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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

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.

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

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

Validity and Reliability

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)

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 SubscalesScale

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 pain

Norton Braden

#1

#2

#3

#4

#5

#6

Let’s Use the Scores:

Scoring: Comparison

Braden Scale

Sensory perception = 2

Moisture = 2

Activity = 2

Mobility = 3

Nutrition = 2

Friction/shear = 2

Total = 13

Norton Scale

Physical condition = 2

Mental condition = 2

Activity = 2

Mobility = 3

Continence = 2

Total = 11

When to Measure Risk On admission Quarterly and annual assessments Significant change in condition Depression Upon return to facility Anytime there is doubt

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

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

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

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

• Hematocritnormal adult (Female) range: 37 – 47%normal adult (Male) range 40 – 54%

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 Areas

No matter how you say it!

Massage may decrease rather than increase blood flow

Reduce Shear

Shear diminishes blood supply to skin

Use positioning, transferring & turning techniques to minimize friction/shear injury

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 sacrum

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

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 position

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 mattress

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/mattress

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 distribution

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

To order your copy of

Pressure Ulcer Quick Reference Guide for Clinicians - Number 15

Call 1- 800-358-9295

Treatment

Q: What is the best treatment choice for a

pressure ulcer?

A: Avoidance!

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 You

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

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

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 Services. The contents

presented do not necessarily reflect CMS policy. 8SOW-TX-NHQI-05-22