PRESSURE ULCERSA Quality Approach to Prevention

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PRESSURE ULCERSA Quality Approach to Prevention

Objectives

The learner will be able to:1. Describe the best approach to prevention

2. Identify the major risk factors for developing pressure ulcers

3. Describe the eight major elements of a prevention program

4. Demonstrate how to use at least one assessment tool

Disclaimer

TMF Health Quality Institute has no relevant financial relationships to disclose.

TMF does not accept commercial support from other organizations or companies for the development of Continuing Nursing Education activities.

Pressure Ulcer: Definition

Any lesion caused byunrelieved pressure

resulting in damage of underlying tissue.

U.S. Department of Health and Human ServicesAgency for Healthcare Research and Policy www.ahrq.gov

A Pressure Ulcer is:

A localized area of tissue injury

Caused by unrelieved pressure

Usually located over bony prominences

Resulting in damage of underlying tissue

How Big is the Problem? Cost of treating a pressure ulcer:

$5,000 - $60,000

5,737 individuals with pressure ulcers* in Texas

659 are low risk individuals*

Treating these numbers for just one pressure ulcer at only $5,000 would cost $28,685,000!

$78,589 per day (Texas)*Quality Indicators Quarter 1 - 2005

National Goal

Healthy People 2010 initiative target:Less than a 1% incidence of avoidable pressure ulcers (Target: 8 diagnoses per 1,000 residents)

Current as of 08/24/2005 www.healthypeople.gov/document/html/objectives/01-16.htm

Best Treatment Option

AVOIDANCE!

Elements of a Prevention Program

1. Risk assessment2. Skin assessment and inspection3. Nutritional assessment4. Preventive skin care5. Proper positioning6. Use of support surfaces7. Accurate documentation8. Education

Risk Factors Inability to perceive pressure

Exposure to incontinence/moisture

Decreased activity level

Inability to reposition

Inadequate nutritional intake

Friction and shear

Factors That Increase Risk

Co-morbidities :• Cerebrovascular disease • Central nervous system injury• Degenerative neurological disease • Depression • Drugs that adversely affect alertnessAlterations in sensation or response to discomfort

Factors That Increase Risk Alterations in mobility

• Neurological disease/injury • Fractures • Pain • Restraints

Factors That Increase Risk Significant changes in weight (> 5% in 30 days or

> 10% in the previous 180 days) • Protein-calorie under nutritional needs• Edema• Dehydration

Factors That Increase Risk

Incontinence/moisture • Bowel and bladder• Excessive sweating

Skin folds increase retention of moisture and bacteria.

Benefit of Early Risk Assessment

Identify individual risk factors in order to choose appropriate interventions that will reduce risk.

Turning schedules

Mattresses/overlays/beds

Nutritional supplements

Skin protection during incontinence

If no risk factors are found, continue periodic monitoring for development of risk factors.

If the patient has risk factors, develop intervention strategies, as appropriate, to correct or manage the conditions. Image: picture of a fortune teller

Risk Assessment Tools Braden Scale Norton Scale Agency produced – Caution!

• Reliability?• Validity?

Validity: Accuracy of Measurement

1. Does the tool predict who will and who will not develop a pressure ulcer?

2. Does it have the necessary sensitivity, specificity, predictive value of both positive and negative results

Does the tool allow for consistentdetermination of risk?

Note: • Inter-rater reliability important• Training staff is vital in assuring reliability

Reliability: Consistency of Measurement

Validity and Reliability

AHRQ: sufficient research has been done on Braden Scale and Norton Scale to justify use in clinical practice

AHRQ (Agency for Healthcare Research and Quality) www.ahrq.gov

Screening Tools

Must be BOTHValid and Reliable

This is done through research and trial

Use caution before developing your own or adopting one

Braden Subscales

Sensory perception Moisture Activity Mobility Nutrition Friction and shear

Braden Risk Assessment Scale(abridged version)

figure is the Braden Risk Assessment Scale (abridged version): Sensory Perception, 1 completely limited, 2 very limited, 3 slightly limited, 4 no impairment: Moisture, 1 constantly moist, 2 very moist, 3 Occasionally moist, 4 no impairment: Activity, 1 bedfast, 2 chairfast, 3 walks occasionally, 4 walks frequently: Mobility, 1 completely immobile, 2 very limited, 3 slightly limited, 4 no limitation: Nutrition, 1 very poor, 2 probably inadequate, 3 adequate, 4 excellent: Friction and shear, 1 problem, 2 potential problem, 3 no apparent problem.Copyright Barbara Braden and Nancy Bergstrom www.bradenscale.com

Sensory Perception

1 Completely limited

2 Very limited 3 Slightly limited

4 No impairment

Moisture1 Constantly moist

2 Very moist 3 Occasionally moist

4 No impairment

Activity1 Bedfast 2 Chairfast 3 Walks

Occasionally4 Walks

frequently

Mobility1 Completely

immobile2 Very limited 3 Slightly

limited4 No limitation

Nutrition1 Very poor 2 Probably

inadequate3 Adequate 4 Excellent

Friction and Shear

1 Problem 2 Potential problem

3 No apparent problem

Copyright Barbara Braden and Nancy Bergstrom www.bradenscale.com

Examine Braden Scale

Highest possible score is 23

Mild risk = 15-18 Moderate risk = 13-14 High risk = 10-12 Very high = <9

Lowest possible score is 6

Norton Scale

Physical condition Mental condition Activity Mobility Continence

Norton Subscalesfigure is a table of the Norton Subscale: Physical condition, 4 good, 3 fair, 2 poor, 1 very bad: Mental condition, 4 alert, 3 apathetic, 2 confused, 1 stupor: Activity, 4 Ambulant, 3 Walk/help, 2 Very limited, 1 Immobile: Mobility, 4 full, 3 slightly limited, 2 very limited, 1 Immobile: Continence, 4 Not continence, 3 Occasional, 2 usually urine, 1 urine and feces. Doreen Norton, Rhoda McLaren, and A.N. Exton-Smith. An investigation of geriatric nursing problems in the hospital. London. Centre for Policy on Ageing 1962

Scale

Physical condition

4 Good 3 Fair 2 Poor 1 Very bad

Mental condition

4 Alert 3 Apathetic 2 Confused 1 Stupor

Activity4 Ambulant 3 Walk/help 2 Chair-

bound 1 Bed

Mobility4 Full 3 Slightly

limited 2 Very

limited 1 Immobile

Continence4 Not

incontinent 3 Occasional 2 Usually

urine 1 Urine and

Feces

Doreen Norton, Rhoda McLaren, and A.N. Exton-Smith. An investigation of geriatric nursing problems in the hospital. London.Centre for Policy on Ageing 1962

Norton Scale Highest possible score is 20

Onset of risk = 16 or below High risk = 12 or below

Lowest possible score is 5

Score Mr. Williams on the Norton and the Braden Scales:Case History Newly admitted 68-year old, retired

nurse HTN, long term ETOH abuse, Type II

Diabetes, COPD Reports no medical care X20 years yet

has been receiving care Smells of old urine-denies incontinence Self-ambulates only if asked Sits for long periods of time without

changing position

Assessment

Findings Very thin Several reddened places

on the back of his legs and hips

No c/o painMr. Williams, is a 68 year old, retired Nurse, admitted this morning. His primary medical concerns are high blood pressure, long term ETOH (Alcohol) abuse, Type II Diabetes and COPD that have not been well controlled the past several years. His physician has ordered several medications related to the concerns. His family ensures that he makes all of his appointments. However, Mr. Williams says that he hasn’t seen a doctor or taken medications in over 20 years. He tells you that just because he gets sweaty doesn’t mean he is incontinent however; he does smell of old urine. He is able to self-ambulate only if you ask him to do so. Otherwise he prefers to sit for long periods of time without changing position. During your assessment you find that he is very thin and has several reddened places on the back of his legs and hips. He says they don’t bother him and has never noticed them before. He then accused you of doing something to cause them.

Let’s Use the Scores:Figure is a chart which has 2 columns and 6 rows: The first column has "Norton's" name in it and the second column has "Braden's" name in it: the left side is numbered from #1 to #6 and the chart is completely empty except in #6 Norton's column is blacked out.

Norton Braden

#1

#2

#3

#4

#5

#6

Scoring: ComparisonNorton Scale

Physical condition = 2

Mental condition = 2

Activity = 2

Mobility = 3

Continence = 2

Total = 11

Braden Scale

Sensory perception = 2

Moisture = 2

Activity = 2

Mobility = 3

Nutrition = 2

Friction/shear = 2

Total = 13

When to Measure Risk On admission Quarterly and annual assessments Significant change in condition Depression Upon return to facility Anytime there is doubt• Change in mobility Change in continence Change in mental awareness Change in ability to communicate

Develop Care Plan

Review results of screening tool and choose an intervention for every risk factor.• Braden

– sensory perception, moisture, activity, mobility, nutrition, friction and shear

• Norton– physical condition, medical condition, activity,

mobility, continence

Develop Care Plan

Think beyond the tool – use your experience and training

Base the Care Plan on subscale scores and other conditions (minimum standards)

1. Immobile = reposition q 2 hrs in bed

2. Inactive = reposition q 1hr in w/c

3. Incontinent = protect skin from exposure

4. Malnourished = supplement oral intake

5. Shearing = keep HOB as low as possible

6. Limited awareness= assess skin daily

Frequent Reassessment! Daily if condition is changing rapidly

(e.g., acute care, ICU) Monthly/quarterly at minimum Always if significant change in condition

Optimal frequency unknown• Resident specific• One size does not fit all

Skin Inspection & Assessment

Full assessment of skin on admission Daily with routine care Document assessment results Follow established plan of care Revise care plan as need is identified Communicate changes to all care givers

Preventive Skin Care

Active ongoing process Maintain skin health

• Keep skin clean and dry• Daily personal hygiene• Clean skin with warm/tepid

water• Moisturize skin

Preventive Skin Care Reduce exposure to irritants

• Clean immediately after incontinence• Apply skin protectants• Keep linens clean/wrinkle free• Check fit of braces, splints, medical

devices (e.g., oxygen tubing, NG tube, stockings) and skin underneath

• Maintain environmental humidity

Individualize frequency Document

Nutritional Care Identify contributing factors

• Impaired nutritional intake• Low body

weight/unintentional weight loss

• Evaluate clinical signs of malnutrition

Evaluate appropriate lab data• Albumin normal adult range: 3.2 - 5.0 mg/dl

• Pre-albumin normal adult range: 16 – 42 mg/dl

• Hemoglobinnormal adult (Female) range: 12 - 16 mg/dlnormal adult (Male) range: 14 – 18 mg/dl

• Hematocrit– normal adult (Female) range: 37 – 47%

normal adult (Male) range 40 – 54%

Correct protein/calorie/fluid intake

Consider nutritional supplementation

Nutritional Care

Incontinence Management Bowel and bladder training

Indwelling catheters may be used for short periods of time only. Avoid whenever possible as they increase UTI risk

Incontinence pads/briefs (no diapers)

Incontinence Management

DO: Use gentle soap or skin cleanser Apply topical barrier to protect skin

DON’T Scrub the skin Use plastic incontinence pads on low air loss

beds

Avoid Massage of Red AreasNo matter how you say it!

Massage may decrease rather than increase blood flow

Image of Stop sign

Reduce Shear

Shear diminishes blood supply to skin

Use positioning, transferring & turning techniques to minimize friction/shear injuryFigure of a person sitting up in bed showing how shearing diminishes blood supply to skin.Figure of a person in bed showing the proper way prevent shearing

Reduce Friction Friction injuries involve the superficial

skin layers Occur when moving across

coarse surface High risk persons

• Agitated• Spastic• Sliding down in bed

Prevent with heel protectors, stockings, elevation of heels, skin protectants

Repositioning Patients Bed bound: at least q2h Chair-bound:q1h.

Encourage weight shifts q15 min

Reposition while on special beds/ overlays

Must be turned 40 degrees to remove pressure from sacrumfigure shows how to properly reposition patients

Positioning Devices Teach individual to

reposition using the trapeze

Use lifting devices to move individuals who cannot assist

Place pillows/wedges between knees and ankles Will need to delete this slide. I copied it from the Bryant book. Sorry!

Head of Bed Elevation Limit time head of bed is

elevated to reduce friction and shear

Maintain lowest possible elevation

Avoid more than 30° head-of-bed elevation unless medically needed

Side Lying Position Avoid positioning

directly on the trochanters

Use the 30° lateral inclined positionfigure of a patient in hospital bed

Elevate Heels Ensure space between bed

and heels (float heels)

Use pillows to elevate heels off the bed surface

Avoid hyper-extension of the knees

Check for injury from splints when used for heel elevation

No Donuts

Do NOT use plastic rings or donuts for pressure relief as this can cause larger area of tissue injury because of intense pressure along the donut

X

Rehabilitation Programs Consider therapies if consistent

with overall goals of care:• Physical therapy for ambulation

and strengthening• Occupational therapy for splinting

and self-care• Speech/language therapy for

swallowing• Restorative care for maintenance

Individualize program

Change Support Surfaces

Most pressure reducing devices are more effective than standard hospital mattressfigure is of a patient using a pressure reducing device.

Types of Support SurfacesCategory 1

• Static overlays and mattresses

– Foam, air, gel

Category 2• Alternating pressure

and air flotation

Category 3 • Air fluidized• Low air loss

bed/mattressfigure is of a hospital bed, figure is of a support device, Figure is of a hospital bed

Support Surfaces in ChairsIf resident spends a majority oftime in a wheelchair:

• Use pressure reducing cushion

• Instruct to also relieve pressure with hand

• Lifts if possible every 15 minutes

• Change chair to tilt/recline for more pressure distributionfigure is of a Aktion Gel cushion, figure is of a Ultimate mate cushion, figure is of a Roho cushion, Figure is of a Jay2 cushion

Assessing Performance of a Support Surface Bottoming out

• Surface totally compressed• Use hand check, should not be able to feel person

Memory in foam• Shape remains

Bunching in gels

Deflation in air filled or leakage of fluid or gel

Monitor and Document

Document interventions and outcomes

Multidisciplinary approach is a must

Periodic, consistent, systematic re-evaluation

Education Involve all levels of

health care providers, the individual and the family

Structured, organized and comprehensive

Update content regularly

Treatment

To order your copy of

Pressure Ulcer Quick Reference Guide for Clinicians - Number 15

Call 1- 800-358-9295Figure is of a book titled "Pressure Ulcer Treatment"

Q: What is the best treatment choice for a

pressure ulcer?

A: Avoidance! Most pressure ulcers occur when the soft tissue is compressed between two hard surfaces (i.e. the bony prominence and a resting surface: cart, chair or bed).

Pressure beneath bony prominences can impede blood flow to the skin and underlying tissues, resulting in ischemic injury. Since muscle and subcutaneous tissues are more susceptible to pressure-induced injury than the epidermis, pressure ulcers are frequently worse than they initially appear.

There is a common tendency among physicians to under stage pressure ulcers. The visibly damaged tissue that one sees on the surface of a pressure ulcer may merely represent the "tip of the iceberg".

Don’t Work in a Vacuum:COLLABORATE!

Rapid rate of improvement Teamwork

• Within organizations• Among organizations

Measurable results

TMF Health Quality InstituteCommitted to Quality

Committed to YouFigure is a picture of the TMF Health Quality Institute Team

Thanks to NPUAP (an organization focused on improving pressure ulcer prevention and treatment through education, research and public policy) for making information in this presentation possible. www.npuap.org Logo: National Pressure Ulcer Advisory Panel

Additional information can also be found at the Agency for Healthcare Research and Quality website. www.ahcpr.gov Logo: AHRQ Agency for Healthcare Research and Quality

Thanks to:

TMF Health Quality Institute Logo: TMF Health Quality Institute

1-866-439-5863 www.tmf.org This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Serv ices. The contents presented do not necessarily reflec t CMS policy. 8SOW-TX-NHQI-05-22

This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, 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. 8SOW-TX-NHQI-05-22