Caring for Atypical Wounds in Patients With Severe Obesity: A Case Series.

BACKGROUND: The prevalence of obesity has grown over the past several decades. It exerts a negative effect on multiple body systems, including the integumentary system, and it increases the risk for development of chronic diseases. Caring for hospitalized patients with severe obesity presents unique challenges, especially when wounds are present. CASES: This article reviews 3 patients with severe obesity hospitalized with extensive full-thickness lower extremity wounds. In all 3 cases, the wounds were comparable to the presentation and evolution of a typical deep tissue pressure injury. In addition, none of the wounds were classified as pressure injuries. These extensive wounds seen in patients with severe obesity lack a clear etiology and pathophysiology, but present wound care nurses and other care providers with unique challenges well beyond evidence-based principles for selection of appropriate topical care. CONCLUSION: These cases illustrate lessons learned when caring for 3 patients during several months of hospitalization at a large academic medical center. Additional research is needed to enhance our knowledge of the etiology of these wounds, especially since the population of patients with severe obesity has become more prevalent.

Silicone Foam Dressing for Prevention of Sacral Deep Tissue Injuries Among Cardiac Surgery Patients.

OBJECTIVE: To evaluate the effect of silicone foam dressings, placed preoperatively, on the incidence of postoperative sacral deep-tissue pressure injuries. DESIGN, SETTING, AND PATIENTS: An uncontrolled before-and-after quality improvement method was used. Within a single, urban academic medical center, consecutively admitted adult cardiac surgery patients were included in the pre- and postintervention groups; only those receiving elective procedures were included. INTERVENTION: Nurses applied a sacral silicone foam dressing preoperatively. This dressing was maintained on the patient's sacrum intraoperatively and postoperatively for up to 5 days in the intensive care and step-down units. MAIN RESULTS: This project demonstrated a clinically significant decrease (P < .02) in the incidence of postoperative sacral deep-tissue pressure injuries from 2.3% (preintervention, n = 300) to 0% (postintervention, n = 224). These results were sustained for 24 months after the trial was completed. CONCLUSIONS: The use of silicone foam dressings may be an effective prophylactic intervention to reduce the incidence of perioperative deep-tissue pressure injuries among cardiac surgery patients, a high-risk population.

Deep Tissue Pressure Injury: A Clinical Review.

: A deep tissue pressure injury (DTPI) is a serious type of pressure injury that begins in the muscle closest to the bone and may not be visible in its early stages. Its hallmark is rapid deterioration despite the use of appropriate preventive interventions. In 2007, the National Pressure Ulcer Advisory Panel added suspected deep tissue injuries to the traditional classification system, and by 2010 DTPIs had accounted for about 9% of all pressure injuries and were for the first time more prevalent than stage 3 or 4 pressure injuries. On average, patients who develop these injuries are older and have a lower body mass index than patients who develop other pressure injuries. Most commonly, DTPIs appear on the skin over the coccyx or sacrum, the buttocks, and the heels. This article discusses the pathophysiology; risk factors; and assessment, prevention, and treatment of DTPIs, using a composite case to illustrate the progression of this serious type of pressure injury.

Risk Factors Associated With Pressure Ulcer Formation in Critically Ill Cardiac Surgery Patients: A Systematic Review.

BACKGROUND: Cardiac surgery patients are among those most at risk for developing pressure ulcers (PUs), with a reported incidence as high as 29.5%. Although numerous studies documenting PU risk factors and prevention strategies exist, the availability of literature examining risk factors specific to the cardiac surgery population is limited. AIM: A systematic review was completed that aimed to identify the risk factors associated with PU development in critically ill, adult, cardiac surgery patients. METHODS: The MEDLINE, CINAHL, and Cochrane databases were searched. Studies that focused on PU risk factors in critical care, surgical intensive care, or cardiac surgery populations and used PU occurrences as an outcome variable were included in the review. FINDINGS: Twelve high-quality studies were retrieved and included in the review; they revealed 30 potential PU risk factors. Current evidence is limited in 2 important ways. First, the impact of intraoperative factors, such as cardiopulmonary bypass time or body temperature, appears to be underexplored. Second, a substantive discussion of the risk factors associated specifically with deep tissue injuries, a unique PU category, is absent. CONCLUSION: The relatively high PU incidence among cardiac surgery patients suggests that typical PU prevention methods are insufficient for this population. Targeted prevention measures must be developed and implemented. Completion of this task required identification of risk factors unique to this population. Specific risk factors likely to increase risk among cardiac surgery patients include prolonged exposure to pressure during long surgical procedures, vascular disease, and/or vasopressor use postoperatively. Additional research concerning risk factors specific to this population is urgently needed.

Development of pressure ulcer program across a university health system.

Pressure ulcers were designated as a priority for quality care initiatives at the University of Pennsylvania Health System. The Penn Medicine Pressure Ulcer Collaborative was developed to address the complex issues of pressure ulcers. The Collaborative used a systematic approach to analyze, plan, and implement a health system-wide pressure ulcer program. As a result, the entire health system had a decrease in hospital-acquired pressure ulcer prevalence rates of 37%. This article describes the Collaborative's innovative approach to quality improvement.

Promoting evidence-based practice and translational research.

Evidence-based practice (EBP) is an evolutionary step in the nursing model of excellence in professional practice at the Hospital of the University of Pennsylvania. A healthcare culture focused on excellence and world-class patient care requires that nursing research and EBP are integrated into the professional practice model and nursing care delivery. To achieve this, it requires the development of staff expertise, time allocation for staff to participate in scholarly activities, resources that support EBP and research, and expert consultants in EBP and nursing translational research. This article describes the systems and structures in place to provide staff with resources in order to translate research and deliver EBP and the multiple initiatives in disseminating evidence to the point of care.