Introduction

Mucosal membrane pressure injuries are device-related pressure injuries (DRPI) of the mucous membrane.1 These hospital-acquired injuries are generally considered preventable.2

Incidence and Prevalence

The incidence and prevalence of mucosal membrane PIs are reported as relatively low, but these injuries are more common in the intensive care unit (ICU) than in acute hospital care. One study reported an incidence of hospital-acquired mucosal membrane PIs of 0.1% in a non-ICU setting and an incidence of 2.4% in the ICU.3 Tube-based life support devices used in the ICU may cause oral and nasal mucosal membrane PIs.4 In the acute hospital setting, indwelling urinary catheters raise the risk of urethral erosion and infection.5

Etiology

Mucosal membrane pressure injuries are caused by local ischemia secondary to the use of medical devices such as2,3:

Endotracheal or nasogastric tubes
Oxygen cannulas or masks
Urinary or fecal containment devices

Presentation

Mucosal membrane PIs manifest differently from PIs of the skin.2 The erythema present in stage 1 pressure injuries is not visible in a mucosal membrane PI, nor is wound depth, because of the anatomy of the tissue, but pain and swelling are present.6 To complicate assessment further, mucosal membrane PIs often bleed, leading to blood clots, or coagulum, which resemble the yellow, loosely adherent look of slough in the wound bed.2,6,7 Because of the anatomic properties of mucosal tissue, the National Pressure Injury Advisory Panel classifies these injuries as unstageable.1,6

Risk Factors

Risk factors for mucosal membrane PIs can include a combination of medical devices, the care setting, medications, and/or a patient’s individual characteristics. Specific to oral mucosal membrane PIs, risk factors include the ICU setting, endotracheal tube holder use, patient immobility, undernutrition, and corticosteroid use.8

Because of the higher incidence of these injuries in the ICU, this setting is considered a separate risk factor.3 In both ICU and acute hospital care, medical devices such as endotracheal and gastric tubes increase the risk of nasal or oral mucosal membrane PIs,4 and indwelling urinary catheters raise the risk of urethral erosion and infection.5

Patient-related risk factors for nasal mucosal membrane PIs include a high Acute Physiology and Chronic Health Evaluation II score, cognitive disorders, diabetes, hypoproteinemia, fever, and vasoconstrictor use.4

An additional risk factor for mucosal membrane PIs in ICU patients is COVID-19, as a result of patient immobility, sedation, vasopressor use, and hypoxia.9

How Much Do You Know About Pressure Injury Prevention? Take our quiz to find out! Click here.

Clinical Implications

The adverse effects of a mucosal membrane PI extend far beyond the wound itself. For example, the pain of oral PIs can interfere with a patient’s ability to eat adequately, and urinary devices can lead to urinary tract infections2 or urethral injury.5 Patients who acquire mucosal membrane PIs are usually very ill, and the addition of a mucosal injury increases their already heavy burden of illness.2

Management

The British Columbia Provincial Nursing Skin & Wound Committee recommended using the following protocol, when possible, to manage mucosal membrane PIs10:

Examine the mucosa under and adjacent to medical devices twice per shift or more often.
Ensure that medical-related devices are the correct size.
Reposition medical devices as needed.
Refer the patient to the appropriate health care professional to help with medical device fitting, if needed.

Prevention

Prevention includes meticulous assessment and ongoing monitoring of at risk tissue adjacent to or under devices, checking for issues with device placement and securement, and the use of stabilizing devices to reduce pressure.2,11

Staff education is also a vital component of mucosal membrane PI prevention. In patients at risk, nursing staff must know what to look for, such as poorly secured endotracheal tubes, urinary catheters that are pulling, or food avoidance related to oral pain.2 In long-term care settings, an effective tool for staff education is the use of regular device-related rounds, to ensure appropriate device placement and assess the integrity of patients’ vulnerable tissues.11

Conclusion

Mucosal membrane PIs can cause morbidity in patients who are already seriously ill. As with all PIs, prevention of mucosal membrane PIs is the goal.

References

Hess CT. Classification of pressure injuries. Adv Skin Wound Care. 2020;33(10):558-559. doi:10.1097/01.ASW.0000697324.90597.6d
Lazarevski L. Putting money where your mouth is: a refresher on mucosal medical device–related pressure injuries. WoundSource. 2020. Accessed September 28, 2023. https://www.woundsource.com/blog/putting-money-where-your-mouth-refresh…
Fulbrook P, Lovegrove J, Butterworth J. Incidence and characteristics of hospital-acquired mucous membrane pressure injury: a five-year analysis. J Clin Nurs. 2023;32 (13-14):3810-3819. Accessed September 28, 2023. https://onlinelibrary.wiley.com/doi/10.1111/jocn.16473
Nan R, Su Y, Pei J, Chen H, He L, Dou X, Nan S. Characteristics and risk factors of nasal mucosal pressure injury in intensive care units. J Clin Nurs. 2023;32(1-2):346-356. Accessed September 28, 2023. https://onlinelibrary.wiley.com/doi/10.1111/jocn.16193
Woodmansee BK, Anderson JA. Medical device-related pressure injury due to urinary catheterization: a case report. Wound Manag Prev. 2022;68(12):5-9. Accessed September 28, 2023. https://www.hmpgloballearningnetwork.com/site/wmp/case-report/medical-d…
Edsberg LE, Black JM, Goldberg M, McNichol L, Moore L, Sieggreen M. Revised National Pressure Ulcer Advisory Panel pressure injury staging system: revised pressure injury staging system. J Wound Ostomy Continence Nurs. 2016;43(6):585-597. Accessed September 30, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098472/
Fulbrook P, Lovegrove J, Butterworth J. Incidence and characteristics of hospital-acquired mucous membrane pressure injury: A five-year analysis. J Clin Nurs. 2022; https://onlinelibrary.wiley.com/doi/full/10.1111/jocn.16473
Choi BK, Kim MS, Kim SH. Risk prediction models for the development of oral-mucosal pressure injuries in intubated patients in intensive care units: a prospective observational study. J Tissue Viability. 2020;29(4):252-257. Accessed September 28, 2023. https://www.sciencedirect.com/science/article/abs/pii/S0965206X20300802
Singh C, Tay J, Shoqirat N. Skin and mucosal damage in patients diagnosed with COVID-19: a case report. J Wound Ostomy Continence Nurs. 2020(5):435-438. Accessed September 28, 2023. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7722287/
British Columbia Provincial Nursing Skin & Wound Committee guideline: assessment and treatment of pressure injuries in adults & children. Connecting Learners With Knowledge. 2018. Accessed September 30, 2023. www.clwk.ca/get-resource/pressure-injury-guideline
Hovan HM. Medical device–related pressure injury: creating a culture of prevention. WoundSource. 2019. Accessed September 28, 2023. https://www.woundsource.com/blog/medical-device-related-pressure-injury…

Introduction

Offloading is a cornerstone of pressure injury (PI) prevention. Certain patient populations, conditions, and environmental or institutional factors pose challenges to effective offloading that providers must mitigate to prevent PIs. It is important to note that these challenges often overlap with other complication risk.

Wheelchairs

Patients who use wheelchairs have limited mobility and may have altered sensory perception that renders them unaware of the effects of increased temperature and moisture caused by prolonged wheelchair contact.1

Tips: Use pressure redistribution surfaces such as specialized cushions or even specialized wheelchairs.1 Clinical practice guidelines recommend the patient reposition every 15 minutes to an hour,2 and recommend limiting wheelchair use to 2 hours at a time.3 These repositioning techniques can include vertical push-ups and lateral and forward leans. Providers can use sensors to detect pressure at various points of contact and send an alert for a position change.4

Spinal Cord Injury

The reported incidence of PIs in patients with spinal cord injury is very high, 25% to 66%.1 Risk factors include5:

Immobility
The absence of sensation
Decreased soft tissue resilience
Impaired blood flow response
Smoking
Urinary incontinence
Lack of adequate nutrition

Tips: Educate the patient about ways to offload pressure, and encourage self-management as much as possible.5 To restore blood flow to tissues, many guidelines recommend weight shifts if the patient is sitting for a prolonged amount of time. Providers and caregivers should reposition the patient in supine and lateral postures. Clinicians should use advanced technology such as pressure sensor systems or other objective monitoring systems to ensure that pressure-relieving activities are occurring as needed.5-6

Neonates

Infants in neonatal intensive care units (NICUs) have a higher frequency of PIs than older pediatric patients.7 The nose is particularly predisposed to PI in these patients.7

Tips: Use a pressure redistribution surface or positioner as needed.8 Although evidence is limited, surveyed NICU nurses recommended using a rolled blanket and a small soft object, neonatal mattress overlays, sheepskin, or foam.8 A literature review identified the use of appropriate support surfaces and frequent turning as effective offloading measures.9

Immobility

Immobility may lead to functional decline and is a major risk factor for PIs.3 Older adults are especially vulnerable to the effects of immobility and often have contributing comorbidities.10 In some long-term care facilities, patients are confined to a bed to avoid falls, but this increases PI risk, as does prolonged sitting.3

How Much Do You Know About Pressure Injury Prevention? Take our quiz to find out! Click here.

Tips: Reposition bedridden patients every 2 hours or per facility protocol.2 Avoid friction or shear when moving patients 2 Consider an alternating air mattress.2 Offload heels and other at-risk areas.9 For ambulatory patients with limited mobility, encourage movement as much as possible.3

Bedding and Clothing

Bedding can be a source of pressure when a patient is positioned or turned improperly, thus creating friction and shear.2 Ill-fitting shoes can create pressure on the toe, leading to serious foot problems, especially in diabetic patients.11

Tips: Use proper positioning and turning techniques (lift rather than drag) when moving patients in bed, and reposition every 2 hours.12 Offload heels, and place a pillow between a patient’s knees.13 Ensure that diabetic patients consult a podiatrist to evaluate and prescribe appropriate footwear or orthotics, such as metatarsal additions, apertures, and arch profiles, to offload plantar pressure.11

Staffing and Resource Issues

Health care staff shortages are an ongoing problem affecting all aspects of patient care, especially since the COVID-19 pandemic.14 Digital decision clinical support tools have been proposed to ease the effects of understaffing, but uptake of these tools so far has been limited.14

As for resource allocation, a large study of hospital-acquired PIs determined how cost-effective PI prevention is and that hospitals should invest in nursing staff to enable compliance with PI prevention guidelines.15 Another study found that the cost savings to the health care system after implementing a PI prevention program were statistically significant.16

Tips: Advocate for making offloading a priority in your facility. Assess staffing and resource availability, and create an effective protocol within that framework.

Conclusion

With vigilance and proven offloading techniques, PIs may be prevented, even in patients with challenging conditions or predisposing circumstances.

References

Razmus I. Wheelchairs and pressure injuries: what do we know? WoundSource. 2019. Accessed October 2, 2023. https://www.woundsource.com/blog/wheelchairs-and-pressure-injuries-what…
Pressure injuries. Johns Hopkins Medicine. Accessed October 2, 2023. https://www.hopkinsmedicine.org/health/conditions-and-diseases/pressure…
3 common patient challenges associated with pressure ulcers/injuries. Practice Accelerator. WoundSource. 2017. Accessed October 3, 2023. https://www.woundsource.com/blog/3-common-patient-challenges-associated…
Tavares C, Domingues MF, Paixão T, Alberto N, Silva H, Antunes P. Wheelchair pressure ulcer prevention using FBG based sensing devices. Sensors (Basel). 2019;20(1):212. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6983175/
Brienza DM, Campbell KE, Sprigle S. The past, present, and future of pressure injury prevention in patients with spinal cord injury. Adv Skin Wound Care. 2022;35(2):84-86. https://journals.lww.com/aswcjournal/Fulltext/2022/02000/The_Past,_Pres…
Fryer S, Silvia C, Major D, Bader DL, Worsley PR. Continuous pressure monitoring of inpatient spinal cord injured patients: implications for pressure ulcer development. Spinal Cord. 2023; 61: 111-118. https://www.nature.com/articles/s41393-022-00841-7
Razmus I. Neonatal pressure injury prevention. WoundSource. 2020. Accessed October 2, 2023. https://www.woundsource.com/blog/neonatal-pressure-injury-prevention
Razmus I. Repositioners or redistribution surfaces for neonates. WoundSource. 2022. Accessed October 2, 2023. https://www.woundsource.com/blog/repositioners-or-redistribution-surfac…
Cummins KA, Watters R, Leming-Lee T’. Reducing pressure injuries in the pediatric intensive care unit. Nurs Clin North Am. 2019;54(1):127-140. https://www.sciencedirect.com/science/article/abs/pii/S0029646518300963…
Jaul E, Barron J, Rosenzweig JP, Menczel J. An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatr. 2018;18(1):305. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6290523/
Collings R, Freeman J, Latour JM, Paton J. Footwear and insole design features for offloading the diabetic at risk foot-A systematic review and meta-analyses. Endocrinol Diabetes Metab. 2020;4(1):e00132.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7831212/
Turning and positioning for pressure injury prevention. Practice Accelerator. WoundSource. 2022. Accessed October 2, 2023. https://www.woundsource.com/blog/turning-and-positioning-pressure-injur…
Wolfson J. Making a daily difference in preventing pressure injuries. 2017. WoundSource. Accessed October 3, 2023. https://www.woundsource.com/blog/making-daily-difference-in-preventing-…
Lapp L, Egan K, McCann L, Mackenzie M, Wales A, Maguire R. Decision support tools in adult long-term care facilities: scoping review. J Med Internet Res. 2022 Sep 6;24(9):e39681. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9490521/
Padula WV, Pronovost PJ, Makic MBF, et al. Value of hospital resources for effective pressure injury prevention: a cost-effectiveness analysis. BMJ Qual Saf. 2019;28(2):132-141. https://qualitysafety.bmj.com/content/28/2/132
Singh C, Shoqirat N, Thorpe L. The cost of pressure injury prevention. Nurse Leader. 2022;20(4):371-374. https://www.nurseleader.com/article/S1541-4612(21)00256-1/fulltext

Introduction

Pressure injuries (PIs) often result from sustained pressure and shear on skin and local tissue. As a result, patient position, posture, and load bearing are integral factors to consider to alleviate such forces. A better understanding of the biomechanics of these factors may assist clinicians and scientists in identifying and addressing biomechanical risk factors for pressure injury. As a result, research and design improvement of medical equipment could contribute to preventing device-related pressure injuries DRPIs,1 and clinicians may have better insights into high-risk areas for skin injury.

Why Do Pressure Injuries Occur from a Biomechanical Perspective? 

Epidemiologically and based on anatomic and biomechanical function, PIs in adults are often at the heels, sacrum, or ischial tuberosities.1 These locations of injury are in part due to the mechanics associated with prolonged supine or sitting positions. When a patient is placed in these positions for long periods, these bony prominences take on more pressure. Conversely, thinking about the body mechanics of a neonate, looking at body habitus and function as it relates to typical positioning, the head is more prominent, and therefore the occiput is more typically involved in PI development.1 Other mechanical factors that contribute to pressure injury risk include:

Mobility
Contracture
Spasticity

Spasticity is a patient’s ability to move within that position to naturally offload high-risk spots. Can they shift their weight from side to side, or can they roll over on their own? If not, how can clinicians assist effectively, and/or what devices are available in the facility that may support offloading?

What Recent Literature Points Out

Computer-aided analysis and modeling have been studied concerning the impact of biomechanics on pressure injuries. Gefen found that computerized biomechanical modeling showed that atypical foot anatomy, specifically a sharp posterior calcaneus and thin, soft tissue padding, predicted risk for pressure injury.2 Combining this factor with potential loss of mobility (less ankle range of motion) and a patient’s natural heel position (which part of the heel contacts the bed or chair), one can logically see how biomechanics can provide valuable information in preserving skin integrity.

Biomechanical Assessment

Experts also add that glycosylation of tissues and tissue flexibility changes related to diabetes or other conditions can play a role in altering a patient’s biomechanics, thus placing them at risk for skin breakdown and pressure injury.3 Thought leaders advocate for a biomechanical examination starting with a wound’s initial presentation, and in high-risk patients, even before a wound develops.

“Their biomechanical history is extremely important to look at: the tissue flexibility, the presence of hallux limitus, posterior tibial problems, bunions, hammertoes, all the malformations that the foot takes on over a lifetime,” said James McGuire, DPM, PT, CPed, CWS, FAPWCA, and a Professor in the Department of Podiatric Medicine and Biomechanics at Temple University School of Podiatric Medicine.3

How Much Do You Know About Pressure Injury Prevention? Take our quiz to find out! Click here.

For the lower extremity, a full assessment of gait, stance, range of motion, and deformities, among other factors, is important to identify how a patient functions and how these factors relate to incurring pressure, friction, or shear forces. As with other areas of the body, this pressure can come from sources such as:

Clothing (shoe or sock wear)
Bedding
Walking surface
Resting surfaces (chair or bed)
Medical devices (casts, walking boots, or prosthetics)

A biomechanics specialist related to the area of concern could be a wise referral for a patient at risk. This referral could include a podiatrist for lower extremity concerns or a physical therapist.

Perioperative Repositioning

In the perioperative arena, positioning is a vital component of a procedure’s success. However, the patient’s body mechanics, or limitations thereof, can pose challenges and increased risk for pressure injury. An operating room does not offer the same forms of positioning adaptations as other clinical settings.

An optimal perioperative position for a patient may be a compromise arrived upon by weighing the needs for adequate surgical access and visualization with the resultant pressures exerted by the operating table, anesthesia, other medical devices, and safety equipment utilized.4 The most commonly used position is supine, which has multiple variations.

Considering the biomechanical impact of these position changes may shed light on pressure injury risk. For instance, if a gel roll is used to hyperextend the neck, allowing better access to the chest, the posterior neck is at higher risk for PI.4 Each mechanical positioning schematic carries different functional and pressure-related challenges. However, proper preoperative evaluation techniques and use of appropriate positioning devices are just a few ways that clinicians can use biomechanics to alleviate these challenges. Gefen and team performed a scoping review that stressed the multi-pronged biomechanical approach to protecting tissue in the operating room.4

Conclusion

Biomechanics as it relates to wound development, including pressure injury, is an area in need of continued research. Most of the current literature focuses on soft tissue mechanics from the point of view of how these structures function under tension or stretch. Whereas, in the wound care world, clinicians need to know how these structures function under compression.5 However, by incorporating a biomechanical point of view into one’s evaluation of patients at risk of pressure injury, clinicians may be able to discern new and helpful actionable information to work toward prevention.

References

Levy A, Kopplin K, Gefen A. Device-related pressure ulcers from a biomechanical perspective. J Tissue Viability. 2017;26(1):57-68.
Gefen A. The biomechanics of heel ulcers. J Tissue Viability. 2010;19(4):124-131.
Suzuki K, McGuire J. Biomechanics in wound care. Podiatry Today Podcasts. Published May 1, 2023. Accessed October 25, 2023. https://www.hmpgloballearningnetwork.com/site/podiatry/podcasts/biomech….
Gefen A, Creehan S, Black J. Critical biomechanical and clinical insights concerning tissue protection when positioning patients in the operating room: a scoping review. Int Wound J. 2020;17(5):1405-1423.
Jan Y-K, Major MJ, Pu F, Sonenblum SE. Editorial: soft tissue biomechanics in wound healing and prevention. Front Bioeng Biotechnol. 2022:10. https://doi.org/10.3389/fbioe.2022.897860.

Understanding and Preventing Medical Device-Related Pressure Injury from HMP on Vimeo.

Transcript

Hello, my name is Kelly McFee. I am a family nurse practitioner and wound care provider at Mosaic Life Care. I’m also the director of wound care for Mosaic Health System.

What are some common types of medical equipment that can lead to medical device-related pressure injuries (MDRPIs)? 

There’s actually a lot of different medical equipment that we see in relation to medical device-related pressure injuries. Probably the most common types of devices that we see are respiratory devices. And we really saw this a lot with COVID and we’re seeing it more as we’re getting closer to the cold weather months where we’re seeing more respiratory illnesses.

So things like, you know, nasal cannulas, for example, endotracheal tubes, oxygen masks, BIPAPs, CPAPs, things that are more fixed to the patient’s face to provide oxygen. And then of course there’s other options as well because we know there’s a whole host of medical devices.

We see orthopedic devices. Patients on our ortho -neuro floor may have splints or other kind of orthopedic devices after surgical procedures. And then of course, you know, most patients come in and they have, you know, an IV or they might have like a foley catheter. So we have seen medical device related pressure injuries related to just standard devices such as a foley and maybe it wasn’t positioned well and it causes some issues with that as well. So, all kinds of different devices related with medical device related pressure injuries.

What are the primary factors that contribute to MDRPI?

It’s just the fact that there is a medical device in play. And so we have to be really cognizant that having that medical device on the patient is adding an extra risk factor to that patient’s care.

When we have those medical devices, then we’re educating our nursing staff and our caregivers here in the hospital that we have to make sure that we’re looking at the skin and underneath those medical devices so making sure that things fit well and that we’re doing a routine skin assessment underneath those devices. So really it’s just the fact that the device is there and we have to be cognizant that that is a risk factor.

What measures can clinicians take to prevent MDRPIs, specifically those caused by oxygen delivery devices?

We work really closely with our respiratory team, number one to make sure that everybody is well-educated and the use of respiratory devices. So making sure that respiratory devices fit well, making sure that they’re being applied correctly, and then making sure that we have alternatives when appropriate because maybe it’s not necessarily appropriate for every patient given the circumstances.

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But having the option to be able to swap out every once in a while so that’s something that we’ve actually been working on as an organization. Maybe the patient has the ability and has the respiratory status to be able to alternate from let’s say a nasal cannula to an oxygen mask and we try to alternate those every 2 to 3 hours depending on the circumstances.

Or making sure that the BIPAP mask fits appropriately and we’ve also been looking into changing the kind of masks that we have so that we have a couple different alternatives that we can utilize. Maybe one that is like our standard BIPAP mask but then something that we can change it out with that doesn’t apply pressure in the same places at all times. Just making sure that things fit well and that everybody understands how to utilize those especially for respiratory purposes.

What should wound care professionals look for with respect to regular device maintenance and inspection to prevent MDRPIs?

So there’s a lot of parts to that question and I think the wound care piece is different than maybe looking at device maintenance. For example when we’re talking about respiratory equipment, our respiratory team probably takes control of making sure that the respiratory equipment is well maintained.

So our respiratory team and then of course our bio med folks. So, those are the people that are in charge of making sure that respiratory equipment is working well. But as a wound care clinician, I’m making sure that areas that look like they’re high friction areas or high pressure areas are going to be prevented and that they’re being assessed on a regular basis.

So we have medical device related pressure injury prevention protocols that we utilize. We actually utilize prophylactic foam dressings when appropriate. And so we work together with those team, maybe not with bio med per se, if they’re looking at, doing PM and preventing a maintenance on our on our equipment, but we’re working with respiratory staff to make sure that we’re all identifying and regularly assessing to make sure that we’re implementing medical device related pressure injury prevention protocols when appropriate for those patients.

So they’re checking out the equipment and then we’re making sure that we’re using the preventative protocols.

What other tools or strategies can clinicians implement to prevent these injuries in patients using medical devices?

We have fairly robust pressure injury prevention protocols in place and then especially for medical device related pressure injury prevention protocols. And we do use a bunch of different tools. Respiratory has, you know, their toolbox of things that they like to use to prevent pressure with their respiratory devices. But then we also use prophylactic foam dressings.

Back in COVID, we put together prone packets. So we had packets of prophylactic dressings that we like to use, let’s say for a COVID patient, because that’s when we develop these. So we would pressure proof our patient, let’s say for COVID, they would pad them all up at anterior pressure points, but then they would also go back through and make sure that they’re using prophylactic dressings like on the face so on the across the cheeks across the forehead the bridge of the nose and the chin. We just kind of put these packages all together so they were easy grab packs and they could hit everything at one time and make sure that they were all padded up for the prone position.

We still educate the same way. So even if it’s a standard patient who’s going to be an ICU and they’re not prone, maybe they were a trauma patient, we still have these tools available for those patients that are going to have high -risk devices so everything is still available. It’s still the same kind of education, but they’re just not being prone, so we’re still educating that we need to utilize prophylactic dressings underneath the edge of dressings or maybe it’s just someone who’s going to have a nasal cannula so we’re educating that you can actually wrap the tubing with a prophylactic foam dressing to protect behind the ears. Still the same thought process.

We still work with a multidisciplinary approach, it just depends on what medical devices we’re looking at. We also work very closely with you know orthopedic surgery team and the trauma team when we’re working with our ortho patients that have those extra devices on the ortho neuro unit. We’re still looking for ways that we can work with those devices, and it might be that we’re having to have caregivers call and ask “can I remove this for a period of time to do a skin check and then put it right back on?” It’s always a work in progress, but it involves a lot of skin assessment.

If a patient does develop a MDRPI, what are some of the next steps?

Honestly, it’s interesting because we do a lot of the same treatments, depending on the severity of the pressure injury, that we use to prevent. If we didn’t prevent , we’re still use a lot of foam dressings depending on the level. Certainly, it also depends on the location. The wound care team is involved throughout the process. Let’s say we’ve developed a stage II or a stage III in a particular area, we’re managing exudate, we’re still trying to manage pressure because certainly offloading or being able to get rid of that medical device is going to be key moving forward to trying to help with that healing process. But it is always a little bit of a struggle, of course, if we have developed a MDRPI, because how long are we are going to have to utilize that particular medical device? So, it’s a case -by -case basis. Certainly, we’re utilizing that multi -disciplinary team approach to figure out what the best case is moving forward for that patient.

Can you share an example of when interventions successfully prevented or managed a MDRPI?

We see patients in the ICU develop on occasion pressure injuries of the mucosa related to endotracheal tubes. And I think that one is a struggle at times because you need to maintain a patent airway. And so then you’ve got the endotracheal tube there. And that one is always a struggle for us. But providers should get that respiratory team involved and make sure that the endotracheal tube is the correct size. There’s actually a pathway that Joint Commission recommends for managing devices.

But anyway, we get respiratory team involved and they’re making sure that it’s the correct fit. And then they’re managing that endotracheal tube. Sometimes we can move things around a little bit and we can manage to securement my devices a little bit better so that you can get those mucosal pressure injuries to heal up pretty quickly.

About the Speaker

Kelly McFee, DNP is a Board-Certified Family Nurse Practitioner, Certified Wound Specialist and Advanced Practice Certified Wound Care Nurse who has been practicing Wound Care and Hyperbaric Medicine in Northwest Missouri. She received a BSN from Missouri Western State University, MSN from the University of Missouri – Kansas City, and DNP from the University of South Alabama. Kelly serves as the Director of Wound Care for Mosaic Life Care and practices wound care both in the acute care and outpatient settings. She is an active member of the American Professional Wound Care Association, Association of Advancement of Wound Care, and the Wound, Ostomy and Continence Nurses Society. She serves on the Board of Directors for the American College of Clinical Wound Specialists and will be serving the college as the Chair-elect in 2022. She is also a member of the Prophylactic Dressing Standards Initiative, a joint collaboration between the NPIAP and EPUAP.