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UNIT 4 Supporting Physiological Function
EXAMPLE CLIENT CONDITION: Pressure Injury—cont’d
PREVENTION Is the Priority INTERVENTION !
TAKING ACTION
Linens • Keep the linens soft, clean, dry, and free from wrinkles by changing them frequently. Dressings Also refer to Table 32-5: Types of Wound Dressings. • Hydrating Dressing. Use hydrocolloid or foam dressings to reduce wound size. See Procedure 32-8 in Volume 2. • Negative Pressure Wound Therapy. Placed on a wound packed with foam or gauze dressings to create a vacuum. Subatmospheric pressure reduces edema from swollen tissues, promotes granulation tissue formation, removes exudate and infectious material, and stimulates blood vessel growth to improve wound perfusion. See Procedure 32-6 in Volume 2. • Silver Dressing. Acts as barrier to bacteria in wound bed, eliminates bacterial biofilms, and can reduce prophylactic antibiotic use (therefore preventing antibiotic resistance). • Transparent Dressing. Apply the clear film or drape free of wrinkles. The occlusive dressing creates a seal to help create negative pressure within the wound. See Procedure 32-7 in Volume 2. Minimize Pressure:Turn and Reposition • Most patients who are at risk for pressure injury have mobility problems. • Key Point: Must provide frequent position changes to prevent tissue damage from ischemia. Turning Frequency • Turn at least every 2 hours, more often for fragile skin or little subcutaneous tissue. • Turn every hour for chair-bound patient; teach patient to shift weight every 15 minutes. • Place a turning schedule at the bedside so that all caregivers can aid in the prevention strategy. The “Rule of 30”: Guide to Positioning • Elevate the head of the bed (HOB) to a 30° angle or less. • When side-lying, position at a 30° angle to avoid direct pressure on the trochanter. • If the HOB is up to more than a 30° angle, limit time in this position to minimize pressure and shear. • Use lift devices or drawsheets, heel and elbow protectors, sleeves, and stockings. Never drag a patient up in bed.
For at-risk patients, use visual cues (stickers on charts, dots on ID bands, colored arm- bands) to remind staff to implement preven- tion strategies. Pressure Injury Monitoring • Reassess hospitalized patient daily, at transfer or discharge, and if condition changes. • Assess at-risk patients more often, typically every 8–12 hours. • Reassess nursing home residents weekly for first 4 weeks, then quarterly or if condition deteriorates. • Monitor home patient with every visit. Inform the healthcare provider of the patient’s risk. Manage Moisture Incontinence Care • Provide skin care with gentle cleansing soon after each incontinence episode. • Apply moisture barrier cream to protect perineal skin. • Use absorbent products that wick moisture away from the skin. • For persistent bowel incontinence, consider using a pouching system or fecal containment device to protect the skin from the moisture. Bathing • Diaphoretic patients may need frequent bathing; sweat can irritate sensitive or injury-prone skin. • Older adults don’t usually require daily bathing because of ↓ sebaceous oil and sweat production. • Gently bathe fragile skin, using a minimum of force and friction; washcloths can be abrasive. • Use a mild, emollient cleansing soap only as needed; be sure to rinse thoroughly and gently pat the skin dry. Some soaps remove oils from the skin. • Use warm water; hot water dries the skin. Barrier Cream • Consider using a barrier cream to prevent skin damage in adults at risk for pressure injury (incontinent, edematous, or inflamed skin). Lotion and Massage • Use a gentle massaging motion to promote circulation and wound healing. • Do not massage over bony prominences; this can irritate the area and lead to tissue injury.
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