Pressure Injury Prevention
We're on a journey to zero. Come walk with us! Click the start button
Start
Objectives Activities
1) Pre-Quiz 2) I spy! Click the hot spots 3) Pillow placement pandemonium 4) What's the skkin-y? 5) T.U.B.E.S 6) Quiz time
1) Identify the care team member's roles in pressure injury prevention 2) Identify correct positioning of: -Devices -Patients 3) Identify at least 2 pressure injury prevention strategies.
What are the care team member's roles in pressure injury prevention
Follow the institutional pressure injury prevention policy Communicate barriers to care to the healthcare team Participate in learning opportunities regarding pressure injury prevention
Maine Medical Center has a skin care committee with a focus on preventing pressure injuries. This committee is run by the MMC-P wound nurses. Click the red dot to see them:) The skin team collects pressure injury data the third Tuesday of every month The data is used for internal and external benchmarking. Please assist the team with assessing patients on this day by: Having supplies at the bedside Staying in the room to help with incontinence care
Skin Care Committee & "Skin Day" or "Data Day"
A each unit has a skin representative. Know who your rep is. They are a great resource regarding pressure injury prevention.
Skin assessments
Hospital policy should be followed for the frequency of skin/ physical reassessments:Med/surg q12 IMC q6 ICU q4 hrs Click on the blue plus signs for more information
ANA's Principles of Nursing Documentation
"Documentation should be accurate, valid, and complete. It should be authenticated, that is, the information is truthful and the author is identified." Click on the blue plus signs for more information.
Greetings & Assessments
A 4-eyed skin inspection is to be done on admission and transfer. Introduce yourself and explain to the patient what you are there for: "Hello Mr. Thomas, we are here to look at your skin. It should only take a few minutes. We want to ensure you do not have any wounds or pressure injuries. Consider using the term "bedsores" as most people know this term.
Starting with the elbows and the ears is recommended. It's non threatening and easy to do. Prepare them for all the sites you will inspect. Maintain patient privacy.
Using your Maine Medical Center Rover device, take a photo of any areas you are concerned about. Discuss wounds with the provider team. For chronic, stable wounds, the provider should reconcile the outpatient treatment tplan
Blanching erythema
Blanching erythema is redness that turns pale when pressed. This is a warning sign of pressure. Offload the area.Click the plus signs for more info.
You can use the photograph, gif or illustration you want to give life to the multimedia content.
Non-blanching
Nonblanching redness is a stage 1 pressure injury. When the pressure is relieved, the area will return to normal. Ongoing pressure will result in further injury. When this stage is missed, a deep tissue injury can result, which is an advanced pressure injury. This is why frequent and thorough assessments are very important. Off load the pressure and reassess after 1 hour to see if it still does not blanch. If it does not, this is to be "counted" as a stage 1 pressure injury.
A pressure injury can develop over a period of 1-2 hours if pressure is not relieved.
Slide the bar to see the area evolve from a stage 1 to a deep tissue injury. Assessing this skin according to policy should help catch pressure injuires in the earlier stages. Missing or omitting an assessment can lead to a worsening pressure injury
Pre-Quiz!
1/2
2/2
Activity 1: I Spy
Devices place the patient at risk. Click on the hot spots to learn more about device- related pressure injuries.
Activity 1: I Spy
Consider using this sensor instead:
This fold-over sensor evenly distributes pressure over a larger surface area, creating less pressure and has a lower incidence of pressure injuires particularly in the ICU areas
Incorrect Device Placement
Ear probes should be applied according to the manufacturer's guidelines. This device is not meant for the earlobe or nose
Correct Device Placement
Applying the device correctly can help prevent pressure injuries. Rotate the device with every turn i.e q 2 hours or more frequently. Avoid turning the patient on the side the device is on. If your patient is right side facing, place the device on the left ear and visa versa.
Click here
Mucosal Pressure Injuries
Nasal bridles can cause mucosal injuries to the nares. Keep the bridle in neutral position. Readjust the bridle or remove it to relieve the pressure. If using tape to secure the tube, re-tape q shift and prn.
Click on the hot spots for other other areas of consideration.
Activity 2: Pillow Pandemonium
Pillows are an important tool to help offload the heels.Pillows are available in a variety of thicknesses. Use as many as you need to ensure the heels are "floated" This means the heels are suspended in air and not touching the pillow or bed.
This is not ideal. The heels are sitting directly on the bed causing pressure. The popliteal space is also not supported when the pillow is horizontal.
This is ideal. No pressure on heels. Pillow is thick enough to offload and it is placed lengthwise
Activity 2: Pillow Pandimonium
Pillows are an important tool to help offload the heels.Pillows are available in a variety of thicknesses. Use as many as you need to ensure the heels are "floated" This means the heels are suspended in air and not touching the pillow or bed. click on the blue plus signs
This is not ideal. The heels are sitting directly on the bed causing pressure. The popliteal space is also not supported when the pillow is horizontal.
This is ideal. No pressure on heels. Pillow is thick enough to offload and it is placed vertically
Click here
Effective Turns: Click the circles for more info
- Place wedge behind back and thigh
Click here
You try! Click near the patients back and thigh to properly place the 2 wedges! Keep clicking near those areas until you see 2 blue wedges appear:)
You know your patient is in an effective turn when you walk in the room and you can tell which way he/she is facing. If it is not clear, they are not in an effective turn.
link
Activity-3: What's the SKKIN-Y?
EPIC makes charting easy. Pressure injury prevention intervetions are built right in. Hover over the buttons and + for more info
If a patient's Braden score is less than 19, they are at risk for a pressure injury
S K K I N click here for more tips
Q 2 hour turns is expected for at risk patients
Incontinence Care
Normal skin is slightly acidic. The combination of urinary and fecal incontinence raises the pH by converting urea to ammonia, placing the patient at risk for skin breakdown and secondary infection.Use dri flow pads to wick moisture. Dri flows are air permeable and wick away moisture from the skin by absorbing 1,000 cc of fluid! Consider placing a dri flow vertically and bringing it up between the patients legs to absorb urinary incontinence rather than using a brief. Go to the wound care resource site and view the incontinence page for more information.
Zinc paste is great for loose stool/fecal incontinence. Wipe off the outer layer. Apply it nickel thick.
Zinc ointment goes on clear. It's great for urinary incontinence and protects while maintaining visibility of the skin
Fecal Managment Systems
This is a device for sedated, bedridden patients with loose stool not managed by other means. It is contraindicated in GI bleeds, rectal surgery, injury or impairment. See policy.
T.U.B.E.
Patients can acquire a mucosal pressure injuries from these tubes. Here are some things to consider: T. Tight tubes cause pressure. Create slack to prevent it from pressing on the fagile mucosa U. Unblock kinks or folds in the tubing especially near anus B. Bulking agents can thicken stool. Consider this and other antidiarrheals if appropriate E. Evaluate necessity q shift
When full, the bags can be exchanged .
Thank you for being part of the MMC-P care team and prioritizing pressure injury prevention.Please go to the next page to click on the link to complete the quiz. Thank you!
+ info
CERTIFICATEACHIEVEMENT
of
Please complete the QUIZ by clicking on the link below. The link will bring you to microsoft forms with additional instructions. Thank you!
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Pressure Injury Prevention
Tricia Foley
Created on October 8, 2025
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Transcript
Pressure Injury Prevention
We're on a journey to zero. Come walk with us! Click the start button
Start
Objectives Activities
1) Pre-Quiz 2) I spy! Click the hot spots 3) Pillow placement pandemonium 4) What's the skkin-y? 5) T.U.B.E.S 6) Quiz time
1) Identify the care team member's roles in pressure injury prevention 2) Identify correct positioning of: -Devices -Patients 3) Identify at least 2 pressure injury prevention strategies.
What are the care team member's roles in pressure injury prevention
Follow the institutional pressure injury prevention policy Communicate barriers to care to the healthcare team Participate in learning opportunities regarding pressure injury prevention
Maine Medical Center has a skin care committee with a focus on preventing pressure injuries. This committee is run by the MMC-P wound nurses. Click the red dot to see them:) The skin team collects pressure injury data the third Tuesday of every month The data is used for internal and external benchmarking. Please assist the team with assessing patients on this day by: Having supplies at the bedside Staying in the room to help with incontinence care
Skin Care Committee & "Skin Day" or "Data Day"
A each unit has a skin representative. Know who your rep is. They are a great resource regarding pressure injury prevention.
Skin assessments
Hospital policy should be followed for the frequency of skin/ physical reassessments:Med/surg q12 IMC q6 ICU q4 hrs Click on the blue plus signs for more information
ANA's Principles of Nursing Documentation
"Documentation should be accurate, valid, and complete. It should be authenticated, that is, the information is truthful and the author is identified." Click on the blue plus signs for more information.
Greetings & Assessments
A 4-eyed skin inspection is to be done on admission and transfer. Introduce yourself and explain to the patient what you are there for: "Hello Mr. Thomas, we are here to look at your skin. It should only take a few minutes. We want to ensure you do not have any wounds or pressure injuries. Consider using the term "bedsores" as most people know this term.
Starting with the elbows and the ears is recommended. It's non threatening and easy to do. Prepare them for all the sites you will inspect. Maintain patient privacy.
Using your Maine Medical Center Rover device, take a photo of any areas you are concerned about. Discuss wounds with the provider team. For chronic, stable wounds, the provider should reconcile the outpatient treatment tplan
Blanching erythema
Blanching erythema is redness that turns pale when pressed. This is a warning sign of pressure. Offload the area.Click the plus signs for more info.
You can use the photograph, gif or illustration you want to give life to the multimedia content.
Non-blanching
Nonblanching redness is a stage 1 pressure injury. When the pressure is relieved, the area will return to normal. Ongoing pressure will result in further injury. When this stage is missed, a deep tissue injury can result, which is an advanced pressure injury. This is why frequent and thorough assessments are very important. Off load the pressure and reassess after 1 hour to see if it still does not blanch. If it does not, this is to be "counted" as a stage 1 pressure injury.
A pressure injury can develop over a period of 1-2 hours if pressure is not relieved.
Slide the bar to see the area evolve from a stage 1 to a deep tissue injury. Assessing this skin according to policy should help catch pressure injuires in the earlier stages. Missing or omitting an assessment can lead to a worsening pressure injury
Pre-Quiz!
1/2
2/2
Activity 1: I Spy
Devices place the patient at risk. Click on the hot spots to learn more about device- related pressure injuries.
Activity 1: I Spy
Consider using this sensor instead:
This fold-over sensor evenly distributes pressure over a larger surface area, creating less pressure and has a lower incidence of pressure injuires particularly in the ICU areas
Incorrect Device Placement
Ear probes should be applied according to the manufacturer's guidelines. This device is not meant for the earlobe or nose
Correct Device Placement
Applying the device correctly can help prevent pressure injuries. Rotate the device with every turn i.e q 2 hours or more frequently. Avoid turning the patient on the side the device is on. If your patient is right side facing, place the device on the left ear and visa versa.
Click here
Mucosal Pressure Injuries
Nasal bridles can cause mucosal injuries to the nares. Keep the bridle in neutral position. Readjust the bridle or remove it to relieve the pressure. If using tape to secure the tube, re-tape q shift and prn.
Click on the hot spots for other other areas of consideration.
Activity 2: Pillow Pandemonium
Pillows are an important tool to help offload the heels.Pillows are available in a variety of thicknesses. Use as many as you need to ensure the heels are "floated" This means the heels are suspended in air and not touching the pillow or bed.
This is not ideal. The heels are sitting directly on the bed causing pressure. The popliteal space is also not supported when the pillow is horizontal.
This is ideal. No pressure on heels. Pillow is thick enough to offload and it is placed lengthwise
Activity 2: Pillow Pandimonium
Pillows are an important tool to help offload the heels.Pillows are available in a variety of thicknesses. Use as many as you need to ensure the heels are "floated" This means the heels are suspended in air and not touching the pillow or bed. click on the blue plus signs
This is not ideal. The heels are sitting directly on the bed causing pressure. The popliteal space is also not supported when the pillow is horizontal.
This is ideal. No pressure on heels. Pillow is thick enough to offload and it is placed vertically
Click here
Effective Turns: Click the circles for more info
Click here
You try! Click near the patients back and thigh to properly place the 2 wedges! Keep clicking near those areas until you see 2 blue wedges appear:)
You know your patient is in an effective turn when you walk in the room and you can tell which way he/she is facing. If it is not clear, they are not in an effective turn.
link
Activity-3: What's the SKKIN-Y?
EPIC makes charting easy. Pressure injury prevention intervetions are built right in. Hover over the buttons and + for more info
If a patient's Braden score is less than 19, they are at risk for a pressure injury
S K K I N click here for more tips
Q 2 hour turns is expected for at risk patients
Incontinence Care
Normal skin is slightly acidic. The combination of urinary and fecal incontinence raises the pH by converting urea to ammonia, placing the patient at risk for skin breakdown and secondary infection.Use dri flow pads to wick moisture. Dri flows are air permeable and wick away moisture from the skin by absorbing 1,000 cc of fluid! Consider placing a dri flow vertically and bringing it up between the patients legs to absorb urinary incontinence rather than using a brief. Go to the wound care resource site and view the incontinence page for more information.
Zinc paste is great for loose stool/fecal incontinence. Wipe off the outer layer. Apply it nickel thick.
Zinc ointment goes on clear. It's great for urinary incontinence and protects while maintaining visibility of the skin
Fecal Managment Systems
This is a device for sedated, bedridden patients with loose stool not managed by other means. It is contraindicated in GI bleeds, rectal surgery, injury or impairment. See policy.
T.U.B.E.
Patients can acquire a mucosal pressure injuries from these tubes. Here are some things to consider: T. Tight tubes cause pressure. Create slack to prevent it from pressing on the fagile mucosa U. Unblock kinks or folds in the tubing especially near anus B. Bulking agents can thicken stool. Consider this and other antidiarrheals if appropriate E. Evaluate necessity q shift
When full, the bags can be exchanged .
Thank you for being part of the MMC-P care team and prioritizing pressure injury prevention.Please go to the next page to click on the link to complete the quiz. Thank you!
+ info
CERTIFICATEACHIEVEMENT
of
Please complete the QUIZ by clicking on the link below. The link will bring you to microsoft forms with additional instructions. Thank you!
10/10
1/10
2/10
3/10
4/10
5/10
7/10
6/10
9/10
8/10
Survey
Your opinion is crucial. Complete our assessment survey and help us improve
(1 of 3) Objectives
(2 of 3)Learning Platform
(3 of 3) Feedback
Course completed!