Exploring the Effects of Wound Dressings and Patient Positioning on Skin Integrity in a Pediatric Burn Facility

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Angela Hardy, RN, BSN; Debbie Harrell, RN, MSN; Kim Tran, PT; Suzanne Smith, RN; Teri Mattingly, RN; Betty Zins, RN; Kathy Zaeske, RN; Juli Thomas, RN, BSN; Patti Sharp, OTR/L; and Lisa Annan, RN

These patients frequently are not developmentally or medically able to communicate their discomfort or identify the exact location or nature of the discomfort and may be medicated for perceived pain or anxiety as exhibited by crying, fussiness, increased respiratory rate, increased heart rate, increased blood pressure, restlessness, thrashing, and or parental report, rather than provided interventions to relieve the pressure risk.

  The pressure readings obtained were used to educate the staff on the importance of maintaining therapeutic efficacy without compromising the skin. The committee members utilized lectures and hands-on techniques to demonstrate the differences in a dressing applied correctly and one that is too tight and how to employ various positioning modalities. These techniques supported several adult learning styles (including the concrete experiencer, abstract conceptualizer, and the active experimenter13) to facilitate a thorough learning experience for all levels of staff/learners.

  The staff provided positive feedback on experiencing the pressure of the dressings and positions. Their increased empathy with patients has been reflected in their daily patient care. Policies were modified to ensure that postoperative elastic wraps were changed 2 hours after both excision and grafting surgery. The theory behind this practice is that the operative dressings are applied tightly in an effort to control bleeding. These wraps also may be applied by staff members who have a limited amount of time and do not routinely apply elastic bandages. A new protocol was developed in collaboration with all healthcare professionals involved in patient care and reflected the belief that bleeding at the surgical site should be controlled after 2 hours and that the elastic bandages should be conscientiously applied by personnel who practice this application on a daily basis. In addition, new splints also are molded within this time frame by the occupational or physical therapist to decrease patient contact with rough temporary splints formed by physicians in the operating room, further reducing opportunity for skin compromise. The overall use of elastic wrapping has been decreased before surgery and replaced by other bandage techniques such as spandex and gauze wrappings to maintain dressing integrity.

Implications for Practice

  At the authors’ facility, new positioning strategies are being explored to reduce pressure as a result of neck hyperextension and limb abduction. New products have been utilized that have greatly increased both staff and patient satisfaction with these practices. Continued staff education on prevention and treatment of pressure ulcers is now mandatory and provided on a yearly basis. Research on the efficacy of various new positioning techniques and dressings will further support evidence-based nursing practice. In addition, data collected by the Under Pressure Committee utilizing the pressure ulcer tracking forms completed by nursing staff or occupational and physical therapy, suggest that pressure ulcer incidence and prevalence in the facility is decreasing (see Figure 4). Ways to reduce the use of elastic wraps and better position patients are continually explored to increase patient comfort and reduce the incidence of pressure ulcers.


  Helping staff understand the impact of dressings and positioning on pressure ulcer development, particularly in a population that may not be able to communicate the presence or extent of pressure-inflicting stimuli, can enhance risk assessment and pressure awareness.

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