Prevention of Pressure Ulcers andSkin and Wound Management

ProgramsMary Beth Flynn Makic RN PhD CNS CCNS

Marybeth.Makic@uch.eduResearch Nurse Scientist, Critical Care

University of Colorado HospitalAssistant Professor, Adjoint

University of Colorado, Denver,College of Nursing

Never Events: Pressure Ulcers• Pressure ulcers (PUs) can be identified,

measured, and reported

• Usually preventable

• Result in adverse patient outcomes,prolonged/additional care, increased costs

• Significant body of scientific evidence isavailable to guide practice and prevent PUs

• October, 2008: Stage III and IV PUs acquiredafter admission are not reimbursed

www.cms.hhs.org April 14, 2008 fact sheet;www.qualityforum.orgSerious Adverse Events Working Group March 19, 2008

Pressure Ulcer FactsDorner, B., Posthauer, M.E., Thomas, D. (2009) www.npuap.org/newroom.htm

• 4th leading preventable medical error in theUnited State

• 3 million patients are treated annually• National acute care prevalence rates 7-15%• ↑LOS ~ 4 to 14 days• Cost to treat PU $43,000 per hospital stay

Pressure Ulcer FactsRusso, CA et al (2008). Hospitalizations related to pressure ulcers among adults 18 years and older.

www.hcup-us.ahrq.gov

• 503,300 PU relatedhospitalizations in2006

• 45,5000 admissionswith PU as primarydiagnosis

• 1 of 25 admissionsended in death

• 457,800 admissions,PU secondarydiagnosis

• 1 of 8 admissionsended in death

Pressure Ulcer Prevention:A Nursing Sensitive Indicator

• National Database of Nursing Quality Indicators(NDNQI)

• www.nursingworld.org

• 2004 National Quality Forum• National Voluntary Consensus Standards for Nursing-Sensitive

Carehttp://www.qualityforum.org/publications/reports/nurse_tracking.asp

• IHI 5 Million Lives Campaign• http:/www.ihi.org/IHI/Programs/Campaigns

• National Pressure Ulcer Advisory Panel• www.npuap.org

• European Pressure Ulcer Advisory Panel• www.epuap.org

S.P.A.M.• Prevention of pressure

ulcers is nursingsensitive indicator– This means that prevention

of skin breakdown is a directreflection of care provided topatients by nursingprofessionals

• Nursing practice guided bybest-evidence is essential inthe prevention of pressureulcers (PU)

• At UCH our skinprogram logo isS.P.A.M.– Skin– Prevention– Assessment– Management

Positively Impacting Care:Skin Assessment on Admission

• Essential that nurses complete anddocument full assessment of skin toinclude alterations and pressure ulcerson admission and nutritional status

• Differentiate– Community acquired pressure ulcer:

Present on Admission (POA)

– Hospital acquired pressure ulcer (HAPU)

Risk Assessment On Admission, Daily,Change in Patient Condition

www,ihi.org; Macklebust,JA (2009) The Braden Scale reliable assessment toeffective interventions

• Use standard EBP risk assessment tool• Research has shown Risk Assessment Tools are

more accurate than RN assessment alone.• Braden Scale for Predicting Pressure Sore Risk

– 6 subscales• Rated 1-4

– Pressure on tissues• Mobility, sensory perception, activity

– Tissue tolerance for pressure• Nutrition, moisture, shear/friction

– Score 6-23

Evidence-Based RiskAssessment Tools

Bolton, L. Which pressure ulcer risk assessment scores are valid for use in clinical settings? JWOCN, 2007;34(4): 368. ; Kring, D., Reliability and validity of the Braden scale for predicting pressure ulcer risk.

JWOCN, 2007; 34(4): 399.

Braden Acute care, homecare, nursinghomes

Adult patientpopulations

6 subscales

Scores 6-23

Norton Acute care

Rehab

Adult patientpopulations

5 subscales

Scores 5-20

Gosnell Acute care,nursing home

Neurology,orthopedic,medical, ICU,geriatric patients

4 subscales

Scores 5-20

Braden Q Acute care Pediatrics 6 subscales +tissue perfusion

Pressure Ulcer Prevention (PUP) Protocol Related Policies / Guidelines: Use of Therapeutic Surfaces/Bariatric Suites

Prevention and Treatment of Skin/Tissue Breakdown Skin Tear Management Guideline Pressure Ulcer Prevention / Treatment Guidelines Nursing Standard of Care of Prevention of Pressure Ulcers and Skin Breakdown

? Turning Schedule: turn patient every 2 hours and PRN ? HOB < 30 if pt does not have pulmonary risks; HOB>30 if pt has risk for pulmonary complications (increase tu rning frequency) ? Trapeze when indicated, “Waffle” cushion to all chair surfaces for Braden ‘ACTIVITY’ subscale ? 3 ? Moisturize skin daily and PRN using Dimethicone barrier cream ? Control moisture; determine and treat cause of moisture, add absorbent pads to bed surface, barrier cleansing wipes and Zinc Skin Paste as needed. ? Nutritional Consult if: Braden ‘NUTRITION’ subscale ? 3 and/or Albumin ? 3.4 g/dl and/or Pre -albumin ?20 mg/dl and/or Braden score ?16 ? Minimize Friction & Shear by use of turning sheet s and slide boards to move patient, protect heels and fragile skin of extremities ? Wound Care Consult if: DTI, Stage III, IV, Unstageable or hospital acquired pressure ulcer, prevention challenges or complicated wounds

Braden Score 15-18

At Risk

Braden Score 13-14

Moderate Risk

Braden Score 10-12

High Risk

Braden Score < 9 Very High Risk

INTERVENTIONS:

? Implement turning schedule ? Moisturize skin daily and PRN ? Out of bed, increase activity as

indicated ? Control moisture ? Assess nutritional status ? Minimize friction and shear ? Consider Advanta bed or ensure

prevention mode activated ? Patient/Caregiver Education

INTERVENTIONS: ? Implement turning schedule ? Moisturize skin daily and PRN ? Out of bed, increase activity,

assess need for PT consult ? Control moisture ? Nut rition consult ? Minimize friction and shear on

bed and chair surfaces ? Advanta bed surface ? Patient/Caregiver Education

INTERVENTIONS: ? Implement turning schedule ? Moisturize skin daily and PRN ? Obtain PT consult for activity

level, out of bed as indicated ? Cont rol moisture ? Nutrition consult ? Minimize friction and shear on

bed and chair surfaces ? Advanta bed surface ? Patient/Caregiver Education

INTERVENTIONS: ? Turn every 1 hour as applicable ? Obtain PT consult, out of bed as

indicated ? Moisturize skin daily and PRN ? Control moisture ? Nutrition consult ? Minimize friction and shear on

bed and chair surfaces ? Order Low-Airloss bed per

‘Therapeutic Surfaces’ policy ? Patient/Caregiver Education

Advance to next level of risk if other factors are present: Advanced age, Chronic Illness, Diastolic pressure below 60, Uncontrolled pain Bariatric patients with BMI>40 (www.rd411.com/tools ) should be placed on surfaces as per ‘Therapeutic Surfaces/Bariatric Suites’ policy References:

1. Ratliff, C.R. et al (2003). Guideline for prevention and management of pressure ulcers. Wound Ostomy and Continence Nurses Society. Lake Avenue, Glenview IL. 2. Ayello, E.A. et al (2004). By the numbers: Braden score interventions. Advances in Skin & Wound Care 17(3):150. 3. Nurse’s Association of Ontario . Nu rsing Best Practice Guideline: Assessment and Prevention of Pressure Ulcers. Toronto: RNAO (2005). Available online @ www.RNAO.org/Nursing best practice guideline. 4. Keast, David et al (2007) . Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers. Advances in Skin &Wound Care 20(8): 447 -462. 5. Magalhaes, MD et al (2007). Risk Factors for Pressure Ulcers in Hospitalized Elderly without Significant Cognitive Impairment. Wounds 19(1): 20 -24.

© University of Colorado Hospital, 2008

Accuracy of RN Knowledge

• Assumptions of RN knowledge to correctlyassess, treat, and stage pressure ulcers

• Little didactic knowledge in academic settings

• Little formal education in practice; reliance onspecialists (CWOCN)

• Two skin conditions of greatest concern are:Deep Tissue Injury (DTI) and IncontinenceAssociated Dermatitis (IAD)

Staging Pressure Ulcershttp://www.npuap.org/pr2.htm

• Deep Tissue Injury(DTI)

• Stage I

• Stage II

• Stage III

• Stage IV

• Unstageable

• ?mucosal injury

https://www.nursingquality.org/NDNQIPressureUlcerTraining/default.aspx

Deep Tissue Injury (DTI)• High risk patient

population-ICU– Immobility– Poor perfusion states

• Purple in color, “bloodblister”

• Wound deterioratesquickly

• Usually progressesmuscle, bone

• Heels are high risk areas

www.NPUAP DTIconsensus statement

Fleck, C. (2007).Suspected DTI, FAQs.Advances in Skin &Wound Care. 20(7),413

Treatment of Pressure Ulcer Guidelines:Deep Tissue Injury (DTI)

Pressure Ulcers and ExcessiveMoisture…incontinence

Gray,M., Bliss, D., Doughty, D., et al., Incontinence-associated dermatitis: a consensus.JWOCN, 2007; 34(1): 45-54.

• Incontinence associateddermatitis (IAD)

• Fecal > urineincontinence

• Patients with fecalincontinence 22% >chance developing PU*

• Immobility + fecalincontinence = ↑↑ risk

*Maklebust, J. & Magnan, M. Risk factorsassociated with having a pressure ulcer: asecondary analysis. Adv Wound Care 1994,7: 25.

WOCN Image Files

Evidence-BasedManagement of IAD

Wishin, J., et al. Emerging options for the management of fecal incontinence in hospitalized patients.JWOCN, 2008; 35(1): 104

• 1st identify the source ofIAD– In ICU frequently it is

antibiotics or tubefeeding

– Consult nutritionist:evaluate osmolarity oftube feeding; add fiberto diet

• Consider medications toslow diarrhea

• Evaluate medications thatmay be causing diarrhea– Ace inhibitors, beta-

blockers, digoxin, lasix,mannitol, octreotide,lactulose

• Absorbent underpads,changed frequently

• Low airloss therapeuticmattress

Evidence-BasedManagement of IAD

Gray, M. Incontinence-related skin damage: essential knowledge. OWM, 2007; www.o-wm.com/article/8161

• First, do no harm…– Soaps ↑ skin pH– Wash clothes rough-up

already fragile skin– Diapers/briefs keep moisture,

enzymes in

• Cleans frequently and avoidscrubbing

• Apply barrier creams that:moisturize and protect skin

• Polymer-based underpads;limit linens

What is the evidence forrectal tubes?

• “Rectal tubes”– Mushroom and balloon-

tipped catheters– No evidence to support use– Not intended use of device– Increased risk of liability– Sphincter and mucosal

injury

• Rectal trumpet (Grogan,2002)– Nasopharyngeal trumpet

Rectaltubes

BMS

Evidence-based fecalincontinence management

Palmieri, B et al. (2005). The anal bag: modern approach to fecalincontinence management. OWM, 51:44.

• Fecal containment devices

• FDA approved

• Research on effectiveness

• Requires two healthcare providers to apply

• Perineal skin must be intact

– Clean DRY skin

– Hold 1 minute for adhesive to bind to skin

• Careful removal of device

Evidence supporting bowelmanagement systems (BMS)

Benoit et al. 2007; Echols et al., 2007; Keshava, et al., 2007

• Patient selection– Indications

– Contraindications

• Placement: 29 days

• Practice realities

• Cost effectiveness

• Patient outcomes

Evidence-Based Management of CAUTIand Skin Related Concerns?

Newman,D. (2007) The indwelling urinary catheter, principles for best practice. JWOCN 34(6)655-661

• What about CA-UTIsand urinaryincontinence?

• How to prevent CA-UTIs?– How was the foley placed

– Is foley secured

– Foley always belowbladder

– Daily perineal care

– Metered bag

• Remove foley ASAP

• Bladder scan forbladder volumeBEFORE patient can’tvoid

• Intermittentcatheterization forretention

• Excessive moisture?– Treat cause/protect skin

Therapeutic SurfacesNational Pressure Ulcer Advisory Panel: Support Surface Standards Initiative.

Terms and definitions related to support surfaces 2007.www.npuap.org/npuap_S31_TD Accessed August 28, 2008.

• Rethinking beds as“therapy”

• Change in practicefor all– RNs

– Orderlies

– EVS

• Knowledge ofsurfaces isconfusing

• Movement awayfrom specialty bedsexcept for specificindications

• Linen as a friendand foe

What Lies Beneath the PatientBrostrom, J. et al (1996). Preventing skin breakdown: nursing practices, cost, and

outcomes. Applied Nursing Research

• Linen– Linen increases entrapment

of moisture– Creates wrinkles– May increase risk of skin

compromise– Limit linens on all beds

• Especially on pressureredistribution beds and lowair loss beds

– Newer ICU beds arepressure redistributionsurfaces

– www.npuap.org/npuap_s31_td position statement onbed surface terminology

Williamson, R, et al (2008) LinenUsage Impact on Pressure andMicroclimate Management. Hill-Rom

Knowledge of WoundAssessment and Management

• Address healthcare providerknowledge of wound assessment

• Product knowledge– There is more to wound management

than hydrocolloids and wet to drydressings….

Partial or Full Thickness WoundUsed to describe all wounds other than

pressure ulcers

Partial Thickness• Involved epidermis and dermis

• Shallow

• Moist

• May be painful

• Pink-red color

Full Thickness• Total loss of epidermal and

dermal layers• Extends into subcutaneous

tissue• May involve muscle, bone or

joint• Undermining and tunneling may

be present

How to Measure a Wound

Granulation

Length

Width

Surrounding skin

AB

C

“A” is the wound bed “B” is the wound edge “C” is the surrounding skin

D

Depth: measureat deepest pointin the wound bed

UCH Resource Pocket Cards

Wound Base• Document assessment

of wound base:– Each dressing change

• Describe wound tissue– Eschar or black necrotic

– Red Granulation

– Yellow slough

Used with permission WOCN image library

Surrounding (periwound) Tissue

• Descriptors used todocument theperiwound– Intact

– Erythema

– Macerated

– Blistered

– Indurated

Used with permissionNDNQI

Assess for Signs andSymptoms of Infection

Systemic– Fever, chills, altered mental status

• Wound– Necrotic tissue, erythema, warmth, poor wound healing, increased pain,

increased exudate

• Immunocompromised Patient– Vague symptoms

Tack Your Successand Adjust Plan

• Pressure ulcerprevalence– Quarterly (one day)

– Quarterly (billingchart audits)

• RN knowledgeassessments

• Unit-based processimprovementprojects

• Unit skin rounds

• Journal clubs

• Evaluate productsand processesrelated to products

“Poisoning by the skin is no less certain than poisoningby the mouth—only it is slower in its operation.”

~Nightingale

Nursing Driven Interventionsto Prevent HAPU

• Frequent repositioning• Manual turning

• Managing moisture• Developing and

implementing apressure ulcer preventprotocol/rogram• User friendly• Products available• RNs knowledge of

protocol and products

•Assessment of risk•The obvious factors•Other factors: age,vasopressors, instability,severe agitation,comorbidities, obesity

•Optimize nutrition &hydration

•Albumin, prealbumin•Fluid balance