Unavoidable Pressure Ulcers

1. Unavoidable Pressure Ulcers Presented by: Jeri Lundgren, RN, BSN, CWS, CWCN Director of Wound & Continence Pathway Health Services Director of Clinical Services Gulf South Medical Supply, Inc.

2. Unavoidable Are pressure ulcers always avoidable????

3. Unavoidable • March 3rd, 2010 NPUAP Press Release • The NPUAP Panel agreed that some pressure ulcers could be unavoidable if: • Patients who choose NOT to participate in their own pressure ulcer prevention • Clinical Situations

4. NPUAP Definition of Unavoidable • Evaluated clinical condition, • Risk Factors Identified, • Defined interventions consistent with: • The individual needs/goals • Recognized standards of practice • Interventions implemented, • Monitored and Evaluated the impact of the interventions & • Revised approaches

5. Sound Familiar??? • NURSING PROCESS!!!!! • Assessment • Nursing Diagnosis • Care Planning • Implementation • Evaluation

6. Documentation • Implication– If it is not documented it is not done

7. Prior to Admission • The Process starts PRIOR to admission • Ask if the individual has ANY skin conditions and/or pressure ulcers • Is the individual receiving any treatments to the skin and/or pressure ulcers • Has the individual had any history of skin conditions/breakdown or pressure ulcers

8. Prior to Admission • What is the current plan of care preventative or treatment • Support surfaces • Turning and repositioning • Nutrition • Incontinence management • Topical support, etc

9. Admission • Within the first 24 hours of Admission: • Risk Assessment • Skin Inspection • Development of the temporary care plan – based off of the risk assessment • Interventions indicated on the Nursing Assistant assignment sheet • Interventions implemented

10. Admission Care Plan At a MINIMUM interventions on the temporary care plan (within the first 24 hours) 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 Monitor skin on a daily basis with cares and weekly by licensed staff

11. Admission Care Plan Temporary care plan continued: • If the is a wound present on admission: • Topical treatment as ordered • Monitor for S/S of infection/complications • Weekly wound assessment • Update the Physician/NP, IDT and family with any skin concerns identified, no progress or with a decline

12. Prevention • On-going Risk assessment in LTC: • Admission • Weekly for the first four weeks after admission • Change of condition (mobility, incontinence, nutritional, ulcer development) • Quarterly/annually with the MDS

13. Prevention • On-Going Risk Assessment in Acute Care • Upon Admission • Upon Admission to the unit • Daily

14. Prevention • On-going Risk Assessment in Home Care: • No clear mandate • WOCN with each visit, may want to consider LTC intervals if visits are frequent

15. Prevention • Risk assessment • Break the Braden scale down per risk factor • The Braden is not comprehensive • Ensure EVERY risk factor identified on the Braden/comprehensive risk assessment/MDS/OASIS-C is brought forward to the plan of care

16. Prevention • Care planned interventions MUST correlate with identified risk factors: • For Example; • At risk for immobility • Pressure redistribution surface for the bed • Pressure redistribution surface for the wheelchair • Turning and repositioning program • Heel lift • Appropriate devices to lift individual • Appropriate positioning devices….

17. Skin Inspections • Skin Assessment in LTC: • *Upon Admission • *Daily with cares by the nursing assistants • *Weekly by the Licensed staff • Upon a planned discharge • If the resident has been out for a prolonged period of time • Keep the records!!! * Contained within the F314 guidance

18. Skin Inspections • Skin Assessment in Acute Care: • Upon Admission • Admission to the unit • Daily • Discharge

19. Skin Inspections • Skin Assessment in Home Care • Upon admission • With each visit • Discharge

20. Deep Tissue Injury

21. Photographs • Caution when utilizing photographs of the wound • Dignity/privacy • Infection control • Skew appearance of the wound • Litigation risk

22. Communication • Nursing Assistant Assignment sheets must contain all Interventions they implement • Recommend to keep the assignments sheets • Recommend having a written form of communication for the aides when they find a skin concern

23. Communication • Document communication to outside providers such as dialysis units to ensure continuity of care

24. Physician/NP Involvement • Physician/NP to evaluate overall clinical condition and prognosis

25. Implementation • Recommend having set monitoring programs in place to ensure implementation of care plan • Address individual/family complaints immediately

26. Documentation • Ensure the following match: • Risk assessment • Skin assessment • MDS/RAPS/OASIS-C • Physician orders • Care Plan • Nursing Assistant assignment sheets

27. Care Plan • On-going up-dates of the care plan is imperative • Be careful not to delete any tried interventions

28. Refusal of Cares Documentation of refusal of cares should include: • Discuss individual’s condition • Treatment options • Expected outcomes • Consequences of refusing treatment (pressure ulcer development, sepsis and even death) • Offer relevant alternatives • Recommend showing the individual/families pictures ofpressure ulcers

29. Refusal of Cares • Document resident refusal of care and treatment in care plan • Document the date of discussion in care plan and put individual’s request in care plan • Review quarterly, with re-admission and with change of condition

30. Education • On-going education for ALL staff • Orientation • At least yearly

31. I’m Just a Nurse

32. I’m Just a Nurse… • Who notifies the family of their loved one’s declining status to say their final goodbyes • Who reassures an elderly resident that is unable to sleep through the night • Who you rely on to get you to the bathroom while you are yelling at me • Who helps elderly heal from illness/injury so they can return home • Who will always be there for my patients when no one else can…..

33. YOU ARE NOT JUST A NURSE!

34. 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

35. 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

36. Thanks for your participation!!! Jeri Lundgren, RN, BSN, CWS, CWCN jeri.lundgren@pathwayhealth.com Cell: 612-805-9703