1. Pressure Ulcer Prevention and Treatment Kaleida Health Policy #TX. INT
Pressure Ulcer Prevention and Treatment Kaleida Health Policy #TX.INT.1 and Clin.63
The Purpose of this review is to provide the Kaleida Health Healthcare Provider information on the methods for preventing, identifying, reporting and treating pressure ulcers.

2. Scope of Practice
All RN’s, LPN’s, in all patient care areas.
PCA’s, CNA’s, Monitor Technicians, Nursing Assistants – preventing, identifying and reporting only.

3. Policy
Patients admitted to Kaleida Health will have the Pressure Ulcer Risk Assessment (Braden Scale) completed on admission and every 12 hours thereafter. (Once between 0700 and 1900 and once between 1900 and 0700). At risk patients will be identified.
Consistent preventive interventions and treatment approaches for pressure ulcers, should they occur, will be followed according to the Pressure Ulcer Prevention and Treatment Protocol.

4. Protocol
Pressure ulcer management in the acute and sub acute rehabilitative setting is continuously evolving with innovative technology and treatment modalities. Consistent preventive interventions and reassessment of treatment modalities are essential to decrease pressure ulcer incidence, prevalence and contain associated costs.

5. Protocol Assessment/Data Collection
Assessment/Data Collection every twelve (12) hours - Braden Scale.
Once between 0700 and 1900 and once between 1900 and 0700.
Evaluate skin integrity every eight (8) hours from head to toe, anterior and posterior surfaces for the presence of pressure ulcer(s) with all findings being reported to the R.N.
Once between 2300 and 0700, once between 0700 and 1500 and once between 1500 and 2300.

6. Protocol Assessment/Data Collection
If permanent orthotic device is in place, assess skin integrity at edges of device. Assess for pressure-induced pain under device.
Orthotic technician may be required to evaluate proper fitting of device [do not place additional padding in device unless instructed by orthotic technician].
Key point:
Refer to graduated compression stocking protocol for additional skin care/assessment guidelines.

7. Staging Description
DEEP TISSUE INJURY- DTI (suspected): Purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and or shear. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
STAGE I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color and warmth may differ from the surrounding area.

8. Staging Description
STAGE II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
STAGE III: Full thickness tissue loss. Subcutaneous fat may be visible but bone tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
STAGE IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

9. Staging Description UNSTAGEABLE (UTS):
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and /or (tan, brown or black) in the wound bed.

10. Protocol Assessment/Data Collection
Assess pressure ulcer(s) with each dressing change in the acute hospital setting.
(1) Skin/wound appearance
(2) Amount and consistency of exudate
(3) Presence of odor
(4) Presence of tunneling/undermining
(5) Surrounding skin
(6) Presence and intensity of pain at site

11. Protocol Assessment/Data Collection
Measure length, width and depth weekly - every Wednesday.
Complete the Braden Scale (for adults) and Braden Q. Scale
(for pediatrics) upon admission and every 12 hours thereafter.
Once between 0700 and 1900 and once between 1900 and 0700, in the acute care settings.

12. Protocol Care /Management
a) Implement pressure ulcer preventive measures as necessary for all patients at risk for pressure ulcer development and/or for patients with existing pressure ulcer(s).
b) Notify the physician/practitioner regarding presence of any and/or additional pressure ulcer incidence and any ulcer with a worsening appearance, stage or presence of necrotic tissue and document.
c) The physician/practitioner must prescribe all wound care for stage III and IV pressure ulcers and ulcers containing slough or eschar or wounds that require packing.

13. Protocol Care /Management
d) The licensed professional nurse may select products and treatment modalities for the treatment of stage I and II pressure ulcers from those listed in the Procedure Section D page 3 and/or Appendix A.
e) Product selection for pressure ulcer treatment is based upon wound surface, depth, drainage and presence of extrinsic moisture (refer to procedure section).
f) Product selection for pressure ulcer treatment is discussed with physician/ practitioner if ulcer worsens or every two weeks.

14. Protocol Safety
Implement pressure ulcer prevention measures as appropriate for all
Patients scoring at risk with the Braden or Braden Q Scale and/or for
patients with existing pressure ulcer(s):
(1) Reduce and relieve surface pressure by selecting appropriate chair
cushion, mattress, overlay or low air loss therapy bed (refer to procedure section).
(2) Utilize pillows and supportive devices (foam, troughs, booties, rolled
towels) to elevate heels off firm surfaces and support bony prominences.
(3) Turn and reposition at least every two hours in bed and every hour in
chair. A clock model may be used to facilitate turning schedules.
(4) Carefully reposition tubes (ET tubes, N/G, chest, etc.) throughout shift.

15. Protocol Safety 5) Minimize friction:
Keep skin clean and dry with mild skin cleansers (do not use hot water).
(a) Utilize skin sealants (skin prep), films and moisturizing creams
over bony prominences.
(b) Keep linens wrinkle free.
(c) Utilize booties and foot stockings.
(d) Utilize the least amount of linen possible to enhance therapy of bed.

16. Protocol Safety (6) Minimize shear:
(a) Keep head of bed at or below 30o unless medically contraindicated.
(b) Gatch foot of bed unless medically contraindicated.
(c) Lower head of bed, utilize non friction sheets to lift patient when
transferring and/or boosting patients.
(d) Utilize non-friction sheets.
(e) Utilize a trapeze if appropriate for boosting up in bed.
(f) Utilize a footboard or pillow at foot of bed as necessary.
(g) Utilize a mechanical lift or transfer board.

17. Protocol Safety (7) Minimize excessive moisture
(a)       Promote aeration of skin.
(b)     Contain urine and stool with internal or external devices.
Key point: Diapers should only be used if the patient is ambulatory or
out of bed in a chair.
(c) Utilize barrier creams, do not aggressively massage skin or bony
prominences.
(d) Utilize airflow draw pads to reduce surface moisture.

18. Protocol Safety (8) Provide nutritional support:
(a) Obtain a nutritional consult for:
(1) Patients with pressure ulcer(s)
(2) Patients with low serum albumin, protein or pre-albumin levels
(3) Patients reporting poor intake upon admission
(4) Patients consuming less than ½ meals
(5) Patients scoring at risk with Braden or Braden Q Scales
(b) Encourage adequate intake of fluids and protein to enhance
wound healing unless otherwise medically contraindicated.

19. Protocol Safety
(9) Collaborate with physician/practitioner regarding consultation with
physical/occupational therapy/infectious disease as necessary
(10) Incorporate age/development diversional activities to promote
compliance with mobility and pressure ulcer prevention
interventions.

20. Protocol Infection Control
a) Maintain standard precautions.
b) Dispose of dressings in appropriate containers.

21. Protocol Reportable Incidents
Report the following situations to the attending physician and/or wound/skin care nurse:
a) The presence and description of any pressure ulcer and/or
additional pressure ulcer incidence and any ulcer with a worsening
appearance, stage or presence of necrotic tissue.
b) Signs and symptoms of wound infection.
c) Poor response to current treatment following one week of consistent
therapy per protocol.
d) Signs and symptoms of systemic infection.

22. Protocol Patient Education
(a) Instruct the patient/significant other(s) as per the Pressure Ulcer Prevention/ Management Teaching Protocol:
(1) Definition and causes of pressure ulcer development.
(2) Repositioning techniques/frequency in bed/chair.
(3) Inspection of skin integrity and ulcer condition.
(4) Promoting skin integrity with cleansing, drying and moisturizing.
(5) Associated risk factors of pressure ulcer development (pressure, friction, shear, moisture, poor nutrition).

23. Protocol Patient Education
(6) Provide written information for prevention and treatment interventions:
AHCPR guidelines and IPRO skin savers brochure.
(7) Provide written instructions regarding pressure ulcer treatment(s) and nutrition upon discharge home.
(8) Proper use of pressure reduction surfaces/devices (pillows, foam, troughs, booties, rolled towels, chair cushions, overlays) to elevate heels off firm surfaces and support bony prominences.
(9) Use of pressure relieving low air loss therapy bed is temporary and will
be discontinued when no longer medically necessary to expedite the rehabilitative and discharge planning process.

24. Protocol Documentation
A. Use the appropriate documentation form to record:
  1. Braden Risk score (see attached) upon admission and every 12
hours thereafter (Once between 0700 and 1900 and once between
1900 and 0700).
2. Condition of skin per every eight [8] hours. (Once between the hours
of 2300 and 0700, once between the hours of 0700 and 1500 and
once between the hours of 1500 and 2300.
3. If pressure ulcer present, complete all required information daily or
with each dressing change.

25. Protocol Documentation
4. Measurement of pressure ulcer(s) in centimeters weekly
Key point: When staging pressure ulcer(s), an ulcer may worsen and the stage may increase in intensity but as an ulcer heals, continue to document the highest level of intensity (e.g., a stage IV pressure ulcer will always remain a stage IV pressure ulcer until closure).
5. Pressure ulcer protocol in place per shift for acute patients.
6. Use of prevention interventions and products in use.
7. Bed surface in use.

26. Protocol Documentation
8. Repositioning frequency/turning schedule per shift.
9. Patient’s participation and compliance with pressure ulcer protocol.
10. Instructions given to patient regarding prevention/treatment of pressure ulcers.
11. Reportable situations.