Title: Practical Tips and Interventions for Pressure Ulcer Prevention and Treatment
1Practical Tips and Interventions for Pressure
Ulcer Prevention and Treatment
- Presented by
- Jeri Lundgren, RN, CWS, CWCN
- Pathway Health Services
2Objectives
- Describe practical strategies for implementing a
pressure ulcer prevention and treatment program - Discuss practical monitoring programs that can be
used to evaluate and ensure your pressure ulcer
program is on track and stays on track - Identify pressure ulcer resources to keep your
facility up-to-date with pressure ulcer
prevention and treatment strategies
3Assessing Programs
- Break your pressure ulcer programs down into
three areas - Admission process
- Prevention Program
- Treatment Program
- Utilize the Quality Improvement process when
assessing each program - Ensure communication systems are in place
4Assessing Programs
- Identify skin integrity champions, both licensed
staff and nursing assistants - Prioritize which areas within each program is in
most need - Turning and repositioning
- Implementation of cares and interventions
- Assessment
- Documentation
5Admission Program
- Admission Process Assessment
- Assess when your admissions happen
- How are risk factors being identified and
appropriate interventions being put into place
within the first 24 hours?
6Admission Program
- Admission Process Tips
- At a MINIMUM interventions within the first
24hours should include - Support!surfaces (bed and W/C)
- Turning repositioning schedules
- Incontinence care keeping skin clean and dry
- Heels elevated off bed
- Dietary and Therapy referrals
- Access to topical dressings if admitted with
pressure ulcers
7Admission Program
- Admission Process Tips
- Train on admission assessment on orientation
- Monitor to assess that risk factors and
interventions are actually being put into place
within 24 hours - Assess how risk factors and interventions are
being communicated to the nursing assistants
care planned
8Prevention Program
- Prevention Program Assessment
- Does your current prevention program include
- Risk assessment
- Identified interventions/products for risk
factors, including individualized turning and
repositioning - Daily skin inspections by the Nursing Assistant
with a written reporting system for Nursing
Assistants when a skin concern is found - Weekly skin inspections by a Licensed Nurse
- Interdisciplinary approach with Dietary and
Therapies at a minimum
9Prevention Program
- Prevention Program Assessment
- Do you have monitoring programs in place
- Do you have effective communication systems
- between shifts and between nursing assistants
- Are interventions being communicated to the
nursing assistant
10Prevention Program
- Risk Assessment
- The overall goal of the risk assessment is to
ensure that individualized interventions are
attempted to stabilize, reduce or remove the
underlying risk factors
11Prevention Program
- Risk Assessment
- F314 states
- Although the requirements do not mandate any
specific assessment tool, other than the RAI,
validated instruments are available to assess
risk for developing pressure ulcers
12Prevention Program
- Risk Assessment
- F314 States
- Many clinicians recommend using a standardized
pressure ulcer risk assessment tool to assess a
residents pressure ulcer risks - upon admission
- weekly for the first four weeks after admission
- then quarterly,
- or whenever there is a change in cognition or
functional ability
13Prevention Program
- Regardless of any residents total risk score,
the clinicians responsibility for the residents
care should review each risk factor and potential
cause(s) individually - an overall risk score indicating the resident is
not at high risk of developing pressure ulcers
does not mean that existing risk factors or
causes should be considered less important or
addressed less vigorously than those factors or
causes in the resident whose overall score
indicates he or she is at a higher risk of
developing a pressure ulcer.
14Risk Assessment Tools
- Use a recognized risk assessment tool such as the
Braden Scale or Norton - Use the tool consistently
- Regardless of the overall score of the risk
assessment, assess each individual risk factor - No risk assessment tool is a comprehensive risk
assessment - Incorporate the risk assessment and RAPS into the
plan of care
15Risk Assessment ToolsBRADEN SCALE
- Mobility
- Activity
- Sensory Perception
- Moisture
- Friction Shear
- Nutrition
- Please note Using the Braden scale requires
obtaining permission at www.bradenscale.com or
(402) 551-8636
16A Comprehensive Risk Assessment should include
- Overall skin integrity assessment (history of
ulcers, current ulcers, scars, tissue tolerance,
etc.) - Impaired/decreased mobility
- Decreased functional ability
- Co-morbid conditions, such as end stage renal
disease, thyroid disease or diabetes
17A Comprehensive Risk Assessment should include
- Impaired diffuse or localized blood flow, for
example, generalized atherosclerosis or lower
extremity arterial insufficiency - Drugs such as steroids that may effect healing
- Resident refusal of some aspects of care and
treatment (be specific of what it is that
resident is refusing) - Cognitive impairment
18A Comprehensive Risk Assessment should include
- Exposure of skin to urinary and fecal
incontinence - Under nutrition, malnutrition, and hydration
deficits (i.e., low albumin and/or pre-albumin
levels, inability to intake nutrition/hydration) - Contractures and/or slouching while sitting
- Restraints
- Unrelieved pain
19Prevention Program
- Risk Assessment Tips
- Have a separate risk assessment tool that breaks
down the score of the standardize tool
(Braden/Norton) and have added risk factors that
are not covered by the risk assessment tool - Have identified interventions for correlating
risk factors - On admission designate on the treatment sheet the
initial risk assessment and then the following 4
weeks
20Prevention Interventions that Should be Available
- Support!Surfaces (typically a fully integrated
foam mattress and access to more aggressive
surfaces (i.e., low-air loss) - Wheelchair cushions (ensure surface is
stabilized, air and gel are more aggressive then
foam) - Referral to Therapies for positioning and W/C
cushion evaluation
21Prevention Interventions that Should be Available
- Turning and repositioning that is individualized
for both lying and sitting - In Minnesota you must have an assessment that
shows you assessed appropriate turning intervals
(tissue tolerance) for - Non-mobile residents
- Upon admission, re-admission and change of
condition - In BOTH the lying and sitting position
22Prevention Interventions that Should be Available
- Dietary Referral with access to
- Protein supplements
- Arginaid is used for poor circulation
- Multi-vitamins (extra Zinc and Vit. C is only
necessary if the resident has that specific
mineral/vitamin depletion) - Hydration program (small amount of fluids over a
long period of time)
23Prevention Interventions that Should be Available
- Incontinence and Toileting Programs
- Barrier ointments and creams available at all
times - Individualized toileting plans
- Catheters can only be used when a stage III or IV
pressure ulcer can not be protected from the
urine and the wound is not showing progress.
Must be discontinued once managed or healed - Xenaderm (prescription) good for superficial open
areas on the buttocks that can not be managed
with a dressing
24Prevention Interventions that Should be Available
- Pillows, body pillows and/or foam wedges to
assist with repositioning - Heel lift devices (recommend foam heel lift
boots, if working with Therapy may need boots
with plastic/metal heels (AFO, Prafo) - Daily skin inspections by the Nursing Assistant
- Weekly Skin inspections by Licensed Nurses
- Risk assessments per protocols
25Prevention Interventions that Should be Available
- Appropriate foot care/access to Podiatrist
- Appropriate foot wear at all times
- Petroleum jelly products to the lower legs only
(no lotions with lanolin or mineral oils) - Keep toe web spaces clean and dry at all times
- Corn starch to help reduce friction and moisture
- Psychosocial support
26Other Prevention Program Tips
- Prevention Program continued
- Monitor that the risk and skin assessment are
done at appropriate intervals - Monitor that the plan of care reflects
interventions being implemented - Monitor that products are being utilized
appropriately (i.e., wheelchair cushions, bed
surfaces, devices, etc.)
27Other Prevention Program Tips
- Prevention Program continued
- On-going monitoring of turning and repositioning
- Monitor treatment books
- Ensure IDT is being proactive and discussing high
risk residents (immobile and incontinent) - Monitor that the documentation is consistent
(physician orders, MDS/RAPS, care plan and
nursing assistant assignment sheets)
28Other Prevention Program Tips
- Prevention Program Tips
- Monitor daily cares to ensure they are inspecting
the skin, doing proper peri-care, ROM,
feeding/supplements, weights, I O, etc.
29Treatment Program
- Treatment Program Assessment
- Do you have a system in place to ensure a new
risk assessment gets done - Do you have a system in place to notify the
Physician and family/designee of the wound or
when it declines - Do you have a system in place to initiate
documentation of the wounds progress - Trigger to up-date the care plan
30Treatment Program
- Treatment Program Assessment
- Do you have interventions and products in place
for when a wound develops - Moisture dressings (i.e., hydrogels,
hydrocolloids and transparent films) - Absorbtive dressings (i.e., foams and calcium
alginates) - Enzymatic debriders (usually perscription)
- Access to adjunctive therapies (i.e., V.A.C.,
Infrared, E-Stim, Ultrasound, etc.) - Powered support!surfaces
- Air or foam wheelchair cushions
- Dietary supplementation
31Treatment Program
- Treatment Program Assessment
- Do you have a system in place to notify the
nursing assistant of the area and any changes in
the care - Assess if topical treatment products are being
utilized appropriately (should present with signs
of healing in 2-4 weeks) - Assess ability of nurses to determine etiology
for pressure ulcers and lower extremity ulcers
32Treatment Program
- Treatment Program Tips
- Monitor ALL nurses doing dressing changes and
wound assessments - Monitor treatment records and documentation
records - Monitor the Physician and NP orders, diagnosis
and progress notes appropriate - Ensure IDT is actively discussing/identifying
wounds not showing progress
33F314 Tag Common Performance Gaps
- Failure to document resident refusal of care and
treatment in care plan - Document the date of discussion in care plan and
put residents request in care plan - Review quarterly, with re-admission and with
change of condition
34F314 Tag Common Performance Gaps
- Documentation of refusal of cares should include
- Discuss residents condition
- Treatment options
- Expected outcomes
- Consequences of refusing treatment (pressure
ulcer development, sepsis and even death) - Offer relevant alternatives
- Recommend showing residents/families pictures of
pressure ulcers -
35Educational Programs
- Recommend doing educational programs in this
order - Prevention
- Assessment and Documentation
- Treatment Modalities
- Lower Extremity Ulcers
- Do bedside follow up after educational programs
- Do education on orientation and periodically
throughout the year
36Skin Care Programs
- Once programs are in place one way to monitor
them - is by utilizing
- your quality indicators
- for sample residents
37Skin Care Programs
- Overall, if you keep
- the residents best interest in mind, your
program will succeed!!!
38Resources
- Available Resources and Web Sites
- www.wocn.org (Wound, Ostomy Continence Nurse
Society) - Available Guidelines
- Prevention and Management of Pressure Ulcers
- Management of Wounds in Patients with
Lower-Extremity Arterial Disease - Management of Wounds in Patients with
Lower-Extremity Neuropathic Disease - Management of Wounds in Patients with
Lower-Extremity Venous Disease
39Resources
- Available Resources and Web Sites
- www.ahrq.gov (Agency for Health Care Research
and Quality, formally AHCPR) - Call 1-800-358-9295 for FREE guidelines
- Clinical Practice Guideline Number 3 Pressure
Ulcers in Adults Prediction and Prevention - Clinical Practice Guideline Number 15 Treatment
of Pressure Ulcers - Patient Guide for Pressure Ulcer Prevention
40Resources
- Available Resources and Web Sites
- www.aawm.org (American Academy of Wound
Management) Has a list of Certified Wound Care
Specialists - www.npuap.org (National Pressure Ulcer Advisory
Panel) - www.woundsource.com Great source to find wound
care products and companies/vendors
41- Thanks for your participation!!!
- Jeri Lundgren, RN, CWS, CWCN
- Pathway Health Services, Inc.
- Jeri.lundgren_at_pathwayhealth.com
- Cell 612-805-9703