver Nurse Nursing Assistant Therapy (PT, OT, RT) Dietary MD Leader- ship WOCN Procedures OR, ED
Organizational Responsibilities
(1-3)
- Interdisciplinary team implements and maintains pressure injury prevention program
- Structured, tailored, multi-faceted approach to overcome barriers and enhance facilitators
- Skin champions for units and departments in the clinical setting
- Written expectations for roles in pressure injury prevention (e.g. interdisciplinary team, skin champions, nurses, NA, RTs, RD, etc.)
