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Top Prevention Highlights

Pressure injury evidence-based practice and top prevention techniques

Assessment

  • Assess skin on admission (includes emergency department).
  • Use a structured PI risk assessment tool, i.e., Braden, Norton scales.
  • PI assessment within 24 hours of admission; then daily, with change of condition and unit transfer.
  • Utilize valid nutrition assessment tool for risk of malnutrition on admission.

Skin care

  • Develop a risk-based individualized plan of care as identified by the assessment subscales: sensory perception, activity, moisture, nutrition and friction/shear.
  • Inspect skin each shift for signs of PI, especially nonblanchable erythema.
  • Look for changes in darkly pigmented skin, such as change in skin tone, skin temperature and tissue consistency compared to adjacent skin (tip-moistening the skin assists in identifying changes in color).
  • Keep skin clean/dry under medical devices and use foam prophylactic dressing; reposition devices.
  • Manage skin moisture; use skin barrier and protectants.
  • Monitor additional risk factors: fragile skin, blood flow impairment to extremities and pain in area exposed to pressure.

Prophylactic dressings

  • Consider multi-layer silicone or polyurethane foam dressing based on Braden Scale score and areas of pressure.
  • Continue to assess the skin under a prophylactic dressing daily to evaluate effectiveness.

Repositioning and mobilization

  • Address skin as part of purposeful rounding; offer toileting, fluids as appropriate, positioning and reassess for wet skin.
  • Turn every two hours.
  • HOB (head of bed) not greater than 30 degrees.
  • For 30-degree side-lying position, use hand test to assure sacrum is off the bed.
  • Elevate heels off bed.
  • For immobility risk, use pressure redistributing bed and chair/wheelchair support surfaces.

Support surface

  • Place patient at risk on a specialty support surface as soon as possible, within 24 hours.
  • Use pressure redistribution cushion in chair/wheelchair for prolonged periods or for patients who are unable to perform pressure-relieving maneuvers.
  • Use a pressure redistribution support surface in the operating room for all patients.

Nutrition

  • Refer patient at risk for malnutrition to a registered dietician.
  • Assess ongoing adequacy of oral, enteral or parenteral intake.

Engage and educate patient and care partner

  • Patient and CP participate in risk assessment.
  • Include the patient and CP in PI prevention efforts and care, purposeful rounding tasks and assure understanding with teach-back.

Unit-based staff awareness

  • Incorporate PI prevention, staging and treatment into nursing new hire orientation and annual competencies.
  • Educate all unit-based staff on PI prevention.
  • Hardwire individual patient PI prevention/status into daily rounds, unit and shift handoffs.
  • Conduct PI root cause analysis to inform improvement opportunities related to hospital-acquired PI.

Consider emerging technologies for early detection of deep tissue injury

  • Subepidermal moisture monitoring: differentiates between erythema and Stage 1 pressure injury.
  • High-frequency ultrasound: detects tissue damage not noted by physical skin exam.
  • Thermography: detects temperature differences between injured and adjacent skin.