Pressure Ulcer PreventionPressure Ulcer Prevention

Lessons Learned from Skin FairLessons Learned from Skin Fair

Jeri Lundgren, RN, CWS, CWCNJeri Lundgren, RN, CWS, CWCNPathway Healthcare ServicesPathway Healthcare Services

Jody Rothe, RN, WCCJody Rothe, RN, WCCMetaStar, Inc.MetaStar, Inc.

December 2, 2009December 2, 2009

Skin Care Skin Care

Objectives for our learning session:Objectives for our learning session:The importance of hydrating skinThe importance of hydrating skinHow to handle fragile skinHow to handle fragile skinMoisture – friend or foeMoisture – friend or foeHow to turn the frail elderly patientHow to turn the frail elderly patientWhat causes pressure and the stage definitionsWhat causes pressure and the stage definitionsImportance of nutritionImportance of nutritionOverall care of the skinOverall care of the skin

Causes of PressureCauses of Pressure

InterventionsInterventions

The Daily Post – The Barren DessertThe Daily Post – The Barren Dessert

Protect Dry Skin which can lead to friction Protect Dry Skin which can lead to friction injuries and skin tearsinjuries and skin tears

Use moisturizers frequently and as often as Use moisturizers frequently and as often as necessarynecessary

Always be on the look-out for skin changesAlways be on the look-out for skin changes

The Daily Post – Fragile Handle With The Daily Post – Fragile Handle With CareCare

Be cautious when changing incontinent Be cautious when changing incontinent products, bandages, or even their clothesproducts, bandages, or even their clothes

Your elder’s skin is very fragile and can Your elder’s skin is very fragile and can tear easilytear easily

The Daily Post – The Barrier ReefThe Daily Post – The Barrier Reef

Use a moisture barrier to help protect the Use a moisture barrier to help protect the skin from stool and urineskin from stool and urine

Barrier creams and ointments only work if Barrier creams and ointments only work if they are applied, and applied correctlythey are applied, and applied correctly

These creams can be the first line of These creams can be the first line of defense for your elder to stop a pressure defense for your elder to stop a pressure ulcer before it developsulcer before it develops

The Daily Post – You’re Tearing Me ApartThe Daily Post – You’re Tearing Me Apart

Simple movements, such as turning or Simple movements, such as turning or lifting, can create friction and shearing, lifting, can create friction and shearing, which can injure the skinwhich can injure the skin

To move and reposition residents, use To move and reposition residents, use lifting devices and draw sheets lifting devices and draw sheets

Avoid dragging.Avoid dragging.

The Daily Post – Under PressureThe Daily Post – Under Pressure

Reposition bedbound residents every two Reposition bedbound residents every two (2) hours(2) hours

Reposition chairbound residents every one Reposition chairbound residents every one (1) hour(1) hour

Use devices, such as pillows and cushions, Use devices, such as pillows and cushions, to keep bony prominences from direct to keep bony prominences from direct contact contact

The Daily Post – Taster’s Choice and The Daily Post – Taster’s Choice and Treasure HuntTreasure Hunt

Poor nutrition is a risk factor in developing a Poor nutrition is a risk factor in developing a pressure ulcerpressure ulcer

Assist residents to eat as necessaryAssist residents to eat as necessary

Notify the nurse if there is a decline or Notify the nurse if there is a decline or change in a resident’s eating habitschange in a resident’s eating habits

Choose supplements that are tastyChoose supplements that are tasty

Consider choice in dining as a strategy to Consider choice in dining as a strategy to increase weightincrease weight

The Daily Post – The Princess and the PeaThe Daily Post – The Princess and the Pea

Use support surfaces on beds and chairs to Use support surfaces on beds and chairs to reduce pressurereduce pressure

Avoid donutsAvoid donuts

Use pillows or devices to raise heels off the Use pillows or devices to raise heels off the bedbed

The Daily Post – Dorothy’s ShoeThe Daily Post – Dorothy’s Shoe

Always be on the lookout for anything that Always be on the lookout for anything that could create pressure on the skin, including could create pressure on the skin, including the feetthe feet

The Daily Post – Squeezing Me Too TightThe Daily Post – Squeezing Me Too Tight

Stage IV pressure sores can take the longest Stage IV pressure sores can take the longest to healto heal

In some residents Stage IV ulcers can In some residents Stage IV ulcers can develop in a matter of hours (i.e., if left on develop in a matter of hours (i.e., if left on the wrong surface too long)the wrong surface too long)

Kick Up Your HeelsKick Up Your Heels

Heels are especially vulnerable to pressure Heels are especially vulnerable to pressure even on a good support surface even on a good support surface

Heel elevation will help prevent pressure Heel elevation will help prevent pressure ulcers to the heels ulcers to the heels

Tip: On daily rounds monitor to ensure Tip: On daily rounds monitor to ensure heels are off on the beds and equipment is heels are off on the beds and equipment is being used appropriatelybeing used appropriately

Stages of Pressure Ulcers – Terrors of the Stages of Pressure Ulcers – Terrors of the DeepDeep

DEEP TISSUE INJURY:DEEP TISSUE INJURY:Purple or maroon localized area of discolored Purple or maroon localized area of discolored intact skin or blood-filled blisterintact skin or blood-filled blister

Due to damage of underlying soft tissue from Due to damage of underlying soft tissue from pressure and/or shear pressure and/or shear

The area may be preceded by tissue that is The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissueas compared to adjacent tissue

Stage 1Stage 1

Intact skin with non-blanchable redness of a Intact skin with non-blanchable redness of a localized area usually over a bony localized area usually over a bony prominence prominence

Darkly pigmented skin may not have visible Darkly pigmented skin may not have visible blanching; its color may differ from the blanching; its color may differ from the surrounding areasurrounding area

Stage 2Stage 2

Partial thickness loss of dermis presenting Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink as a shallow open ulcer with a red pink wound bed, without slough wound bed, without slough

May also present as an intact or May also present as an intact or open/ruptured open/ruptured serum-serum-filled blisterfilled blister

Stage 3Stage 3

Full thickness tissue loss Full thickness tissue loss

Subcutaneous fat may be visible but bone, Subcutaneous fat may be visible but bone, tendon or muscle are not exposed tendon or muscle are not exposed

Slough may be present but does not obscure Slough may be present but does not obscure the depth of tissue loss the depth of tissue loss

May include undermining and tunnelingMay include undermining and tunneling

Stage 4Stage 4

Full thickness tissue loss with exposed Full thickness tissue loss with exposed bone, tendon or muscle bone, tendon or muscle

Slough or eschar may be present on some Slough or eschar may be present on some parts of the wound bed parts of the wound bed

Often include undermining and tunneling Often include undermining and tunneling

UnstageableUnstageable

Full thickness tissue loss in which the base Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed(tan, brown or black) in the wound bed

Braden Scale Puzzle – Sensory PerceptionBraden Scale Puzzle – Sensory Perception

Sensory Perception:Sensory Perception:The person’s ability to perceive and respond The person’s ability to perceive and respond MEANINGFULLY to pressure related pain & MEANINGFULLY to pressure related pain & discomfortdiscomfort

InterventionsInterventionsRemember the shoe exercise? Check for anything that Remember the shoe exercise? Check for anything that could be creating pressure on the skincould be creating pressure on the skinFor the resident with limited ability to perceive For the resident with limited ability to perceive pressure, put on a turning schedule to ensure pressure pressure, put on a turning schedule to ensure pressure relieved at regular intervalsrelieved at regular intervals

Braden Puzzle – MoistureBraden Puzzle – Moisture

Moisture:Moisture:The amount of moisture the skin is exposed toThe amount of moisture the skin is exposed to

Interventions:Interventions:Use moisture barrier in particularly wet areas Use moisture barrier in particularly wet areas (peri-area, buttocks, etc.)(peri-area, buttocks, etc.)

Change clothing, incontinence products, and Change clothing, incontinence products, and linen as often as you need tolinen as often as you need to

Braden Scale Puzzle – ActivityBraden Scale Puzzle – Activity

Activity:Activity:Getting up and aroundGetting up and around

Interventions:Interventions:Change position at least every 2 hoursChange position at least every 2 hours

ROMROM

AmbulateAmbulate

Teach resident to change his/her own positionTeach resident to change his/her own position

Braden Scale Puzzle – MobilityBraden Scale Puzzle – Mobility

Mobility:Mobility:Changing position and controlling body Changing position and controlling body positionposition

Interventions:Interventions:Float the heelsFloat the heels

Reposition at least every 2 hours for bed-bound Reposition at least every 2 hours for bed-bound residents; hourly for chair boundresidents; hourly for chair bound

Use pillows for supportUse pillows for support

Braden Scale Puzzle – NutritionBraden Scale Puzzle – Nutrition

Nutrition:Nutrition:USUAL food intakeUSUAL food intake

Interventions:Interventions:Help to eatHelp to eat

Get foods they like (within their diet)Get foods they like (within their diet)

Offer fluids frequently (as diet allows)Offer fluids frequently (as diet allows)

Provide supplements as orderedProvide supplements as ordered

Braden Scale Puzzle – Friction and ShearBraden Scale Puzzle – Friction and Shear

Friction & Shear:Friction & Shear:Ability to move without rubbing or draggingAbility to move without rubbing or dragging

Interventions:Interventions:Use lift sheetUse lift sheetSoft socks on feetSoft socks on feetLong sleeves or elbow protectorsLong sleeves or elbow protectorsKeep the head of the bed at the lowest degree of Keep the head of the bed at the lowest degree of elevation consistent with medical condition and other elevation consistent with medical condition and other restrictions restrictions Limit the amount of time the head of the bed is elevatedLimit the amount of time the head of the bed is elevated

Pressure Ulcer PreventionPressure Ulcer Prevention

You can make a differenceYou can make a difference

Implement preventative interventionsImplement preventative interventions

Report changes in skinReport changes in skin

Thank youThank you

Contact Information:Contact Information:Jody Rothe, RN, WCCJody Rothe, RN, WCCQuality ConsultantQuality ConsultantMetaStar, Inc.MetaStar, Inc.2909 Landmark Place2909 Landmark PlaceMadison, WI 53713Madison, WI 53713

(608) 274-1940 or (800) 362-2320, ext. 8271(608) 274-1940 or (800) 362-2320, ext. 8271

www.metastar.comwww.metastar.com

jrothe@metastar.comjrothe@metastar.comThis material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.  9SOW-WI-PS-09-223.