Pressure Ulcers: Putting Pressure on Prevention Karen Clay, RN CWOCN

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Pressure UlcersPutting Pressure on
PreventionKaren Clay, RN CWOCN
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Why are we failing?

• Insanity
• Doing the same thing expecting different result
• Changing policy not practices
• Looking at paper not people

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Goals

• Respond to pressure ulcer needs assessment
  questionnaire
• Share prevention pearls
• Identify a variety of prevention possibilities
• Encourage honest examination of facility
  practices
• Plan prevention in the context of each residents
  life, routine and preferences

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Questionnaire Results

• 68 of facilities conduct weekly risk assessment
  x 4 weeks after admission
• 85 have process for re-stocking personal care
  products
• 44 randomly audit this
• 52 have process for checking MDS coding accuracy
  for Section M
• 31 have rule to decrease HOB elevation when
  picking up meal tray

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Questionnaire Results contd

• 55 of weekly skin committees include visual
  rounds of residents in their seating or bed
  positioning
• 78 have permanent assignments for CNAs
• 68 have PU prevention as part of orientation

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Assessing Risk
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Other Risk Factors

• History of pressure ulcers, scarring
• Medical diagnoses
• Nutritional deficits - wt loss, low albumin or
  pre-albumin
• Behaviors non-compliance, self-destructive
  behaviors
• Do we create non-compliance when not including
  the resident preferences in the plan?
• Is the resident REFUSING or CHOOSING?

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Complicating Illnesses

• Impaired cardiovascular or pulmonary function
• Compromise perfusion and oxygenation
• Conditions with damage to capillary basement
  membrane - radiation, PVD
• Tissue perfusion is restricted
• Systolic pressure lt100 mm Hg and diastolic lt60
  associated with PU development
• may shunt blood flow away from skin to more vital
  organs..decreasing skin tolerance by allowing
  capillaries to close at lower levels of interface
  pressure

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Pain Control

• Eliminate/control pain
• Affects mobility
• Affects mental status
• Affects motivation
• Affects blood flow/perfusion of tissue
• Affects nutrition

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Sample Protocol
At Risk Moderate Risk High Risk Very High Risk
Turn/reposition every 2 hours (if mobility impaired) ?
Turn/reposition every 2 hours AND prevent direct contact between bony prominences ? ? ?
Protect heels ? ? ? ?
If bedfast, provide pressure-reducing support surface ? ? ? ?
If in wheelchair, provide standard pressure-reducing seat cushion ? ? ? ?
If appropriate, initiate remobilization program (ambulation, stand-pivot transfers, etc) ? ? ? ?
Manage moisture (from incontinence) ? ? ? ?
Manage nutrition ? ? ? ?
Reduce friction/shear ? ? ? ?
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Sample Protocol
At Risk Moderate Risk High Risk Very High Risk
Provide wedges/repositioning aids for 30 degree lateral positioning ? ? ?
Supplement turning schedule with small position shifts (hourly) ? ?
Obtain rehab assessment to determine need for pressure relief cushion assess correct seat height and w/c positioning ? ?
Consider a pressure relieving support surface or powered mattress overlay ?
Sample risk reduction strategies Heel Protection
Friction gripper socks, sheepskin at foot
of bed, transparent dressings, moisturizers,
bunny boots Heel Protection Pressure
elevate lower extremities on pillow, multi-podus
boots, heel-lift boots, loosen bed linens at foot
of bed, foot cradle Manage Incontinence
initiate bowel/bladder program or scheduled
toileting, incontinent care every two hours,
incontinence barriers, briefs, absorbent under
pads, fecal bag (if frequent stools) Reduce
friction/shear draw sheet or lift pad for bed
movement, trapeze, moisturize skin, limit head of
bed elevation to 30 degrees (and only as
required), long sleeve garments/elbow protectors,
careful cleansing during incontinence/hygiene
care, gait belt transfers (as appropriate),
mechanical lift
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Frequency of Assessment

• Minimally
• upon admission
• quarterly
• upon Significant Change in Condition
• Ideally
• day 7, 14, 21, 28 (post admission) and as above
• during acute illness

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Risk Assessment

• Establish guidelines, protocols,
  algorithms/decision trees based on risk
• Low risk does not equal no risk
• Dont just treat the conglomerate of score
• Intervene based on the risk assessment
• What risks can you modify?

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EXTERNAL FACTORS

• Pressure Shear
• Friction Moisture

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Manage Moisture

• BB programs
• Briefs
• Open vs. Closed system at night
• Cleansing and Moisturizing
• Moisture barriers
• Sweat

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Fecal Incontinence

• Maklebust and Magnan (1994)
• 56.7 of patients with PU were fecally
  incontinent
• 22 times more likely to have PU than patients
  without fecal incontinence

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Cleansing Moisturizing

• Perineal cleansers better than soap or products
  for routine skin cleansing
• Soap can dry, raise pH and contribute to
  epidermal erosion
• Perineal cleansers most contain humectants
• Help replace oils in the skin

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Skin Barriers

• Creams water based preparations
• Ointments oil based, longer lasting (more
  occlusive)
• Paste Ointment with powder more durability and
  absorption

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SHEAR
Tissue layers slide against each other, disrupts
or angulates blood vessels
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Heels

• 2nd most common site
• Subject to high interface pressures
• Suspend versus cushion
• Diligent positioning and assessment
• Dont treat just one heel
• Be flexible in approach two hrs in position may
  not be tolerable

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Address Risk Factors

• Skin care
• Repositioning
• 1 hour in chair 15 minutes in chair by resident
  1-2 hours in bed, lift devices
• Pressure relief
• Cushions, support surfaces, off-load heels
• Assess/address nutrition, toileting schedule?
  Rehab? Positioning evaluations?

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Support Surfaces

• Pressure reducing/relief devices
• foam, static air, alternating pressure, low air
  loss, air, gel, etc.
• If foam is used it should measure 3-4 in
  thickness
• Egg-crate foam overlays are inadequate
• Sheepskin booties do not relieve pressure
• Need to learn properties

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Rule of 30

• Head of bed is elevated to 30 degrees or less
• Body is placed in a 30-degree laterally inclined
  position - when repositioned to either side
• Hips and shoulders tilted 30 degrees from supine
• Pillows or wedges to keep position without
  pressure over trochanter or sacrum

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Repositioning

• Every 1-2 hours in bed
• Pros/Cons of facility-wide clocks
• Positioning devices
• No direct contact of bony prominences
• MPB and stablizing bars
• Individualized w/c accessories
• Encourage mobility
• CREATE A CULTURE OF MOVEMENT

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Tissue Tolerance

• Deep tissue ischemia can occur without observable
  changes in skin but it can sensitize the skin.
  After that small increments of pressure may
  result in breakdown
• Husain (1953) research with rat muscle
• pressure of 100 mm Hg 2 hours
• Three days later 50 mm Hg pressure to same
  tissue caused muscle degeneration in only 1 hour

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• Skin Check
• To be completed during the residents 1st bath of
  the week.
• Please check the appropriate box and indicate the
  location. .
• ? Skin tear _____________________________
• ? Bruise _______________________________
• ? Open area ____________________________
• ? Reddened area_________________________
• ? Rash_________________________________
• ? Blister_______________________________
• ? No skin concern
• ? Resident refused
  shower or bath
• Comment__________________________________________
  __________________________________________________
  __________________________
• The Charge Nurse will notify the DON when there
  is a pattern of resident refusals.
• Charge Nurse Signature____________________________
  __ Date__________

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Competencies

• Have staff been taught how to conduct a skin
  assessment
• Competency testing initially and annually
• Follow-up when a necrotic area is discovered
• If skin check during shower..how can we do a
  complete assessment if resident sitting on a
  shower chair?

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Recurrent PU Why?

• Decreased tensile strength of skin
• Characteristics of scar tissue
• Difficulties in assessment
• Higher level of prevention strategies stopped
  when wound closes
• Weekly assessments by team stop when wound closes
• Analogy of active rehab and functional
  maintenance programs

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Wound Care Teams

• ?Focus wound progress vs. prevention
• Wound characteristics assessed
• Cushions may/may not be assessed
• Presence, condition
• Heel off-loading devices may/may not be assessed
• Is there foot drop/deformity, condition of
  device, any evidence of pressure from device
• Posture in chair
• Feet firmly planted (on floor or foot rest)
• How is position overall? Need therapy?

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Mini-Focus Studies

• Check all residents requiring mechanical lifts
• What time does the person get up in a.m.?
• What time does the person go back to bed
• If interval greater than two hours how is
  pressure relieved? How is incontinence care
  given?
• Have we worked with the resident to design a
  schedule that honors their preferences and
  protects skin
• Discussing benefit vs. risk with residents

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Assignments Appointments

• Many facilities have 11-7 assist a group of
  residents up in a.m.
• What is criteria for developing this list
• Is skin risk considered
• If high risk resident assisted by 11-7 resident
  may be ready for position change, incontinent
  care/ toileting or back-to-bed at the beginning
  of 7-3 shift
• How are routines altered if it is hairdresser
  day? Podiatry visits?
• Potential for prolonged waiting times

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Facility Patterns and PU

• Retrospective review of residents using restraint
• How many restrained residents had any stage PU in
  the past 3 or 6 months?
• Referrals to therapy for bed mobility?
• Any program to teach/encourage resident(s) how to
  use chair rail to stand up?

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Wheelchair Standard Issue

• How is it decided who keeps a w/c at all times?
  
• Versus out of room storage for those requiring
  for long distances
• Honest evaluation
• Is there a culture of mobility or immobility
• Wheelchairs for mobility
• Not used as furniture

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Pondering Points

• When folding bedcovers back and putting extra
  blankets at the end of the bed
• Where is the weight?
• When we remove pillows from under the heels to
  boost the resident
• What happens?
• When we dont use foot rests on wheelchairs when
  needed
• What happens?

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Involving Residents Families

• Education in Resident Council
• Educating families
• Ways they can help
• Prohibiting family-provided devices unless
  assessed by the team (cushions from home, etc.)
• Encouraging culture of mobility

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Involve Everyone!

• Adopt a Resident program
• Every two hour theme music/signal
• Rounds aligning with area of expertise
• Therapy random rounds for positioning
• CNA cross-audits of another unit for presence of
  skin care supplies at bedside (if appropriate)
• SDC random competency check of skin assessment
• Any employee walk thru after bfast/meals to
  confirm HOB has been lowered (unless clinically
  contraindicated)
• Activities who needs more movement incorporated
  into activities program

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Super CNA or Lead CNA

• Lighter assignment
• Enhance skin prevention role
• Verifying position changes, presence/use of
  devices
• Work with nurse to modify resident schedules
• Participate in rounds
• Update peers weekly on progress

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Care Plans

• Identify modifiable and non-modifiable risks
• Link assessment with interventions
• Understand rationales for care
• Continually re-assess and update
• Weigh benefit versus risk
• Document

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Quality Improvement

• Look for problems that exist in the delivery of
  care
• Systems versus individuals
• How will you identify the problem(s)?
• What steps will you take to correct them?
• How will you measure your success?

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Reality Check

• Check the budget for treatment supply allocations
• Then..
• Check the budget for prevention supplies,
  pillows, positioning devices, cushions
• What does it show?

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Incentives and/or Recognition

• When goal is reducing staff sick time
• Incentives often provided
• When goal is reducing workers comp
• Incentives often provided
• Staffing shortages and recruitment plans
• Incentives often provided
• When goal is reducing PU
• I wish our numbers would come down

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The Devil is in the Details

• Communication to staff
• Equipment provision and condition
• Resident and facility routines
• Availability of positioning devices
• Willingness/commitment to have a living,
  breathing, changing POC
• Improving one step at a time
• Dont try to solve everything pick one and
  start

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QI Lessons Learned

• Systems improvement does not happen from
• Writing a new program
• Providing education one time
• Having weekly measurements
• Good intentions

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MOST IMPORTANT

• The resident WILL get your time
• Either proactively with PREVENTION
• Or
• Reactively with TREATMENT

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My Challenge to You

• For the State that has the greatest decline in
  pressure ulcers in the next measurement
  period..
• I will provide a complimentary four hour
  educational presentation on any pressure ulcer or
  wound care topic chosen by that State
• The facility within that State with the greatest
  improvement will be honored at that presentation

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Thank you for your time attention!

• Karen Clay, RN, BSN, CWCN
• Clay Associates
• (formerly Kare N Consulting)
• KSC4LTC2_at_AOL.COM