Sandy Burke BSN RN CWCN Deb Perry MS RN Olmsted Medical Center - - PowerPoint PPT Presentation

Sandy Burke BSN RN CWCN Deb Perry MS RN Olmsted Medical Center Rochester, MN

Deb has a passion for wound care starting with her 26 years

• f experience in nursing homes. She has been a nurse for a

total of 401/2 years. She completed her Master’s degree in nursing in 2013. Deb participated and co-authored the ICSI’s Pressure Ulcer Prevention and Treatment Protocol. She has been the nurse manager of medical surgical nursing at OMC Hospital for the last 121/2 years. Sandy has loved and participated in wound care for 20 years in Nursing Homes, Home Care, Hospice, and Med Surg. She is certified in Wound Care through the Wound Ostomy and Continence Certification Board. She has presented a poster at a national wound conference, was one of the co-authors for the ICSI Pressure Ulcer Prevention and Treatment Protocol, and is the Supervisor of the Advanced Wound Healing Clinic at Olmsted Medical Center.

 Deb Perry MS, RN  Sandy Burke BSN, RN,

CWCN

• Pressure ulcers have a huge impact in a

persons life.

• The cost of a treating a pressure ulcer can be

in the thousands of dollars.

• Lost time from work
• Frequent medical visits
• Possible surgery
• Dressings
• Pain pain pain

• 82 yr old male with cancer. Was still active, able to

ambulate, alert and oriented. In a nursing home. Complained of “sore butt”. Got worse and he couldn’t stand to sit in a chair. He would leave the table early to lie down because it hurt to sit. He couldn’t lay down long because it hurt. He couldn’t sit in the lobby and enjoy activities long because it hurt too bad. It was found he had a small stage 2 pressure ulcer on his coccyx. He stated the pain from the pressure ulcer was worse than any pain from his cancer or surgeries. It affected his daily life and took a long time to close. It was shallow and small but those are the painful ones. A pressure ulcer affects your life in a big

• way. You are always thinking about it because you are

either changing the dressing or having pain to remind you it is there.

• A 45 year old paraplegic had a pressure ulcer on his
• ischium. It was found to be a stage 4. He had been

fighting pressure ulcers for many years and has had multiple different stages of ulcers. He is active and gets around well. He works at a desk job so spends a lot of time in his chair. He has a special cushion for offloading. He still developed the ulcer and had been treating it on his

• wn. It got away from him and was very deep. He required

hospitalization, surgery and bed rest on a special bed for a

• month. He was not able to work.
• Cost, lost work, interrupted life, dressings, home care

because wife needed to work, special equipment at home, pain, medical costs, and bills don’t wait for you to heal.

• Pressure ulcers have a huge impact on quality of life and

costs.

• 34 year old mother of a 1 and 3 year old
• Came to wound clinic with a pressure ulcer from a cast on her foot
• Needed weekly visits, brought the kids with
• Dressing changes
• More lost time from work
• Non weight bearing
• Very painful
• Surgical problem healed that needed the cast for but now had longer

healing from a wound that cast caused.

• Could have been prevented by educating her to alert her PCP about pain

and burning under cast. She just thought that was part of having a cast.

• Cast could have been removed and area checked before it became a big

problem.

• Off loading and elevation education could have been given to her when

she got the cast to prevent pressure areas

• Big impact and inconvenience in her busy life

• As a baby this pt had open heart surgery.
• Developed a pressure ulcer on the back of his

head due to positioning.

• He ended up having a bald spot on the back of

his head. He stated “I was so self conscious of

• this. I could cover my incision scar on my chest

but I couldn’t cover my head. As a kid going to school I would get picked on. It could have been prevented if they would have just moved me sometimes.”

• A pressure ulcer doesn’t just affect a person right

now, it can be a long term problem.

• Identify patients at risk of developing

pressure ulcers

• Improve frequency of skin inspections
• Increase the use and implementation of PU

prevention plans

• Improve education
• Improve coordination and communication

between care providers regarding the plan for patients with PU

 To be done within 6 hours of admission  Reevaluate daily  When there is a significant change in their

condition (ex: change in consciousness, level

• f care, return from surgery or procedure)

• It is also important to identify patients at risk

in all areas of health care such as outpatient settings.

• This has identified some barriers for multiple
• reasons. (education of staff, not always

nursing, time constraints, difficulty assessing skin due to pt mobility)

• This is when pt is presenting to all areas of

healthcare

 Is the pt in a wheelchair or do they require

assistance to transfer?

 Will the pt be immobile or sedated for more

than 2 hours?

 Is the pt incontinent?  Do they have current PU or history of?  Do they appear visibly malnourished?

• If yes to any of those questions a plan should be

put into place to prevent pressure ulcers.

• This has resulted in lots of barriers

– Who is going to follow up on the plan – Time to check for pressure ulcers – Knowledge of accurate practice Documentation and putting in place some interventions for prevention are important. example: pt presents to same day surgery, is incontinent, needs assistance to transfer and reposition. Interventions should be in place and documented that incontinence was addressed, that heels were elevated and pt was repositioned during surgery and pre and post

• p care.

• Total Score Range 6-23
• Lower the score, the higher the Risk
• Patients with a total score of 15-18

are considered to be “at risk” for developing pressure ulcers

– 19-23 No risk – 15-18 Mild Risk (“At Risk”) – 13-14 Moderate Risk – 10-12 High Risk – 9 or below Very High Risk

14

• Sensory Perception
• Moisture
• Activity
• Mobility
• Nutrition
• Friction and Shear

15

Sub-scales

16

Friction and Shear:

 Friction: The force of two surfaces moving across one another, such as the

mechanical force exerted when skin is dragged across a coarse surface such as bed linens.

 Shear: Force per unit magnitude of the area acting parallel to the surface of

the body. This parameter is affected by pressure, the coefficient of friction between the materials contacting each other, and how much the body interlocks with the support surface.

 Minim

imiz ize P Pressure re(suggesti

tions)

• Use

e sup uppor

• rt surf

urfaces to to red redistribute pres ressure re for

• r bed

ed and nd cha hair

• Consider pts

s we weight, for over 300 lbs s may ay need bar ariat atric si size ze, al also so cons

• nsider hei

height

• Mini

nimize/ e/el elimina nate te pressure e from devices es

• Have minimum amou
• unt of
• f laye

yers of

• f linens or
• r pads betw

etwee een the the su support su surface an and the pat atient

• Enc

ncoura rage e small freq requent cha hanges to to pos

• sition, floa
• at heel

heels, pad bony

• ny

prominen nences es

17

Other Interventions Related to Pressure

 Manage M

Mois isture re (suggesti

tions)

• Use commerc

ercial moistu ture e barriers ers

• Use

Use ab abso sorbent pad ads s or diap apers that at wi wick an and hold moisture

• Iden

entify and nd manage the the cause of

• f moi
• isture

re, if pos

• ssible
• Offer

er bed ed pan n or

• r uri

urinal with th ea each turn turning schedule

• Uti

tilize fec ecal cont

• ntainment dev

evices for

• r liquid stool

tool

• Offer

r water r with th each h turni rning sched hedul ule

18

Other Interventions Related to Specific Risk Factors:

 Manag

age N Nutriti tion

• n (sug

uggesti tions

• ns)
• Consult

t dieti titi tian

• Quickly

y asses ess to identi ntify y and allev eviate te any nutri triti tiona

• nal deficits

ts

• Inc

ncrea ease protei rotein and nd calorie int ntake, if need needed

19

Other Interventions Related to Specific Risk Factors:

 Manage Fric

ricti tion

• n & Shear (suggest

stions) s)

• Elevat

ate HOB (he head of

• f bed

ed) ) no no more

• re tha

than 30º

• Use

e lift shee heets or

• r othe
• ther

r tra transfer dev evices whe hen mov

• ving pati

tient

• Prote

rotect el elbow

• ws, hee

heels, sacrum and nd back of

• f hea

head from rom fri riction forc

• rces
• PT ref

referr erral to to assist with th mob

• bility
• Suppor
• rt

t surface e selec ecti tion

• n
• Keep skin

n moistu turi rized ed

20

Other Interventions Related to Specific Risk Factors:

 Othe

her Ge Gene neral Ca Care Iss ssues

• Do Not massage reddened areas over bony prominences
• Do Not use donut type devices
• Maintain good hydration
• Avoid dry skin

21

 Cause of pressure ulcers  Prevention  Dietary needs  Positioning

• Document education

You have done the risk assessment now it’s time to do the skin inspection

 When: Every 8-24 hours

• on admission
• When returning from surgery
• Change in condition or level of care
• Every shift if has an ulcer or is at risk
• Daily on all patients
• When they have a device (frequency may be

different depending on the device, some devices should be checked more frequently)

• Skin assessment vs. wound assessment

– Skin assessment - entire body – Wound assessment – wound & surrounding skin

• Routine Head-to-Toe Inspection

– Temperature – Color – Moisture – Turgor – Intact skin

• Palpate and Inspect

 Temperature

• Normally warm to touch
• Warmer than normal could signal

inflammation

• Cooler than normal could signal poor

vascularization

 Color

• Normal (light ivory to deep brown, yellow to olive,

light pink to dark ruddy red)

• Intensity – paleness may indicate poor circulation
• Hyperpigmentation or Hypopigmentation reflect

variations in melanin deposits or blood flow

03/01/04 Healed

 Moisture

• Dry or moist to touch
• Flaking, scales
• Eczema
• Dermatitis, psoriasis, rashes
• Edema

Dry, flaky, cracked skin

 Turgor

• Normal – quickly returns to original state
• Abnormal – slowly returns to original state

(dehydration, aging)

 Integrity

• Intact (no open areas)
• Type of injury (use appropriate classification

system, e.g., pressure ulcer staging)

Fissure-crack in skin Blisters- may also be red or purple Open sores

Fissure-crack in skin Fungus- bright red, itches

• r burns

Red areas over bones Blisters- may also be red or purple Black areas on heels or feet Open sores Dry, flaky or cracked White, moist, or wrinkled

No padding Padding

 the skin inspection findings  abnormal findings and document other

wounds like venous ulcers, skin tears, arterial ulcers or other.

 History of when, how, and what has been

done to treat the area

 Full wound assessment

Stage I Stage II Stage III Stage IV Unstageable Suspected Deep Tissue Injury

Skin is red but not open. Does not turn white when pressed. Caused from pressure or friction.

What would you do? 1) _____ 2) _____ 3) _____ 4) _____ 5) _____

What would you do? 1) _____ 2) _____ 3) _____ 4) _____ 5) _____

IAD

• Etiology: continued skin

exposure of urine, feces or both

• Location: diffuse rash
• Color: red or bright red
• Depth: partial-thickness (ie,

limited to epidermis and/or dermis); two dimensional

• Necrosis: None
• Symptoms: pain and itching

Pressure Ulcers

• Etiology: Ischemia from pressure
• Location: circumscribed and

usually over bony prominences

• Color: red to bluish/purple
• Depth: partial or full-thickness;

three dimensional; deep tissue injury

• Necrosis: may be present
• Symptoms: pain and itching

1. Gray M, Bohacek L, Weir D, Zdanuk J. Moisture vs Pressure; Making Sense Out of Perineal Wounds; J Wound Ostomy Continence Nurses Society; 2007(34):134-142.

Skin Injury: Irritant Contact Dermatitis *Not a pressure ulcer*

Irritant contact dermatitis: Non-allergic dermatitis occurring as a result of a chemical irritant; a well-defined affected area correlates with the area of exposure; may appear reddened and swollen and vesicles may be present; typically of shorter duration.

Stage I Pressure Ulcer I ncontinence-Associated Dermatitis

What would you do? 1) _____ 2) _____ 3) _____ 4) _____

Skin Injury: Allergic Dermatitis *Not a pressure ulcer*

Allergic Dermatitis: Cell-mediated immunologic response to a component of tape adhesive or backing; typically appears as an area of erythematous, vesicular, pruritic dermatitis corresponding to the area of exposure and/or beyond; persists for up to a week.

 Heal

• Moist wound healing
• Surgical debridement, intervention

 Palliative

• Manage pain, moisture, odor

 If it is dirty, clean it  If it is deep, fill it  If it is open, cover it  If it is dry, moisten it  If it is wet, absorb it

 Braden subscales: address the at risk areas  Document all interventions  Document education given to pt and family  Document patient tolerance and compliance

 Small frequent turns  Pressure off the trochanters  Support with pillows  HOB less than 30 degrees

 HOB at lowest

position, change level as able to tolerate

 Float the heels off

the bed

 Remember to pad

areas like behind the ears, back of head, bridge of nose

Should be in every at risk patients chair/wheelchair. Up to 300 lbs. Send the cushion home with them to use in recliner or wheelchair Waffle boot to elevate heels Green is bariatric cushion for pts

• ver 300 lbs.

Offloads the heel, keeps foot from dropping

• r rotating, and helps improve circulation

 Use dressings that will meet the goal and

based on the wound absorb or add moisture

 Large deep wounds consider Negative

Pressure Wound Therapy

 Dressings can help with friction and shear

also

 Skin Teams- multidisciplinary team of

members to be the representative for their unit about PU prevention.

 Meet monthly, quarterly, or based on need  Have a designated Wound Care Nurse to be

the expert

 Do audits, check, train, make it a priority  Evidence based practice

• ffload

clean Moisture balance nutrition Educate

 Thank you!