pressure ulcers a quality approach to prevention bridgepoint i, suite 300 5918 west courtyard drive...
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PRESSURE ULCERSA Quality Approach to Prevention
Bridgepoint I, Suite 3005918 West Courtyard DriveAustin, TX 78730-50361-866-439-5863www.tmf.org
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