Practical Tips and Interventions for Pressure Ulcer Prevention and Treatment

1. Practical Tips and Interventions for Pressure Ulcer Prevention and Treatment Presented by Jeri Lundgren, RN, CWS, CWCN Pathway Health Services

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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”

12. Prevention Program Risk Assessment • F314 States “Many clinicians recommend using a standardized pressure ulcer risk assessment tool to assess a resident’s 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”

13. Prevention Program • “Regardless of any resident’s total risk score, the clinicians responsibility for the resident’s 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.”

14. 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

15. 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 (402) 551-8636

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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)

23. 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

24. 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

25. 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

26. 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.)

27. 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)

28. 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.

29. 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

30. 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

31. 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

32. 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

33. 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 resident’s request in care plan • Review quarterly, with re-admission and with change of condition

34. F314 Tag Common Performance Gaps Documentation of refusal of cares should include: • Discuss resident’s condition • Treatment options • Expected outcomes • Consequences of refusing treatment (pressure ulcer development, sepsis and even death) • Offer relevant alternatives • Recommend showing residents/families pictures ofpressure ulcers

35. 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

36. Skin Care Programs Once programs are in place one way to monitor them is by utilizing your quality indicators for sample residents

37. Skin Care Programs Overall, if you keep the resident’s best interest in mind, your program will succeed!!!

38. 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

39. 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

40. 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

41. Thanks for your participation!!! Jeri Lundgren, RN, CWS, CWCN Pathway Health Services, Inc. Jeri.lundgren@pathwayhealth.com Cell: 612-805-9703