“My Work Matters!” It’s More Than Paperwork Compliance… It’s Quality Resident Care

1. “My Work Matters!”It’s More Than Paperwork Compliance…It’s Quality Resident Care Relevant Nursing Assessment and Care Planning using THE BRADEN SCALE

2. Speakers Members of PUPC- (Pressure Ulcer Prevention Coalition) Sheri Rogers, RN, RCA, LTC Consultant President, Western Health Care Corp. Martie Hawkins RN-BC BSN CWOCN CCM is a certified wound care/ostomy and Legal Nurse Consultant.

3. Prevention of Pressure Ulcers • It’s just GOOD Nursing! • It’s a Federal Requirement in LTC • F 314 Pressure Sores • Based on the comprehensive Assessment of a resident, the facility must ensure that—

4. A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable 2) A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing.

5. Guidance To Surveyors “An admission evaluation helps identify the resident at risk of developing a pressure ulcer, and the resident with an existing pressure ulcer(s) or areas of skin that are at risk for breakdown”

6. Guidance To Surveyors “Because a resident at risk can develop a pressure ulcer within 2-6 hours of the onset of pressure, the at-risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches”.

7. Timing of Assessments • Admission • Weekly x 4 weeks (in some facilities) • Quarterly • With a significant change of condition (ie-fall, change in mobility, pneumonia, GI disorder causing diarrhea, fractured hip)

8. The Facility must become a pressure detective! Find the pressure BEFORE it finds the patient/resident. • Dr. Margaret Doucette, 2005

9. BRADEN SCALE Developed with a greater sensitivity and is specific to the risks of the patient. Measures six characteristics that have a bearing on the crucial determinants of pressure sores. These determinants are the intensity and duration of the pressure and the tolerance of skin and supporting structures to endure that pressure.

10. RISK FACTORS • Sensory Perception • Moisture • Activity • Mobility • Nutrition • Friction and Shear • The Braden Risk Assessment Tool measures the above areas. • It is an inverse scale (the smaller • the score, the higher the risk).

11. At Risk Everyone is at risk for skin breakdown. Braden Scale rates the risk of the patient for skin breakdown. Rated at this point in time – risk changes as the patient’s condition changes. Low risk – Score is 19 and above At Risk-Score is 15-18 Moderate Risk – Score is 13-14 High Risk – Score is 10-12 or less

12. Sensory Perception Ability to respond meaningfully to pressure- related discomfort 4 points – No Impairment. Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 3 points – Slightly Limited. Responds to verbal commands, but cannot always communicate discomfort or the need to be turn, OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 2 points – Very Limited – Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness, OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body. 1 point – Completely Limited – Unresponsive (does not moan, flinch, or grasp) to painful stimuli, d/t diminished level of consciousness or sedation, OR limited ability to feel pain over most of body.

13. Moisture Degree to which skin is exposed to moisture 4 Points – Rarely Moist: Skin is usually dry; Linen only requires changing at routine intervals. 3 Points – Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 2 Points – Often Moist: Skin is often, but not always moist. Linen must be changed as often as 3 times in 24 hours. 1 Points – Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned.

14. Activity Degree of physical activity. 4 Points – Walks frequently. Walks outside bedroom twice a day and inside room at least once every 2 hours during waking hours. 3 Points – Walks Occasionally. Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of day in bed or chair. 2 Points – Chairfast. Ability to walk severely limited or non-existent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 1 Point – Bedfast Confined to bed.

15. Mobility Ability to change and control body position. 4 Points – No Limitation. Makes major and frequent changes in position without assistance. 3 Points – Slightly Limited. Makes frequent though slight changes in body or extremity position independently. 2 Points – Very Limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 1 Point – Completely Immobile. Does not make even slight changes in body or extremity position without assistance.

16. Nutrition Usually food intake pattern. 4 Points – Excellent. -- Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. 3 Points – Adequate. -- Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR Is on a tube feeding or TPN regimen which probably meets most of nutritional needs. 2 Points – Probably inadequate. -- Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR Receives less than optimum amount of liquid diet or tube feeding. 1 Point – Very Poor. Never eats a complete meal. Rarely eats more than ½ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR Is NPO and/or maintained on clear liquids or IV’s for more than 5 days.

17. Friction & Shear 3 Points – No Apparent Problem. Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair. 2 Points – Potential Problem. Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 1 Point – Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.

18. Protocals by Level of Risk AT RISK (15-18)* FREQUENT TURNING MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR PRESSURE-REDUCTION SUPPORT SURFACE IF BED- OR CHAIR-BOUND * If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability)

19. MODERATE RISK (13-14)* TURNING SCHEDULE USE FOAM WEDGES FOR 30! LATERAL POSITIONING PRESSURE-REDUCTION SUPPORT SURFACE MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR If other major risk factors present, Advance to next level of Risk.

20. HIGH RISK (10-12) INCREASE FREQUENCY OF TURNING SUPPLEMENT WITH SMALL SHIFTS PRESSURE REDUCTION SUPPORT SURFACE USE FOAM WEDGES FOR 30 degree LATERAL POSITIONIING MAXIMAL REMOBILIZATION PROTECT HEELS MANAGE MOISTURE, NUTRITION AND FRICTION AND SHEAR

21. VERY HIGH RISK (9 or below) ALL OF THE ABOVE plus USE PRESSURE-RELIEVING SURFACE IF PATIENT HAS INTRACTABLE PAIN OR SEVERE PAIN EXACERBATED BY TURNING OR ADDITIONAL RISK FACTORS *low air loss beds do not substitute for turning schedules.

22. MANAGE MOISTURE USE COMMERCIAL MOISTURE BARRIER USE ABSORBANT PADS OR DIAPERS THAT WICK & HOLD MOISTURE ADDRESS CAUSE IF POSIBLE OFFER BEDPAN/URINAL AND GLASS OF WATER IN CONJUNCTION WITH TURNING SCHEDULES MANAGE NUTRITION INCREASE PROTEIN INTAKE INCREASE CALORIE INTAKE TO SPARE PROTEINS. SUPPLEMENT WITH MULTI-VITAMIN (SHOULD HAVE VIT A, C & E) ACT QUICKLY TO ALLEVIATE DEFICITS CONSULT DIETITIAN (contact Cindy Jo or Lee Ann) if needed

23. MANAGE FRICTION & SHEAR ELEVATE HOB NO MORE THAN 30! USE TRAPEZE WHEN INDICATED USE LIFT SHEET TO MOVE PATIENT PROTECT ELBOWS & HEELS IF BEING EXPOSED TO FRICTION OTHER GENERAL CARE ISSUES NO MASSAGE OF REDDENED BONY PROMINENCES NO DONUT TYPE DEVICES MAINTAIN GOOD HYDRATION AVOID DRYING THE SKIN

24. Risk Factors and Interventions Risk Factors Interventions Immobility/ Encourage mobility as tolerated Inactivity/ Position with pillows Sensory Keep linen dry and wrinkle free Perception Provide pressure relief surface Establish individual turning schedule Protect elbows and apply heel protectors - reduces shear and friction Keep heels elevated at all times Consult physical therapist Provide assistive devices to increase activity Do Not use donuts ROM every shift Turning Schedule

25. Risk Factors and Interventions Risk Factors Interventions Incontinence Bathe daily with mild soap, Moisture rinse and dry thoroughly Skin Hygiene and Do not scrub the skin Inspection Moisturize skin BID and PRN with lotion to keep skin soft and pliable Keep local areas of skin clean, dry and free of body wastes, perspiration and wound drainage Inspect the skin q shift and when bathing, note any changes Assess etiology of incontinence

26. Risk Factors and Interventions Risk Factors Interventions Nutrition Provide adequate nutritional and fluid intake Monitor nutrition and hydration Monitor weight, intake/output PRN or as ordered Monitor lab data for deficiencies (i.e. low serum albumin or total protein levels, prealbumin) Obtain Dietary Consult

27. Risk Factors and Interventions Risk Factors Interventions Friction and Shear Lift - do not slide or drag patient Skin Protection Keep HOB at or below 30 degree angle Use assistive devices to reduce friction and facilitate patient movement (turning sheets, overhead trapeze, patient lift) Provide padding for casts, braces, splints, elbows and heels Apply skin sealant under adhesives Institute measures to contain fecal and/or urinary incontinence and to protect the skin from incontinence Apply skin sealant around the ears to protect from oxygen cannula irritation and over bony prominences to reduce friction

28. Case Study

29. 70 year old female Very weak States no appetite Barely taking in much food and fluid Walks with walker – standby assist Needs assistance in turning in bed Occasional incontinence Unstageable breakdown on coccyx Appears to have lost a lot of weight Wants to stay in bed

30. 79 year old male • Post CVA – right sided hemiparesis • Uses walker – brace to right leg • Wears diapers – incontinent occasionally • Skin breakdown – perineal area • Wheelchair bound but can transfer with assist • Able to feed self • Eats 3 meals a day with snacks • Weight has been stable

32. What Would Their Care Plans Look Like? Group Discussion

33. Thank You