6 facts about pressure injuries nurses need to know

Nurses are challenged every day to stay up to date, especially when it comes to wound care.

Whether it’s learning about a new treatment or product, the numerous wound types and multiple best practices, clinicians provide patients with the current standard of care thanks to a strong knowledge base.

Managing pressure injuries is something many nurses encounter regularly because of their pervasiveness across the healthcare continuum, whether that’s in home health, acute care or long-term care.

1 — Pressure injuries are dynamic

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Care practices from the past, Wollheim said, may not be what is done today. And what is done today may not be considered a best practice in the future. Simply put, wound care is always changing.

One example is the timing of conducting a Braden Scale wound assessment for predicting skin breakdown in patients.

“For many years, the practice was to conduct a Braden Scale assessment within 24 hours upon admission to a facility,” he said. “The new guideline now is conducting a Braden Scale risk assessment within eight hours of admission. This is the new standard of care and the result of scientific findings that pointed out that 24 hours may be too late for some patients as necrotic tissue can present much sooner — and as soon as six hours. Timely administration of the Braden Scale, along with using it correctly, is essential.”

Another common wound care practice in years past was wet-to-dry dressings. This is now considered outdated and no longer considered the standard of care, Wollheim said.

2 — Terminology and documentation changes

Just as care practices change, so does healthcare terminology. And when clinicians are caring for wound care patients, using the current terms is essential to ensure proper required charting, according to Wollheim.

Pressure injuries used to be called decubitus or pressure ulcers. In 2016, the National Pressure Injury Advisory Panel recommended the name change to pressure injury.

Another recent change has been an update to the staging system of pressure injuries, along with their numbering. Roman numerals are no longer used. Instead, clinicians are now using Arabic numbers, Wollheim said.

3 — Pay attention to the healing rate of wounds

Nurses caring for a patient’s pressure injuries will want to monitor how quickly a wound is healing.

“We want a wound to heal as quickly as possible,” he said. “The goal is to see a wound reduce in its size by 50% (in length and width) within three to four weeks of initiating treatment,” Wollheim said.

So what if a wound isn’t healing as quickly as expected? At that point, a change in treatment should be considered.

4 — Use TCOM to predict who will likely respond to hyperbaric treatment

A new trend in wound care is the use of transcutaneous oximetry, also known as TCOM.

If the TCOM level is at 30, there is a good chance a wound won’t heal, according to Wollheim. But if the TCOM is 40 or higher, the wound likely will respond to hyperbaric oxygen therapy.

5 — Educate colleagues, as needed

When knowledgeable and certified wound care clinicians encounter an order for the wrong materials or treatment — or see a colleague practicing an outdated or unproven practice — be proactive in educating them, Wollheim said.

“When differences arise, it’s best to approach an ordering clinician or colleague in a non-judgmental and collaborative way,” he said. “You’ll likely get less resistance, and the other person may realize they can learn something from you.”

Another approachable method to help healthcare team members learn about wound care is to schedule lunch-and-learn webinars or educational sessions. These often can be provided by company reps for the various products used in your organization.

Promoting wound care dialogue also can be accomplished with monthly patient care meetings with all disciplines involved in wound care is another way to encourage a dialogue.

For example, ordering physicians, nurses, physical therapists, dietitians and even assistive personnel can be on-hand to collaborate with staff such as:

  • Discussing current treatment approaches
  • Making suggestions if something is not working
  • Ensuring everyone is using the same terminology

6 — Ensure everyone knows how to use new products

Changing from one brand of a wound care product to another can involve different sets of instructions for the use of each new product.

“Anytime you change brands, you need to make sure all staff know how to use the new products,” he said. “This may require an in-service to make sure all staff are on the same page and using the current products correctly — as the manufacturer intended — to achieve the best outcomes for patients.”


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