7.3 Friction, Heel Protection, and Preventing Treatment Complications

Lift, do not drag: friction and shear during movement

Friction is two surfaces rubbing—skin against a sheet, elbow against a bedrail. Shear is the skeleton sliding while skin stays stuck, stretching and kinking perforating vessels. High Fowler's position plus a slow slide toward the foot of the bed is a classic sacral shear recipe. Independent OpenExamPrep teaching for CWCN candidates treats how you move the person as a wound intervention.

Boosting someone by grabbing the axillae or dragging the heels is a procedure error. Use a slide sheet or other friction-reducing device, a trapeze if the person can assist, and a mechanical lift when the load or the person's ability requires it. Two-person boosts with a slide sheet beat a one-person yank. Keep heels off the mattress during the move if you can. Draw sheets help only if they actually slide; a cotton sheet that bunches becomes another friction surface. After the move, straighten folds under the sacrum and check that devices did not migrate onto bone.

Elbows and heels take the scrape of every independent reposition. The product question is the same as in section 7.1: does the device float the prominence, or does it merely wrap it? A fluffy heel “protector” that leaves the calcaneus on the mattress is padding theater. You should be able to slide a hand under a truly offloaded heel. Watch for new injury on the Achilles, malleoli, and posterior calf from a boot that was sized wrong or left damp. Elbow protectors have the same test: unload the olecranon, do not macerate it inside a sleeve.

Prone injuries are still pressure, friction, and moisture

Turning a person prone relocates—not deletes—pressure risk. Common prone sites:

• Forehead, cheeks, chin, lips, and ears (plus medical-device injury from tubes and tape)
• Breasts and anterior chest
• Iliac crests and genitalia
• Knees, shins, dorsum of the feet, and toes (especially if the feet plantarflex into the mattress)

Use prone cushions or rolls that unload the face and anterior bony points, micro-reposition the head on a schedule, keep tubing off the skin, and float the toes. Penile and breast edema plus pressure can create full-thickness injury faster than teams expect if they only inspect the back. Moisture under a prone pack is still MASD. Document anterior skin as carefully as the sacrum.

Preventing complications of treatment

Wound treatment can create the next wound. Inspect for iatrogenic injury at every dressing change, not only for “percent granulation.”

Maceration from too-wet dressings. White, soggy periwound skin means the dressing is holding more moisture than the skin can tolerate: change more often, step up absorbency, improve the seal, and protect the periwound with a barrier film or ointment. A wet dressing that is “keeping the wound moist” is actually enlarging it.

Stripping from aggressive adhesive. See section 7.2. If epidermis comes off with the dressing, the product or the removal technique is wrong. Switch to silicone, add a barrier film, and slow down.

Contact dermatitis from topicals. Neomycin (often in “triple antibiotic” ointments), bacitracin, lanolin, and some preservatives are classic allergens. The rash matches the application map, itches, and may spread beyond the wound. Stop the allergen; do not interpret the rash as inevitable maceration or as a new pressure injury. Fragrance-heavy barrier creams can do the same.

Constriction from tight wraps. Elastic wraps applied with residual stretch, circular turns on a limb whose edema is falling, and layered compression without a skin check can act like a tourniquet. Pain, pallor, coolness, numbness, delayed capillary refill, or a wrap that leaves a deep groove are stop-and-remove findings. Recheck wraps after edema changes. Never hide a wrap under a blanket without a neurovascular check.

Device-related injury from NPWT tubing or compression. Tubing, connectors, and the edge of foam are rigid enough to cause a medical-device-related pressure injury (MDRPI) when they lie over bone or under a compression layer. Route tubing off prominences, pad, and do not use the sacrum as a convenient channel. Compression garments and wraps over unprotected tubing print a linear ulcer. Oxygen tubing, catheter hubs, bed rails, and splints follow the same rule: the device is the etiology.

Hydrocolloid on an infected, highly exudative wound. Hydrocolloids are occlusive or semi-occlusive products for relatively clean wounds with low to moderate exudate. On a wet infected wound they trap moisture, can hide odor and drainage, and may worsen the bioburden. Choose a dressing that can handle the exudate and allow inspection. Occlusion is not “more advanced care.”

Clinical scenario

A person with a sacral pressure injury is on negative-pressure wound therapy (NPWT). Overnight, someone tucked the tubing under the left buttock “so it would not catch on the rail,” then applied an abdominal binder for support. In the morning there is a new linear, nonblanchable purple streak exactly under the tubing path, and the periwound is white where the dressing was too wet. The original wound is not the only problem anymore. Pad and reroute the tubing off the prominence, stop using the binder as a tubing clamp, increase dressing absorbency or change frequency, and protect the periwound. If staff had used a hydrocolloid over a frankly infected, highly draining satellite area, you would remove that occlusion as well. If a “triple antibiotic” ointment had been added around the drape edge and an itchy rectangular rash appeared, stop the neomycin-containing product. None of those fixes is a new brand of foam; they are prevention of treatment complications.