Preventing pressure injuries

Prevention is better than treatment!  You will be reading this statement in many of our chapters because this fact cannot be stressed enough. That is why we have placed this chapter before the chapter on treating pressure ulcers.  We don't want to treat pressure ulcers!  We don't want to see them - we want to prevent them. If you have ever treated a deeper pressure ulcer, you will appreciate how long this takes, how much suffering, and how many resources are involved in healing these.

 

The most important step to preventing pressure injuries is to understand which patients are at risk and train caregivers on what preventive measures should be taken, especially in the patient groups with high and very high risk. Because the incidence of pressure-related injuries remains disappointingly high globally, there have been many international campaigns in the last years to heighten awareness of this problem. We recommend that you arrange pressure injury prevention days at your workplace at least twice a year            (preferably more often) because we all need to be reminded about this at regular intervals.   You do not have to set aside a whole day for these activities; even just an hour or so with pressure injury-related topics will make everybody more vigilant when it comes to protecting these patients.

 

The first step is to identify the patients who have an increased risk of developing a pressure-related injury when it comes to prevention.  We have written about this in the previous chapters, so we just summarize the most essential risk factors once more. If your patient has one or more of these risk factors, you have to set in motion preventive measures; otherwise, you have failed the patient! 

  • Bedridden patient

  • Chairbound patient (i.e., wheelchair)

  • Reduced level of consciousness

  • Nerve damage ( including stroke)

  • Diabetes ( diabetic neuropathy)

  • Patient with major orthopedic fracture ( hip/femur/ back fractures) 

  • Poor nutritional status

  • Incontinence

  • History of previous pressure injury/ulcer

 

 

Here is a short list ( not complete) of common preventive measures we can use to protect the patient.  Some will not be available in most healthcare settings in Africa, while some of the most effective preventive measures do not cost anything.  Having few resources at hand is no excuse for not being able to prevent pressure injuries! 

  • Information to the patient/closest caregivers ( this may be relatives or neighbors)

  • Daily inspection of the skin of the patient in pressure prone locations

  • Manual methods like improving the positioning of the patient in the bed

  • Implementing a two-hour cycle turning regime for bed-ridden patients

  • Providing adequate cushioning in the seat area for patients who use a wheelchair

  • Improving skin condition with creams/lotions

  • Improving nutritional status, including adequate hydration

  • Special mattresses ( see chapter on offloading aids)

  • A long list of orthotics in all shapes and sizes  ( see chapter on offloading aids)

Manual preventive measures

These essential preventive measures cost you basically nothing.  So no matter how few resources you have, there are no excuses for not following these international recommendations.  The main principle here is that the patient must be placed in such a way in the bed or a chair that we minimize pressure and shear/ friction in the common problem areas ( sacrum, heels, etc.).  In patients who are sitting, the ischial tuberosity ( just distally to our gluteal muscles) is the most significant danger zone.  While you are reading this - place a hand just distally to your gluteals and press feeling for the bony prominence there - you will easily locate the ischial tuberosity here.  Bedridden patients are most likely to develop pressure injuries to the sacrum, heels, and trochanteric regions ( the sides of the hips) 

Avoid shearing forces in the back area

It is important to understand that continued shearing/friction on the skin is as dangerous as pressure. Avoid having the head end of the bed higher than 30° degrees; otherwise, most patients will tend to sag downwards in the bed, leading to strong shearing forces in the sacral area. Make sure that clothing at the back of the patient is lying straight and not in a crumple at the lower back.  Moist skin due to incontinence but also sweating increases the risk of skin damage from shearing/friction

Figure 1  Patients at high risk for developing pressure injuries should avoid lying with the head end elevated more than 30° degrees. Above this level, shearing forces increase exponentially in the lower back region. Be aware that many pressure ulcers actually will start due to shearing more than just pressure by itself. Remember to check regularly that clothing is not crumpled in the lower back region. 

Supine, lateral, and 30°lateral positions

If you have a bedridden patient identified as high risk, the caregivers must change the positioning every two hours. For patients at homecare, this may be challenging as family, relatives, or neighbors will have to get up at night to perform this.  If the patient is in the high-risk category, it is not sufficient to have a great turning regime only during the daytime!

 

We have three options for bedridden patients for positioning: supine on their back, lateral (on their side), or a 30° degree lateral position ( also called 30° degree tilt). So altogether, you have a choice of 5 common positions (since we have two sides to our body), and the patient should vary between these in the course of a day. Actually, you have six positions to choose from - remember that you can have the patient lying on the stomach side as well. Not all patients tolerate lying on their stomachs while others actually like this.  This brings us to the topic of patient preferences -Some patients are quite clear about their preferences - you may, for example, have a patient who has a painful right shoulder due to arthritis, and he/she never likes to lie on the right side because of this. Some patients with airway problems also may prefer to lie on one side because they feel they can breathe better. We recently had a patient who always got congested when he lay on his left side but lying on the right side was fine. These situations, unfortunately, limit your choices of positions to use. 

 

If the patient has redness ( or even an ulcer) over the sacral area, you obviously want to avoid having them lying on their back at all costs. In this case, you will have to use the lateral and 30° degree lateral position giving you four positions to vary between ( since we have two sides to our body). Suppose the patient has redness( or even an ulcer) over the trochanteric region. In that case, they obviously should avoid both the lateral and 30° degree lateral position on the same side, leaving you the option of three other positions ( lying on the back, lateral, and 30° degree lateral position on the opposite side).

Video 1  An example of achieving a 30° lateral tilt using just a few pillows. We find this video quite illustrative to show that just a few minor changes can accomplish a change of position. You will appreciate that the method shown here is best for preventing pressure injuries. If the same patient above already has a pressure ulcer on his right buttock, we would want to offload the buttock even better and try to position him, as shown below.

Figure 2 A different method for obtaining a 30° lateral position. This may even be slightly more than 30° degrees which is also acceptable. This method is preferable to the technique shown in the video above if the patient, for example, already has a pressure ulcer on one side of the buttocks. In this example, special positioning pillows were used to place the patient. However, you can achieve this easily with regular pillows or a blanket/duvet. Note that it is essential to have cushioning between the thighs to prevent pressure from occurring there. 

Patient repositioning regimes

According to the Clinical Practice Guideline, “if changes in skin condition should occur, the repositioning care plan needs to be re-evaluated” (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan Pacific Pressure Injury Alliance).  Repositioning high-risk patients every two hours has been a gold standard globally.  This is obviously a resource-demanding intervention, and it requires a dedicated plan which all involved caregivers have to follow. There may be room for some individualization here- some patients absolutely need to be repositioned this often; in other cases, a longer interval may be acceptable.  Our advice is to start with two-hour intervals - if you see no signs of redness or other pressure indicators, you could try every 2,5 hours - maybe every third hour as long as you can closely monitor the patient's skin condition.  

It is usually effortless to reposition a patient if you are two caregivers.  However, with some practice and correct technique, one caregiver alone can also manage to turn quite a heavy patient.
 

Video 1  A well-explained demonstration of how to turn an immobile patient on the side when you are alone. 

As clearly demonstrated above, it is not difficult to reposition a patient even when you are working alone- it just requires practice.  There are, however, electrical repositioning aids available to make this even easier. Obviously, these aids are not a realistic option for most patients in Africa, but some specialized hospital departments working with, for example, quadriplegic patients may have the resources to purchase such aids. These turning aids make the repositioning more comfortable for the patient ( and possibly in a more dignified manner) and reduce the physical load on the caregiver's side. 

Video 2 Demonstrasjon of TurnAid - an automated system allowing the repositioning of the patient with only one caregiver.  There are several similar systems available.  These aids are obviously not realistic for many African patients but may be available in some specialized hospital departments. 

Skincare

Using moisturizing creams and lotions is important to maintain the moisture balance and thus flexibility of the outer skin layers. A good skincare regime will make the skin more resistant to pressure- and shearing forces. Dry skin tears much easier.  The number of products available is downright confusing, and often you may have to use what is available at your workplace or what the patient can afford. 

Creams/Lotions are water-in-oil emulsions (w/o) or oil-in-water emulsions (o/w), depending on how high the fatty substances they contain are.  If the oil fat concentration is 30% or more, these products are usually water in oil emulsions.  Facial creams and normal body lotions typically have a lower fat content and are therefore oi- in-water emulsions.  These are easier to apply to the skin and don't leave the skin sticky, which most people prefer for daily use. 

However, when it comes to improving and protecting the skin of patients at high risk for developing pressure injuries, we need a cream with a high-fat content ( water-in-oil emulsion). There are many good products on the market, and the prices in Africa for these are usually fair. 

Figure 4  Some of the assortment of water in oil emulsion creams available - this is only a small selection of products available.  The products displayed are some of the creams available in Northern Europe - we will in the future try to make a list of products that are readily available in Africa.  All these creams here have a high-fat content, but the creams like Locobase and Locobase repair have the highest fat contents. Note that some products like the two on the bottom right - Tena Barrier Cream and Cavilon  Barrier Cream also contain substances that protect the skin from moisture like sweat/incontinence.  Noen gode fuktighetskremer som egner

Many caregivers think that if a lotion is thin, it is easier absorbed by the skin - this is also mostly true - but this doesn't mean it is best for the skin in the long run.  In fact, using thin oil-in-water emulsions regularly can cause the skin's oil glands in the subcutaneous layers to " get lazy,"  leading to potential dryer skin over time.  That is also one of the reasons we prefer fattier creams that are only partially absorbed.

 

When using creams/lotions, do not expect a miracle to happen overnight - it usually takes a few weeks before we see a visible effect with the skin gradually improving.  It is essential to apply these products daily.

 

When applying the products, do this gently.  DO NOT MASSAGE them into the skin.  Some caregivers think that massaging the skin will increase blood circulation locally.  In reality, massaging vulnerable skin is harmful! Rubbing the skin is actually believed to increase the oxygen demands of the skin and may lead to local inflammation.  Apply the cream using only the gentlest of pressure. 

Nutrition

We spend many resources repositioning patients with pressure ulcers and are busy changing dressings but often forget how important nutrition is for wound healing. This also applies to the prevention of pressure injuries.

 

Large pressure ulcers have a significant impact on the patient's calorie- and protein reserves. When an ulcer has much exudate, this represents an enormous protein loss ( exudate often contains many proteins).  Remember that also overweight patients need to compensate for this with additional food intake - if your patient is overweight and has a pressure ulcer, then this is not the time for a diet! We have written a separate chapter on nutrition  - please refer to this for more information. 

Using silicone, silicone-coated foam dressings, and felt as preventive measures. 

We have written a separate chapter on offloading- aids like special mattresses and orthotics for preventing and treating pressure injuries.  Below, we discuss soft and pressure-reducing dressings to prevent pressure injuries. These dressings are applied directly on the intact skin to reduce shear and pressure forces. There is reasonably good documentation that these dressings help prevent pressure injuries.  These aids are not a substitute for other interventions like repositioning the patient regularly!  These offloading dressings may be the only treatment necessary to prevent pressure injuries in patients at low risk for developing pressure injuries.

There are, in principle, four categories of adhesive products which we can attach to the skin as protective aids.  The thinnest dressings are the hydrocolloids - these adhere very well and act almost like a second layer of skin and are good at reducing shear but too thin to relieve pressure effectively.  The second group is products that are pure silicone pads; the third group is multilayered polyurethane foam dressings with an inner coating of silicone in contact with the skin; and lastly, self-adhesive compressed felt ( usually made of sheep wool).  Our skin seems to thrive in contact with silicone which makes it an ideal product for this use - also, silicone does not adhere firmly to the skin, so it is gentle on the removal of the dressing. Note that the polyurethane foam dressings we use as prophylactic measures here are the same dressings we can use for treating an open wound. 

Especially the silicone coated polyurethane dressings come in all shapes and sizes  - there are special shapes to fit nicely onto the sacrum area or around a heel. The silicone layer allows the dressing to be lifted daily for inspection and then placed back onto the skin. If the dressing does not become wet or soiled, it can be used for up to one week - in situations where resources are limited; you can use it some days longer. 

Unfortunately, we still see all too often that a caregiver has wrapped a silicone-coated foam dressing around a heel, thinking that this is all the patient needs!  We can not stress this point enough: these sorts of dressings are NOT enough protection for patients at moderate risk to high risk! And definitely not sufficient offloading for a patient who already has a pressure injury!  Here you need other interventions in addition, like making sure that the heel never is in contact with the mattress ( place a pillow under the leg) or use a special offloading orthotic that keeps the heel lifted.

Figure 5 With a bit of imagination, you can improvise with the dressings  - in the image above, an Allevyn foam dressing designed for the heal has been used to cushion the center of the back.  You could also use a sacrum dressing for this purpose. Note: sometimes, it can be wise to place two dressings on top of each other for extra cushioning, but usually, this is not necessary.  

An interesting product is Dermapad®  which is a silicone "cushion" that can be placed directly onto the skin in areas with bony prominences.  It has excellent pressure relieving properties and can be used anywhere on the body - also on the face, which can be helpful, for example, in an intensive care unit where tubing can cause pressure on the nose and ears. We highlight the product here because it is relatively unknown to many caregivers. It is washable and can be used for many weeks.  It can also be cut with scissors if necessary.   A downside of the product is that it is not self-adhesive - that is, you have to use some form of other adhesive to apply it on the skin and keep it there. 

wounds africa dermapad.JPG

Figure 6  Dermapad are whole silicone pads that come in various shapes and as strips. In the image above, we see the pad designed for the sacrum, but it can also be used in other body areas. In some countries, it is marketed as Aderma Dermal Pads; in other countries, it is sold as Dermapad.  

Figure 7  Dermapad are whole silicone pads that come in various shapes and as strips. The image above shows the pad designed for the sacrum, but it can also be used in other body areas. In some countries, it is marketed as Aderma Dermal Pads; in other countries, it is sold as Dermapad.  

Video 1 The application of a Dermapad on the heel. 

Aderma Dermal Pads are usefult for offloading almost any area of the body. they are not self-adhesive which means you have to use tape or other bandages to hold these in place.

Producer: Smith & Nephew

Trykkavlastning Reston Heel /Elbow Protectors. Versatile padding - adheres well. Lightweight and comfortable. Hypoallergenic​. Supplier: 3M

Hapla Wool felt

A very useful prduct for off-loading and padding most areas of the body. Made of 100% sheep wool. Self-adhesive but also available as non-adhesive. Sites extremely well. Can be cut and shaped as desired. Supplier: Hapla

Mepilex Border Sacrum- 5 layer foam dressing for prevention and management of sacral wounds

Producer: Mölnlycke

Mepilex® Border Heel- 5 layer foam dressing for prevention and management of heel ulcers

Leverandør: Mölnlycke

Allevyn® LIFE Sacrum - multilayered foam dressing for the prevention and management of sacral wounds

Leverandør: Smith & Nephew

Allevyn® Life Heel - multilayered foam dressing for the prevention and management of heel ulcers

Producer: Smith & Nephew 

Allevyn® Heel - multilayered foam dressing for the prevention and management of heel ulcers. This is not self-adhesive and requires tape or other products to keep it in place

Producer: Smith & Nephew 

Klinion Kliniderm Foam Sacrum Border - multilayered self-adhesive foam dressing for the prevention and management of sacral ulcers

Producer: Klinion

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List 1  Some of the commonly used products available for the prevention of pressure related injuries. If you are using a polyurethane foam dressing make sure it is multi-layered which is considered best for pressure redistribution. There are many producers of such multi-layered foam dressings. On this list we want to highlight Hapla wool felt because it is a unique and versatile prduct which many are not aware of yet. 

When patients don`t follow our advice

Patients with cognitive changes or psychological conditions can be a big challenge when it comes to off-loading. These patients can often not follow our advice, and here we have to be extra vigilant and keep checking whether the prescribed preventive measures still are in place.  

Another challenge is that patients sometimes remove offloading products by themselves. On some occasions where the preventive dressing or wool felt is critical because we see an imminent pressure injury developing, we may have to use more drastic measures. One method to hold a heel dressing in place is to use a plaster of paris cast, for example.  Be aware that you must have good experience in how to apply a safe cast!  A poorly made cast can harm the patient - for example, pressure points in the cast or sharp edges can cause new ulcers to develop! Furthermore, a cast can increase the risk of falling!  This is not a solution for many patients and is a choice you have to make individually.

 

When offloading devices cause new ulcers

 

Whenever you put an offloading device on a patient, be aware that the device itself can cause harm if not properly used.  It is highly unlikely that a multi-layered foam dressing can cause much harm, but it can do so if caregivers think that our job is done once we have placed a dressing.   No offloading measure is enough by itself- we have to inspect the pressure areas daily and provide other offloading as well.  Let us use a multilayered heel dressing as an example - remember that the dressing by itself is NOT enough to prevent pressure injury. You will, in addition, have to make sure that the patient is lying with the heel elevated above the mattress by, for example, positioning a pillow under the leg.  

Most commonly, though, we see pressure-related injuries when we use orthotics.  What is an orthotic?  This is a very general term used for products like supports, braces, or splints, which we attach to the patient with velcro or other fastening methods.  Especially patients with neuropathy or other nerve damage are at high risk of developing a device-related injury if we are not vigilant.  Every time a patient is supplied with a new orthotic, keep a close eye on the patient to make sure it fits well and comfortably.  Also, whenever you are using an orthotic on the foot or leg, make sure that it doesn't increase the risk of falling.  if you, for example, have a patient who is known to get up regularly at night and wander around, we would be more hesitant about fitting a chunky orthotic on the foot during the night