Medical device–related pressure injuries (MDRPIs) are recognized as a significant problem, evidenced by the inclusion in the National Pressure Injury Advisory Panel pressure injury definitions and described by Pitman and Gillespie in 2020.1 Prevention of medical device-related pressure injuries is a goal that may be achieved through meticulous patient care.
One of the largest pressure injuries (PIs) I have seen was from a device-related pressure injury. The woman was only about 60 years old and had undergone a total hip replacement. When I came on for a late shift, she had been back on the medical-surgical unit for over 4 hours, and it appeared that she had not been repositioned at all. We had difficulty moving her and realized she had a wood block under her pelvis that allowed the x-ray plate to be slid in and out while in the operating room. We worked out that the wood block had been there for 6 hours. Her buttocks were raised about 2 inches by the block, and this would have increased the pressure.
On the side of her replaced hip, the corner of the block was digging in particularly hard. The skin there and across the sacrum was red, nonblanching, and obviously damaged. Over the next day or so, a deep tissue injury developed, and the skin peeled away. Instead of going home or to rehabilitation, she stayed with us for close to 2 weeks, during which time the wound developed depth and was surgically debrided. Pressure injuries from bed debris, such as a pair of glasses, intravenous caps (IV), dentures, ear buds, etc, are not uncommon. Such items dig into the skin and often cause odd patterns on the skin defined by the object.
It is not always obvious that the injury is pressure or device related. The following photograph is from a woman over 75 years old. She had diabetes that was poorly controlled with oral medication. She had visited her primary care provider 2 days before this picture was taken and had been prescribed a cephalosporin. There had been no traumatic injury to her foot that she could recall. She had claw toes with some neuropathy. Her foot was a little edematous, and the dorsalis pedis was palpable. There was minimal serous drainage, and she had no signs of infection and no fever. She had not had a nail on this toe for some time.
When asked for more detail on how the wound developed, the patient’s daughter described a fluid-filled blister that became purple. Initially, the health care professionals did not tie this to an event. When it was suggested to the patient and caregiver to see a vascular surgeon, they said that they had just had an appointment for some tests 10 days earlier. This was the “aha!” moment. The fluid-filled blister occurred 2 days after the visit. and yes, “come to think of it, they put a miniature blood pressure cuff around her toes” (to perform toe pressures)! The vascular service was called, and a follow-up appointment was made. A copy of this photograph was sent to them. A simple Xeroform dressing was applied by the daughter every other day, and the wound went on to heal, with no further complications. The testing had been done by a medical assistant, and despite some requests for information, it was not discovered whether any kind of mitigation had been performed. It is not known whether the patient and her family followed through with a formal complaint.
Casts and splints are major causes of medical device-related pressure injuries. There are 2 main factors for this:
Splints and casts that injure patients should be removed, preferably with the knowledge of the ordering physician. This is not always as easy as it sounds because doctors can be difficult to track down, and some splints seem impossible puzzles. If a cast needs removal when there is a “do-not-remove” order and the prescribing physician is unable to be contacted, an x-ray study should be done, and a suitable plan for fixation or treatment after cast removal should be devised. If a cast is then replaced, windows can be cut to allow wound inspection and dressing changes, or the cast can be bivalved to allow for regular removal.
The following photograph is of a 23-year-old male patient who had experienced a head injury and ankle fracture. There was a do-not-remove cast order in his chart on admission to rehabilitation, and the cast had been on for 2 weeks. There was considerable odor, and the cast was soiling the sheets. The cast was removed, revealing wounds medially and laterally. This photograph was taken several weeks later as the wounds were healing in a fresh bivalved cast that was removed every 3 days.
Nasogastric tubes (ng tubes) can cause significant pressure injuries. Securing ng tubes can be challenging, and the method shown here for placement that is recommended by the American Association of Critical Care Nurses is very effective. It does not force the ng tube onto the skin and allows sufficient, comfortable movement. The method used in intensive care unit in the United Kingdom does not split the end of the part that goes around the ng tube. Manufacturers make rather bulky devices that are better than other tape methods of placement. It is unfortunate that no company has made this simple, effective tape technique available.
Method of nasogastric (NG) tube and small-bore feeding tube (SBFT) taping. (Copyright 2014, American Association of Critical Care Nurses.)
The infographic on nasogastric tube placement above reads: Innovation: New Taping Method Leaves the tube free-floating, eliminating pressure on the nares Requires change every 24 hours and as needed New NG/SBFT Taping (effective January 2013)
Preventing medical device-related pressure injuries is better than treating these injuries. Prevention saves both patients and health care professionals time, resources, and discomfort. As seen the previous case studies, medical device-related pressure injuries can result in longer hospital stays for patients, not to mention detective work for health care professionals to find the origin of the injury. Here are 10 hints and tips to assist in preventing medical device-related pressure injuries:
Education relating to medical devices, splints, and casts tends to be from staff on the unit. This education is most often utilized if a patient is on maternity and has a knee brace. Often, it is the patient who is likely to be more familiar with the device than the nurse. Asking the patient should not be viewed as a problem and is preferable to patient repositioning of the device afterward. Medical device procurement must include staff involvement with medical device purchasing so that company rhetoric and cost are not placed above patient comfort and safety or staff experience and expertise.
The prevention of medical device-related pressure injuries is very much the responsibility of the whole health care team, and nurses need to involve and corral them all. The patient’s plan of care can’t include every action needed to prevent device-related injury. Caregivers need to make it routine to smooth sheets, “clear the skin,” and move and secure all tubes. This is Care. Do-not-remove orders for splints and casts need to be clarified, and staff need to feel competent and confident to manage devices needed for patient care and treatment. We need to protect the patient and the “skin they are in.”
Margaret Heale has a clinical consulting service, Heale Wound Care in Southeastern Vermont and draws on her extensive experience as a wound, ostomy and continence nurse in acute and long-term care settings to provide education and holistic care in her practice.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies.