Clinical Update Innovations in dressing technology for leg ulcer patients


five-fold[3]


. The team embarked on a programme of ensuring


that clinicians understood how to refer patients to the dieticians, how to use the Malnutrition Screen Tool (MST) on the Waterlow Pressure Ulcer Risk Assessment tool and preparing patients for mealtimes. If patients score more than 2 on the MST, they are referred to the dietician[4]


.


Equally, the team felt that continence had been neglected in the hospital and was not generally recognised by nurses as a high-risk factor. Upon investigation of staff attitudes and knowledge, it became evident that there was an ad hoc approach to skin care and continence management. Staff were using their favourite creams or simply applying what was available, rather than drawing on evidence-based practice to make decisions. As a result, an audit was performed on the hospital's


stocks of skin care products and staff knowledge. Results indicated that 80% of staff said they were confident in managing continence. However, 50% had a problem with leaking pads and, therefore, were not actually managing patients' continence effectively. Evidenced-based research recommends replacing


standard bed baths with pH neutral cleansing wipes, which incorporate a built-in moisturiser, as well as built-in water- based barrier for perineal hygiene [5]


. The wipes are more


like a coating than a cream, which goes on as the clinician wipes the skin. It is important to check the manufacturer's guidelines to


ensure any wipes are in the neutral pH range (5–5.5pH) to match the skin's neutral pH value. This will maintain the skin's flora and prevent unwanted microorganisms from gaining a foothold. The team decided to introduce a product called Comfort Shield® Barrier Cloths (Sage Products) as it met all the criteria of a barrier wipe and the company provided educational support. This change of practice ensured that skin hygiene was standardised throughout the hospital and that patients' skin was automatically moisturised and protected with a barrier cream. It is important to recognise that a water-based barrier cream will avoid the problem of expensive continence aids leaking because they are clogged by oil-based barrier creams[6]


. The team also recognised


the principle of covering and protecting damaged skin as outlined in local pressure ulcer prevention guidelines[7]


.


Covering and protecting the skin can also reduce the damage caused by the forces of pressure, shear, friction and moisture. The team developed a protocol to ensure that patients


who were at risk of developing a sacral pressure injury would be protected by the application of a silicone sacral dressing (such as Mepilex®


dressing helps to reduce the shear and friction on the sacral skin, protects the area from contamination with faeces and urine and also allows some extra padding to the sacral bony prominence. The criteria for the protocol include the


following: n Patient has been on bed rest for over 48 hours n Patient has a body mass index (BMI) of less than 18 or greater than 35


n Patient has recently undergone surgery that lasted for Border Sacrum [Mölnlycke]). The protective


over eight hours


n The patient is malnourished as defined by the Malnutrition Screen Tool (MST) on the Waterlow Pressure Ulcer Risk Assessment Tool[4]


n There is evidence of a stage 1 pressure injury or a past history of a sacral pressure injury.


Overall, staff seem to have embraced the principles of


prevention and those patients who have been bedridden long-term have benefited from the dressing application. Feedback from staff includes reports of reddened areas resolving within 24 hours and not progressing to a stage 1 pressure injury. The team's first pressure injury prevalence audit post-implementation of the protocol indicated a 50% reduction in sacral pressure injury. It should be noted, however, that this was not the only contributing factor to


this decrease in prevalence. Others factors include: n Nutrition n Repositioning n Patient compliance n Evaluation n Providing appropriate support surfaces n Keeping pressure off bony prominences n Reducing shear and friction.


Conclusion Pressure injury prevention remains complex and challenging. It is important not to fall into traditional clinical habits, but rather to continue moving forward in exploring evidence-based practice. It is no longer acceptable to expect that another member of the team will implement these practices and staff in all areas should remember that pressure injures are painful, preventable and potentially fatal. As Florence Nightingale once observed[8]


:


‘Poisoning by the skin is no less certain than poisoning by the mouth — only slower in its operation’.


Tracy Nowicki is a clinical nurse consultant working at the Prince Charles Hospital, Brisbane, Australia.


1. Young C. What cost is a pressure ulcer ? Primary Intention 1997; 5(4) 24–31.


2. Graves N, Birrell F, Whitby M. Modeling the economic losses from pressure ulcers among hospitalised Australians. Wound Repair Regen 2005; 13(5): 462–67.


3. Banks MD, Graves N, Bauer JD, Ash S. The costs arising from pressure ulcers attributable to malnutrition. Clin Nutr 2009; 29(2): 180–6.


4. Queensland Health. Waterlow Pressure Ulcer Risk Assessment Tool. 2012; Available at: http://www.health.qld.gov.au/psq/pip/docs/waterlow.pdf (accessed 18 January, 2012)


5. Dibsie LG. Implementing evidence-based practice to prevent skin breakdown. Crit Care Nurs Q 2008; 31(2): 140–9.


6. Cohen E. Skin and Oral Hygiene, Aged Care Nursing: A Guide To Practice. 2003; Ausmed Publications, Melbourne/San Francisco


7. Queensland Health. Pressure Ulcer Prevention and Management Resource Guidelines. 2009; Available at: http://www.health.qld.gov.au/psq/pip/docs/ pup_guidelines.pdf (accessed 18 January, 2012)


8. Nightingale F. Notes on Nursing: What it is and what it is not. 1970; Dover Publications, New York


www.woundsinternational.com


14


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33