Skin Prevention for Manual Prone Therapy in ARDS
The purpose of this project was to decrease the amount of skin
breakdown in patients who received prone therapy after being
diagnosed with severe acute respiratory distress syndrome (ARDS).
ARDS is characterized by acute diffuse inflammation throughout the
lungs, which causes the alveoli to fill with fluid. Research suggests
that prone therapy results in a 16 percent mortality rate, compared
to 32.8 percent in patients remaining supine.1
The combination of decreased oxygen saturation, hemodynamic instability, malnutrition,
utilization of deep sedation, chemical paralysis, and prone therapy
puts the patient at high risk for skin breakdown.
Patients with severe ARDS previously received this treatment using
automated prone therapy. Due to a combination of problems –
including the amount of varying stages of skin breakdown from
the use of automated prone positioning in the critical care units
– manual prone positioning was implemented in an attempt to
remedy issues associated with automated prone therapy.
|Automated Prone Therapy
- Patient proned with
the push of a button
- Patient, tubes, drains,
and lines secured
- CPR mode available
- Labor intensive (initial setup)
- Difficult to assess and access
- Increased skin
breakdown and PIs
- Line compression
- Cost (equipment/increased PIs)
|Manual Prone Therapy
- Easy access to patient
- Decreased skin
- Decrease in PIs
- Unplanned extubation
- Mainstream bronchus
- Endotracheal tube obstruction
- Prolonged CPR initiation
- Labor intensive (staff)
An education program was developed using a literature review
of evidence-based practices pertinent to prone therapy, pressure
injury prevention in patients with ARDS, and device-related
pressure injury prevention. The program was used to train the
critical care nurses of a large urban hospital in Pittsburgh, Pa., in
the safe manual proning of patients and the prevention of skin
breakdown using a preventative skin care bundle. This included a
turning and repositioning schedule, use of appropriately placed
pillows and foam dressings, and use of a low air loss mattress.
Teaching methods included video instruction, demonstration
during various skills trainings, and critical care classes for new staff.
Manual prone therapy involves a team of 4-6 caregivers,
with at least two on each side of the patient.
To avoid brachial plexus injury, patient’s elbow should not be
placed superior to shoulder. Photos courtesy Raquel Felix.
Occurrence and severity of skin breakdown is noted to have
dramatically decreased since implementation of this preventative
education program. It is believed to be best practice in patients
with severe ARDS.
About the Authors
Raquel Felix, BSN, RN, CCRN
Raquel is clinician of the Medical ICU at UPMC Mercy Hospital in Pittsburgh, Pa. Her role is to ensure staff
competency through various education. firstname.lastname@example.org
Aimee L. Skrtich, MSN, RN, CCRN, NE-BC
Aimee is unit director of the Medical ICU at UPMC Mercy Hospital in Pittsburgh, Pa. email@example.com