PRESSURE ULCERS:

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PRESSURE ULCERS
THE GOAL IS ZERO
JOY L EDVALSON MSN FNP, CWOCN 9/2008
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Where Are We?

• FY 2007
• CMS reports 257,412 cases of preventable PU as
  secondary diagnosis
• Incidence rates in acute care is around 7
• Average cost/case w/PU as secondary dx estimated
  43,180 per hospital stay

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IMPACT to Individuals

• Painful
• Expensive
• Unnecessary harm
• Serve as a vehicle for infection
• Delaying functional recovery

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IMPACT to Facilities

• October 1, 2008 Medicare PPS will no longer
  provide additional reimbursement an acquired PU
• Physician/Provider determination during the
  hospitalization that PU was present on admission
• Competence of provider in assessment is critical
  to do accurate skin assessment
• Raises awareness of prevention as a culture
  change

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Pressure Ulcer Prevention Strategies for Culture
Change

• Patient Education
• Clinician/Provider Training
• Multidisciplinary involvement
• Clearly written protocols for documentation/commun
  ication
• Staff acceptance and compliance
• Continual monitoring

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Culture of Prevention

• Multidisciplinary Improvement Team
• Nursing unit/exec level
• Education
• Quality
• Dietary

• Team (cont)
• Medical Records
• Medical Exec Committee
• Materials Management staff
• Patient representative

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Patient Education

• Patients Families can be critical in the
  prevention of PU
• Knowledge can recruit cooperation participation
  in the prevention plan
• Written handouts in reading level appropriate
  language
• Multi-lingual formats of handouts

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Clinician/Provider Training

• Start with education to the multi-disciplinary
  team of the new initiative Culture of
  Prevention
• Provide information of the fiscal impact
  potential to the facility
• Outline the plan
• Set the GOAL No Pressure Injury

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Identification of Risk? for Pressure Ulcer
Development

• Conduct comprehensive, systematic, consistent
  assessment of pressure ulcer risk factors
  complete the Braden Risk Assessment Scale
  analyze the co-morbidities
• Complete Skin Assessment on admission and routine
  individuals combine w/ routine interventions

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Risk Assessment for Pressure Ulcer Development

• Use clinical judgment based on co-morbidities in
  addition to the risk assessment tool to assess
  risk
• Assess demographic, physical/medical,
  psychosocial risk factors associated with
  pressure ulcer development

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Aging Factors are Significant in Risk of Pressure
Injury

• Flattening/thinning of outer layer of skin
• Loss of integrity of the dermal-epidermal
  junction, increasing risk to trauma shear
• Decrease in melanin, less tolerant protection
  from sun.

• Atrophy of dermis
• Decrease in cellularity vascularity
• Fewer fibroblasts resulting in decrease
  production of collagen elastin, which gives
  skin strength elasticity
• Basal and peak cutaneous blood flow reduced 60

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Age related Changes

• Overall decrease in Sub-Q layer which decreases
  shock absorption thermoregulation
• Distribution change of Fatty layer which alters
  ability to diffuse pressure over bony prominences

• Nerve density decreases resulting in decrease in
  sensation of light touch
• Structural changes dryness, roughness,
  wrinkling, laxity increase of neoplasms

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Additional Factors of Risk

• Peripheral Vascular Disease
• Diabetes
• Coronary Artery Disease
• COPD
• Spinal Cord Injury

• Renal Dialysis
• History of Pressure ulcers
• Cognitive Impairment
• Steroid Therapy
• End Stage Renal Disease

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Key Components of Prevention

• Identify Patient at Risk for PU development
• Develop prevention strategy for individuals
• Pressure Relief
• Nutrition/Hydration
• Skin Care
• Patient Movement
• Patient/family education
• Ongoing Assessment

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Admission, Initial Opportunity

• On each admission complete a risk assessment
  (Braden, Norton)
• Incorporate this assessment into routine
  paperwork
• During this admission assessment there should be
  a skin assessment using both inspection
  palpation
• If the individual is identified at risk how is
  this communicated to the team? Some sort of a
  visual cue

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Skin Inspection Risk Assessment at routine
intervals

• Admission? Daily? Weekly?
• Reassess on pts found at risk?
• Re-evaluation of strategies for prevention with
  each Skin Risk Assessment
• Communication of plan for prevention to
  caregivers on the team
• Easy identification of individual at risk i.e.,
  sticker on door, chart w/symbol or cue word

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Assessment

• Skin should be checked daily including touching
  the following areas (Standard of Care)
• Sacrum/coccyx
• Hips
• Heels
• Darker skin may not show redness, so the touching
  may reveal early injury by hardness, warmth or
  swelling

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Identifying a Pressure Area

• A reddened area, usually over a bone, which does
  not go away after pressure is relieved
• A break in the skin caused by unrelieved pressure
  from
• the bed
• the wheelchair (inappropriate cushion)
• supportive or therapeutic device (casts, braces
  etc.)

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Color Change from Unrelieved Pressure
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Be Alert to Changes Prevention of Pressure
Ulcers
You dont need to use your crystal ball Factors
to identify at risk individuals needing
prevention

• Immobility
• Inactivity
• Malnutrition
• Incontinence
• Sensory loss
• Friction/Shear activities

• Old Age
• Poor physical condition
• Altered mental status
• Hemodynamic Instability

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Prevention Intervention

• Inspect skin of all individuals
• paying particular attention to bony prominences
• w/each assistance of the individual by all team
  members
• If changes in skin re-evaluate the prevention
  strategy

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Prevention of Pressure Ulcers

• Protect against the enemy!
• adverse effects of external mechanical forces
• pressure, friction and shear.

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What is the cause of Shear?

• The gravitational pull of the body downward while
  the skin stays stationary on the surface of bed
  or chair
• This gravitational pull creates a change in the
  angle of capillaries.

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Intervention

• Minimize friction and shear forces
• proper positioning, transferring and turning
  techniques.
• use of lubricants
• Assist the individual to improve mobility and
  activity whenever possible.

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Management of Pressure,Friction Shear

• Assuring that individuals are being repositioned
  and that nurses understand
• Resident should avoid lying directly on the
  trochanter shoulder bony prominences and be
  certain pressure on heels is eliminated, use 30
  degree rotation
• Teach their staff that it is essential to team up
  with other nurses and assistants to move or
  transfer an individual in and out of bed

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Intervention

• Monitor dietary intake
• Inadequate dietary intake of protein or calories,
  will compromise patient
• Consider Nutritional consultation

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Nutrition

• Micronutrients assessment supplementation
  Zinc, Vitamin C, Vitamin A, Vitamin E
• Adequate Fluid Intake
• Enteral Nutrition w/HOB elevation increases risk
• Long term NPO status without enteral
  supplementation is a HUGE Risk
• Implement aggressive nutritional support measures
  if dietary intake has changed over 3 days and is
  inadequate and/or if individual is nutritionally
  compromised

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MANAGE MOISTURE

• Excess moisture exposure
• softens skin increasing risk for injury
• Increase in rash development
• Potential for fungal involvement

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Prevention Interventions

• Minimize skin exposure to moisture due to
  incontinence, perspiration, or wound drainage
• When necessary, use underpads and briefs that
  absorb moisture
• Use topical agents that act as barriers to
  moisture

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Prevention w/ Routine Care

• Cleanse skin at time of soiling and at regular
  intervals.
• Avoid hot water
• Use a mild cleansing agent
• minimizes irritation and dryness of the skin
• minimizes force and friction to the skin during
  the cleansing process.

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Prevention w/Routine Care

• Minimize environmental factors such as low
  humidity
• Minimize extreme temperatures
• Treat dry skin with moisturizers
• Avoid massage over bony prominences
• Available products _at_ the bedside

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Intervention

• Bedfast individuals assessed to be at risk for
  developing pressure ulcers should be repositioned
  at least every 2 hours
• Use a written schedule for systematically turning
  and repositioning

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Intervention

• Positioning devices such as pillows or foam
  wedges should be used to keep bony prominences
  (such as knees or ankles) from direct contact
  with one another

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Intervention

• Completely immobilized, bedfast individuals
  should have devices utilized which completely
  relieve pressure on the heels, most commonly by
  raising the heels off of the bed. Do not use
  donut type devices

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Intervention

• Avoid positioning directly on the trochanter
• Maintain the head of the bed at the lowest level
  possible
• Limit the time the head of the bed is elevated

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Intervention

• Chair-bound individuals
• use pressure reducing devices (foam, gel, air)
• Do not use donut type devices
• Assist in maintaining
• alignment, distribution of weight
• balance, stability, pressure relief.
• Teach able individuals to shift
  own weight every 15 minutes

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Intervention

• Use lifting devices, a trapeze or linens to move
  individuals in bed, use 2 people

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Pressure Ulcer Prevention and Management

• Using support surfaces that reduce or eliminate
  pressure, control moisture and reduce friction
  and shear.

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Evaluate Support Surfaces

• Daily skin assessment both visual and palpation
  to evaluate effectiveness of skin care
  equipment as R/T pressure ulcer prevention
• Re-evaluate surfaces as the medical or health
  status changes for individual

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Pressure Ulcer Prevention

• Use only minimal padding on static or dynamic air
  beds
• airbed, double folded undersheet, bottom sheet,
  quad folded sheet, 4 blue chux - 11 layers total
• Multiple Layers defeat the purpose of the bed
  surface
• Flat sheets best over mattress, to avoid
  hammocking

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Communication Terminology

• Documentation is critical to meeting new payment
  provisions
• Physician documentation throughout
  hospitalization needed
• Necessary to use NPUAP definitions of 2007 should
  be used across continuum
• Speaking same language with identified
  terminology helpful

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Where Do You Start?

• Look at Admission Assessment, incorporate skin
  risk assessment
• Establish policy/protocol/SOC
• Identify unit champions
• Solicit ideas from staff to bundle care
  activities to accomplish prevention plan
• Develop plan with evaluation time frames for all
  changes
• Post report cards for each inpatient area

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Steps to Consider?

• Assess your Facility
• Track your PU incidence/prevalence?
• Analyze each acquired PU?
• Pressure redistribution mattress on all bed?
• Evaluate type of underpads and incontinent
  supplies?
• Staff clear on protective ointments?
• Assess skin cleansers/soaps used?
• Method for identifying at risk pts?

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Steps to Consider?

• Facility Assessment (cont)
• Lifting equipment available?
• Develop standard of care that combines
  prevention activities together?
• Staff awareness? Education?
• Patient/Family Education?
• Available positioning devices?
• Medical Staff education about initiative their
  role

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Evaluate Monitor

• Compliance with documentation
• Risk Assessments completed timely?
• If at risk, is there a plan for prevention?
• Is the planned followed? Re-evaluated?
• Are identified Pressure Ulcers actually pressure
  related?
• Are physicians documenting these skin conditions
  accurately?

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IHI 5 MILLION LIVESPU Resources

• Institute for Healthcare Improvement
• http//www.ihi.org/NR/rdonlyres/CCAF8C31-CE3B-46A6
  -8260-28CBA3D5C087/0/PreventingPressureUlcers.pdf
  
• http//www.ihi.org/IHI/Programs/Campaign/PressureU
  lcers.htm

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GO FOR THE ZERO!