Sandy Burke BSN RN CWCN Deb Perry MS RN Olmsted Medical Center Rochester, MN
Deb Perry MS, RN Sandy Burke BSN, RN, CWCN Sandy has loved and participated in wound care for 20 years Deb has a passion for wound care starting with her 26 years in Nursing Homes, Home Care, Hospice, and Med Surg. She of experience in nursing homes. She has been a nurse for a is certified in Wound Care through the Wound Ostomy and total of 401/2 years. She completed her Master’s degree in Continence Certification Board. She has presented a poster nursing in 2013. Deb participated and co-authored the at a national wound conference, was one of the co-authors ICSI’s Pressure Ulcer Prevention and Treatment Protocol. She for the ICSI Pressure Ulcer Prevention and Treatment has been the nurse manager of medical surgical nursing at Protocol, and is the Supervisor of the Advanced Wound OMC Hospital for the last 121/2 years. Healing Clinic at Olmsted Medical Center.
• 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 own. 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 of 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 op 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
Sub-scales • Sensory Perception • Moisture • Activity • Mobility • Nutrition • Friction and Shear 15
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. 16
Other Interventions Related to Pressure Minim imiz ize P Pressure re (suggesti tions) ◦ Use e sup uppor ort surf urfaces to to red redistribute pres ressure re for or 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 onsider hei height ◦ Mini nimize/ e/el elimina nate te pressure e from devices es ◦ Have minimum amou ount of of laye yers of of linens or or 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 osition, floa oat heel heels, pad bony ony prominen nences es 17
Other Interventions Related to Specific Risk Factors: 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 of moi oisture re, if pos ossible ◦ Offer er bed ed pan n or or uri urinal with th ea each turn turning schedule ◦ Uti tilize fec ecal cont ontainment dev evices for or 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 on (sug ons) uggesti tions ◦ Consult t dieti titi tian ◦ Quickly y asses ess to identi ntify y and allev eviate te any nutri triti tiona onal 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 on & Shear (suggest stions) s) ◦ Elevat ate HOB ( he head of of bed ed ) ) no no more ore tha than 30º ◦ Use e lift shee heets or or othe other r tra transfer dev evices whe hen mov oving pati tient ◦ Prote rotect el elbow ows, hee heels, sacrum and nd back of of hea head from rom fri riction forc orces ◦ PT ref referr erral to to assist with th mob obility ◦ Suppor ort t surface e selec ecti tion on ◦ Keep skin n moistu turi rized ed 20
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
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