PREVENTING PRESSURE ULCERS

1. PREVENTING PRESSURE ULCERS CNA Education and Training

2. Objectives • Discuss the reasons why patients and residents develop pressure ulcers • Discuss implications of patient disease process at end of life such as: anxiety, anger; depression, and how this processes impact CNA care modalities • Incorporate preventive/intervention measures into one’s role as a CNA

3. Why patient’s get pressure ulcers • Age • Lack of mobility • Poor diet • Moisture • Mental, neurological and other physical disease processes • Friction and shearing • Bed sheets and chairs with wrinkled sheet or hard objects • Previous hx of pressure ulcers

4. How do they form? • 1st warning sign: • Pink skin on bony prominence that turns white (blanching) • Further progresses to red/irritated area…may be warm to the touch…patient may feel “burning” sensation at ulcer site • Top layers of the skin will break down/away…becoming an “open sore” which may exposure bone, muscle or joint

5. CNA Interventions • Prevent skin breakdown and discomfort through proper positioning in bed • Thoroughly clean patient after any soiling • Apply moisturizing lotion as directed by nurse • Place padding between knees or other bony prominence areas • Anticipate need for special pressure mattresses and other devices

6. Common Emotional Symptoms at EOL • Anxiety • Feelings of apprehension, worry, uneasiness or dread • Causes: • Medication side effects • Fear of the unknown • Inability to perform tasks at hand • Financial concerns • Family conflicts • Spiritual distress

7. CNA Interventions • Listen with empathy • Provide reassurance • Decrease environmental stimuli (turn lights down, turn off TV, remove from crowded or loud areas) • Offer to engage in distraction activities • Engage other team members – multidisciplinary approaches to care

8. Confused / Combative patients • Disorientation to time, place or person • STM loss • Unusual or inappropriate communication • Talking nonsensical • Yelling • Searing • Rudeness • Hallucinations

9. CNA Interventions • Gently reorient to person, place and time • Provide calendar, clock, etc. if appropriate) • Ensure use of hearing aides and eyeglasses • Decrease clutter, keep environment organized and simple • Pace patient activities, provide rest periods • Use simple, brief instructions • Provide emotional support • Reassurance of safety • Calm tone of voice • Avoid arguing • Be patient

10. Depression Patients • Depression: Extreme and ongoing cluster of feelings that may include: sadness, hopelessness; helplessness; lack of self-worth; anger;

11. Causes of Depression • History of depression • DM; Thyroid disease • Dementia • ETOH • Brain METS • Pain; nausea, diarrhea • Radiation/chemo side effects • Profound loss of control; fear; grief • Spiritual grief; family dysfunction or lack of support

12. CNA Interventions • Provide emotional support to patient – be present and be a good listener… • Avoid trying to “cheer” patient; maintain normal level of social conversation • Encourage as much independence and control as possible; particularly ADL’s • Provide opportunity for talking about and remembering significant life events • Encourage use of previous helpful coping mechanisms – prayer, family/friend visits..

13. Possible Causes – prolonged position stasis • High fowlers • Semi-Fowlers • Supine • Prone • Lateral or side lying position • Right lateral position • Sim’s position

14. Fowler’s Position / both low and high • Heels • Pelvis • Spine • Sacrum

15. Supine or Back Lying Position • Heels • Sacrum • Elbows • Scapulae • Occipital region (back of head)

16. Prone Position • Ankle bone • Knees • Hip bone • Shoulder • Side of the head (parietal region) and ears

17. Lateral Position • Toes • Knees • Male genitals • Breasts • Shoulder • Cheek and ears

18. Sim’s Position • Ears • Cheek • Shoulder • Hip • Feet • Toes

19. Pressure Ulcer Prevention • Providing good skin care • Keep skin clean and dry • Turn and position patients at least every 2 hours (educate your patient, family/caregivers) • Observe condition of skin and report to nurse (bathing is an excellent time to do this) • Encourage mobility • Empower patients in the plan of care

20. Prevention continued • Provide for toileting needs • Encourage and provide nutrition and fluids (as appropriate) • Use pressure ulcer reducing cushions, mattresses, beds, booties, elbow pads, etc.) • Be cognizant of disease process progression / intervention modalities

21. References • Berman, A., Snyder., S., Kozier, B., and Erb, G. (2010) • Fundamentals of Nursing: Concepts, Process and Practice. 8th edition.; Pearson Prentice Hall • Presentation adapted for in-house training only