Items included in the Norton scale and Braden Scale

Documentation

• General skin condition and risk assessment
• Position: indicate frequency and time client’s position was changed
• Record pressure injury:
  • characteristics of the wound (i.e., presence of granulation tissue)
  • Location and size (i.e., depth, width)
  • Stage
  • Type of preventive measures / care given
  • Treatment and progress

Exercise

After studying the previous chapters, what will you do for the below case?

Case scenario 2

Amy is a 78-year-old woman who is living in a residential care home. She is suffering from Parkinson’s disease and diabetic mellitus. She has double incontinence. Her body mass index is below 18 kg/m² which is lower than normal. She always rests on her bed and seldom go to the activity room or dining room. 

1. Do you think she is at risk of pressure injury?
2. How would you assess her risk of pressure injury?
3. What is your care plan to prevent pressure injury?

Answer

Let's return to case scenario 1 Mr. M's situation:

After assessment, he was at high risk of pressure injuries. He used to sit on his wheel chair all day long that made him more prone to develop pressure injuries. There were also warning signs: red skin colour and complaint of pain. If there was no skin breakdown, Stage 1 pressure injury was suspected. Prompt intervention should be provided in order to relieve the pressure and protect his skin with proper care.

Various strategies can help to improve his situation. Care plan can be decided according to the risk assessment that we have done. Let’s move on to Chapter 3.4 to know more about the intervention and management.

3.4 Prevention and Management of Pressure Injuries

Prevention is always the golden rule. It is the most cost-effective treatment for pressure injuries.

The key is how we take appropriate prevention and in case of developed pressure injuries, how we manage it.

Management of Pressure Injuries

Prevention of Pressure Injuries

Prevention of pressure injuries

3.4.1 Skin care

3.4.2 Pressure Redistribution

• Proper positioning
• Reduce friction and shearing forces
• Use of pressure relieving devices
• Optimize mobility

3.4.3 Nutritional support

3.4.4 Education

3.4.1 Skin care

Skin care is playing an important role in prevention of pressure injuries.

• Keep skin dry and clean
• Proper continence care, check and change napkins frequently to avoid skin maceration
• Do not vigorously rub skin that is at risk for ulceration
• Use skin emollients to hydrate dry skin and protect the skin from exposure to excessive moisture to reduce risk of skin damage
• Frequent skin inspection
  • Frequent assessment for any warning sign
  • Perform the assessment at any time e.g. personal care, bathing, positioning etc.
  • Inspect any sign of erythema and blanching over body pressure area
  • Early detection and treatment accelerate recovery and reduce complications of pressure injuries

3.4.2 Pressure Redistribution

Proper positioning

• High pressures over bony prominences, for a short period of time, and low pressures over bony prominences, for a long period of time, are equally damaging. Passive or active mobilization is recommended.
  
• Proper repositioning should be undertaken to reduce the duration and magnitude of pressure over vulnerable areas of the body.
  
• Frequent turning, formulate reposition schedule / turning schedule at least every 2-4 hours.

  Example of repositioning /turning schedule:
  1000-- Prone position
  1200--Left Sim's position
  1400--Supine position
  1600--Right Sim's position
  1800--Prone position (Generally, seldom use in Hong Kong)

  • Avoid pressure on the pressure injury and high-risk areas.
    

• Keep proper body alignment while repositioning
  
• Use support device or foams wedges to separate skin areas in contact each other and to assist with maintaining positions.
• Use cautiously because these devices can become an additional source of pressure if they are not properly placed.
  
• Follow the “Rule of 30” in positioning.
  

Reduce friction and shearing forces

• Keep bed as flat as possible while turning. Limit Fowler's position to only 30 minutes at a time.
• Use enough personnel to lift the client up in bed or chair rather than pulling or sliding skin surfaces.
• Use lifting devices to raise patient in bed.

 



• No dragging client across the surface in the bed.

Proper sitting position

Prevention of Pressure Injuries - Proper Sitting Position

For chair-bound cases:

• Proper sitting position is important in preventing pressure injuries
• Plan the sitting schedule to shift weight for prevention of pressure injuries
• Perform pressure relief exercise
• Provide pressure-reducing support surfaces e.g. gel, air, or foam cushion

Can you recommend a suitable chair to the case Mr. M and educate him on the proper sitting position now?

Also, let’s teach him on the following pressure relief exercise!

Pressure relief exercises for wheelchair/chairbound clients

Regular pressure relief techniques are effective for prevention of pressure injury.

Before the chair exercise, remember to check that the wheels are locked or the chair is stable and undone the seat belt.

• The forward lean – Lean forward as far as you can – imagine that you are trying to rest your chest on your knees! This movement is particularly good for relieving pressure on the coccyx.
• Leaning side-to-side – Whilst seated, shift your body weight onto your left side to lift your right side out of your seat. Then repeat on the other side. This movement relieves pressure from the buttocks and the lower back.
• The push-up – If the upper limbs are strong enough, use the wheelchair armrests (or wheels if you don’t have any) to push up out of the seat with your arms. You should straighten your arms fully so that your elbows are locked. Then ensure that the buttocks and lower back are fully out of the seat.

Performing each movement for 10 seconds for every 15 minutes of wheelchair use.

Any of the three movements mentioned above can be performed independently, or with assistance, depending on individual mobility levels. For frail cases, seek for health care professional advice for the best way of chair exercise.

Use of pressure relieving devices

• Support pillows or foam wedges
• Flotation gel pads
• Trapeze bar
• Bed cradles
• Heel protectors
• Bed / mattress
  • Polyurethane foam overlays
  • Gel-filled overlays
  • Air-filled overlays
  • Water-filled overlays
  • Alternating pressure mattress
  • Low air-loss bed

Optimize mobility

• Assess level of immobility for appropriate intervention
• Increase mobility level
• Encourage active exercise and perform passive exercise as indicated
• Adhere to turning and sitting schedule

3.4.3 Nutrition and Pressure Injuries

Nutrition and pressure injuries

Role of nutrition in pressure injuries

• Malnutrition is an independent risk factor of pressure injury development
• Nutrient is essential for tissue regeneration
• Optimize circulation around wound site

Challenges in nutrition Management

• Various impacting factors that affect nutrient requirements
  • Infection
  • Malabsorption
  • Chronic diseases
• Requirement differs from different staging of pressure injuries
• Nutrition review and close monitoring plays a key role

Nutritional Risk Factors

• Malnutrition
  • Measured using MNA-SF (validated in older adults)
• Pressure injuries staging
  • Later stage = greater malnutrition risk
• Unintentional weight loss
  • Strong indicator of poor nutrition
  • Pattern of 3-month weight change
• Oral intake
  • Appetite and amount of food consumed
  • Reason? (taste changes, chewing ability, food choice…)
• BMI
  • Obese adults have a higher risk due to poorer circulation and greater capillary pressure, skin friction etc.
    However, it’s controversial. Some researchers argued that obese adults have extra body fat stores that reduced the risk of PI, rather than adding pressure on the skin, provide an enhanced subcutaneous cushion to ease the pressure.

• Mobility
  • Greater risk if bed bound, spinal cord injured, etc.

Delayed healing due to nutrition issues

1. Screening – suggest reviewing regularly (monthly)

• MNA-SF
• Staging of pressure injuries (refer to previous chapter)

2. Risk identification

MNA-SF Chinese version
A guide to completing the Mini Nutritional Assessment – Short Form (MNA®-SF)

Risk identification - delayed healing of pressure injury site

Actions if the older adult is identified as…

• Low risk of delayed healing
  • Give healthy eating information to ensure balanced diet
• Moderate or high risk of delayed healing
  • Dietetics referral
  • High protein high energy diet
  • Adequate fluid intake
  • Use supplements where necessary
    • Multivitamins
    • Arginine

Monitoring by Dietitian

• 2-3 weeks intervention → repeat screening
• Adjust protein/energy content until wound healing is observed
• Prioritization over chronic disease management, but still consider special medical conditions (renal diseases, food allergy, etc.)

Common nutrition strategies used

• Small frequent meals

• Split main meals into 2 meals
• Include healthy snacks between meals (up to 3-4 snacks daily is optimal)
  • Yoghurt, fruit, nut, scrambled eggs, wholemeal biscuits…
• Avoid low energy density food to maximise energy intake
  • Salad → stir fried choi sum
  • Water, tea → milk/ nutritional formula/ soy milk/ juice
  • Jelly → cake, biscuit

• Food fortification

• Oil in the meal
  • Add margarine into oatmeal/congee
  • Use more vegetable oil to stir fry food
• High energy beverage/food
  • Fatty fish
  • Full cream milk

• Minimize food restriction

• Eliminate food phobia due to worries on increasing blood cholesterol/blood pressure etc.
• Prioritizing energy and protein intake in a meal over low fat, low sugar etc.
  • Consume rice and meat first before vegetable
  • Allow them to eat meat with some fat until wound healing is observed
  • Still need to consume enough fruit and vegetable for effective wound healing (without compromising energy intake)
    • Splitting meal is key
• Improve appetite as the main goal

• Supplementation

• As indicated by doctor or dietitian
• Calorie-containing drink may be useful as a high energy beverage option such as full cream milk & nutritional formula
• Important to try all food options (frequent meals, fortification) before commencing supplementation
• Arginine supplement is only found effective in PI stage 2 or above, such as Abound and Arginaid
  • Require close monitoring by medical professional if arginine supplement is to be used
• Multivitamin Supplement can be considered if the older adult’s appetite is very poor and unable to consume enough fruit and vegetable

Case Study – Mary Q1

• 70-year-old female, no observable PI
• Independent, sedentary most of the time
• No special medical issues in the past months
• Very responsive in chatting
• No habit of measuring body weight (measured on the day: 59kg, 160cm)
• In the past year, appetite is not as good as before, and feel full if eat less food
• Action?

Answer

Case Study – Mary Q2

After 1 year, you see Mary again…

• PI stage 1
• Rarely leave home in the past year
• Weight measured:  49kg (17% loss in 1 year)
• Getting thinner than before and listless
• Feel full as soon as eating, and stomach acid refluxes all day long, eating less than before
• Other conditions are the same as last year
• Risk?
• Action?

Answer

Summary of nutritional support

• Nutritional assessment is essential
• Provide appropriate nutrition intervention, based on individual need
• Maintain adequate nutrition – protein, calories, vitamins, fluid
• Monitor and evaluate the nutritional outcome, with reassessment of nutritional status at frequent intervals while an individual is at risk

3.4.4 Education

• Educate patient, family members and caregivers
• Educate causes and risk factors of PI development and ways to minimize risks
• Provide information and technique:
  • Understanding pressure injury
  • Risk assessment tools
  • Use of support devices
  • Skin assessment
  • Proper skin care
  • Appropriate positioning
  • Documentation of appropriate data

3.5 Treatment in pressure injuries

• Debridement - remove dead tissue from the pressure injury to help healing.
  • Types of debridement:
    • surgical sharp
    • conservative sharp
    • autolytic
    • enzymatic
    • mechanical
    • larval (also called Biological debridement, but this is not common in Hong Kong)
      

• Dressings - wound care with appropriate dressing is crucial to facilitate the wound healing.
• alginate dressings – made from seaweed and contain sodium and calcium, which are known to speed up the healing process
• hydrocolloid dressings – encourages the growth of new skin cells in the ulcer
• other dressing types: foams, films, hydrofibres/gelling fibres, gels and antimicrobial dressings may also be used
  

• Antibiotics for severe wound infection

Multidisciplinary team care approach

• Geriatricians, nurses, dietitians, physiotherapists and occupational therapists
• Evaluate the contributing factors and formulate the care plan for pressure injury management

Reference

- End of Chapter 3-