As I read through wound care articles on pressure injuries and treatments, I keep going back to one thought: why are they still occurring? They are preventable! Staff are educated, have certifications and equipment, and have been oriented on policy to prevent pressure injuries. I think it comes down to opportunities and choices.

A culture of care – bottom to top and back down again – can drastically reduce incidence.

Every person that comes into contact with a client or patient has the opportunity to decrease the risk of a pressure injury. Yes, every person. You say you have no skilled training in pressure relief? If a person asks you for a drink, perhaps you cannot give it to them, but you can ask a primary caregiver to provide it… While replacing a battery or paper towels in the room, you notice the patient's head lying on a bed rail, and are pleased you could make sure a pillow was there… When the room is clean to receive a new patient, you are the one making sure there are enough pillows (3) in the room to position the new patient for pressure injury prevention.

Your Role in Addressing Pressure Injury Risk Factors

As an administrator completing patient satisfaction rounds with a distantly-used clinical degree, you notice "float heels" on the dry erase board in the patient room, and take time to make sure they are available. By asking the client/family how long the patient has been in that chair/position, and then providing relief or requesting help to make it happen, the patient and family are impressed by your thoughtfulness. You use acuity scores in staffing to make sure there are enough hands to provide care and prevent burnout, knowing it can lead to disengagement and shortcuts that can harm patients.

You are the physician managing the care of this patient and making sure a thorough review of systems, medical record review, and physical exam reveals the systemic disease, sensory changes, vascular compromise, physical strength, and decreased mobility. Your staff relies on this to make critical decisions in preventing pressure ulcers—and the patient/family's trust in you grows.

So, you are the caring soul who bathes or toilets the client because this most private personal care can't be done alone by your client. Consider that your eyes see what most others in patient contact won't. The patient tells you things they tell no one else. Is the tailbone or heel tender, red with no blanching, or with an open sore? Has the remote or a piece of medical equipment been lost under the patient all night, and you noticed an oddly shaped area of redness or bruising on the patient? Positioning the patient for pressure relief and notifying the nurse or therapist can allow for an upgrade in care to heal this area (improved cushions, mattresses, foot wear, or restrictions in position can be instituted if providers are aware). You are not merely moving the patient to the bed or chair, toileting, or bathing the client. Your eyes are assessing the client's skin and if current levels of pressure relief care are working. Barrier creams are brought into the room because your nose and eyes notice incontinence. This can increase risk for pressure injuries, as well as chemical injury to the skin.

You are "just" bringing the patient back to their room post-therapy, but see the patient can't lift their legs onto the bed. Float heel orders are requested by the nurse when this change in functional ability is shared by you. The extra pillow to do this magically appears under a grateful client's calves because of your mindful care.
Perhaps you notice the podus boots strapped onto the footboard, and take a minute to put them on the patient and educate them about why these awkward items are needed. The patient has been in therapy all morning and a good bit of the afternoon, and you empathize with their complaint of a sore buttock. So, the grateful client finds herself (or himself) tucked into bed, tipped off their sore tailbone by magically appearing pillows. Their nurse requests changes in care because of your shared words!

Making a Daily Difference in Wound Prevention

As a therapist, you notice many of the above as you rehab the patient for functional use of their arms, body, and legs. You are moving the patient and preventing friction on their delicate skin as it moves near metal edges. Limbs and trunk are positioned with mindfulness in rehab equipment to prevent pressure build up or friction injuries. A podus boot is requested because the patient states their heel hurts when they stand in the parallel bars. Thoughtfully, you provide a gel cushion because of patient's low BMI, history of a pressure injury, or pain complaint. Discharge equipment is requested by you to prevent pressure injury, and a grateful family learns how to use it. A bony elbow gets a pillow on their hemi-tray. Nurses and doctors initiate protocols because of your shared information.

As you pass meds to the patient, you ask if there is pain in their heels or tailbone, and add this to all the comments shared by the housekeeper, CNA, therapist, case manager, administrator, and so on throughout the shift. The client's Care Plan is updated, and you show a confident smile that this patient will not develop or worsen a pressure injury because you know there are 15 other people helping you every day to assure this client's skin stays intact. The patient returns your smile with their own. It's been a comforting and reassuring day at the hospital because so many people show they care in their deeds!

Show you care:

ASK (and LOOK): are you having pain in your heels or buttock?

TURN: off of buttocks or hips.

FLOAT: heels with a pillow or medical boot.

Sources:

Gowen B. Why Working ‘Just’ Three Days a Week As a Nurse Is Utterly Exhausting. Huffington Post. http://www.huffingtonpost.com/brie-gowen/why-working-just-three-days-a-…. April 11, 2016. Updated August 3, 2016. Accessed March 1, 2017.

van Rijswijk L. Editorial Opinion: Quality of Care and Pressure Ulcer Prevention: Not a Just a Matter of Risk and Intervention. Ostomy Wound Management. 2017;63(2):6. Available at: http://www.o-wm.com/article/editorial-opinion-quality-care-and-pressure…

About the Author
Janet Wolfson is a wound care and lymphedema educator with ILWTI, and Lymphedema and Wound Care Coordinator at Health South of Ocala with over 30 years of field experience.