Bonnie SparksDeFriese RN, CWOCN, PT, CWS

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Bonnie Sparks-DeFriese RN, CWOCN,PT, CWS
Pressure Ulcers and CMS-314
Emory Wound Ostomy ContinenceNursing Education
Center Atlanta, GA
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Whats new?

• Focus Individualized Care
• Using Current Standards of Care

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Tools Needed by Clinicians

• Multidisciplinary Team
• Effective Communication
• Philosophy Commitment

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Facility must ensure that

• PU do not develop unless
• The individuals clinical condition demonstrates
  that PU were unavoidable
• Resident with PU receives necessary care to
  promote healing, prevent infection and prevent
  new ulcers from developing

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AVOIDABLE vs. UNAVOIDABLE
Facility DID NOT
Facility DID
Vs.

• eval residents clinical condition and PU risks
• define and implement interventions that are
  consistent with resident needs, goals and
  recognized standards of practice
• monitor and evaluate the impact of the
  interventions
• revise the interventions as appropriate

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Resident Assessment

• Assess Resident
• Physical condition
• Systemic issues
• Mental condition
• Alert/Oriented/Follows direction
• Pain
• Risk(s) for breakdown
• Skin Status
• Ulcer(s)
• Etiology

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Prevention is Early Intervention

• Risk Factors
• ID individuals at risk
• ID the risk factors
• ID and evaluate factors that can be removed or
  modified
• Implement interventions to attempt to stabilize,
  reduce or remove underlying risk factors
• Monitoring the impact of the interventions

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Risk Assessment Tools

• Resident Assessment Instrument (RAI)
• Braden Scale
• Norton Scale

• Upon Admission
• Weekly for the first 4 weeks then quarterly
• Whenever there is a change in cognition or
  functional ability

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Numbers vs. Clinical Picture

• Staff is responsible for reviewing each risk
  factor and potential cause(s) individually to
• ID those at risk
• Determine if factor can be modified, stabilized,
  removed etc
• Determine if management protocols need to be
  implemented

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Support Surfaces

• Wheelchairs
• No prolonged sitting in wheelchairs with sling
  seats
• Match surface to patient
• Mid-Level
• Overlays
• High Level
• Low air loss
• Heels/elbows
• Pillows
• NO DONUTS

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INTERVENTIONS Prevention

• Positioning
• Pressure Reduction
• Turning/Repositioning
• Control Friction/Shear
• Contain/Control Moisture
• Monitoring
• System

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Check for Bottoming Out

• Necessary process to determine if mattress
  overlay is effective for the resident
• Hand is placed between the mattress and the
  overlay under a bony prominence

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Pressure Points Tissue Tolerance

• Hi-Risk Locations
• 1 heels 2 Sacrum
• Other areas
• devices (tubes, casts)
• surfaces
• Cushions, lap boards
• positions
• slouching

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Productsfor COMFORT

• Sheepskin
• Heel and elbow protectors
• These do help prevent rubbing together of bony
  prominences

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Repositioning

• Instruction-Supportive devices-Encouragement
• At least every 2 hours
• off loading no less than 1 hour
• Teach redistribution every 15 minutes when
  sitting in chair
• HEELS OFF Bed

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Under-Nutrition and Hydration Deficits

• Determine severity of compromise
• Rate of weight loss or appetite decline
• Probable causes
• Residents prognosis and projected clinical
  course
• Resident's wishes and goals

• Dietitian Assessment
• Lab Values-useful but not conclusive
• Overall clinical presentation

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Moisture

• Incontinence
• Urine
• Feces
• Dermatitis vs. Partial thickness injury

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Monitoring

• DAILY skin checks is
• BEST
• Bathing, ADLs, changing bed, transferring,
  therapies
• At least weekly
• Multidisciplinary Team
• the bedside staff C.N.A. is critical

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Management Priorities

• Etiology
• PU
• Pressure
• Pressure Shear
• Systemic Support
• Co-morbidities
• Nutrition
• Topical Therapy
• DIPAMOPI

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Assessment

• Assess Ulcer
• Differentiate type
• Pressure vs. non-pressure
• Progress toward healing
• Potential complications
• Surrounding skin
• Pain

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Pressure Ulcers

• Location Over bony prominences
• Depth To muscle or bone
• Contours Round or slightly oval no tunneling
  or undermining

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Pressure Ulcers

• Management
• Repositioning program (300 tilt in sidelying
  position limited HOB elevation heels off bed
  avoid positioning on involved surface if
  possible limited time up in chair with sitting
  surface ulcers)
• Therapeutic support surface (check for inflation
  of air devices check for bottoming out with
  overlays)

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Pressure-Shear

• Location over bony prominences
• Depth To subcu tissue or muscle possibly to
  bone
• Contours Irregular wounds with tunneling and
  undermining

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Pressure-Shear

• Repositioning guidelines Q 2 hr repositioning
  measures to prevent sliding (limited head of bed
  elevation) attention to use of support devices
  while up in chair
• Support surfaces need surface with low
  shear-low friction surface (to minimize damage
  with sliding)

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Friction/Shear Injuries

• Location over fleshy surfaces contacting bed
  and chair
• Depth may be superficial or may extend into fat
• Contours typically irregular

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Friction-Shear

• Low shear low friction support surface
• GENTLE skin care
• Lifting as opposed to dragging
• No taping directly onto fragile skin
• Use of protective arm sleeves

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Systemic Support

• Measures to optimize perfusion
• pain Pain control
• Edema control
• Smoking cessation
• Oxygen/revascularization if needed

• Measures to minimize effects of high-dose
  steroids topical Vit A to wound bed (25,000
  100,000 IU daily, depending on size of wound)

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Systemic Support

• Nutritional Support
• 30 35 cal/Kg/day
• 1.2 1.5 gm protein/Kg/day (glutamine
  l-arginine)
• MVI
• Zinc only if needed and only short-term
• Consider oxandrolone for pt with significant wt
  loss who does not respond to standard therapy

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Systemic Support

• Tight Glucose Control
• Goal Normoglycemia
• Impact of glucose gt180
• Implications check glucose records each visit
  constantly reinforce link between glucose levels
  and ability to heal

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Topical Therapy Acronym
Emory WOCNEC

• D Debride necrotic tissue
• I Identify and treat infection
• P Pack dead space, lightly
• A Absorb excess exudate
• M Maintain moist wound surface
• O Open wound edges
• P Protect healing wound
• I Insulate healing wound

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Clinical Decision-Making

• Wound Assessment
• Location
• Dimensions and depth
• Undermined/tunneled areas
• Status of wound base granulating? clean but not
  granulating? necrotic?
• Exudate
• Status of wound edges/surrounding tissue

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Assessment of Pressure Ulcer

• Location
• Dimensions (cm)
• Stage (depth)
• Wd Bed
• Tissues
• Drainage
• Edges
• Infection
• Surrounding Skin
• Pain
• PHOTO Doc is ok IF

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PU Stages

• Stage I vs. DTI
• Stage II
• Partial thickness
• Stage III
• Full thickness
• Stage IV
• Full thickness

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Stage I vs.Deep Tissue Injury
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PU Staging
CMS acknowledges it is not correct, but

• What if covered with necrotic tissue?
• Stage IV
• What to do regarding re-staging as PU heals?
• Reverse Stage

For now
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PAIN

• Assessment and treatment of a residents pain
  integral components of PU prevention and
  management
• Goal eliminate the cause of P, provide analgesia
  or both

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PAIN Assessment

• Determine presence characteristics
• Nature, intensity frequency
• Vary individualistic
• If resident reports pain, they have pain
• Continual pain procedural pain
• Debridement, dressings, movement, infection

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Debridement

• Many clinicians believestable, dry, adherent
  and intact eschar on the foot/heel should not be
  debrided, unless s/s local infection
• Need to show your treatment is based upon current
  standards of practice and agree with facilitys P
  P (approved by medical director)

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Necrotic Wounds

• Debridement Options
• Surgical
• Conservative sharp
• Enzymatic
• Chemical
• Autolytic
• Biologic/MDT

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Infected Wounds

• Wounds involving infection of soft tissue
• Clinical S/S erythema, peri-wound warmth,
  edema, increased pain or tenderness, purulent
  exudate
• Treatment systemic antibiotics (culture based
  if possible)
• Wounds involving osteomyelitis
• Clinical S/S exposed bone nonhealing tunnel
• Treatment systemic antibiotics

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Cultures

• Purpose to determine infecting organism and
  antibiotics to which it is sensitive
• Procedure
• Sterile tissue aspirate
• OR
• Semi-quantitative/Modified swab
• -flush with N/S
• -swab 1 sq cm of viable tissue
• -enough force to produce exudate

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Infected Wounds

• Wounds with sufficient bacterial load at wound
  surface to interfere with repair
• Clinical S/S deterioration in quantity or
  quality of granulation tissue persistent high
  volumes of exudate pain
• Treatment topical agents to reduce bacterial
  loads (cleansers, sustained release iodine or
  silver dressings)

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Infected Wounds

• Topical Agents for Bacterial Control
• Necrotic wounds consider Dakins
• Technicare cleanser for wd with daily dsg changes
  (kills 99 of bacteria within 2 min) Caretech
  Labs
• Sustained release iodine (Healthpoint)
• Sustained release silver agents (Acticoat,
  Silvasorb, Aquacell Ag, Contreet, Actisorb)

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Dressing Selection

• Critical Goals
• Wick and absorb exudate
• Maintain moist wound surface
• Provide bacterial barrier/protection against
  trauma
• Insulate
• Goals will change as the healing process

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Dressing Guidelines

• CLEAN not sterile for mostmay use sterile if
  recently surgically debrided or repaired
• repeated use (of wet to dry gauze dressings)
  may damage healthy granulation tissue in healing
  ulcers and may lead to excessive bleeding and
  increased resident pain.

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Dressing Options Deep and wet gt 0.5 cm deep
(or tunnels or undermining) mod to lg amt
exudate

• Filler Dressing
• Filler dressing alginate or hydrofiber rope or
  damp gauze (least effective option) note
  Nugauze or Mesalt rope best for narrow tunnels
• Cover Dressing
• adhesive foam gauze tape or transparent
  adhesive dressing (consider need for bacterial
  barriere.g., pt who is incontinent and has trunk
  wound)

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Dressing Options Deep and dry gt 0.5 cm deep
(or tunnels or undermining) minimal or no
exudate

• Deep and dry
• Filler dressing layer of wound gel damp
  fluffed gauze gel-soaked gauze
• Cover dressing gauze transparent adhesive
  dressing (maintains hydration and provides
  bacterial barrier)

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Dressing Options Shallow and wet lt 0.5 cm deep
(no tunnels or undermined areas) mod lg amt
exudate

• Shallow and wet
• Alginate foam or gauze
• Hydrofiber foam or gauze
• Nonadherent contact layer gauze
• Adhesive foam alone

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Dressing Options Shallow and dry lt 0.5 cm deep
(no tunnels or undermined areas) minimal or no
exudate

• Shallow and dry
• Solid gel (glycerine-based gels better for wounds
  with exudate)
• Hydrocolloid
• Nonadherent wrap gauze (for wound on extremity)
• Transparent adhesive dressing (if no exudate)

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Management Nonhealing Wounds

• Definition Wound that shows no measurable
  progress for 2 weeks despite appropriate mgmt
• Causes persistence causative factors systemic
  issues high bacterial loads

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Mgmt Non-healing Wounds

• Review current mgmt plan modify as needed
• Consider active wound therapy (tx designed to
  actively manipulate wd healing process)
• Negative pressure
• Growth factors
• MMP inactivator
• Skin Equivalent

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Strategies for Creating a Deficiency-Free Facility

• Establish Educate team
• C.N.A.s ideal for Prevention Program
• Establish protocols prevention and assessment
• Develop algorithms (consider current evidence and
  standards of practice)
• Provide easy-to-use documentation tools

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Summary

• Facility-wide Philosophy of Prevention
  Early Intervention
• Knowledgeable Clinicians
• Current Standards of Practice
• Management Plan
• Assessment--goals
• Prevention--Interventions
• Monitor for progress
• Intervene for failure to progress!

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QUESTIONS
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The End