BUNDLE FOR THE PREVENTION OF PRESSURE INJURIES ASSOCIATED WITH MEDICAL DEVICES IN OBESE PATIENTS

Andrade, Vanusa Silva do Nascimento; Sebold, Luciara Fabiane

doi:10.1590/ce.v28i0.92827

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Brasil

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Sumário

ORIGINAL ARTICLE • Cogitare Enferm. 28 • 2023 • https://doi.org/10.1590/ce.v28i0.92827 copy

BUNDLE FOR THE PREVENTION OF PRESSURE INJURIES ASSOCIATED WITH MEDICAL DEVICES IN OBESE PATIENTS ^* * Article extracted from the master’s “Bundle de cuidados de enfermagem para prevenção de lesão pressão relacionada a dispositivo médico em pessoa com obesidade em Unidade Coronariana”, Universidade Federal de Santa Catarina, Florianópolis,SC, Brasil, 2022.

Authorship SCIMAGO INSTITUTIONS RANKINGS

HIGHLIGHTS

The development of the Bundle reflects scientific and safe care.
The Bundle supports targeted care for people with obesity.
The preventive care Bundle systematizes nursing actions.
Bundle-supported care demonstrates the development of best practice.

ABSTRACT

Objective:

to build and validate a Bundle for the prevention of pressure injuries associated with medical devices in obese people in intensive care.

Method:

methodological study, with a scoping review and validation of the Bundle. Data collection took place between April and May 2022 at a university in southern Brazil.

Results:

nine nurses, experts in enterostomal therapy, validated the Bundle, whose items were: assessment of the skin of the obese person; hygiene care for the obese person using a medical device; nursing care for the obese person using a medical device; health education on healthy habits; continuing education on nursing care for the obese person. The items obtained a Content Validity Index ≥0.80% and 89.8% agreement.

Final considerations:

The Bundle can standardize nursing care, guiding, and equipping nurses with the best care intervention practices.

DESCRIPTORS:
Nursing Care; Nursing; Pressure Ulcer; Obesity; Intensive Care Unit; Patient Care Bundles.

Category	Validation form questions	Achieved (scores %)		Comments/ Suggestions	Modified item
Category	Validation form questions	CVI	%C	Comments/ Suggestions	Modified item
	1. Carry out a structured risk assessment, using the Braden Scale, and check the Body Mass Index (BMI) on admission of people with obesity.	0.80	80%	Comprehensive assessment with BMI. Body distribution for those who are bedridden or have difficulty changing position. Notify if the person has already been admitted to the unit with a pressure injury or injury of another etiology.	Repositioning body weight in patients with impaired mobility. Assessing the skin to identify pre-existing lesions (PI, traumatic) and reporting them.
Skin assessment for obese people	2. Carry out a complete assessment of the skin by inspecting it daily.	0.80	80%	I think it depends on the scenario we’re in. You need to identify the obese person who is functional, ambulates and has bodily activity in bed and the one who has functional impairment of the body. There is a risk in both, but in addition to the body, we need to look at the underlying disease associated with the current clinical complication condition. Evaluate the person with a flexible schedule according to their perspiration and/or other eliminations, regardless of whether they use equipment for urinary and/or fecal retention.	Carry out the Braden Scale assessment whenever necessary. Perform skin assessment after bowel/vesical eliminations and during hygiene and comfort care. Perform skin assessment at medical device insertion sites and adjacent areas at each shift change. In pronated patients, assess the device insertion site and adjacent areas.
	3. Assess the skin of the obese person where the medical devices are located	0.80	80%	In general, aren’t you already doing this during your daily assessment? However, in addition to these points, you should always assess the entire anatomical structure while the person is bedridden and/or in a hospital bed. - At each change of duty	This question is already part of the previous ones
	4. Assess the skin of the obese person in the prone position where the medical devices are located.	0.80	80%
	5. Assess the fixation of the device or fixation method	0.90	90%	In general, aren’t you already evaluating during the daily evaluation? Or is it continuous evaluation? And to study better devices with less local friction, as well as observing the microclimate thus, avoiding local humidity.	Assess the fixation of the medical device and adjust where necessary in the event of swelling, redness and pressure or any change in the skin. Evaluate the adjustment of the fixation of the medical device.
	6. Evaluate the tension of the medical device, adjusting, if necessary, when edema, redness and pressure are observed.	1.0	100%
Hygiene care for obese people using medical devices	1. always keep the skin around the medical device clean and dry	0.80	80%	As well as clean and dry, you can opt for a spray that provides a barrier on the skin. Dry when referring to moisture-free skin but hydrated/maintained turgor I think are more appropriate words. Use of adjuvant for protection	Apply barrier cream and protective spray to moisturize the skin.
	2. Carry out frictionless cleaning near medical devices	0.80	80%	Cleaning should be done on the entire surface of the skin without rubbing. More sensitive skin will be more easily damaged. There are products that can be protocolized for use, which clean without trauma. - Train the staff.
	3. Clean the skin with warm water and pH-neutral soap near the medical devices.	0.55	55%	What if the setting where the professional works doesn’t have soap with a neutral pH? I think we need to think about the overall context to establish functional strategies for proper management I don’t agree with the word friction because it leads to the connotation of trauma. If she wishes, gentle cleansing with light, soft fabric is more appropriate. Train the staff and guide the family members.
	4. Carefully assess the obese person in the prone position for skin humidity and keep the area around the medical device clean and dry.	0.67	67%	Dry place refers to being free of moisture, but hydrated/maintained turgor, I think, are more appropriate words.
Nursing care with the medical device for people with obesity	Nursing care with the medical device for people with obesity	1.0	100%
	2- Evaluate with the multi-professional team the replacement or early removal of the medical device.	1.0	100%
	3- Avoid humidity, friction, and pressure in the area where the medical device is installed.	0.90	90%	Not only at this location.
	4-Discuss the safe early removal of medical devices with the multidisciplinary team.	1.0	100%
	5- Choose the right size of medical device according to the characteristics of the obese person.	1.0	100%	Adapt each patient’s anatomy.
	6- Take care with the devices when performing prone positioning.	1.0	100%	Train the staff.
Health education on healthy habits	1- Encourage and help people with obesity to eat according to the nutritional prescription.	0.90	90%	Observe the acceptance of the diet and keep informed about diarrhea and intolerances.	Observe acceptance of oral and/or enteral diet and keep informed about diarrhea and intolerances.
	2- Encourage and advise on the importance of eating a proper diet/nutrition.	0.90	90%
	3- Stimulate and support water intake according to the needs of the obese person.	0.90	90%
	4-Estimulate and advise on the importance of water intake according to the needs of people with obesity.	0.90	90%
Continuing education on nursing care for people with obesity	1- Promote training courses for nursing staff on skin care for obese people.	0.90	90%	Promoting training involving skin care for all partially or totally bedridden people is synonymous with the evolution of nursing care in minimizing iatrogenic in the person under their care.
	2- Promote on-site training on nursing care of medical devices for people with obesity.	1.0	100%	It’s an excellent strategy. I’ve done it this way and had very good results! Constant training, quick objectives.
	3- Promote training on nursing care for obese people in the prone position.	0.89	100%	In training the person for promotion, we discuss the issue of body structure in relation to the lean and obese person, contextualizing, in general, but showing the profile that is more likely to develop an MDRPI.

Bundle of nursing care - preventive approach CVI		Achieved (scores %)
Bundle of nursing care - preventive approach CVI		%C
Skin assessment of the obese person
1	Assess the skin to identify pre-existing lesions (PI, traumatic) and report them.	1.0	100%
2	Carry out the Braden Scale assessment whenever necessary.	0.80	80%
3	Perform skin assessment after bowel/vesical eliminations and during hygiene and comfort care.	0.89	89%
4	Perform skin assessment at medical device insertion sites and adjacent areas at each shift change.	1.0	100%
5	In pronated patients, assess the device insertion site and adjacent areas.	1.0	100%
6	Evaluate the fixation of the medical device and adjust whenever necessary in the event of edema, redness and pressure or any change in the skin.	1.0	100%
7	Check that the medical device is securely fastened.	1.0	100%
8	Clean the skin and areas adjacent to the medical device gently with soft tissue.	0.67	67%
Hygiene care for obese people using medical devices
9	Apply barrier cream or protective spray to moisturize the skin.	0.80	80%
10	Clean the skin and areas adjacent to the medical device gently with a soft cloth.	0.67	67%
Health education on healthy habits
11	Observe the acceptance of the oral and/or enteral diet and keep informed about diarrhea and intolerances.	1.0	100%

Preventive care for medical device-related pressure injuries in people with obesity
Skin evaluation
Carry out a structured risk evaluation using the Braden Scale and checking the Body Mass Index (BMI) on admission of people with obesity¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... -¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... .
Carry out a skin evaluation to identify pre-existing lesions (PI, traumatic) and report them¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... -¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... .
Evaluate the skin after bowel/vesical elimination and during hygiene and comfort care¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... -¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Evaluate the skin at medical device insertion sites and adjacent areas at each shift change¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... .
In pronated patients, evaluate the insertion site of the device and adjacent areas.¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... Evaluate the fixation of the medical device and adjust whenever necessary in the event of edema, redness and pressure or any change in the skin¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... -¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... .
Hygiene care for people with obesity and using medical devices
Keep the skin around the medical device clean and dry at all times¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... -¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Clean the area around medical devices without rubbing¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Apply barrier cream or protective spray and moisturize the skin¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... -¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... ,¹⁹19 Shearer SC, Parsa KM, Newark A, Peesay T, Walsh AR, Fernandez S, et al. Prone facial pressure injuries in the COVID-19 era. The laryngoscope. [Internet]. 2021 [cited 2022 June 20]; 131(7):E2139-E2142. Available from: https://doi.org/10.1002/lary.29374. https://doi.org/10.1002/lary.29374... .
Nursing care with medical devices for people with obesity
Assess the need to maintain the medical device in the obese person¹⁶16 Lucchini A, Russotto V, Barreca N, Villa M, Casartelli G, Marcolin Y, et al. Short and long-term complications due to standard and extended prone position cycles in CoViD-19 patients. Intensive Crit. Care Nurs [Internet]. 2022 [cited 2022 June 22]; 69:103158. Available from: https://doi.org/10.1016/j.iccn.2021.103158. https://doi.org/10.1016/j.iccn.2021.1031... -¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... .
Assess with the multi-professional team the replacement or early removal of the medical device¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... ,²⁰20 Apte Y, Jacobs K, Shewdin S, Murray A, Tung L, Ramanan M, et al. Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing bench-to-bedside practice changes in the era of coronavirus disease 2019. Australian Critical Care. [Internet]. 2021 [cited 2022 June 20]; 34(2):176-81. Available from: https://doi.org/10.1016/j.aucc.2020.08.002. https://doi.org/10.1016/j.aucc.2020.08.0... .
Avoid moisture, friction, and pressure where the medical device is installed¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... -¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Choose the right size of medical device according to the characteristics of the obese person¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Pay attention to device care when performing prone positioning¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... .
Health education on healthy habits
Encourage and help people with obesity to eat according to the nutritional prescription¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... -¹⁹19 Shearer SC, Parsa KM, Newark A, Peesay T, Walsh AR, Fernandez S, et al. Prone facial pressure injuries in the COVID-19 era. The laryngoscope. [Internet]. 2021 [cited 2022 June 20]; 131(7):E2139-E2142. Available from: https://doi.org/10.1002/lary.29374. https://doi.org/10.1002/lary.29374... .
Encourage and advise on the importance of eating an adequate diet/nutrition¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... -¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Encouraging and advising on the importance of drinking as much water as the obese person needs¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... -¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... .
Continuing education on nursing care for obese people
Promote training courses for nursing staff on skin care for obese people¹⁸18 Challoner T, Vesel T, Dosanjh A, Kok K. The risk of pressure ulcers in a proned COVID population. The Surgeon. [Internet]. 2022 [cited 2022 June 22]; 20(4):e144-e148. Available from: https://doi.org/10.1016/j.surge.2021.07.001. https://doi.org/10.1016/j.surge.2021.07.... ,²⁰20 Apte Y, Jacobs K, Shewdin S, Murray A, Tung L, Ramanan M, et al. Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing bench-to-bedside practice changes in the era of coronavirus disease 2019. Australian Critical Care. [Internet]. 2021 [cited 2022 June 20]; 34(2):176-81. Available from: https://doi.org/10.1016/j.aucc.2020.08.002. https://doi.org/10.1016/j.aucc.2020.08.0... .
Promote on-site training on nursing care with medical devices for obese people¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... ,²⁰20 Apte Y, Jacobs K, Shewdin S, Murray A, Tung L, Ramanan M, et al. Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing bench-to-bedside practice changes in the era of coronavirus disease 2019. Australian Critical Care. [Internet]. 2021 [cited 2022 June 20]; 34(2):176-81. Available from: https://doi.org/10.1016/j.aucc.2020.08.002. https://doi.org/10.1016/j.aucc.2020.08.0... .
Promote training on nursing care for obese people in the prone position¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... .
Observe acceptance of oral and/or enteral diet and keep informed about diarrhea and intolerances¹⁵15 Moore Z. Prevention of pressure ulcers among individuals cared for in the prone position: lessons for the covid-19 emergency. J Wound Care. [Internet]. 2020 [cited 2021 Apr 25]; 29(6):312-20. Available from: https://doi.org/10.12968/jowc.2020.29.6.312. https://doi.org/10.12968/jowc.2020.29.6.... ,¹⁷17 Binda F. Complications of prone positioning in patients with COVID-19: a cross-sectional study. Intensive Crit. Care Nurs. [Internet]. 2021 [cited 2022 June 25]; 67:103088. Available from: https://doi.org/10.1016/j.iccn.2021.10308. https://doi.org/10.1016/j.iccn.2021.1030... ,¹⁹19 Shearer SC, Parsa KM, Newark A, Peesay T, Walsh AR, Fernandez S, et al. Prone facial pressure injuries in the COVID-19 era. The laryngoscope. [Internet]. 2021 [cited 2022 June 20]; 131(7):E2139-E2142. Available from: https://doi.org/10.1002/lary.29374. https://doi.org/10.1002/lary.29374... .

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[1] Associate editor: Dra. Cremilde Radovanovic