​Thinking Differently About the Causes of Pressure Injury Part 3: Prevention

Posted by Nurse Linda in Daily Dose on July 19, 2022 # Health

glovesThere are all sorts of reasons why pressure injury occurs. Sometimes they develop from not using preventive measures effectively, other times from internal changes in the body, and sometimes a combination of both. If you have a pressure injury at any stage, it is critical to begin treatment immediately.

The first line of treatment for any pressure injury is to stay off the area. That seems simple enough, but it is a real challenge. First, people believe that just sitting for a few moments, laying on the side of the injury, or getting up to brush your teeth is ok. Some will test the area for blood flow by pressing on the area once or repeatedly without thinking that pressing is adding pressure. Staying off the pressure injury site truly means no pressure on the area at all. That means if the pressure injury is on your body where you sit, no sitting. If the pressure injury is on a side that you lay on, you cannot lay on that side. If it is from a shoe rubbing or a piece of equipment, you cannot use those items. No pressing on the area should occur. As soon as you add any pressure to the area, even for a few seconds, you are adding more pressure.

This misconception is due to really old thinking. In the hospital setting, individuals are turned every two hours. Two hours is the old demarcation for avoiding pressure injury. The reason for the two-hour indicator was originally advocated by Florence Nightingale! She certainly was a nurse ahead of her time and we all give credit to her for advancing healthcare like no one else before her. However, science has moved ahead greatly since her time.

The pressure that can affect blood flow occurs in seconds and minutes, not two hours. There are also considerations about the environment as well. If you are on pressure dispersing equipment, have good nutrition and hydration, use activity to improve your blood flow and muscle health, contain moisture, and avoid friction and shear, you may be able to increase your skin tolerance over time. You may be able to be in one position for 10 to 15 minutes before releasing pressure. You can incorporate pressure release activities into your daily functions making it not so overwhelming.

Hydrate your body both inside and out. Dehydration affects metabolism and wound healing. Drink fluids, especially water. Gradually increase your fluid intake, very slowly over time so as not to overload your heart. If you are on a bladder management program, you will need to pay particular attention to the type of fluid you take in along with your fluid limits. Check with your healthcare professional for the right amount for you. Everyone should avoid alcohol, caffeine, and sugary drinks as they tend to dehydrate or not add value to your intake. Water is the best although you can enjoy a morning cup of coffee or other drink on occasion. Just limit your intake of specialty drinks, opting instead for water. To hydrate the outside of your body, use emollient lotions to keep the outer layers of your skin moist which helps with surface elasticity.

Eat a well-balanced diet. Your skin will need the nutrients to keep it healthy as well as the underlying structures of muscles, blood vessels, and connective tissue. Every body part has a role to play in keeping your skin intact and free from pressure injury. Make an attempt to maintain a healthy weight. Fat does not disperse pressure but adds to pressure points. Muscle cushions boney areas and disperses pressure. If you do develop a pressure injury, even if it is at the level of change in pigmentation (remember more injury is inside your body where you cannot see it) you will need to increase protein and reduce fat in your meal planning. Eat plenty of fruits and vegetables to increase vitamin C. Keep your blood sugar in control. Obtain a consultation for nutrition specifically in your diet while wound healing.

Add activity into your daily schedule. This can take many forms. You may be a person who is able to take part in advanced therapies like functional electrical stimulation exercise, walking with braces or splints as an exercise, or engaging in adaptive athletics or gym workouts. Perhaps you need some assistance with stretching or range of motion exercises to move your body repeatedly through every joint. Either way, do some movement to your body several times a day. You will need to check with your healthcare professional to ensure your body is ready for this type of movement particularly to ensure there are no hidden barriers such as deep vein thrombosis, that your joints are supple, and your cardiovascular system is up to it.

Although you should move your body regularly through specific exercises, an additional way to add activity is through pressure reduction movements. Pressure releases should be done through wheelchair push-ups or tilt in space in a powerchair a minimum of every ten minutes. Some individuals wear a watch that will indicate ten minutes, others will take cues from the environment. For example, when typing, do a pressure release when hitting the enter key, in a busy office when a phone rings, when a commercial comes on during a television show, or other frequent signals that occur naturally in your environment. Turning at night can be done by alarm if you do not do it naturally.

Moisture containment needs to be monitored to avoid pressure injury. Adding toxic moisture to the skin from the outside works in tandem with pressure from the inside. Toxic moisture is from urine, stool, and sweat. These body wastes have enzymes in them that break down the top layers of skin. If someone is incontinent of urine or stool, you can see a red rash develops from excoriation. Sweat is the least toxic but still can excoriate skin. Diarrhea is the most toxic moisture to the skin. The longer these moistures stay on the skin the more time they have to harm the skin surface. Sometimes rashes develop that can be very difficult to clear especially in warm, dark, moist areas of the body.

Excessive sweating can be harmful to your skin. Make sure you are wearing cotton garments that will allow the moisture to wick away from your body as opposed to polyester undergarments that will contain the moisture next to your body. If you can, make your bed in layers so you can remove wet sheets without having to change the entire bed at night. Speak with your healthcare professional as there are treatments that can help control excessive sweating.

Incontinence containment devices such as male external catheters, adult incontinence pants, and bed protectors are made of non-breathable materials that do not let air circulate around the body. These items will hold toxic moisture against the skin and keep body skin folds moist. Allowing time with these devices off the skin allows natural air to flow around the skin thereby reducing rashes from developing.

Keeping skin clean and dry is essential. Wash with mild soap and pat dry thoroughly. Avoid cosmetic powders and lotions but opt for medicinal treatments to these areas if rashes or other skin issues occur. Placing the body in a ‘frog’ position is also helpful. This can be for as little as 15 minutes to allow the area to completely dry.

Friction and shear injuries are not from pressure but the breakdown between layers of the skin. These typically occur from not completely lifting the body when moving, such as when transferring, using poorly fitted equipment, or dressing. Bodies change all the time. Adding or losing weight, changing muscle tone, growth in children, and feeling stronger, or fatigued at some point of the day all can add up to an opportunity to drag the body instead of lifting it. Recognize your limitations so you can discuss them with your healthcare provider who will be able to advocate for additional lifting equipment for you. If you have a disease that affects fatigue, you may be eligible for additional transfer equipment. Friction and shear injuries can be cues that you require more assistance in your mobility.

Pressure dispersion equipment is essential to reducing your risk of pressure injury. This should be for any part of your body that is at risk for pressure injury. Ensure the equipment is at the level of protection you need. Make sure you are using medical-grade equipment, not pillows or craft foam. Pillows and craft foam do not disperse pressure but contain it, putting you at a much greater risk of pressure injury.

All equipment can wear out or your needs can vary with normal body changes, especially pressure dispersing equipment. Many of these devices can be successfully repaired, occasionally new equipment will be needed. Body pressure mapping is a simple procedure that can be completed by most therapy providers. It is done by laying or sitting on a flat mat that will detect where pressure is greatest in your body. This can also be accomplished when using your pressure dispersing equipment to ensure it is working properly.

Activities to prevent pressure injury can be worked into your typical day without much effort once you establish a routine. You probably are already doing most of them. Integrating these activities not only helps with skincare but also bowel and bladder care and general health. Making them a part of your routine limits the intrusion in your life. If you keep up with prevention methods, you can reduce your risk of pressure injury.

Pediatric Consideration:

Children and teens outgrow equipment often more quickly than payors allow for replacements. Most of the equipment for children comes with adaptions to allow for growth. If you find your child is growing more quickly than replacement equipment allows check with medical closets in your community to see if you can swap equipment for what you need. Many medical closets are managed through disease-based organizations, but rarely do they turn people in need away. Other parents may also have used good equipment that they are willing to give to someone who can use it.

Letters of medical necessity can be written by your healthcare provider to your payor. Engaging your nurse case manager to work within your healthcare policy may help. Many states have children’s programs that might be able to obtain the right size equipment when needed. Be creative but persistent in your efforts. They will pay off over time.

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

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