Pressure Injuries Prevent, Treat and Sustain Gains Joyce Black, - - PDF document

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Pressure Injuries – Prevent, Treat and Sustain Gains

Joyce Black, PhD, RN, FAAN University of Nebraska Medical Center Omaha, NE

April 18, 2019  Is it accurate?

• What does a circle around the buttocks indicate?
• What does excoriation mean?

 If skin it showing early signs of pressure injury --- what is

done?

 Is resident or family shown the problem?

4 eyes in 4 hours is a reasonable approach to skin assessment

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 High risk residents should have skin examined for 72 hours

following admission

• Prior hospitalization, esp. if critically ill or in surgery
• Wearing elastic stockings, splits, bi-valved casts, braces
• Have injury in or surgery on the legs
• Significant peripheral vascular disease (PVD)

 hairless legs, thick nails, weak pulses

• Deep tissue pressure injury does not appear for 48 hours after the

pressure was present

 If the resident is admitted in that 48 hour window the skin can be intact and not found until the following weekly assessment

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 Accuracy is important

• Is the immobile patient accuracy identified?

 When compared to PT notes?  When compared to underlying disease state?

• Is malnutrition accurately identified?

 When compared to weight record/ nutritionist notes?

 Is the risk assessment simply a paper document?  Is the plan of care derived from the total score?

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 Heel risk factors

• Leg immobility

 Does the resident move the leg? Not can…

• Neuropathy

 Stroke, DM, MS

• Peripheral vascular disease

 Common in the aged

 Use of braces, splints, and stockings  Chronic use of recliner chairs/slide boards  Use of Geri-Chair

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 Long period of

immobility/confinement to the chair

 Unable to move due to fear of

dislodging the lines

 Often unable to eat  Very weak at end of run, unable to

move self

 Low protein intake makes healing of

existing ulcers very difficult

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 End stage co-morbid disease

• Marked dyspnea
• Anasarca with risk of tissue injury

during movement

• Breakthrough pain with movement
• Odor from extruding head and neck

and breast cancers

• Request not to move

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 If the resident arrives

• at high risk, does the care plan include turning rather than “assist to

turn as needed”?

• at high risk, is the mattress upgraded?
• with early signs of pressure injury, is the area offloaded?
• with plans for rehab and need to sit, is the wheelchair padded?
• needing dialysis, is the overlay sent along? Offloaded when they

return?

• What happens over the weekend and holidays?

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 When intensity of pressure is high, duration can be short

• Dialysis run, unpadded chairs

 When intensity of pressure is moderate, duration can be

moderate

• Not turned adequately in the bed, not turned often, presumed resident

is moving self

 When intensity of pressure is low, duration can be fairly

long…depending on tolerance of tissue for pressure

• Use of speciality bed can lengthen turning frequency

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 Study of residents in long term care on foam

mattresses

• Well designed randomized controlled trial (RCT), well powered
• Residents turned randomly Q2, Q3 and Q4 hours
• Compliance with turning measured

 Outcomes

• Pressure injury formation varied by turning frequency

 Q2 hours = 2.5%  Q3 hours = 0.6%  Q4 hours = 3.1%

 Can we now get to a turning schedule we can live with?

Bergstrom, m, et al, 2013 JAGS

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 If head of bed (HOB) up to

30 degrees, pressure is applied to sacrum

 Resident must be turned to

• ffload the sacrum when in

bed

• Use hand check to determine

sacrum is clear

 Use of pillows seldom holds

resident in 30 degree position

 Use of wedges works, if the

wedge is placed properly

• Under the body, it should

hardly be visible

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Bottomin

• ming

g out t indicated ted by high gh inter terface pressure surface

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 Expectation in long-term care (LTC) is not to note each

position

• However, relying on the CNA documentation of the amount of

assistance needed to move is difficult to follow and prove the case

• Nurses should document that turning is occurring, once a day in high

risk patients

 Charting by exception (CBE)is especially difficult to defend

• Almost always the very thing to help provide evidence of care

provided is missing

• If CBE, why are vitals charted (if normal?)

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One of the most common chronic wounds

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 Not fixing the problem that caused the wound

• Continued pressure
• Continued shear
• No improvement in arterial flow

 Not providing enough protein and calories to promote healing

• Body becomes catabolic

 Not reducing risk of infection in wound bed

• Exposure to fecal matter
• Prolonged inflammation

 The cells become senescent

• Biofilm develops

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 Return to form and function

• Seen best in acute wound healing
• Scar prevents form and function in

large wounds and chronic wounds

• Wound closure in patients at end
• f life or end stage disease is not

the priority for care

 Patient engagement

• Management of condition
• Management of wound

These ischial ulcers have little hope for closure without a comprehensive plan and patient engagement

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 Controlling or curing the cause

• Pressure redistribution
• Arterial bypass for heel wounds

Shear reduction

 Wound care (From 2014 Guidelines)

• Debridement, dressings/packing, topicals
• Do not debride ischemic tissue or malnourished pts

 Nutrition (from 2014 Guidelines)

• Increased protein and calories
• Vitamin and zinc supplement if low

3 legged stools tip over when any one leg is missing

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 Continued pressure

• makes the wound ischemic
• increases shear
• destroys deeper tissue in the wound
• injures healing tissues

 Why is everyone’s head of the bed elevated?

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 Education works for some patients  Consider that all behavior has a reason

• Why does the patient want to lie on his back?
• Why won’t the patient keep her heel off of the bed?

 If the patient’s wound is deteriorating due to the patient not

remaining off of the wound…

• Is the patient competent? Able to understand why?
• Let the POA know of the issues
• Inform the provider of the issues
• Consider a higher immersion surface

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 A common issue in nonhealing wounds  Again, why is the patient not eating?

• Is this an area where the family can help?

 If tube fed, is it possible to provide the ordered calories?

• How often is the tube feeding stopped in 24 hours?
• Would the provider consider ordering a daily volume of tube feeding

and allow the staff to figure out the best timing?

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 Does the staff know what signs or symptoms in a wound

indicate a need to change the treatments?

 Are these orders ever written in your facility? If so, how to you

handle it?

• Wet to dry until healed?
• Collagenase until healed?
• Dakin’s packing with no stop order?
• Hydrocolloids over inflamed, or slough filled wounds?

 Are all wounds debrided? Should they be?

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 Patient or family thought that wound could heal

• Thought it was minor or small until seen in ED
• Did not understand that débridements were for necrosis in the wound

 Does the family have assessment skills to determine if the

wound is worse?

• What if they are taking pictures of the wound?

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Even the sloth doesn't know how he got into the wound bed

CONSERVATION INTERNATIONAL/PHOTO BY REBECCA FIELD

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 Systematic review with both conclusions and root

causes backed up with evidence

 An independent team is best

• All causes should be identified
• If more than one cause is found, solutions are more

difficult to sustain

 A sequence of events is usually effective to

understand relationships

 RCAs can be threatening to many cultures and

environments

• Non-punitive policy for problem identifiers needed



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 1. Define the problem or event factually  2. Gather data (chart and interview) as evidence  3. Create a time line of events

• Ask “why?” with each piece of data and each step in time line

 4. Identify all causes of problem  5. Identify all possible solutions for each cause  6. Monitor effectiveness of solutions

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 64 year old female  Past Medical Hx: Diabetes on

insulin, hypertension on meds, overweight

 Had a left total knee done 3

days ago

 Has been wearing TEDs and

using sequentials

 Purple heel found 2 days after

admission

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 Is this wound a pressure ulcer?

• Was it due to pressure?
• Was it due to shear?
• What is the role of poor perfusion?

 Is this a diabetic foot ulcer?  When did it start?

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 What was the condition of the skin on admission?

• What happens to the RCA if the admission assessment:

 Is blank in skin assessment?  Lists skin is intact?

 Were there any additional assessments?

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 What was admission risk score?

• Was it accurate?

 Did a prevention plan stem from

the score?

• Was the heel elevated from the bed?

However, we are only at the physical roots….The symptoms What more information is needed?

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 What leg had surgery?  What position was the leg/legs

in on the table?

 What leg has the DTI?

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 What does PT teach the patient to

do to strengthen the leg?

 How is the patient moved in bed?

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 1. Define the problem or event factually  2. Gather data (chart and interview) as evidence  3. Create a time line of events

 Ask “why?” with each piece of data and each step in time line

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 Is this wound a pressure

ulcer?

• Was it due to pressure?
• Was it due to shear?
• What is the role of poor

perfusion?

 Is this a diabetic foot ulcer?

 Yes, this is a DTPI  Yes, it could be pressure from

the bed or the TED. Could be shear from doing leg exercises in bed. Her risk could be high due to DM and HPT

 No, DFU occur on walking

surfaces of the foot

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 Stage at time of initial discovery

• Stage I --- likely began in last 12-24 hours
• DTI --- purple tissue without epidermal loss likely began 48 hours ago

 Important because

 you might not have had this patient 48 hours ago  Turning may have been impossible  OR cases

• Stage II --- likely began in last 24 hours
• Stage III-IV --- began at least 72 hours ago

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4/15/2019 19 HOB UP HOB UP SEATED FLAT ROTATED

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 What was the condition of

the skin on admission?

• What happens to the RCA if the

admission assessment:

 is blank in skin assessment?  lists skin as intact?

 Were there any additional

assessments?

Intact, it is not possible to determine if the TEDs were removed – Why? No assessments show DTI Did the patient c/o pain in her heel? Care techs thought that nurse would examine the skin

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 What was admission risk

score?

• Was it accurate?

 Did a prevention plan stem

from the score?

• Was the heel elevated from the

bed?

• Were boots used?

 Braden

• 4,4,3,3,4,3 = 21
• Why wasn’t the leg immobility

and DM captured?

 No, none was needed per

Braden score

 Boots were still in the bag on

window sill

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 4. Identify all

causes of problem

 Was this ulcer POA? Why did no

• ne see it?

 Why did the TEDs stay on?  Why did the boot not get put on?  Was this ulcer less severe

yesterday?

 What did the patient say about the

heel?

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 5. Identify all

possible solutions for each cause

 Day nurse tried to remove TEDs

but resident c/o pain in her knee

 CNA did not know what the heel

boot was for and she did not have time to ask because she was trying to care for other residents

 Nurses do not know how serious

Deep Tissue Pressure Injury can become

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 6. Monitor

effectiveness of solutions

 Skin assessment of the heel

reviewed,

• Mirrors placed on med carts to help

“see” the heel

 Information on DTPI provided to

staff

 In-services developed on how to

don and doff TEDs and use heel boots

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 Relevant policy and procedure manual

• If staging cannot be done by staff, then

treatment policy should be written by type of tissue in wound bed

 If epidermis, apply skin care moisturizer  If exposed dermis, apply hydrogel  If granulation tissue, apply hydrogel  If slough, apply debriding agent  If eschar, use topical antiseptic if stable

 Stable eschar is hard and not open on the edges

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Patient- Centered –

providing care that is unique to a patient's needs.

Effective –

avoiding overuse and misuse of care.

Timely – reducing wait times and

harmful delays for patients and providers.

Efficient – avoiding waste of

equipment, supplies, ideas and energy.

Safe – avoiding

injuries to patients from care that is intended to help them.

Equitable – providing care that does

not vary across intrinsic personal characteristics.

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This material was prepared by Lake Superior Quality Innovation Network, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 11SOW-MI/MN/WI-C2-19-46 040919

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