Prevention of Pressure Ulcers andSkin and Wound Management
ProgramsMary Beth Flynn Makic RN PhD CNS CCNS
[email protected] 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
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