Pressure Ulcers:Putting Pressure on

Prevention

Karen Clay, RN CWOCN

Why are we failing?

• Insanity– Doing the same thing & expecting different

result

• Changing policy not practices

• Looking at paper not people

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 resident’s life, routine and preferences

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

Questionnaire Results cont’d

• 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

Assessing Risk

Braden Scale Norton Scale

Activity Mobility Incontinence Sensory Perception

Moisture

Friction & Shear

Nutrition

Physical Condition Mental Condition

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?

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 <100 mm Hg and diastolic <60 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

Pain Control

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

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

“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” bootsHeel Protection – Pressure: elevate lower extremities on pillow, multi-podus boots, heel-lift boots, loosen bed linens at foot of bed, foot cradleManage 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

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

Risk Assessment

• Establish guidelines, protocols, algorithms/decision trees based on risk– Low risk does not equal no risk

• Don’t just treat the conglomerate of score– Intervene based on the risk assessment

• What risks can you modify?

EXTERNAL FACTORSPressure Shear

Friction Moisture

Manage Moisture

• B&B programs• Briefs• Open vs. Closed

system at night• Cleansing and

Moisturizing• Moisture barriers• Sweat

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

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

Skin Barriers

• Creams = water based preparations

• Ointments = oil based, longer lasting (more occlusive)

• Paste = Ointment with powder; more durability and absorption

SHEAR

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

Heels

• 2nd most common site

• Subject to high interface pressures

• Suspend versus cushion

• Diligent positioning and assessment– Don’t treat just one heel

• Be flexible in approach – two hrs in position may not be tolerable

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?

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

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

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

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

Skin CheckTo be completed during the resident’s 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__________

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?

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

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?

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

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

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?

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”

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 don’t use foot rests on wheelchairs when needed– What happens?

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

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 b’fast/meals to confirm

HOB has been lowered (unless clinically contraindicated)

– Activities: who needs more movement incorporated into activities program

“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

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

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?

Reality Check

• Check the budget for treatment supply allocations

Then……………..

• Check the budget for prevention supplies, pillows, positioning devices, cushions

What does it show?

Incentives and/or Recognition

• When goal is reducing staff sick time– Incentives often provided

• When goal is reducing worker’s comp– Incentives often provided

• Staffing shortages and recruitment plans– Incentives often provided

• When goal is reducing PU– “I wish our numbers would come down”

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

– Don’t try to solve everything – pick one and start

QI Lessons Learned

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

MOST IMPORTANT

The resident WILL get your time……

Either proactively with PREVENTION

Or

Reactively with TREATMENT

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

Thank you for your time & attention!

Karen Clay, RN, BSN, CWCNClay & Associates

(formerly Kare N’ Consulting)

KSC4LTC2@AOL.COM