2. Pressure Ulcer Prevention
Lessons Learned from Skin Fair
Jeri Lundgren, RN, CWS, CWCN
Pathway Healthcare Services
Jody Rothe, RN, WCC
MetaStar, Inc.
December 2, 2009

3. Skin Care Objectives for our learning session:
The importance of hydrating skin
How to handle fragile skin
Moisture – friend or foe
How to turn the frail elderly patient
What causes pressure and the stage definitions
Importance of nutrition
Overall care of the skin

4. Causes of Pressure

5. Interventions

6. The Daily Post – The Barren Dessert
Protect Dry Skin which can lead to friction injuries and skin tears
Use moisturizers frequently and as often as necessary
Always be on the look-out for skin changes

7. The Daily Post – Fragile Handle With Care
Be cautious when changing incontinent products, bandages, or even their clothes
Your elder’s skin is very fragile and can tear easily

8. The Daily Post – The Barrier Reef
Use a moisture barrier to help protect the skin from stool and urine
Barrier creams and ointments only work if they are applied, and applied correctly
These creams can be the first line of defense for your elder to stop a pressure ulcer before it develops

9. The Daily Post – You’re Tearing Me Apart
Simple movements, such as turning or lifting, can create friction and shearing, which can injure the skin
To move and reposition residents, use lifting devices and draw sheets
Avoid dragging.

10. The Daily Post – Under Pressure
Reposition bedbound residents every two (2) hours
Reposition chairbound residents every one (1) hour
Use devices, such as pillows and cushions, to keep bony prominences from direct contact

11. The Daily Post – Taster’s Choice and Treasure Hunt
Poor nutrition is a risk factor in developing a pressure ulcer
Assist residents to eat as necessary
Notify the nurse if there is a decline or change in a resident’s eating habits
Choose supplements that are tasty
Consider choice in dining as a strategy to increase weight

12. The Daily Post – The Princess and the Pea
Use support surfaces on beds and chairs to reduce pressure
Avoid donuts
Use pillows or devices to raise heels off the bed

13. The Daily Post – Dorothy’s Shoe
Always be on the lookout for anything that could create pressure on the skin, including the feet

14. The Daily Post – Squeezing Me Too Tight
Stage IV pressure sores can take the longest to heal
In some residents Stage IV ulcers can develop in a matter of hours (i.e., if left on the wrong surface too long)

15. Kick Up Your Heels
Heels are especially vulnerable to pressure even on a good support surface
Heel elevation will help prevent pressure ulcers to the heels
Tip: On daily rounds monitor to ensure heels are off on the beds and equipment is being used appropriately

16. Stages of Pressure Ulcers – Terrors of the Deep
DEEP TISSUE INJURY:
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
The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue

17. Stage 1
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 may differ from the surrounding area

18. Stage 2
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

19. Stage 3 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

20. Stage 4 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

21. Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed

22. Braden Scale Puzzle – Sensory Perception
The person’s ability to perceive and respond MEANINGFULLY to pressure related pain & discomfort
Interventions
Remember the shoe exercise? Check for anything that could be creating pressure on the skin
For the resident with limited ability to perceive pressure, put on a turning schedule to ensure pressure relieved at regular intervals

23. Braden Puzzle – Moisture
The amount of moisture the skin is exposed to
Interventions:
Use moisture barrier in particularly wet areas (peri-area, buttocks, etc.)
Change clothing, incontinence products, and linen as often as you need to

24. Braden Scale Puzzle – Activity
Getting up and around
Interventions:
Change position at least every 2 hours
ROM
Ambulate
Teach resident to change his/her own position

25. Braden Scale Puzzle – Mobility
Changing position and controlling body position
Interventions:
Float the heels
Reposition at least every 2 hours for bed-bound residents; hourly for chair bound
Use pillows for support

26. Braden Scale Puzzle – Nutrition
USUAL food intake
Interventions:
Help to eat
Get foods they like (within their diet)
Offer fluids frequently (as diet allows)
Provide supplements as ordered

27. Braden Scale Puzzle – Friction and Shear
Friction & Shear:
Ability to move without rubbing or dragging
Interventions:
Use lift sheet
Soft socks on feet
Long sleeves or elbow protectors
Keep the head of the bed at the lowest degree of elevation consistent with medical condition and other restrictions
Limit the amount of time the head of the bed is elevated

28. Pressure Ulcer Prevention
You can make a difference
Implement preventative interventions
Report changes in skin
Thank you

29. Contact Information:
Jody Rothe, RN, WCC
Quality Consultant
MetaStar, Inc.
2909 Landmark Place
Madison, WI
(608) or (800) , ext. 8271
This material was prepared by MetaStar, the Medicare Quality Improvement Organization for Wisconsin, 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.  9SOW-WI-PS