The incidence of device related pressure ulcers nationwide is unknown. An analysis of Minnesota AHE reports from Oct 7 2008 to Aug 1 2009 showed an average of 25% of hospital acquired stage III, IV, and unstagable pressure ulcers were caused from medical devices.
Types of devices associated with pressure ulcers • Respiratory equipment like oxygen tubing, CPAP masks, endotrachial tubes (ETT) • Nasogastric (NG) tubes • Orthotics (splints and collars)
Good news
This group of AHE includes zero pressure ulcers caused from antiembolism stockings as seen in previous years
Risk Factors for device related pressure ulcers • Use of a medical device • Impaired sensory perception (impaired ability to respond meaningfully to pressure-related discomfort). Patients without sensory perception impairment remove or request removal of shoes, stockings, or medical devices that feel uncomfortable or too tight. Conversely, patients with sensory perception impairment may not adequately communicate discomfort such as with confusion, disorientation, over-sedation or unresponsiveness. Patients who are alert and oriented may also be unable to communicate discomfort if they are orally intubated, speak a different language than their caregivers, or cannot feel pain due to paralysis or neuropathy. • Moisture may be a cofactor for the development of device related pressure ulcers making the skin less resilient in the presence of nasal, oral, or gastric secretions or oxygen humidity.
Common Presentation/Differential Diagnosis • Located under or near a medical device • May not be associated with a bony prominence • Sometimes in the shape of a medical device • Rapid deterioration to sDTI, stage III, IV or unstagable due to locations without fatty tissue (i.e. nares, behind the ears, occiput, bridge of nose) • Unstagables may be mistaken with dried exudate buildup (oral, nasal, gastric) therefore assessment must follow meticulous and routine hygiene
Common Action Plans and Examples
|Action |Examples |
|Admission Inspection |2 heel ulcers that were reported in Minnesota were found under teds that |
|Assess, remove, reposition, palpate on admission |were not removed for skin inspection upon admission |
|Consult appropriate discipline for equipment advice |Orthotics (collars and splints), respiratory therapy, radiology (NG, GT) |
| |for advice on proper fitting, stabilization, alternative product choices |
|Incorporate manufacturer’s instructions into written |Antiembolism stockings are contraindicated with PVD, specific measurements|
|procedures |of the patients leg must be obtained for proper fitting. |
|for indications, contraindications, sizing, and skin | |
|care | |
|Resize as indicated |Collars and braces come in multiple sizes, sizes may change as edema |
| |decreases |
|Remove removable devices at least twice a day for skin |Remove heel protectors, splints, stockings, oxygen tubing, masks, and |
|inspection or palpation, and hygiene |collars during skin inspection and hygiene |
|Reposition non-removable devices as possible for skin |Move Nasogastric (NG) tubes, Endotrachial (ET) tubes to a different area |
|inspection or palpation and hygiene |of the mouth or nose |
|Commercial stabilizers for non-removable devices to |Use NG or ET tube stabilizers that are clear or have repositioning clamps |
|facilitate better positioning and skin inspection | |
|Reposition pannus and tubes at least every two hours; |Prevent pressure from a patient laying on an indwelling urinary or IV. |
|when patient is turned and repositioned. | |
Specific Devices and Action
|Device |Action |
|Nasogastric (NG) Tubes |Procedures (i.e. Lippincott) call for daily site care |
| |Move tube to a different area of the nose (slight changes make a difference) |
| |Consider commercial stabilizers to facilitate easier repositioning and inspection than|
| |tape will alow |
| |Proper application of stabilizers to keep clamp from touching the skin |
| |Use skin preps and every other day changes with FTAD (Hollister) stabilizers to |
| |prevent accidental dislodgement |
| |Document skin condition with site care |
|Oxygen Masks |Consult with RT for proper sizing and fitting |
| |Refitting may be indicated as edema changes |
| |Consider alternative masks with gel borders for select patients |
| |Apply minimal tension to mask strap required to create an adequate seal |
| |Add skin checks under respiratory equipment to RT worklists or documentation |
|Nasal Oxygen |Use commercially available foam ear protectors that can be attached to the tubing |
| |Make ear protectors easily accessible (i.e. stock near oxygen tubing) |
| |Purchase oxygen tubing with protectors already attached to the tubing |
|Endotrachial Tubes (ETT) |Combine ETT site care with oral cares |
| |Reposition tube to different locations in the mouth |
| |Consider commercial stabilizers (ie ETAD) to facilitate easier repositioning and |
| |inspection than tape will allow |
| |Proper application of stabilizers to keep clamp from touching the mouth |
|Removable Splints/Protectors/Braces |Keep manufacturers application instructions accessible |
| |Keep schedule accessible, if there isn’t one, ask for one |
| |Add device removal BID for skin inspection to documentation |
|Collars |Proper sizing critical |
| |Palpate for skin changes within hairline |
| |Use collars that cause lower levels of mandibular and occipital pressure |
| |Review recent articles related to the reduction of occipital pressure ulcers from |
| |cervical collars (references and abstract attached) |
Tescher A, Rindflesch A, Youdas, Jacobson T et al: Range-of-Motion Restriction and Craniofacial Tissue-Interface Pressure From Four Cervical Collars The Journal of Trauma: Injury, Infection, and Critical Care: November 2007 - Volume 63 - Issue 5 - pp 1120-1126
Background: Occipital pressure ulcers are well-known complications for trauma patients wearing cervical collars. We assessed the effects of four commercial cervical collars (Aspen, Philadelphia, Miami J, and Miami J with Occian back [Miami J/Occian]) on cervical range of motion (CROM) and mandibular and occipital tissue-interface pressure (TIP).
Methods: Forty-eight healthy volunteers (24 men, 24 women; mean age, 38.9 years ± 10.5 years) were stratified by body mass index. CROM was measured in the seated position without and with collars. Sagittal, coronal, and rotatory CROM was measured with a goniometer. Occipital and mandibular pressures were mapped with subjects in upright and supine positions.
Results: All collars significantly restricted CROM in all planes (p < 0.001). The Philadelphia and standard Miami J collars were the most restrictive. The Aspen collar was the least restrictive for flexion and rotation. The Miami J/Occian back was the least restrictive for extension and lateral flexion. For supine measurements, Miami J and Miami J/Occian back had the lowest mean TIP, whereas Aspen and Philadelphia collars had the greatest (p < 0.001). For upright measurements, the Miami J/Occian back produced the smallest mean TIPs; the other collars, ranked by ascending TIP, were Philadelphia, Miami J, and Aspen (p < 0.001). Philadelphia and Miami J collars had significant collar-body mass index interaction effects on supine occiput mean pressure (p = 0.04).
Jacobson TM, Tescher AN, Miers AG, Downer L. Improving practice: efforts to reduce occipital pressure ulcers. J Nurs Care Qual. 2008 Jul Sep;23(3):283-8.
St Mary's Hospital, Mayo Clinic, Rochester, Minnesota 55902, USA.
Abstract. Cervical collars are necessary to stabilize the cervical spine of trauma patients but are known to contribute to the development of occipital pressure ulcers. A quality improvement project that began on one nursing unit stimulated the development of evidence-based practice guidelines and a multidisciplinary research study. As a result, a standardized plan of care and cervical collar recommendations were implemented, resulting in a sharp decline in the incidence of occipital pressure ulcers.
Powers, J, Daniels D, McGuire C, Hilbish Chris: The Incidence of Skin Breakdown Associated With Use of Cervical Collars. Journal of Trauma Nursing: October/December 2006 - Volume 13 - Issue 4 - pp 198-200
ABSTRACT: The most common adverse complication associated with cervical immobilization is skin breakdown. The purpose of this prospective, descriptive study was to assess the incidence of tissue breakdown associated with cervical immobilization. In this convenience sample of 484 patients, skin breakdown was noted in 33 (6.8%) patients. All cases of documented skin breakdown were stage I or II, with only 2 (0.4%) patients having stage III breakdown. Days in the cervical collar is a significant predictor of skin breakdown, along with presence of edema. Results from this study demonstrate that there is a very low incidence of complications of skin breakdown associated with the use of Aspen cervical collars. The collars are safe and effective to use in patients with actual or suspected head or spine injuries.
