Pressure Ulcers

Patients who develop stage 3 and 4 pressure injuries with prolonged wound chronicity and complexity may require surgical intervention. One surgical method used to encourage healing in pressure injuries is flap surgery, which involves taking a section of skin with an intact blood supply and placing it over the injured area. Flaps play a major role in the healing of wounds with exposed structure. Flap surgery can help prevent hospitalization and decrease morbidity. Flap surgery is used to prevent and resolve complications, including surgical site infections and other infections, dehiscence, recurrence, flap necrosis, nutrient deficiencies, and prevention of future malignancy (Marjolin ulcer) and seroma or hematoma.

When pressure injury prevention fails as a result of non-adherence, various comorbidities, or gaps in care, it makes a major impact on the nation’s economy and has estimated costs of more than $100 billion in the United States.

Pressure injuries are among the most significant health and patient safety issues that health care facilities face daily. Aside from the strong impact on patients’ quality of life, they also have high costs of treatment, not just to the patient, but also to the health care industry. The Agency for Healthcare Research and Quality reported $20,900 to $151,700 per individual patient and pressure injury in health care costs. The prevalence of present-on-admission (POA) pressure injuries is 26.2% among those admitted to the hospital from a nursing home and 4.8% among those admitted from another living setting. Hospital-acquired pressure injuries (HAPIs) cost the US health care system $9.1 to $11.6 billion a year.

The coronavirus disease 2019 (COVID-19) pandemic has forced health care professionals to take a closer look at the most effective and appropriate measures for pressure injury prevention. In 17% of all COVID-19 cases pneumonia secondary to acute respiratory distress syndrome is the most common complication; therefore, prone positioning is used as an adjuvant therapy. The prone position allows for dorsal lung region recruitment, end-expiratory lung volume increase, and alveolar shunt decrease. To be most effective, this position should be maintained for 10 to 12 hours, thereby increasing prolonged pressure on certain areas of the body. However, prone positioning should be supervised and monitored regularly by nursing staff experienced with this positioning technique.

Adherence: Adherence is a term used to replace "compliance" in reference to a patient following clinician orders for wound care. Compliance implies that the patient should passively comply with the health care provider’s instructions, whereas adherence allows for patients to have the freedom to follow the provider’s recommendation without blame being focused on them if they do not or are not able to follow these recommendations.

Medical device–related pressure injury (MDRPI): MDPRIs are localized injuries to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace, splint, cast, respiratory mask or tubing, or feeding tube.

Offloading: Offloading refers to minimizing or removing weight placed on the foot to help prevent and heal ulcers, particularly those caused by poor circulation to the feet due to diabetes.

By Heidi Cross, MSN, RN, FNP-BC, CWON

In the previous blog, I briefly went through the standards of care when it comes to nutrition and pressure injury (PI) prevention and development and discussed what a large role nutrition plays in PI litigation. Here are several instances: Punitive damages of $92 million, later lowered to $11,855,000, were imposed where malnutrition and dehydration were proven against a nursing home. A dietary manager for a nursing home told state surveyors that her nursing home had "dropped the ball" on a resident's nutrition needs when that resident had lost 17 pounds in 75 days; a $1,385,000 settlement was reached. Malnutrition with a loss of 27% of body weight in 15 months led to a $380,000 settlement just before trial. Shocking, isn't it? It literally "pays" to pay attention to nutrition standards of care.

By Ivy Razmus, RN, PhD, CWOCN

As we continue to develop our evidence on pediatric pressure injuries, more information has been reported about the risk factors nurses are using for clinical judgment. We know that the newborn skin can vary based on gestational age, and nurses use their clinical judgment frequently when compared with using a pressure injury risk assessment scale. It therefore is important to answer this question: “What are nurses using for clinical judgment for assessing pressure injury risk?”

By Lauren Lazarevski RN, BSN, CWOCN

As I contemplate the current conversation around ventilators, I am encouraged to refresh my knowledge about mucosal pressure injuries. Pressure injuries on the mucous membranes present and are staged differently from cutaneous pressure ulcers, and they are usually attributed to a medical device or tube. Nasogastric or orogastric tubes, oxygen cannulas or masks, endotracheal tubes, and urinary and fecal containment devices pose a risk of causing local ischemia to tissue in the nose, mouth, genitals, or rectum, respectively. Once a mucosal injury occurs, the patient is at increased risk of other problems, including pain, infection (especially if injury occurs to the urinary tract), and even malnutrition, if pain from oral wounds makes it difficult to eat and drink. These hospital-acquired pressure injuries contribute to the physical burden on the patient, as well as the financial burden on the hospital because they do count as a nosocomial—and usually, preventable—ulcer.

By the WoundSource Editors

COVID-19: The name of the disease caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The abbreviation COVID-19 is short for coronavirus disease 2019.

Fit test: A 15- to 20-minute testing of the seal between the respirator's facepiece and your face. After passing a fit test with a respirator, you must use the exact same make, model, style, and size respirator on the job.

Liquid sealant: Liquid skin sealants are designed to protect vulnerable areas from the effects of skin injury. They form a transparent protective coating on the skin. Indicated for use on stage 1 pressure injuries and low-exudating stage 2 pressure ulcers, pressure points and bony prominences, and under adhesive products to protect the skin.

By Holly M. Hovan MSN, RN-BC, APRN, CWOCN-AP

With National Nurses Week approaching, we will once again be seeing the work of Florence Nightingale highlighted, along with the concepts and values that have built the nursing profession. As we've heard many times, nursing is an art and a science. The basic foundations and concepts of nursing are built from evidence, books, and what we learn in school from our teachers, professors, and clinical instructors. The science behind nursing is important—there are formulas, math, research, memorizations, and concepts that must come from a book. However, there is also a huge piece of nursing that comes from our hearts. Nursing is caring, compassion, kindness, and wanting what is best for someone else. Nursing is wanting to help our patients and our peers. Being a nurse is a calling and a passion, and that piece can't always be learned... it starts in our hearts, and it shows in our practice.