1. PRESSURE ULCERS A Quality Approach to Prevention Bridgepoint I, Suite 300 5918 West Courtyard Drive Austin, TX 78730-5036 1-866-439-5863 www.tmf.org PRESSURE ULCERS A Quality Approach to Prevention

2. 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

3. 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.

4. Pressure Ulcer: Definition Any lesion caused by unrelieved pressure resulting in damage of underlying tissue. U.S. Department of Health and Human Services Agency 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

5. 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

6. 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.htmwww.healthypeople.gov/document/html/objectives/01-16.htm

7. Best Treatment Option AVOIDANCE!

8. Elements of a Prevention Program 1.Risk assessment 2.Skin assessment and inspection 3.Nutritional assessment 4.Preventive skin care 5.Proper positioning 6.Use of support surfaces 7.Accurate documentation 8.Education

9. Risk Factors  Inability to perceive pressure  Exposure to incontinence/moisture  Decreased activity level  Inability to reposition  Inadequate nutritional intake  Friction and shear

10. Factors That Increase Risk Co-morbidities : Cerebrovascular disease Central nervous system injury Degenerative neurological disease Depression Drugs that adversely affect alertness Alterations in sensation or response to discomfort

11. Factors That Increase Risk  Alterations in mobility Neurological disease/injury Fractures Pain Restraints

12. 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

13. Factors That Increase Risk  Incontinence/moisture Bowel and bladder Excessive sweating Skin folds increase retention of moisture and bacteria.

14. 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

15. Risk Assessment Tools  Braden Scale  Norton Scale  Agency produced – Caution! Reliability? Validity?

16. 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

17. Does the tool allow for consistent determination of risk? Note: Inter-rater reliability important Training staff is vital in assuring reliability Reliability: Consistency of Measurement

18. 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.govwww.ahrq.gov

19. Screening Tools Must be BOTH Valid and Reliable This is done through research and trial Use caution before developing your own or adopting one

20. Braden Subscales  Sensory perception  Moisture  Activity  Mobility  Nutrition  Friction and shear

21. 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.comwww.bradenscale.com Sensory Perception 1 Completely limited 2 Very limited3 Slightly limited 4 No impairment Moisture 1 Constantly moist 2 Very moist3 Occasionally moist 4 No impairment Activity 1 Bedfast2 Chairfast3 Walks Occasionally 4 Walks frequently Mobility 1 Completely immobile 2 Very limited3 Slightly limited 4 No limitation Nutrition 1 Very poor2 Probably inadequate 3 Adequate4 Excellent Friction and Shear 1 Problem2 Potential problem 3 No apparent problem Copyright Barbara Braden and Nancy Bergstrom www.bradenscale.comwww.bradenscale.com

22. 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

23. Norton Scale  Physical condition  Mental condition  Activity  Mobility  Continence

24. Norton Subscales figure 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 Good3 Fair2 Poor1 Very bad Mental condition 4 Alert3 Apathetic2 Confused1 Stupor Activity 4 Ambulant3 Walk/help2 Chair- bound 1 Bed Mobility 4 Full3 Slightly limited 2 Very limited 1 Immobile Continence 4 Not incontinent 3 Occasional2 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

25. Norton Scale  Highest possible score is 20  Onset of risk = 16 or below  High risk = 12 or below  Lowest possible score is 5

26. 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 Mr. 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.

27. 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. NortonBraden #1 #2 #3 #4 #5 #6

28. Scoring: Comparison Norton 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

29. 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

30. 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

31. Develop Care Plan Think beyond the tool – use your experience and training

32. 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

33. 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

34. 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

35. 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

36. 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

37. Nutritional Care  Identify contributing factors Impaired nutritional intake Low body weight/unintentional weight loss Evaluate clinical signs of malnutrition

38.  Evaluate appropriate lab data Albumin normal adult range: 3.2 - 5.0 mg/dl Pre-albumin normal adult range: 16 – 42 mg/dl Hemoglobin normal adult (Female) range: 12 - 16 mg/dl normal 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

39. 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)

40. 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

41. Avoid Massage of Red Areas No matter how you say it! Massage may decrease rather than increase blood flow Image of Stop sign

42. Reduce Shear  Shear diminishes blood supply to skin Use positioning, transferring & turning techniques to minimize friction/shear injury Figure 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

43. 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

44. 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 figure shows how to properly reposition patients

45. 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!

46. 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

47. Side Lying Position  Avoid positioning directly on the trochanters  Use the 30° lateral inclined position figure of a patient in hospital bed

48. 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

49. 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

50. 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

51. Change Support Surfaces Most pressure reducing devices are more effective than standard hospital mattress figure is of a patient using a pressure reducing device.

52. Types of Support Surfaces Category 1 Static overlays and mattresses –Foam, air, gel Category 2 Alternating pressure and air flotation Category 3 Air fluidized Low air loss bed/mattress figure is of a hospital bed, figure is of a support device, Figure is of a hospital bed

53. Support Surfaces in Chairs If resident spends a majority of time 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 figure 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

54. 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

55. Monitor and Document  Document interventions and outcomes  Multidisciplinary approach is a must  Periodic, consistent, systematic re-evaluation

56. Education  Involve all levels of health care providers, the individual and the family  Structured, organized and comprehensive  Update content regularly

57. Treatment To order your copy of Pressure Ulcer Quick Reference Guide for Clinicians - Number 15 Call 1- 800-358-9295 Figure is of a book titled "Pressure Ulcer Treatment"

58. 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".

59. Don’t Work in a Vacuum: COLLABORATE!  Rapid rate of improvement  Teamwork Within organizations Among organizations  Measurable results

60. TMF Health Quality Institute Committed to Quality Committed to You Figure is a picture of the TMF Health Quality Institute Team

61. 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 www.npuap.org 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 www.ahcpr.gov Thanks to:

62. TMF Health Quality Institute Logo: TMF Health Quality Institute 1-866-439-5863 www.tmf.orgwww.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 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