Acting under pressure: the use of prophylactic dressings in the management of stage I pressure injuries

Alan Shackleton Nurse Consultant Wound Care CMH CMH Wound Care Service team leader Member of the CMH PI prevention group I see all pressure injury incident reports and I am involved in the care of the more complex cases

Presentation structure Acting under pressure: the use of prophylactic dressings in the management of stage I pressure injuries Observations Practice concerns New approaches Research

Assessment Through the use of assessment tools we are able to assess an individuals relevant systemic condition and identify their level of susceptibility to the effects of pressure related ischemia through: Shear Friction Direct pressure

Precautions This assessment allows us to take precautions such as: Regular skin assessments Continence management Nutritional support Pressure offloading through the use of pressure relieving devices and regular turning plans

Practice Observations

Observation I am finding that Nurses are consistently using prophylactic dressings in cases that present with a high risk of pressure injury susceptibility Dressings commonly used are: Hydrocolloid dressings eg DuoDerm, Comfeel Films eg Opsite, Tergaderm Foams eg Allevyn

Reasoning When asked to rationalise this practice Nurses state that they use these dressings as they: Provide pressure relief Protects the skin Sticks well Reduce incontinent encroachment Also: they thought it was our policy because a senior nurse told them to This practice is consistent across the DHB and when asked to rationalise this practice Nurses state they use the dressings as they: Protects the skin Sticks well Reduces the chance of incontinent episodes from encroaching onto the site A number of Nurses also answered that they used the dressing as they thought it was our policy or because a senior nurse told them to.

Concerns

Out of sight, out of mind! The site is hidden from view!!! Dressings such as Hydrocolloids on intact skin can lead to complications such as moisture damage, skin tears / pain on dressing removal and pressure damage as a result of the dressings roll

Is this practice due to confusion? This practice would suggest that Nurses are trying to fill a gap that has not been effectively resolved by clinical guidelines Is this practice due to confusion? All the identified dressings are promoted as appropriate for Stage II and above pressure injuries e.g.

2012 “Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injuries” promotes Hydrocolloids for the management of stage II pressure injuries to promote a moist wound environment, thus reducing pain and promoting wound healing

New Approaches

Prophylactic dressing The use of prophylactic dressings is a hot topic at the moment with a number of wound care product manufacturers seeing this as an opportunity to tap into a new area of use e.g.

Smith&Nephew’s Aderma Redistribution of pressure away from local areas of high risk (bony prominences) through the prophylactic use of a gel pad has been researched (mainly in-vitro)

If not integrated correctly this approach could be detrimental to the patient’s skin integrity due to poor knowledge, confusion and inappropriate use

Research

Microclimate Impact of Prophylactic Dressings Using In Vitro Body Analog Method Recent research into the subject by Call et al (2013) investigates the benefits of promoting an optimal microclimate (defined as: the temperature and moisture level at the skin surface) and suggests that prophylactic dressing should be evaluated against the following:

Evaluation Moisture management (reducing moisture levels trapped next to the skin) Vapour permeability (moisture escaping from the back of the dressing) Temperature management (heat trapped under the dressing next to the skin)

Demonstrated as inappropriate dressing showed the potential to reduce the body’s ability to dispel heat causing heat to become trapped in the dressing This led to an increase in perspiration, adding to the moisture level under the dressing An increase in moisture level will increase metabolic stress on cells and produce maceration

Conclusion The use of occlusive wound care products such as hydrocolloids and gel pads in theory would protect the skin from risk factors, such as friction and external contaminants but when considered against clinical observations and recent research these products may be causing new issues for the areas of intact skin that we are trying to protect

Further research is needed around this topic and out of this research clinical guidelines will need to be developed keeping in mind the conclusions of Call et al.

Any questions? Call, E., Pedersen, J., Bill, B., Oberg, C., Ferguson-Pell, M. (2013) “Microclimate Impact of Prophylactic Dressings Using In Vitro Body Analog Method” Wounds Research Vol. 25, No 4. Retrieved from: http://www.woundsresearch.com/print/1745