Practical Tips and Interventions for Pressure Ulcer Prevention and Treatment

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Practical Tips and Interventions for Pressure
Ulcer Prevention and Treatment

• Presented by
• Jeri Lundgren, RN, CWS, CWCN
• Pathway Health Services

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Objectives

• 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

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Assessing 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

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Assessing 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

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Admission 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?

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Admission 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

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Admission 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

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Prevention 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

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Prevention 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

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Prevention 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

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Prevention 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

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Prevention 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

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Prevention 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.

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Risk 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

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Risk 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
  [phone]

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A 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

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A 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

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A 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

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Prevention 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

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Prevention 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

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Prevention 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

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Prevention 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)

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Prevention 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

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Prevention 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

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Prevention 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

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Other 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.)

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Other 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)

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Other 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.

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Treatment 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

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Treatment 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

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Treatment 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

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Treatment 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

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F314 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

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F314 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

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Educational 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

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Skin Care Programs

• Once programs are in place one way to monitor
  them
• is by utilizing
• your quality indicators
• for sample residents

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Skin Care Programs

• Overall, if you keep
• the residents best interest in mind, your
  program will succeed!!!

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Resources

• 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

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Resources

• 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

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Resources

• 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

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• Thanks for your participation!!!
• Jeri Lundgren, RN, CWS, CWCN
• Pathway Health Services, Inc.
• Jeri.lundgren_at_pathwayhealth.com
• Cell 612-805-9703