Preventing Pressure Injuries

A pressure injury, also called a pressure ulcer or bedsore, is damage to skin and tissue from pressure over a bony area. It can start in a matter of hours, can take months to heal and can lead to serious infection. Most are preventable. The people who bathe, turn and toilet a patient do the most to stop them.

What You Will Be Able to Do

• Explain what causes a pressure injury and who is at risk.
• Find the areas most likely to break down.
• Reposition a person on the right schedule and in the right way.
• Control friction, shear and moisture.
• Recognize the stages well enough to report what you see.

How Pressure Injuries Start

When skin is squeezed between a bone and a surface like a mattress or a chair, blood cannot reach the tissue. Without blood, tissue dies. Three other forces make it worse:

• Friction: skin rubbing against sheets.
• Shear: skin stays put while the body slides, stretching the blood vessels. This happens when a person slides down in bed.
• Moisture: sweat, urine and stool soften skin and make it tear more easily.

People at highest risk cannot move themselves, cannot feel pressure, are poorly nourished or dehydrated, have poor circulation or diabetes, or are incontinent. Older skin is also thin and fragile.

Where to Look

Check areas where bone is close to the skin:

• Lying on the back: back of the head, shoulder blades, elbows, tailbone, heels.
• Lying on the side: ear, shoulder, hip, inner and outer knees, ankles.
• Sitting: tailbone, sit bones, shoulder blades, backs of the knees, heels.
• Under medical devices: oxygen tubing behind the ears, splints, catheters.

Check the skin during every bath and every turn, and pay extra attention to heels and the tailbone.

Repositioning

Moving the person is the most effective thing you can do.

1. In bed, reposition anyone who cannot turn themselves at least every 2 hours, or as the care plan says. Keep a written schedule.
2. In a chair, reposition at least every hour, and encourage people who can to shift their own weight more often.
3. Use a 30-degree side-lying position, with pillows or a wedge behind the back, instead of lying directly on the hip bone.
4. Keep the head of the bed at 30 degrees or lower unless the care plan calls for more, such as during meals. Higher angles cause sliding and shear.
5. Float the heels. Put a pillow under the calves so the heels touch nothing.
6. Lift, do not drag. Use a lift sheet or a second person.

Follow the care plan even if a special mattress is in use. Pressure-relief surfaces reduce pressure but do not replace turning.

Warning: Do not use donut-shaped or ring cushions. They concentrate pressure on the skin at the edge of the ring and cut off circulation.

Skin Care and Moisture

• Clean skin promptly after any incontinence, using a mild cleanser and patting it dry.
• Use barrier cream if the care plan calls for it.
• Keep linens dry and free of wrinkles and crumbs.
• Do not massage red areas over bone. It can cause more damage.
• Check briefs and pads often.
• Offer the toilet on a regular schedule.

Food and Fluids

Skin needs protein, calories and fluid to stay healthy. Encourage meals and drinks, record how much the person eats and tell the nurse if they are eating or drinking less. Weight loss raises the risk.

Recognizing the Stages

Only a nurse or provider officially stages a pressure injury, but you should know what each looks like so that you can report it. These are the stage names used by the National Pressure Injury Advisory Panel.

To check for Stage 1, press gently on a red area for a few seconds and let go. Healthy skin lightens, then reddens again. In skin that stays red, the blood flow has been damaged. In darker skin tones, redness can be hard to see. Compare the area with nearby skin and look for a change in color, or for skin that feels warmer, cooler, firmer, softer or painful.

Report any new area of concern to the nurse the same day. Keep the person off that area.

Common Mistakes

Check Your Understanding

1. During a turn you see a dark pink patch on a resident's hip that stays the same color when you press it. How would the nurse likely describe it, and what do you do?

It suggests Stage 1. Keep pressure off the area, tell the nurse the same day and document what you saw.

2. A patient in a wheelchair says her bottom hurts after sitting for two hours. What needs to change?

Help her change position at least every hour, and tell the nurse about the pain. Check the skin when you can.

3. A family member puts a donut pillow on a chair to help a sore tailbone. What do you say?

Explain that ring cushions can make pressure worse, take it off and tell the nurse so the right cushion can be ordered.

4. A bed-bound patient slides down in bed every hour with the head raised at 60 degrees. What are the risks and what can you do?

Sliding causes shear. Lower the head of the bed to 30 degrees or less unless the care plan requires more, and use a lift sheet with help to move her up.

Key Takeaways

• Most pressure injuries can be prevented.
• Turn bed-bound people at least every 2 hours, and those in chairs more often.
• Check skin over bony areas at every chance.
• Control friction, shear and moisture, and encourage food and fluids.
• Never use a donut cushion, and never massage a red bony area.
• Report new changes the same day, and let the nurse stage the wound.