17.2 Infection Control, Repositioning, Moisture, Nutrition, and Trauma Avoidance for Teams

17.2 Infection Control, Repositioning, Moisture, Nutrition, and Trauma Avoidance for Teams

Quick Answer: Prevention teaching is a bundle the whole team can execute: turns that actually offload, device checks, head-of-bed discipline, moisture control, nutrition and glucose as shared work, tobacco as a wound issue, and a short never-do trauma list. Infection control for dressing work means a clean field, glove changes from dirty to clean, and no shared scissors between patients without sterilization.

This OpenExamPrep section is independent teaching for CWCN-style team education. It is not a WOCNCB publication.

A bundle is not a poster

Units already have a turning clock on the whiteboard. The CWCN question is whether that clock changes the surface that is bearing weight. Education that only says “turn every two hours” fails when the patient is rolled from a 10-degree tilt to another 10-degree tilt on the same sacrum, or when the clock is updated from the doorway. Survey language about a “prevention bundle” is useless if each piece lives in a different person’s head and nobody can demonstrate it.

Teach the bundle as five concurrent jobs, not five separate lectures that never meet.

If you cannot audit the row, you did not teach it. A signed attendance sheet is not an audit.

Turning clocks that actually offload

A two-hour interval is a starting cadence for many at-risk adults, not a law of physics. Tissue tolerance falls with hypotension, fever, moisture, low body mass, and device pressure. Some patients need more frequent small shifts; a few with a high-specification surface and excellent perfusion tolerate a longer interval. The exam-relevant teaching is position, not just time.

• Use a 30-degree lateral tilt so the sacrum and trochanter are not the load-bearing points. A 90-degree side-lying position parks the patient on the greater trochanter and trades one pressure injury for another.
• Float the heels off the mattress. Extra pillows that shove the Achilles into the bed are not flotation.
• Small shifts count for a patient who cannot tolerate a full turn, but they must still leave the prior surface free.
• Seated patients need timed weight shifts and a cushion that is not a donut ring. Donuts concentrate pressure at the rim and impede venous return from the center of the ring.
• Document the actual position (left 30-degree, right 30-degree, supine with heels off) rather than the word “turned.”

If the unit uses a clock drawing, stand at the bedside and move the patient through two clock positions during the in-service. If staff cannot build a 30-degree tilt with pillows, the clock is decoration. Watch for the “we turned them” note written after a linen change that never unloaded the sacrum.

Head of bed, shear, and competing risks

Elevating the head of the bed (HOB) above about 30 degrees increases sacral shear as the trunk slides toward the footboard. Aspiration risk, ventilatory needs, and many tube-feeding protocols require a higher HOB. Teach the tradeoff out loud: raise the HOB when those risks dominate; use a knee gatch or the bed’s anti-shear feature if it has one; boost the patient with a draw sheet and enough helpers so you are lifting, not dragging; return the HOB as soon as the competing indication allows. “Never raise the HOB” is as wrong as “HOB at 45 all night for comfort video.” Write the competing indication in the turn note so night shift does not “correct” a respiratory HOB back to 20 degrees without a plan.

Devices are pressure sources

Medical-device-related pressure injury is its own teaching module. Oxygen tubing behind the ears, nasal-cannula prongs, endotracheal-tube ties, pulse-oximeter probes left on one finger, sequential-compression sleeves, urinary catheters taped in a straight line across the thigh, and cervical collars all create focal load. The CNA skill is look under the device during cares and report a mark that does not fade. The RN skill is to reposition or pad without creating a new pressure point, and to call the CWCN when a mark persists after the device is moved. Do not hide a red ear under more tape. Do not celebrate a “clear sacrum” while an unnoticed collar is staging an occipital injury.

Build a 60-second device hunt into the in-service. On one volunteer or mannequin, the team must find every tube, strap, probe, and fold. The group that misses the cannula behind the ear has just identified tomorrow’s in-service photo.

Moisture, nutrition, tobacco, and glucose as everyone’s job

Moisture control is prevention, not housekeeping. Teach timed brief checks, gentle cleansing without vigorous perineal scrubbing, a barrier product staff can name from the cart, and a rule that a leaking pouch or drain is a same-shift repair. Wet skin plus shear is how MASD and pressure injury travel together. Stacking extra incontinence pads under a moist sacrum is not offloading; it is a moisture sandwich.

Nutrition teaching fails when it lives only on the dietitian consult. CNAs already see the tray. Teach them to record what was eaten, not “appetite fair.” Nurses escalate protein-calorie gaps, swallowing problems, and days of nothing-by-mouth. Serum albumin is a late, nonspecific marker; do not wait for a low albumin to start the protein conversation. Hydration belongs in the same huddle as calories.

Tobacco is vasoconstriction and impaired collagen, not a lifestyle lecture you save for discharge. If the patient is smoking in a wheelchair on the ramp, the wound plan is incomplete. Hyperglycemia in a consistent 250–300 mg/dL range impairs leukocyte function and collagen deposition. Teach staff to treat that day of glucose values as a wound issue, not only an endocrine issue. The prevention bundle includes who calls the covering provider when the glucose pattern and the wound trajectory are both going the wrong way.

Trauma you must un-teach

These practices still appear in “that is how we were taught” stories. Put them on a never list and say why:

• Do not massage reddened bony prominences. Massage adds mechanical injury to already ischemic tissue. Nonblanchable redness is a stop sign, not a sports-medicine problem.
• Do not use donut rings under the coccyx, ischium, or heels.
• Do not use heat lamps to dry a wound or a moist perineum. They burn, desiccate tissue, and do not treat etiology.
• Do not drag the patient up in bed. Friction strips epidermis; shear injures deeper tissue.
• Do not stack multiple pads and call the pile a support surface.

Scenario. During a 14:00 turn, a CNA massages a nonblanchable left trochanter “to get the blood going,” slides the patient up by the axillae, and asks for a foam donut for the chair. The CWCN stops the massage, demonstrates a lift with a draw sheet and a second helper, shows a 30-degree tilt that unloads the trochanter, and explains that the donut will peak pressure at the rim. The CNA’s new skill is the lift and the report—“red trochanter, does not blanch”—not a staging number.

Infection control that belongs in the same huddle

Prevention of infection is both do not inoculate this wound and do not carry this patient’s organisms to the next room.

Teach a dirty field and a clean field. The old dressing, used gloves, and irrigation runoff never share a pad with the new tray. Sequence: hand hygiene; clean setup; gloves; dirty removal; discard; glove change (and hand hygiene in the facility’s required order); cleanse; new dressing. If you touch the siderail, the brief, or the old gauze, you are dirty again. Night shift skipping the glove change “because I was careful” is the habit to drill, not a knowledge deficit about bacteria names.

Scissors that have been in a dressing or near a wound are not community property. Do not carry one pair from Patient A’s hydrocolloid to Patient B’s packing after an alcohol wipe. Alcohol does not sterilize hinged instruments used on nonintact skin. Use patient-specific scissors, single-use instruments, or send reusable instruments through the facility’s sterilization process. The same rule applies to reusable measurement tools that contact the wound bed.

Other habits to drill: do not touch the saline-bottle lip to the wound; date multi-dose containers; do not double-dip a cotton tip from the wound back into a clean cup; keep isolation precautions in place during the dressing; wipe the reusable cart between patients. Clean versus dirty is a spatial rule the whole team can see. If the only clean surface is the overbed table, clear it before you open the tray.

Close with a two-minute dirty-to-clean demonstration and the device-check race. If the team can turn, lift, look under tubing, and change gloves without coaching, the bundle has been taught. If they can only recite the poster, teach it again at the bedside.