Pressure Injury Prevention: General Principles
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
Okay, so in the last class, we talked about general guidelines for putting together an agency wide program for pressure injury prevention.
Speaker A:In this class, we're going to talk about a pressure injury prevention bundle to be used for an individual patient.
Speaker A:We will not talk in detail about support surfaces during this class.
Speaker A:We will cover that in the next class.
Speaker A:So here are your key elements of prevention.
Speaker A:This should be initiated for any at risk patient.
Speaker A:It should be initiated promptly at the time the patient's identified as being at risk.
Speaker A:It should be staff nurse driven.
Speaker A:It's what you already know.
Speaker A:So it should incorporate pressure redistribution devices for the bed and the chair.
Speaker A:It should incorporate routine repositioning, usually Q2 to 4 hours, measures to reduce shear and friction, moisture management approaches and products, padding and repositioning for medical devices, nutritional assessment and management and routine skincare and assessment.
Speaker A:So we'll talk about each of those in a little more detail.
Speaker A:Although I think you know most of this already.
Speaker A:So support surfaces, actually, that is a critical element in your prevention protocol.
Speaker A:So we're going to talk about support surfaces for the bed in detail in the next class.
Speaker A:But what about chair cushions?
Speaker A:When you think about it, any patient who needs a support surface for the bed needs a chair cushion when they're out of bed.
Speaker A:Any patient at risk needs a chair cushion when they're out of bed.
Speaker A:Absolutely critical to prevent ischial pressure injuries.
Speaker A:So at one time we found that we had great surfaces for our beds.
Speaker A:Our staff was very tuned into repositioning.
Speaker A:They were also very aware of the importance of early mobility.
Speaker A:And they were committed, everyone, nurses and physical therapists and occupational therapists committed to getting patients up as quickly as possible and keeping them out of bed as long as possible.
Speaker A:But then here's what happened.
Speaker A:They forgot to get chair cushions.
Speaker A:And so they were getting patients up in the chair.
Speaker A:And then because of their focus on early mobility, the patient was staying up in the chair for four to six hours and they were developing ischial wounds.
Speaker A:So we were eliminating sacrococcygeal wounds.
Speaker A:We were eliminating heel wounds, but now we have ischial wounds.
Speaker A:So critically important.
Speaker A:Go back, reeducate.
Speaker A:You're doing a great job.
Speaker A:While the patient's in the bed.
Speaker A:Here's what we need to modify.
Speaker A:When the patient's up in the chair, they've got to be on a pressure redistribution chair cushion.
Speaker A:They should not be up in the chair more than two hours unless they can be repositioned while they're up in the chair.
Speaker A:What about donuts?
Speaker A:I still have family members Asking me about donuts, because it looks like when you put a patient on a donut shaped device, it looks like you've done just what you should.
Speaker A:It looks like you have offloaded the ischial areas.
Speaker A:But what happens is you create circumferential interference to arterial inflow and venous drainage.
Speaker A:You actually create tissue congestion, tissue ischemia, and you increase the risk of issue breakdown.
Speaker A:So no donuts.
Speaker A:I have a friend who did this whole agency wide education program.
Speaker A:He made little flyers in Dunkin Donuts, colors brown and pink.
Speaker A:And basically his message was, donuts are for coffee, not for pressure injury preventions.
Speaker A:So no donuts.
Speaker A:They should be out of your formulary so no one can get them.
Speaker A:When your patient's in the chair, the best position is reclining with the legs elevated, because that all flows the sacrococcygeal area and the ischial area to some extent.
Speaker A:And most of the time we have the ability to do that turning and repositioning.
Speaker A:This is probably the most critical element of a prevention program.
Speaker A:To me, it's the hardest because it requires so much consistency.
Speaker A:So it has to be every patient, every shift.
Speaker A:Now in our setting, and when I talk to people across the country, I find this is very common.
Speaker A:Our highest incidence of hospital acquired pressure injuries is in our intensive care patient population.
Speaker A:In the literature, those are the highest risk patients.
Speaker A:And when you talk to ICU patients, they're aware that they need to reposition their patients, but it seems so much less important many times than everything else they're doing.
Speaker A:They've got all of these drips to maintain.
Speaker A:They're worried about cardiac function.
Speaker A:They have patients on crrt, maybe they're patients on ecmo.
Speaker A:All of these things going on and positioning, repositioning just doesn't seem so critically important.
Speaker A:So our current message to the staff is repositioning is critically important for preservation of skin integrity.
Speaker A:But that's only one reason to reposition the patient.
Speaker A:Repositioning is not just for preservation of skin integrity.
Speaker A:Repositioning affects vascular function, affects pulmonary function, affects renal function, and is an absolutely critical first step in all of our early mobility programs.
Speaker A:And early mobility has been shown to be essential to getting patients off the ventilator, out of the unit, out of the hospital, and back on their feet.
Speaker A:So you want to convey to your staff, yes, repositioning matters for the skin, but not just the skin.
Speaker A:How often?
Speaker A:Every two to four hours.
Speaker A:Now, most of us were taught every two hours.
Speaker A:We actually have research that shows that with the new pressure redistribution Surfaces that we use in every agency that patients can be turned less frequently, so they can be turned every four to six hours without causing problems with skin integrity.
Speaker A:Most agencies are maintaining their turning frequency at every two to four hours for all the reasons I just mentioned to promote vascular function, pulmonary function, renal function.
Speaker A:If you have a patient who's heavy and very difficult to turn, you want to use your lift systems.
Speaker A:Another strategy that's been found effective in many settings is to create turn teams so that two people are assigned to turn these patients at this interval.
Speaker A:So you have a turning partner, because, you know that's one of the hardest things.
Speaker A:If you're the staff nurse responsible for this patient, it's time to turn them.
Speaker A:You can't do it yourself, and it's very hard to find someone.
Speaker A:So turning teams can be very, very beneficial in making sure that repositioning is done on a routine basis.
Speaker A:If you have a patient who already has breakdown, let's say they have sacrococcygeal breakdown, you want to try to protect that area.
Speaker A:You want to try to turn them side to side and keep them off the sacrococcygel area as much as possible.
Speaker A:But what if I have a patient who has right trochanteric breakdown and left trochanteric breakdown?
Speaker A:I can't just leave them on their back.
Speaker A:So I'm going to end up doing right, left back, right, left back, right, left back.
Speaker A:And I'm going to make sure that they're on a very effective air support surface to minimize the interface pressure against those areas of breakdown.
Speaker A:You know the guidelines for both sideline positioning and supine positioning.
Speaker A:So in the sideline position is basically a 20 to 30 degree tilt from supine.
Speaker A:No more than 30 degrees.
Speaker A:Okay, so 20 to 30 degree tilt from supaine, just get them off the sacrococcygeal area.
Speaker A:You want to pad bony prominences, make sure their knees are not rubbing together.
Speaker A:Supine position, a very challenging position because the vast majority of our patients require head of bed elevation.
Speaker A:When you elevate the head of the bed, there's a marked increase in pressure shear forces over the sacrococcygeal area.
Speaker A:So head of bed elevation is a major risk factor for sacral and coccygeal pressure injury development.
Speaker A:But many of our patients absolutely require head of bed elevation for pulmonary issues, for cardiac issues, or because they're on tube feedings and we're trying to prevent aspiration.
Speaker A:So here's what you want to do.
Speaker A:You want to keep the head of the bed as low as possible, taking into consideration all other conditions, therapies, et cetera.
Speaker A:When the head of the bed is elevated, you want to gatch the knees so that you get less sliding and you kind of offset that pressure over the sacrococcygeal area.
Speaker A:And when they're in the supine position, you've got to focus on keeping the heels off the bed.
Speaker A:Now, we've mentioned this a little bit, but we now have more data on management of hemodynamically unstable patients when it comes to turning and positioning.
Speaker A:So in the past, our approach was frequently, we can't turn that patient because they're too unstable, Their blood pressure drops, their O2 sats drop, they develop arrhythmias, whatever.
Speaker A:So fortunately, at the Virginia Commonwealth University, they put together a very knowledgeable team for a consensus conference on turning and repositioning of hemodynamically unstable patients and actually looked at what are the current contraindications to repositioning patients.
Speaker A:So they pulled in orthopedics, they pulled in neuro, they pulled in cardiovascular, they pulled in pulmonary.
Speaker A:Things we have to think about.
Speaker A:First of all, repositioning is critically important to these patients because the longer I leave you in one position, the less tolerant you become of any repositioning.
Speaker A:So there's many things that work together in the cardiovascular system to allow us to accommodate to changes in position.
Speaker A:But if we do not change the patient's position, then those functions are lost.
Speaker A:So the longer you lie in one position, the more unstable you become.
Speaker A:So goal number one is to always reposition every patient to the extent of their tolerance.
Speaker A:Secondly, tolerance to repositioning is now defined as hemodynamic parameters return to baseline within 10 minutes.
Speaker A:So when I turn you, if your O2 sats drop, but they come back up within 10 minutes, you are considered to have tolerated that term.
Speaker A:If your blood pressure drops but rebounds within 10 minutes.
Speaker A:So that's the window.
Speaker A:That's the definition of tolerance.
Speaker A:We've also learned that people can tolerate slow and limited approaches to turning, which is frequently not what we've been taught to do.
Speaker A:So what was I taught to do is basically 1, 2, 3, flip.
Speaker A:They're not going to tolerate that.
Speaker A:But can I very gradually turn them and place a wedge and then come back in an hour and turn a little bit more and re wedge?
Speaker A:Many patients can tolerate that, and it starts them down the path on progressive mobility.
Speaker A:The other thing we should be thinking about, for critically ill patients who are hemodynamically unstable, who are on ecmo, et cetera is the potential benefits of continuous lateral rotation therapy.
Speaker A:So those are surface sets that constantly and gradually change patient position.
Speaker A:So instead of a sudden turn, it's very gradual.
Speaker A:And in some of the early mobility programs that are being evaluated, that's a key component of an early mobility program.
Speaker A:So if you have access to continuous lateral rotation therapy surfaces in your agency, you want to be using them for these patients.
Speaker A:Okay, we keep coming back to if you need a support surface on the bed, you also need a support surface in the chair.
Speaker A:So foam, air or gel can be used effectively in the chair.
Speaker A:We've talked about limiting time up to one to two hours or assist the patient to reposition within the chair.
Speaker A:Also, we should be particularly cautious if we have patients with what I call sitting surface ulcers.
Speaker A:So these are patients with sacrococcygeal or ischial ulcers.
Speaker A:They should definitely have limited time up in the chair, no more than one to two hours.
Speaker A:They definitely have to have an effective chair cushion.
Speaker A:And ideally we position them reclining with legs up to help offload sacrococcygeal and ischial areas.
Speaker A:Heels deserve special attention and special mention.
Speaker A:So the current guidelines, if you look at the NPIEP guidelines, if you look at WCN guidelines, are heels off the bed at all times, even if the patient's on an air mattress.
Speaker A:Why?
Speaker A:Look at the top right where you see the diagram of the heel.
Speaker A:Notice how large the calcaneus is.
Speaker A:That heel bone is a big bone.
Speaker A:Palpate the tissue over your heel.
Speaker A:How much soft tissue do you have over that great big bone?
Speaker A:Practically none.
Speaker A:So even the highest level support surface doesn't adequately protect the heel.
Speaker A:What protects the heel is keeping it off the bed.
Speaker A:Like we've said, we don't want our patient to survive some kind of catastrophic health event only to have an unstageable or a stage 4 heel pressure injury that may progress to osteomyelitis, might require long term antibiotics, surgery, even amputation.
Speaker A:So everyone needs heel protection.
Speaker A:You have two options.
Speaker A:You can put them in an offloading boot, or you can put their lower legs over pillows and float the heels.
Speaker A:The issue is keep the heels off the underlying bed.
Speaker A:We've talked about the fact that boots are usually better because people tend to kick off pillows.
Speaker A:Sometimes pillows become very flat, so the heel is still on the underlying mattress.
Speaker A:It really doesn't matter how you float the heels.
Speaker A:I shouldn't say that it does matter how you float them because you don't want to create other problems.
Speaker A:But when you're looking at heel protection, the critical concern is the heel is not resting on the underlying surface.
Speaker A:Educating your patients is critical.
Speaker A:So I've heard staff say, you know, you walk in the room and where are the heel boots?
Speaker A:In the window.
Speaker A:Right.
Speaker A:They're not wearing their heel boots.
Speaker A:They don't like them, they don't want them.
Speaker A:They told me to take them off.
Speaker A:Well, not surprised that they don't like them, that they don't want them, because sometimes they're heavy, sometimes they make patients feel a little bit claustrophobic.
Speaker A:But think how many things patients don't like that we have to do.
Speaker A:So they don't like their nasogastric tube, but we don't take it out.
Speaker A:Right.
Speaker A:So we have to explain the critical importance of protecting their heels, why we have them in those boots, and what their options are for protecting the heels.
Speaker A:What about your silicone adhesive foam dressings?
Speaker A:Are they going to provide the same level of protection as getting the heel off the bed?
Speaker A:No, but we have some limited data that they can be helpful for patients who may be using pillows for protection, but who may kick off the pillow.
Speaker A:At least that silicone adhesive foam dressing gives you a little bit of additional protection.
Speaker A:We've briefly talked about measures to reduce shear.
Speaker A:So remember, shear occurs when patients slide down, and specifically where they're on a surface, where the skin sticks to the surface, the deep layers move down in response to gravity and soft tissues shear.
Speaker A:Shearing causes disruption or angulation of the blood vessels running through the soft tissues.
Speaker A:So you have two choices in reducing shear.
Speaker A:You can either keep me from sliding.
Speaker A:Good luck with that.
Speaker A:Or you can allow me to slide, but you can stop the drag.
Speaker A:In other words, you can markedly reduce friction so that when I slide down, all tissue layers slide together so that you're not getting this phenomenon.
Speaker A:What are the specific strategies we can use?
Speaker A:We're going to limit head of bed elevation to the extent possible.
Speaker A:And when the head of the bed is elevated, we're going to gatch the knees like you see on the top.
Speaker A:When we have the patient in the chair, we're either going to position them in a reclining position with the legs elevated.
Speaker A:That's ideal.
Speaker A:Or if they're sitting straight up, we're going to be sure their feet are on the floor so that they it minimizes the risk of them sliding down and out.
Speaker A:We're going to use lift sheets for repositioning so that we're not dragging and shearing the tissues when we're repositioning patients.
Speaker A:One of the most beneficial things we have.
Speaker A:And again, you look at the surface on top is low friction mattress covers and linens.
Speaker A:So on the one hand, it's frustrating to staff that patients are always sliding down and the beds always look so messy.
Speaker A:But it's very protective of the skin and the soft tissues.
Speaker A:So the reason you see the little kid on the sliding board, remember when you were a kid and you went down the sliding board and if your skin was cool and dry, you just went flying down the sliding board and it was so much fun.
Speaker A:But if your skin was hot and wet, it was summertime, you were sweating, everything was sticky, and you were kind of like down the sliding board.
Speaker A:So we want to make any movement down in bed friction free.
Speaker A:We want them to slide without drag.
Speaker A:That's what those slit covers do for our patients.
Speaker A:So, yes, the linens look messy, yes, the patients look messy, but their skin is in much better shape.
Speaker A:And of course, the soft silicone multilayered foam dressings used over the sacrum, the heels, the elbow, have been shown in multiple studies now to help reduce the incidence of hospital acquired pressure injuries.
Speaker A:So let's talk a little bit more about those.
Speaker A:I'm betting a lot of you are using these as part of your pressure injury prevention protocol.
Speaker A:You want to make sure that staff is using them correctly.
Speaker A:So one of the things we found in our agency, and I've talked to many people, and they're like, yes, this is a common issue in our agency as well, is that staff would put down moisture barriers because the patient was incontinent, and then try to put the adhesive foam on top of the moisture barrier ointment.
Speaker A:And of course, it wouldn't stick.
Speaker A:So then they compensated by moving the foam dressing up so that it was over the thoracolumbar area instead of the sacrococcygeal area.
Speaker A:For a while I wondered if the sacrum had moved anatomically, but turns out, no, it hasn't.
Speaker A:So here are the things you want to teach your staff.
Speaker A:You always apply these to clean dry skin.
Speaker A:So if you're using these protective dressings and you're also using a moisture barrier, put this down first and then apply your moisture barrier to the perineal area.
Speaker A:Make sure you are covering the appropriate area, the sacrococcygel area.
Speaker A:Tell your staff it's okay if they're going to get a better fit and better coverage by rotating the dressing, putting it on upside down, that's fine.
Speaker A:And remember, this is Part of your prevention protocol, you need to know what's happening underneath that dressing.
Speaker A:So every day or every shift, they should peel the dressing down, check the bony prominence and replace it.
Speaker A:Nutrition matters tremendously.
Speaker A:What we know is that our cachetic patients are very high risk and they're also very slow to heal.
Speaker A:So you may already have this built in, but if not, you want to make sure that your dietary nutritional support team gets consulted for any patient with breakdown, but also any at risk patient with nutritional compromise.
Speaker A:So if you have an at risk patient who's been losing weight unintentionally, if you have an at risk patient who's very thin, if you have an at risk patient with what looks like to be a prolonged period of time with limited oral intake, your nutritional or dietary team needs to be involved.
Speaker A:We should be monitoring weight, we should be looking at intake, and we should be actively educating and encouraging our patients to eat as much as they can, to focus on foods that provide protein and calories to maintain their weight and their ability to repair tissue damage.
Speaker A:You want to encourage them to drink their nutritional supplements instead of stacking them up on their bedside table.
Speaker A:Moisture management, another critical element.
Speaker A:So we have to think both about diaphoresis, which is internally produce moisture, and incontinence, which is externally produced moisture.
Speaker A:So with diaphoresis, of course, you tend to trap moisture in your body folds, and the goal is to wick moisture away from the body folds and keep those folds dry.
Speaker A:So many of you have the wicking fabric with silver Intra Dry AG is the most commonly used.
Speaker A:So you just want to make sure, like we have discussed in previous classes, that staff knows how to use it.
Speaker A:It's a wicking fabric.
Speaker A:It moves moisture from here to here.
Speaker A:The top portion of the fabric should be at the base of the body fold.
Speaker A:The distal 2 to 4 inches have to be open to the environment for evaporative loss.
Speaker A:So make sure everybody's using this correctly.
Speaker A:It can be extremely beneficial.
Speaker A:Low air loss surfaces can also be beneficial in providing airflow against the skin that helps keep the skin cool and dry.
Speaker A:Incontinence.
Speaker A:We talked a lot about this when we talked about prevention and management of incontinence associated dermatitis.
Speaker A:Ideally, we use containment products, so a rectal pouch, an internal bowel management system, an external catheter, the suction systems for women with urinary incontinence.
Speaker A:If the patient's not a good candidate for a containment system and we have to use absorptive products, we want to use them correctly.
Speaker A:So we want to minimize occlusion.
Speaker A:We should be using products that are highly absorptive that wick fluid away from the skin.
Speaker A:We should keep those products open under the patient when they're in bed.
Speaker A:Close them only when the patient's out of bed, out in the hall, off the unit.
Speaker A:And we should incorporate evidence based skincare for any patient who has issues with incontinence.
Speaker A:So we should be using ph balance, no rinse cleansers or impregnated cleansing wipes.
Speaker A:We should routinely be providing moisturizers and moisture barriers so our creams, our ointments, our impregnated wipes for skin protection.
Speaker A:And finally, don't forget your medical devices.
Speaker A:A lot of pressure injuries are medical device related and most of these are avoidable.
Speaker A:So first of all, is it a product that should be sized?
Speaker A:What about compression stockings, TED stockings?
Speaker A:Yes, they should be sized.
Speaker A:They should not be cutting into the skin.
Speaker A:They should not be creating a tourniquet effect.
Speaker A:So make sure stockings are sized correctly.
Speaker A:What about your cervical collars?
Speaker A:Yes, make sure they're sized correctly.
Speaker A:What about urethral catheters?
Speaker A:They can cause urethral damage, so make sure that there is no tension on that urethral catheter.
Speaker A:For ET tubes, for nasogastric tubes, you want to use commercial stabilization devices.
Speaker A:So because they have been designed to effectively secure that tube in position while minimizing the risk of any skin and soft tissue damage.
Speaker A:So we have very high level devices for stabilizing ET tubes but protecting the skin.
Speaker A:Most of them have hydrocolloid base.
Speaker A:We have very good options for securing nasogastric tubes without tension.
Speaker A:Make sure you're using appropriate stabilization devices and that everyone knows how to use them.
Speaker A:What about devices that press against the skin like tracheostomy tubes, like G tubes, like J tubes, then the current guidance is that we should be using padding between the device and the skin so that there's even distribution of pressure forces, elimination of friction, management of moisture.
Speaker A:We should avoid placing our immobile patients on lines.
Speaker A:Catheters, devices sound so easy, but it takes constant vigilance.
Speaker A:A lot of our patients have multiple lines.
Speaker A:Many of them are very heavy.
Speaker A:So it really has to be incorporated when we turn the patient, after we turn the patient, after we stabilize them with a wedge or whatever, check all of the lines or any of the lines underneath the patient.
Speaker A:What about the catheter?
Speaker A:What about the bowel management system?
Speaker A:Did any of our equipment get left in the bed?
Speaker A:Is there any bed trash?
Speaker A:So turn the patient, stabilize the patient Check the lines.
Speaker A:Clear trash.
Speaker A:What about things like endotracheal tubes?
Speaker A:Nasogastric tubes that can be creating a lot of pressure against the lips, against the mouth, against the nasal septum, against the nare.
Speaker A:Those tubes should either be stabilized in a position that eliminates tension against the mucosal membranes and against the skin, or the position should be routinely changed.
Speaker A:So nasogastric tubes can typically be positioned so that there is no tension.
Speaker A:But what about endotracheal tubes?
Speaker A:The tube itself can put pressure on the mouth even if it's correctly stabilized.
Speaker A:So the current guidelines are reposition the tube within the mouth, not within the airway, but within the mouth.
Speaker A:And usually you want to work with respiratory therapy.
Speaker A:Determine who's going to be responsible for this.
Speaker A:Is it going to be respiratory therapy on their rounds?
Speaker A:Is it going to be nursing every time they turn the patient so that you're moving from right side to the middle of the mouth to the left side?
Speaker A:Just make sure that that does get addressed so that you minimize the incidence of lip, tongue and mucous membrane pressure entries.
Speaker A:We just talked about this.
Speaker A:Obviously I got ahead of myself.
Speaker A:What about oxygen masks?
Speaker A:Again, you're collaborating with respiratory therapy.
Speaker A:We have a great team and my agency, so they're really good about padding if they have oxygen masks or whatever.
Speaker A:So work with other people on your team.
Speaker A:Be aware that every device has the potential to cause a problem.
Speaker A:Our goal is to use the device appropriately and minimize the risk of associated skin and soft tissue damage.
Speaker A:Now, device specific, I think we've covered a lot of this.
Speaker A:If you have patients with nasogastric tubes, very helpful to use a liquid skin barrier on the surface of the skin.
Speaker A:That gives you a really good base for your adhesive product.
Speaker A:Commercial stabilization devices are much more appropriate than just using tape because typically when people use tape, they pull the tube up against the near or against the septum.
Speaker A:If this is your patient, when you walk in, in addition to looking at what's going on with their iv, what's going on with all of their other equipment?
Speaker A:What position are they in?
Speaker A:Are their heels off the bed?
Speaker A:Look at your devices.
Speaker A:Look at that nasogastric tube.
Speaker A:Does it need to be re taped?
Speaker A:What about collars, splints, braces?
Speaker A:A lot of times people are very reluctant to remove these.
Speaker A:So you want to know exactly what that device is there for.
Speaker A:You might need help, and you probably will need help to safely remove the device.
Speaker A:Check the skin underneath.
Speaker A:Pad the skin if necessary.
Speaker A:So work with physical therapy.
Speaker A:Pad those devices Minimize the risk that you're going to end up with a significant pressure injury.
Speaker A:We talked about removing your stockings every shift.
Speaker A:So finally, you've done all of these things to prevent pressure injury development.
Speaker A:Monitor.
Speaker A:Monitor the skin.
Speaker A:Is it working?
Speaker A:Do you need to change anything?
Speaker A:Do you need to ramp it up in any area?
Speaker A:So we should be doing skin assessment minimally, daily.
Speaker A:Really, it should be done every shift.
Speaker A:And what we tell our techs is you're the ones, you're going to be the first to see anything going wrong.
Speaker A:So every time you turn that patient, check the skin.
Speaker A:Do you see anything that worries you?
Speaker A:Do you see anything that's different?
Speaker A:Go get the nurse.
Speaker A:So that we get right on any early breakdown.
Speaker A:What are we looking for?
Speaker A:Persistent erythema, non blanchable erythema.
Speaker A:That's a warning sign.
Speaker A:We need to get in there.
Speaker A:We need to modify our treatment plan, our prevention plan, so it does not progress.
Speaker A:What are the typical changes or upgrades?
Speaker A:Well, most of the time it's going from a foam surface to an air support surface.
Speaker A:Is that evidence based in the literature?
Speaker A:No, we don't have those studies, but it's certainly science based because foam is a solid, air is a gas.
Speaker A:It's much easier for gas to move and to conform around bony prominence than foam.
Speaker A:So if you have a patient on a foam surface and they develop any deterioration in skin status, does it make sense to upgrade them to an air surface?
Speaker A:Yes, it does.
Speaker A:What about increasing turning frequency?
Speaker A:If you're currently turning every four hours, maybe we should turn every two to three and make sure everyone knows.
Speaker A:Probably everyone does.
Speaker A: In: Speaker A:In the past, that's what we taught people to do, to massage red areas to, to increase circulation.
Speaker A:But when you see erythema, what are you seeing?
Speaker A:Vasodilation.
Speaker A:And it's in response to some degree of tissue trauma.
Speaker A:So the last thing you want to do is add more trauma.
Speaker A:So we all know basically what to do.
Speaker A:Any set of guidelines tells you the same thing.
Speaker A:Turn your patients, put them on an appropriate pressure redistribution surface.
Speaker A:Be careful when you move them around so that you're not creating friction and shear damage.
Speaker A:Feed them hydrate, protect against moisture, monitor skin status.
Speaker A:The challenge is prevention is never as sexy as treatment.
Speaker A:So the challenge is getting your staff involved and excited about prevention.
Speaker A:And some of the things that you can do are to keep staff informed about what's happening with your pressure injury or happy rates.
Speaker A:So when you get the rates down, let everybody know.
Speaker A:Celebrate.
Speaker A:If there's been a particularly difficult patient.
Speaker A:And you got that patient through, the staff got that patient through without any hospital acquired pressure injury.
Speaker A:They deserve recognition for that.
Speaker A:So maintaining a high level of consciousness in regards to prevention, that's one of our major challenges.
Speaker A:Okay, so I think we have talked about all of these points.
Speaker A:I'm not going to read them to you again in the next class.
Speaker A:We're going to talk specifically about the role of support surfaces in pressure injury prevention.
Speaker A:But for this moment, you're done with this class.
Speaker A:Thank you.