7 Keys to Reducing Pressure Injuries

If you think residents of nursing homes are the only people who wind up with agonizing pressure injuries because they've been laying in the same position for weeks at a time, consider the case I saw while overseeing a multi-year project to develop and initiate a comprehensive pressure injury prevention program for a large hospital system.

A 19-year-old woman came to the outpatient surgery center for a mandibular surgery, which was a success. During the post-op appointment with the surgeon, however, she arrived with a deep-tissue pressure injury on her left buttocks from being in the same position on the operating table for approximately eight hours. This patient, whose mandible was healing perfectly, actually took the post-op pain medication prescribed to her not for her jaw pain, but for the pain in her buttocks. If this healthy young woman with perfect skin integrity can suffer an injury like this, you better believe older patients with comorbidities are at risk as well.

Research has demonstrated that a pressure injury can develop within minutes due to the cascade of events associated with cell deformation. In clinical practice, we have found that surgical patients immobilized for more than three hours are at risk for the development of a pressure injury. Take note, because the last thing you want is for one of your patients to visit their surgeon with a Stage 4 pressure injury on their heel, tailbone or occiput that happened when they entered the operating room for an elective procedure. Here are several ways to make sure these injuries don't happen at your facility.

Examine the status and integrity of every mattress in your ORs. They should be at least four-inches thick. Many older tables, and some newer ones, come with smaller two-inch pads that are insufficient to protect patients and can cause skin damage. Some companies simply don't have skin protection in mind when they manufacture these two-inch mattresses. When purchasing new mattresses, manufacturers should be able to provide information about their pressure-relieving capabilities. Also, vinyl surfaces should be avoided. All your mattresses should be covered with one of several skin-safe fabrics on the market.

Once you've upgraded your mattresses and positioning devices, you need to protect the areas of the patient's body that are most vulnerable to pressure injuries. For patients in the supine position, that's the heels, the sacrum and the occiput. Anyone who is going to be under anesthesia in that position for three hours or more should have their heels floated, their sacrum protected with a prophylactic five-layer foam dressing and the occiput lying on a fluidized positioner.

The area of the body a prophylactic dressing is applied depends on the surgical position. The prone position puts the forehead, chin, shoulders, breasts, anterior iliac crests, knees and dorsal foot surfacers at risk. The lithotomy position places stress and strain on the sacrum and heels; while lateral side-lying causes additional pressure on the opposite ear, shoulder, hip, knee and malleolus.

In the prone position, manage moisture, shift the head from side to side every two hours and take care of the eyes by applying drops if appropriate. The patient's tongue should remain in the mouth, using a small bite block to do so if necessary. For torso protection, tubing should be secured away from the skin and tubing channels should be created with positioning devices. Using a combination of adhesive dressings, egg crate foam and fluidized pillows for proper positioning all help protect patients' chins, shoulders, elbows and ribs. Padding the areas of the table where those parts will be resting also helps to minimize injuries to these areas. ?Always follow manufacturers' instructions for OR tables and positioning devices.

We never want anyone who was under our care to leave in worse shape than when they came in.

Pressure injury risk doesn't end when patients leave the OR. When they arrive in recovery, they should be repositioned so they're lying in a different position than the one they were in during the procedure. For instance, if they were in a supine position, you can position them on their side. If they were proned, they can recover in the supine position. If they were laterally positioned, they can be placed on their back or on the alternate lateral side.

Nurses who admit, recover and discharge patients should do a head-to-toe, front-to-back skin assessment. They'll want to do this full-body visual check before the surgery, after the procedure and again before the patient leaves the facility. If there is a pressure injury anywhere, it needs to be not only documented, but also treated. Your facility should have standardized evidence-based, nurse-driven protocols for treatment of Stage 1 and 2 pressure injuries, as well as a wound care consult service to respond in the event of a more severe injury. If none exist, document that their skin was normal.

There are national guidelines for pressure injury prevention — and these guidelines should be followed to the letter. A copy of these recently updated evidence-based practices is available from the National Pressure Injury Advisory Panel (npiap.com). Several years ago, the Wound, Ostomy and Continence Nurses Society (WOCN) began collaborating with the Association of periOperative Registered Nurses (AORN) to highlight and bring awareness of pressure injuries occurring in the OR. This collaboration resonated with AORN and, as a result, its published guidelines now include preventing pressure injuries as an additional reason to position patients properly. All trusted, relevant organizations are now following suit because everyone recognizes that most pressure injuries are preventable and that many happen as a result of inappropriate practices. Following national guidelines is one sure way to prevent hospital-acquired pressure injuries.

An unacceptable outcome

Pressure injuries are a patient-safety issue, a quality-of-care issue and a patient-satisfaction issue — and the majority of them are largely avoidable.

We never want anyone who was under our care to leave in worse shape than when they came in. It took three months for the buttocks wound on the woman who underwent the jaw surgery to heal. As caregivers, it's simply unacceptable to prolong unnecessary pain and suffering like that. It's horrendous for the patient and exposes the facility to a potentially costly legal entanglement. OSM