By the WoundSource Editors

Pressure injuries are a significant risk for patients and pose a tremendous clinical challenge to medical providers. Serious pressure injuries can present a substantial threat to patients' survival when comorbidities are present, and even less serious pressure injuries can negatively affect a patient's comfort and well-being. Although some pressure injuries are unavoidable, best practices in patient skin care can greatly reduce the risk in many circumstances,¹ with some research demonstrating that up to 95% of pressure injuries are preventable.²

Skin Assessment and Risk Factors

The first step in determining a patient's care plan in relation to the development of pressure injuries is the completion of a risk assessment. Certain patient populations are at high risk for the development of pressure injuries, and individual risk can be identified using a standardized risk assessment tool such as the Braden Scale for Predicting Pressure Sore Risk©, the Pressure Ulcer Scale for Healing (PUSH), or the Waterlow tool.³ These tools can help to identify at-risk populations, such as patients who⁴:

• Experience impaired mobility
• Have incontinence or difficulty controlling moisture
• Do not have adequate nutrition or hydration
• Are older
• Are obese
• Have a lack of sensory perception secondary to spinal cord injuries or neurological disorders
• Have an amputation
• Have a medical condition that affects blood flow, such as diabetes or vascular disease
• Are unable to communicate adequately
• Have a history of developing pressure injuries

Patients should also be assessed for the presence of pressure ulcer complications, such as cellulitis, bone and joint infections, cancer, and sepsis. Some of these complications can be life-threatening, but at the very least, they represent challenges in delivering effective treatment and promoting healing of the injury.⁴

Best Practices for Patients At-Risk for Pressure Injuries

Pressure injury prevention can be achieved, in most cases, by following treatment guidelines and best practices, including the following:

Inspecting and Monitoring the Skin
Skin care begins with routine assessment of the skin itself. Patients and/or caregivers should look closely for early warning signs of pressure injuries (especially at high-pressure points), always keep the skin clean and dry, and protect the skin at points with high friction. Advanced monitoring tools, such as pressure mapping or real-time patient monitoring, can use sensors to alert the patient or caregiver to any changes in the environment that may increase the risk for the development of a pressure injury. This provides the opportunity for early intervention and prevention of a pressure injury.⁵

Best practices for skin care in this patient population include the following:

• Perform daily skin inspections.
• Moisturize at least twice daily to maximize the lipid barriers.
• Use additional skin barriers, such as silicone, petrolatum, dimethicone, or zinc oxide, particularly if the patient experiences incontinence.
• Cleanse, rinse, and dry the skin after incontinence or when excessive moisture is present.
• Pad and protect vulnerable areas with the appropriate dressings.
• Use breathable fabrics and change every two hours, or when necessary.

Pressure Redistribution
Managing friction and shear is essential in preventing pressure injuries. There are two primary ways to do this. The first consists of selecting the best materials available for the patient environment and support surfaces, such as beds, mattresses, and cushions. These support surfaces should also redistribute weight equally. The fabric selected can also have a tremendous impact on the amount of mechanical stress the patient experiences; for instance, it has also been shown that materials made of silk create much less friction force than cotton-based fabrics.⁵ Achieving proper pressure redistribution involves the following procedures:

• Use appropriate support surfaces. Assess the current ones in use, and identify when there are better options available.
• Identify and account for any comorbidities.
• Use a mechanical lift when moving bariatric patients.
• Use the appropriate fabric to minimize friction, shear, and pressure.
• Pad the edges of casts, splints, braces, and other medical devices.
• Keep the head of the bed flat or below 30 degrees, when possible.
• Check for bottoming-out with patients in bed and chair pressure redistributing cushions or mattresses.

Patient Positioning
Properly managing mechanical stress also involves repositioning the patient at the recommended interval, which should be at least every two hours.¹ Auditory tools, such as alarms or sensors, may be used to remind the patient or staff when repositioning should occur. Repositioning may also be facilitated by devices, pads, or slings that make it easier to move the patient. Pressure mapping technologies can also be used to optimize the positioning of the patient. This technology enhances the visual inspection of a patient's skin by assessing the cellular-level mechanisms and biomarkers that are associated with the early development of pressure ulcers.⁶ Proper patient repositioning includes the following^4,5:

• Reposition patients in chairs hourly, and encourage those who are able to shift their weight to do so every 15 minutes.
• Turn and reposition at least every two hours for patients confined to a bed.
• Use draw sheets or positioning devices to pull up, transfer, and position your patients.
• Use heel or elbow protectors for hospice and palliative care patients.
• Check medical devices every two hours.

In addition to the listed best practices, patients and caregivers should pay particular attention to nutrition and hydration. Those patients with inadequate nutrition are much more likely to develop pressure injuries. Ensuring that the patient has a well-balanced diet, adequate intake of fluid, and supplements when needed can also significantly reduce the likelihood of developing pressure injuries.¹

Conclusion

Pressure injuries can negatively affect patient outcomes and it is vital to prevent them whenever possible. Pressure injury prevention starts with good skin care and a head-to-toe skin assessment. Evaluate patients on admission to determine a care plan in relation to pressure injuries. Care plans can include moisturizing the skin, protecting bony prominences, protecting the skin from moisture, pressure redistribution, and more. Always involve the patient in the care plan in order to achieve greater compliance.

References
1. Fitzpatrick MA. Pressure injuries: prevention across the acute-care continuum. American Nurse Today. 2018. https://www.americannursetoday.com/wp-content/uploads/2018/05/DabirSupp…. Accessed September 26, 2019.
2. Ebi WE, Hirko GF, Mijena DA. Nurses’ knowledge to pressure ulcer prevention in public hospitals in Wollega: a cross-sectional study design. BMC Nurs. 2019;18:20.
3. Moore ZEH, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2019;(1):CD006471.
4. Mayo Clinic. Bedsores (pressure ulcers). https://www.mayoclinic.org/diseases-conditions/bed-sores/symptoms-cause…. Accessed September 26, 2019.
5. Boyko TV, Longaker MT, Yang GP. Review of the current management of pressure ulcers. Adv Wound Care. 2018;7(2):57-67.
6. Patton D, Moore Z, O'Connor T, Budri AMV. Using technology to advance pressure ulcer risk assessment and self-care: challenges and benefits. J Eur Wound Manage Assoc. 2018;19:23-27.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.