Pressure Ulcers: Putting Pressure on Prevention - PowerPoint PPT Presentation

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Pressure Ulcers: Putting Pressure on Prevention

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Egg-crate foam overlays are inadequate. Sheepskin booties do not relieve pressure ... The Devil is in the Details. Communication to staff. Equipment provision ... – PowerPoint PPT presentation

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Title: Pressure Ulcers: Putting Pressure on Prevention


1
Pressure UlcersPutting Pressure on Prevention
2
Why are we failing?
  • Insanity
  • Doing the same thing expecting different result
  • Changing policy not practices
  • Looking at paper not people

3
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

4
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

5
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

6
Assessing Risk
7
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?

8
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

9
Pain Control
  • Eliminate/control pain
  • Affects mobility
  • Affects mental status
  • Affects motivation
  • Affects blood flow/perfusion of tissue
  • Affects nutrition

10
Sample Protocol
11
Sample Protocol
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
12
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

13
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?

14
EXTERNAL FACTORS
  • Pressure Shear
  • Friction Moisture

15
Manage Moisture
  • BB programs
  • Briefs
  • Open vs. Closed system at night
  • Cleansing and Moisturizing
  • Moisture barriers
  • Sweat

16
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

17
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

18
Skin Barriers
  • Creams water based preparations
  • Ointments oil based, longer lasting (more
    occlusive)
  • Paste Ointment with powder more durability and
    absorption

19
SHEAR
Tissue layers slide against each other, disrupts
or angulates blood vessels
20
(No Transcript)
21
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

22
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?

23
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

24
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

25
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

26
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

27
  • 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__________

28
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?

29
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

30
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?

31
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

32
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

33
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?

34
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

35
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?

36
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

37
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

38
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

39
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

40
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?

41
Reality Check
  • Check the budget for treatment supply allocations
  • Then..
  • Check the budget for prevention supplies,
    pillows, positioning devices, cushions
  • What does it show?

42
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

43
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

44
QI Lessons Learned
  • Systems improvement does not happen from
  • Writing a new program
  • Providing education one time
  • Having weekly measurements
  • Good intentions

45
MOST IMPORTANT
  • The resident WILL get your time
  • Either proactively with PREVENTION
  • Or
  • Reactively with TREATMENT

46
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

47
Thank you for your time attention!
  • Karen Clay, RN, BSN, CWCN
  • Clay Associates
  • (formerly Kare N Consulting)
  • KSC4LTC2_at_AOL.COM
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