Bariatric Pressure Injury: Skin and Wound care in the Home Care Setting

By Vicki Haugen RN, BAN, MPH, CWOCN, OCN 

Obesity is an increasingly serious health care issue and health risk in America with more than one third of Americans considered obese (NIH/CDC). An even greater health care concern is the increasing rate of morbid obesity (the bariatric patient) as well as the increasing rate of super obesity. According to the CDC a BMI (body mass index) of >40 is morbid obesity and a BMI >50 is now considered super obesity. The rate of persons with a BMI greater than 40 or 50 is growing in prevalence.1

Skin injury to bariatric patients can involve a combination of factors such as pressure injury, moisture or incontinence associated injury, and alteration in skin perfusion. Unique needs in the bariatric population involve problems such as pressure injury from catheters buried deep in skin folds or sides of wheel chairs or other furniture that are too small. Due to their body shape, any point of contact such as the fleshy gluteal part of the buttocks is often at risk for pressure injury, rather than a bony prominence.

Enteral Connectors: Being Prepared and Adopting New Enteral Connectors: 

Interview with Peggi Guenter, PhD, RN, FAAN  


Why do enteral nutrition (EN) connectors need to change?

To reduce the frequency of medical tubing misconnections. An international group of clinicians, manufacturers and regulators, such as the FDA, is collaborating with the International Organization of Standardization (ISO) and the Association for the Advancement of Medical Instrumentation (AAMI) to develop ISO 80369 standards. Unique international standard designs will promote better patient safety and help ensure that connectors for unrelated delivery systems are incompatible. The program that is helping introduce the new standards is called the Stay Connected initiative for using safer connectors. Much of the information in this article came from the extensive FAQ documents on that site.


Enteral Connectors: Long Term Care and Home Care

Kristy Klug, RD, LDN

Tubing is used in the healthcare setting to connect patients to medical devices for the provision of liquids and gases. Tubing misconnections can occur when tubing from one medical device is inadvertently connected to a functionally dissimilar tube of a patient, allowing for medical liquids or gases to be delivered into parts of the body for which they were not intended. For example, tubing from an enteral feeding accidentally connected to an intravascular (IV) port, allowing enteral nutrition to be administered into the patient’s bloodstream. The results of these misconnections can be devastating, often leading to severe patient harm including permanent injury or death.1 Industry changes are occurring across the healthcare continuum to create safer connections for all patients. In this article, we will discuss the introduction of the new ENFit enteral connectors in the long term care and home care settings.


Prevention of Pressure Ulcers Due to Medical Devices

Vicki Haugen, BSN, RN, MPH, CWOCN, OCN


Pressure ulcers from medical devices are a growing concern to care providers and facilities alike. While the typical presentation of a pressure ulcer is near or over a bony prominence, a device-related pressure ulcer occurs near or under the medical device and may have the same shape as the device. Any medical device can cause a pressure ulcer if unattended long enough; e.g., an unconscious person with a cochlear implant who remains lying on that side without repositioning.

An increasing array of medical devices is multiplying the risk for this type of skin injury. A patient with a medical device is 2.4 times more likely to develop a pressure ulcer than a patient without a device.1 


Implementing And Sustaining Urinary Catheter Securement 

By Denise Nix, MS, RN, CWOCN


In this article and quality improvement study, there will be a brief overview of the significance, risk factors and interventions for preventing CAUTI and pressure ulcers followed by a detailed discussion related to catheter securement including importance, selection, and implementation.


Fighting VAP one step at a time: Early mobility for the ventilated patient


With the introduction of VAP prevention bundles by the Institute for Healthcare Improvement (IHI), critical care units have reported dramatic reductions in VAP rates. In her article, Ms. Andrews reviews the evidence supporting or questioning recommendations for VAP prevention and explores the evidence-based practices beyond the basic bundle including early tracheostomy and early mobility.


Since its inception, tracheostomy has become one of the more frequently performed procedures in ICU care. It has been estimated that 15-20% of ICU patients undergo tracheostomy at some point during their clinical course. Tracheostomy offers several important advantages over endotracheal intubation. Over the years many technological advances have occurred both in terms of the procedure and the tracheostomy tube technology. In his article, Mr. Davies describes the types and incidences of complications in light of today’s technology and population distributions.  


Best Practices in Managing the Urinary Catheter for the Homecare Patient


By 2050, an estimated 27 million people will need some type of long-term care. Home healthcare and hospice agencies are the major providers of community based long-term care. Currently, about 7.6 million people receive community-based care for post-acute and chronic conditions, often with multiple co-morbidities. This number is expected to increase as the population ages. This issue of Perspectives focuses on best practices in the management of home care patients, in particular patients with either an indwelling catheter or a trachesotomy.


Although there is ample research-based evidence regarding indwelling urinary catheter management in acute and long-term care settings, there is limited home care information. Dr. Wilde’s and Mr. Zhang’s article describes the application of evidence-based practices for the home care patient. Care of the tracheostomy in the home is a growing trend due to the increased efforts to transition patients to less costly points of care, along with the technologic advances that allow caregivers to deliver limited forms of medical care in the home. 

Prevention of NG Tube Misplacement: Nursing Practices

In today’s health care environment, patient acuity and mean age are on the rise. One result of this trend is the increased use of enteral (tube) feeding for critically ill patients.  Clinicians are often challenged to establish and maintain temporary feeding access via nasal or oral-gastric route without high risk of misplacement. 


Safe placement of temporary feeding access has traditionally relied on clinical exam during the procedure (overt signs of airway placement) and then radiographic confirmation of tube position before feeding is initiated. Additional tools have been developed to guide the clinician and enhance safety during and after the procedure. These include capnography, evaluation of aspirated fluid, and newer techniques such as virtual imagery.  An “old” test showing new promise is pH determination of tube aspirate. This method can be employed during the insertion procedure or at any time while the tube is in place, for routine nursing assessment or if misplacement is suspected. Paul Merrel and our panel of experts discuss the best practices for the safe insertion of the feeding tube 

Tracheostomy and VAP

Ventilator-associated pneumonia (VAP) is defined as a lower respiratory tract infection occurring at least 2 days after beginning mechanical ventilation. The estimated associated mortality rate is 24% to 50%.  Because VAP is prevalent in ICU patients on mechanical ventilation, numerous studies have been undertaken to determine ways to decrease its incidence. One area of study surrounds the utility of early tracheostomy as a deterrent to VAP. The association of tracheostomy with VAP, the benefits of an early tracesotomy is the purpose of Dr. Durbin’s review.


Tracheostomy is an intensive-care measure that requires specialized care and monitoring. Despite its potential for reducing ventilator-associated pneumonia, it has its own risks, which are minimized by careful attention to device and patient care.  In this issue of Perspectives, we have assembled a panel of experts to discuss trach care, strategies to minimize morbidity and mortality in this patient population, patient and family education, and decisions regarding weaning and decannulation. Differences in adult versus pediatric populations are also highlighted.


The 2011 Infusion Nursing Stands of Practice: Vascular Access Device Stabilization, Joint Stabilization And Site Protection Enteral Tube Dislodgement


Catheter stabilization is as an important intervention for increasing the dwell time and reducing the risk of complications associated with central vascular access devices (CVADs) and peripheral IV (PIV) catheters. Properly stabilized devices can preserve site integrity and improve patient satisfaction. While “stabilization” is often equated with applying a dressing and tape, the newly released Infusion Nurses Society Guidelines state that stabilization is best achieved with the use of a specifically designed device or system.


Nasal feeding tube dislodgement is reported to occur frequently in hospitalized patients, and the negative consequences of dislodgement are underestimated. Tube dislodgement poses significant health risks and increases the cost of care. Studies show that the rate of removal for nasogastric tubes due to unintentional dislodgement is 28.9% to 40%. This rate can be decreased dramatically by practicing “MARK” methods of preventing tube dislodgement and following five levels of strategies for tube securement.


Nurse Patient Safety: Ensuring Involvement of the Frontline Healthcare Worker in Product Decisions


During past recessions, the financial stability of hospitals seemed to be nearly indestructible. But researchers at the University of Michigan Health System and St. Joseph Mercy Health System1 say the current national economic crisis may be an exception. Hospitals are reporting declining profits. The researchers that speculate hospital cutbacks may risk the quality and safety of healthcare delivery, resulting in overcrowding emergency services and lower nurse-to-patient ratios. In some cases, to achieve short-term cost reductions, some facilities have opted to purchase products that offer savings but may jeopardize the safety of healthcare workers and their patients. In this issue of Perspectives, we have asked a panel of experts in infection control, risk management, and nursing management how they are coping with the challenges to balance costs and ensure the safety of healthcare delivery. 


Respiratory Care of the Morbidly Obese Patient – Nurses


The word obesity has its origins in the Latin language; it refers to the state of becoming “fattened by eating.” Obesity is a relatively common health condition, and its prevalence is increasing nationally and globally. Of all Americans between the ages of 26 and 75, 10 - 40% are obese, and nearly 5% are morbidly obese. The health consequences of obesity range from chronic conditions that reduce the general quality of life to a significantly increased risk of premature death. Along with other organs, the respiratory system is compromised by obesity. In their article, Gentile and Davies, discuss the many challenges to health professionals when caring for the respiratory needs of the obese, and how to reduce complications associated with their hospitalization. Critically ill morbidly obese patients are more likely to be intubated and remain intubated. They will stay in the ICU longer and are at risk for mortality during their stay when compared with their non-obese counterparts. In his article, Dr. Op’t Holt discusses the role of tracheostomy in the mechanically ventialted obese patient.


Oral Care in the IC Preventing Hospital-acquired Catheter-Associated Urinary Tract Infections: Case Study


Oral care is an important component of intensive care nursing but is often given low priority when compared with other critical practices. Recent evidence indicates that colonization of the mouth with respiratory pathogens may contribute to ventilator-associated pneumonia (VAP). Oral care may be an important preventive measure against VAP and not merely a comfort measure. Pneumonia is the most common nosocomial infection in ICUs and significantly contributes to morbidity patterns and mortality among mechanically ventilated Oral care protocols have proved effective in reducing oropharyngeal colonization and pneumonia risks. 


Catheter-associated urinary tract infections (CAUTI) is the most frequent nosocomial infection and comprises the largest reservoir of antibiotic-resistant pathogens in healthcare institutions. Despite evidence that CAUTIs can often be prevented, these infections remain among the most predominant healthcare-acquired infections in the US. Some organizations have adopted the practices advocated in evidence-based guidelines, and in this issue, Ms. Marshall describes a protocol that has successful reduced the incidence of CAUTI at her institution.


Treating a Patient with an Intestinal Obstruction Closed
Enteral Feeding


Intestinal obstructions account for 20% of all acute surgical admissions. Mortality and morbidity are dependent on the early recognition and correct diagnosis of obstruction. If untreated, strangulated obstructions cause death in 100% of patients however, the mortality rate decreases to 8% with prompt surgical intervention. Intestinal obstruction is caused by a variety of pathologic processes including, postoperative adhesions, malignancy, Crohn’s disease, and hernias. In her article, Dr. Kent outlines the diagnosis and perioperative treatment of the patient with intestinal obstruction.


Enteral nutrition plays an essential role in the care of adults or children who are unable or unwilling to eat. One potential complication of open enteral nutrition feeding systems is bacterial contamination which is estimated to occur in a significant number of tube feedings. Closed enteral feeding systems offer a number of advantages over open systems, including less bacterial contamination and a safe increase in hang times. In her article, Ms. Lau will provide evidence that closed feeding systems have the potential to improve patient outcomes and safety.


Postoperative recovery in the elderly Unplanned Extubation


The increasing population of older adults will result in an increased amount of surgical procedures being performed on geriatric patients. The number of elderly (> 65 years) patients who undergo noncardiothoracic surgery is projected to increase from 7 million to 14 million over the next 30 years. Surgery can potentially be debilitating for older adults. While survival may be the ultimate goal, improving quality of life and functional capacity may be far more important to the elderly. Ms. Sorenson outlines in her article how many of the postoperative pulmonary complications can be prevented with advances in medicine, technology, and risk stratification.


Unplanned extubation (UE) can be a devastating event for critically ill patients, with potentially life threatening complications including airway trauma, bronchospasm, severe hypoxemia, and cardiac arrest. UE can lead to an increased number of ventilator days, resulting in excessive resource use for patients, and increased risk of litigation for healthcare professionals. Dr. Foster describes methods to protect against UE including education, quality improvement processes, sedation protocols, physical restraints, and tube securing methods. 


Expert Review: Best Practices


Despite significant progress in our understanding of the physiology of the lower urinary tract and range of effective treatment options, placement of an indwelling catheter remains an important and frequently used treatment option. For example, approximately 25% of patients cared for in acute care hospitals will have an indwelling catheter during some portion of their hospital admission 1 and 7% of nursing home residents are managed by long-term indwelling catheterization.2 While the initial directive to place a catheter is typically initiated by a physician, it is the nurse who primarily manages the indwelling catheter. A panel of clinical experts in urologic and gerontological nursing convened to examine the management of the indwelling catheter in acute and long-term care settings.