Best Nursing Practices in Care for Older Adults

1. Best Nursing Practices in Care for Older Adults ELDER Project Fairfield University School of Nursing Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

2. Session 6 Topics: Pressure Ulcers in Older Adults and Nutrition/Eating for Older Adults Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

3. Healthy People 2010 • One target is to reduce the proportion of nursing home residents with a diagnosis of pressure ulcers to 8 diagnoses per 1,000 residents. • (current number varies greatly from institution to institution) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

4. Pressure Ulcer • What is it? Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

5. Definition of Pressure Ulcer: • Any lesion caused by unrelieved pressure and resulting in damage of underlying tissue Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

6. Prevention is the Key! • Difficulty in healing pressure ulcers due to • Decreased ambulation/mobility • Decreased nutritional status • Incontinence • Underlying medical issues Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

7. Tools to Assess Risk for Pressure Ulcers • Braden Scale : for elderly population, score should be < 18 Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

8. Staging Pressure Ulcers There are 4 stages of Pressure Ulcers Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

9. Stage I Pressure Ulcer • Observable pressure-related alteration of intact skin • Changes include one or more of the following: • Skin temperature (warm, or cool) • Tissue Consistency (firm, or boggy) • Sensation (pain, or itch) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

10. Stage 1 continued • In lighter skin: It is a defined area of persistent redness • In darker skin: May appear with persistent red, blue or purple tones Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

11. Stage I Pressure Ulcer Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

12. Stage II Pressure Ulcers • Partial thickness skin loss • Involves epidermis and/or dermis • Superficial • Presents as: • an abrasion • blister • shallow crater Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

13. Stage II Pressure Ulcer • Blister Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

14. Stage III Pressure Ulcer • Full thickness skin loss • Damage or necrosis to subcutaneous tissue • Presents as • Deep crater • With or without undermining to adjacent tissue Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

15. Stage III Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

16. Stage IV Pressure Ulcer • Full thickness skin loss • Extensive destruction • Tissue necrosis • Damage to muscle, bone or supporting structures (tendons, joints) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

17. Stage IV Pressure Ulcer Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

18. Eschar • If eschar is present, the ulcer cannot be staged Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

19. Risk Assessment • Patients are at risk if: • Bedbound or chairbound • Impaired ability to reposition self Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

20. Other Risk Factors • Decreased mental status • Moisture • Incontinence • Nutritional deficit (low albumin) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

21. When to Assess for Risk: • Upon admission • At regular intervals after admission depending on the setting Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

22. Acute Care • Assess every 48 hours or whenever the condition changes Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

23. Long Term Care • Weekly for the first four weeks • Then quarterly at a minimum Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

24. Home Care • At every visit Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

25. Skin Care & Early Treatment • Inspect skin daily and document Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

26. Skin Care & Early Treatment • Individualize bathing frequency • Mild cleansing agents (or no soap) • Avoid hot water • Avoid excessive friction Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

27. Skin Care & Early Treatment • Assess and treat incontinence • Cleanse at time of soiling • Topical moisture barrier • Absorbent briefs or pads Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

28. Skin Care & Early Treatment • Use moisturizers for dry skin • Avoid massage over bony prominences • Use dry lubricants (cornstarch), or protective coverings to avoid shearing Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

29. Skin Care & Early Treatment • Use proper positioning, transferring, turning to decrease friction Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

30. Skin Care & Early Treatment • Identify and correct nutritional problems • Consider nutritional supplements Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

31. Skin Care & Early Treatment • Institute a rehabilitation program • Monitor and document interventions • Monitor and document outcomes • Modify night regimen as needed Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

32. Positioning and Alignment • Reposition bed-bound patients at least every 2 hours • Reposition chair-bound patients at least every hour • Use a written repositioning schedule Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

33. Positioning and Alignment • Place at risk persons on a pressure reducing mattress/chair/cushion • Do not use donut type devices Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

34. Positioning and Alignment • Teach chair bound patients to shift their weight every 15 minutes • Use lifting devices to move, rather than drag patients Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

35. Positioning and Alignment • Use devices that totally relieve pressure on heels (ie: pillow under calf) • Use pillows or foam wedges to keep boney prominences from direct contact with each other Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

36. Positioning and Alignment • Avoid positioning directly on trochanter when side-lying (use 30 degree angle) • Elevate the head of bed as little as possible for short times only (max 30 degrees) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

37. Plan of Care • Include strategies for • Nutrition • Pain management • Psycho-social issues Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

38. Plan of Care • May need to include: • Debridement • Cleansing • Dressing • Pressure relief Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

39. Care for Pressure Ulcers: Tips • Assess the whole person • Measure wound healing • Use solutions to cleanse that do not kill good cells • Normal saline • SOME commercial wound cleansers Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

40. Avoid Cytotoxic Solutions • Dakin’s Solution • Acetic Acid • Providone Iodine • Hydrogen Peroxide • Some Commercial Skin Cleansers Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

41. Selecting Dressing Materials • Maintain a moist environment (not soaking) • Avoid desiccating (drying out) wound bed • Eliminate dead space (loosely fill) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

42. Topic # 2: Nutrition • Nearly 50% of adults aged 65 and over are clinically malnourished upon admission to the hospital • This number increases upon discharge Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

43. Food Diary • A 3 day food diary is the best method of obtaining a diet history Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

44. Weight • It is important to track weight and changes in weight • Don’t rely on self report Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

45. Physical Assessment for Nutrition • Focus on • Skin turgor • Skin lesions • Changes in skin color • Brittle hair • Muscle wasting • Oral status Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

46. Physical Assessment Continued • Focus on • Hydration • Oral lesions, fissures around lips • Hyperplasia of gums • Enlarged, smooth, or beefy red tongue • Poor hygiene Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

47. Hypoalbuminemia • Low albumin levels, below 3.5 g/dl • Key to assessing for malnutrition • Indicates low-protein malnutrition Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

48. Serologic Parameters • Albumin ** (less than 3.5 g/dl) • This is KEY • Total protein (falsely elevated if dehydrated) • BUN/Creatinine Ratio (for hydration and renal function) • Complete Blood Count (CBC) (for anemia) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

49. More Serologic Parameters • Blood glucose (for hypo/hyperglycemia) • Transferrin, iron, ferritin, Vitamin B12 (for anemias) Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858

50. Consider Religion and Culture • Some people may observe rituals about • Preparing • Blessing • Serving the food Supported by DHHS/HRSA/BHPr/Division of Nursing Grant# D62HP06858