Archive for the ‘Pressure Injuries’ Category

Pressure Injuries and Medical Device Dilemmas

Friday, June 16th, 2017

Medical device-related pressure injuries (MDRPIs) are a standard part of wound care, but preventative practices can make a big difference.

Medical Device-Related Pressure Injuries

 

One of the first things clinicians learn about treating pressure injuries is to find the cause of the pressure and simply remove it. Sounds simple, doesn’t it? But what do you do when the cause of the pressure injury is a medical device which is not only necessary, but literally sustaining a patient’s life?

While some medical device-related pressure injuries are unavoidable, there are things clinicians can do to relieve the pressure and heal the injury. Here’s what you need to know.

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Pressure Injury Case Shines Spotlight on Wound Care Education

Friday, March 10th, 2017

Trained wound care clinicians truly make a difference in the lives of their patients. This caregiver knows first-hand, and wanted to share her story. 

Pressure Injury Case Shines Spotlight on Wound Care Education

January 10, 2017

 

Recently, a 45-year-old caregiver by the name of Annie* contacted WCEI for help. She was desperate and in search of answers. Her personal account serves as a sobering reminder of why we do what we do. Here is her story.

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When Your Patient Refuses to Be Turned and Repositioned—And Then Sues!

Friday, February 3rd, 2017

Nancy Collins, PhD, RDN, LD, NWCC, FAND

The battle between optimal medical care and patient rights is one to fight with empathy and finesse to keep it out of the courtroom.

patient adherence

I recently reviewed a lawsuit filed by the family of a patient* with a spinal cord injury. The patient was involved in a car accident and sustained multiple traumatic injuries. The medical team worked tirelessly over the course of many weeks to stabilize him. Because of this catastrophic accident, the patient was understandably quite devastated and depressed. He refused all physical therapy and spent most days lying in bed on his back, despite encouragement from his medical team and pleading from his family. He frequently stated that he wished he was dead and that he wanted everyone to leave him alone, often escalating things to the point of screaming.

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Wound Care Myths: 5 More Debunked

Friday, November 25th, 2016

Whether it involves heel protectors, anti-embolism stockings, or letting wounds “breathe,” there are still plenty of wound-care myths circulating out there. Ready for the truth? You can handle it.

Wound Care Myths: 5 More Debunked

Do you use wet-to-dry dressings in order to save money? Have you administered oral antibiotics to treat infected wounds? And do you follow physicians’ orders for wound treatments even though you know they’re inappropriate?

If you answered yes to any of these questions, then you are not alone. You are among a host of other professionals who have believed or participated in some of the most common wound care myths. In an earlier post, we revealed why these and other wound care myths simply need to go away. But wait! Here are five more myths that run counter to the evidence and wound care standards that guide our clinical practice.

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Pressure Injuries with Cartilage? Stage Away

Wednesday, September 14th, 2016

When it comes to wound care, staging pressure injuries with visible or palpable cartilage doesn’t have to be complicated. Here’s what to do.  

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(Photo: NPUAP copyright & used with permisson)

If you’ve ever treated wounds around the ear or in the area just below the bridge of the nose, you know how very little subcutaneous tissue there is. As a result, pressure injuries in these areas tend to be quite shallow, and they typically reveal cartilage.

So when encountering a pressure injury with visible or palpable cartilage, how should you stage it? We’ve got the answer.

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Pressure Injury (Ulcer) Staging: More Real-World Answers

Friday, April 15th, 2016

More real-world wound care questions and answers relating to pressure injury staging, including slough, debridement and skin breakdown.

pressure injury staging

Can’t get enough of pressure injury staging? Neither can we. That’s why we’re excited to present even more questions and answers about this topic, based on what wound clinicians experience out in the field (versus what we might learn from textbooks or in a classroom).

In our first such post – packed with some awesome pressure injury staging questions from the field – we discussed slough, levels of destruction and debridement. Here, you’ll find out more about pressure injury staging as it relates to abrasions, surgical flaps, skin breakdown due to clothing, and more. So here they are – five more tips for staging pressure injuries, based on real questions from clinicians.

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Real World Pressure Injuries: Staging Can Be Tricky

Tuesday, March 29th, 2016

This wound care Q&A answers five of the most common questions about pressure injury staging dilemmas (that you probably didn’t learn from textbooks).

Real World Pressure Injury Staging

 

In the world of wound care, just as in real life, the phrase, “Expect the unexpected” couldn’t be more appropriate. Clinicians can do everything exactly by the book, only to find that a wound just won’t heal, or the source of the problem appears to be one thing but then ends up being another. This is especially true with pressure injuries and often makes pressure injury staging a challenge.

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Floating Heels: More Than Just Pillow Talk

Friday, November 20th, 2015

The way you float the heels matters: new guidelines mean better patient care and lower risk of citations.

Floating Heels

When it comes to wound care, the term “float the heels” means that a patient’s heel should be positioned in such a way as to remove all contact between the heel and the bed. So given this context, is the following statement true or false?

Patients on support surfaces do not require their heels to be floated. 

If you guessed false, then give yourself a gold star. Yes, all patients at risk of breakdown, and those with pressure ulcers on the heel, must have their heels totally offloaded. This requirement has not changed.

But here’s the catch – what has changed is the manner in which we should be accomplishing this.

Official Floating Heels Guidelines

Traditionally, the most common approach to floating heels has been by placing pillows under the lower leg, positioned so as not to place pressure on the Achilles tendon and the heel.  Unfortunately, there has always been a problem with this method.

While you might position your patients perfectly in bed, with heels properly floated, the chances that they’ll remain perfectly still once you’re gone is slim to none. Patients naturally move and reposition themselves for comfort, which means upon returning, you will most likely find that the legs and heels are no longer in that same position.

This repositioning is a common occurrence, and leaves your patients vulnerable to the forces of friction, shear and pressure on the heel.  This traditional heel-floating technique often leads to unnecessary heel breakdown, and a failure to protect our patients properly. Additionally, facilities may be cited for floating Stage III heel ulcers on a pillow.

So what’s the official word on the subject? The 2014 International Guidelines on the Prevention and Treatment of Pressure Ulcers tell us that:

  • You can continue to float the heels with pillows under the full length of the calf for short-term use in alert and cooperative individuals.
  • For individuals with Stage I or II pressure ulcers on the heel, you can float the heels, or use a heel suspension device.
  • For individuals with Stage III, Stage IV or Unstageable pressure ulcers, heel suspension devices are strongly recommended.

What is a proper heel suspension device?

First of all, let’s talk about what a heel suspension device is not. A padded bootie (the kind we’ve used for years) simply doesn’t qualify.  Padding will never offload the tissues, it will only serve to somewhat cushion the skin.

What you do need is a lower leg boot specifically constructed to place the heel in a cup-like device that does not allow the heel any contact at all with any surface. Patients can then reposition themselves in bed without fear of losing the pressure offload. Some devices also have stabilization bars that can be used to prevent outward or inward rotation of the lower extremity.   When selecting a heel suspension device, it’s important to assess how much heat and humidity will be trapped on the skin underneath the boot. This is a potential issue, since heat and humidity on the skin can predispose it to breakdown.

Is this a legal matter?

Wound care clinicians often ask if these revised techniques are lawfully required. The short answer is no, they are not. But – and it’s a big but – it is not uncommon for lawyers to refer to these guidelines in court, and question whether practices were in accordance with these standards.

So if you or your practice were subjected to such inquiries in a court setting, would you want your reply to be no? Of course not. Citing ignorance when it comes to the change in heel-floating standards will not excuse wound care clinicians from the consequences.

Have you changed your practice to reflect these new guidelines? 

As responsible wound-care professionals, we know the use of heel suspension devices is the best way to offload. And because current guidelines support this, if your practice hasn’t already done so, it’s time to implement them now.

Are heel suspension devices already used in your work setting? If so, have you seen a noticeable difference in patient care, compared to the traditional use of pillows and positioning? If not, do you have plans to foster change within your practice? We’re curious to hear your stories. Please leave your comments below.

Will the Real Pressure Ulcer Please Stand Up?

Wednesday, October 28th, 2015

How to know the difference between Incontinence Associated Dermatitis (IAD) and pressure injury.

IAD vs Pressure Injuries

 

As wound care clinicians, we treat our patients to the best of our ability and heal wounds – that’s what we do. But unfortunately, even under the best of circumstances, facility-acquired pressure injuries happen. And we have to document them … because again, that’s what we do.

So then it would stand to reason that no one would ever purposely document this type of pressure injury without cause, right? So here is the big question of the day: why is it that Incontinence Associated Dermatitis (IAD) is often documented as a Stage 2 pressure injury? We’ve got your answer.

The truth about pressure injuries and staging

We know that any staged skin lesion, by definition, is an area of skin disturbance caused by pressure, and according to the National Pressure Ulcer Advisory Panel, only pressure injuries should be staged. We also know that once any skin lesion is staged, you might find yourself sitting on the “hot seat” – having to defend the development of this new wound. And since part of our job is to prevent pressure injuries, staging areas like this puts us on the defensive when we don’t have to be.  The truth: unnecessary staging could lead to charges of inadequate assessment.

Let’s take a closer look

So how do we keep from putting ourselves in such an uncomfortable situation? First, let’s review the difference between these two types of lesions.

Incontinence Associated Dermatitis (IAD)

  • IAD is a form of Moisture Associated Skin Damage (MASD), and is defined as inflammation of the skin from prolonged exposure to urine and stool.
  • This is usually seen in conjunction with friction and/or chemical and/or bacterial factors – they work together to cause IAD.
  • The skin injury that results is always partial thickness in nature.
  • You may see some loss of epidermis and superficial dermis leading to a partial thickness wound, but these are not pressure injury.
  • These are moisture related injuries, and should never be staged.

Pressure Injuries

  • Pressure injuries are caused by unrelieved pressure or shearing forces (which is not what happens in the case of IAD).

When IAD becomes a Pressure Injury

Even though we are talking about two distinct lesions, there are times when IAD converts to a pressure injury. Here’s what you need to know:

  • A previously identified IAD must be considered a pressure injury when you see new evidence of full thickness and damage below the dermis (slough, eschar, and granulation tissue are good examples).
  • This indicates that the deeper acting forces of pressure and shearing are present (read more about friction vs. shearing here).
  • You cannot damage the subcutaneous layer and below by moisture alone.
  • Remember – moisture damage to the skin can only be partial thickness.

Do you see evidence of full thickness injury? That means there was ischemic damage that took place and it’s no longer considered IAD, it’s considered a pressure injury. So it’s time to stage it and get to work healing it.

The importance of pressure injury risk assessment

Under such circumstances, this would be considered a facility acquired pressure injury.  Hopefully, your patient was previously identified as being at risk for pressure injury development, and prevention interventions are already in place.

Once staging happens, it’s time to go back and do another full assessment of your patient and the wound, and put in place both the proper treatment plan and more advanced prevention interventions. Moving forward, all incontinent patients should be considered at risk for skin breakdown. In other words, implement a care plan to prevent IAD and pressure injury from the get-go.

What do you think?

We’d appreciate hearing about your own experiences with staging IADs, versus true pressure injuries. Do all clinicians in your setting know how to tell the difference between these two types of wounds?  Do you feel you have adequate interventions in place for IAD patients?  And what are your biggest challenges in treating these patients and assuring proper identification? Please leave your comments below.

 

Wound Care Education Institute® provides online and onsite courses in Skin, WoundDiabetic and Ostomy Management. Eligible clinicians may sit for the prestigious WCC®, DWC® and OMS national board certification exams through the National Alliance of Wound Care and Ostomy®(NAWCO®). For details, see wcei.net.

DISCLAIMER: All clinical recommendations are intended to assist with determining the appropriate wound therapy for the patient. Responsibility for final decisions and actions related to care of specific patients shall remain the obligation of the institution, its staff, and the patients’ attending physicians. Nothing in this information shall be deemed to constitute the providing of medical care or the diagnosis of any medical condition. Individuals should contact their healthcare providers for medical-related information.

Friction vs. Shearing in Wound Care: What’s the Difference?

Thursday, August 20th, 2015
Friction vs. Shearing: What's the Difference?

It’s a common question among wound care providers: what exactly is the difference between friction and shearing? These two conditions are common with limited mobility patients, and often contribute to the development of pressure ulcers. Knowing the answer to this question will help you provide better treatment for your patients. Plus, you’ll be able to amaze your friends at dinner parties! So in the interest of your patients and social life, we’ve got some answers.

What is Skin Friction?

Friction is when two forces rub together.  The result will be a superficial, partial thickness skin injury that will look like an abrasion.  For instance, a patient in bed might be agitated or restless, and as a result, continuously rub his feet across the sheets. No pressure is involved, his feet are simply sliding against the surface. This constant friction can cause the damage to the epidermis (and upper dermal skin layers) known as “sheet burn.”  The damage will be superficial in depth and irregular in shape. But this type of damage is not caused from pressure and therefore won’t be staged.

Friction can be avoided in this example by having the patient assist as much as possible when moving in bed, or using two caregivers and a lift sheet to avoid dragging across the bed.

What is Skin Shearing?

Shearing, on the other hand, is friction plus the force of gravity.  Let’s think of that same patient in bed, with his head in a raised position.

Example of a Stage 3 pressure injury, which can result from friction and shearing.
Example of a Stage 3 pressure injury, which can result from friction and shearing.

As the weight of gravity pulls down on the skeleton towards the foot of the bed, his skin might be stuck against the mattress due to friction. As his bones slide down, vessels in between the skin and the bone can become compressed, stretched and/or torn.  This causes a lack of blood flow to the tissue leading to ischemia. This is how we end up with a full thickness wound.

If pressure is present (and it almost always is with shearing), then it’s staged as a full thickness pressure injury. This is either a Stage 3 or 4, depending on the depth of tissue destruction, based on NPUAP definitions.  Have you seen a Stage 3 or Stage 4 pressure injury with an oblong or teardrop in shape,  irregular or jagged edges, and undermining or tunneling? This is a significant clue that shearing forces were present.

The Bottom Line

Remember this: it is not possible to have shear without friction, but it is possible to have friction without shear. Because shear is a result of a combination of friction and gravity, it can be avoided by keeping the head of the patient bed at a lower angle.

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.