Presentation on theme: "Pressure Ulcer Prevention and Treatment Kaleida Health Policy #TX. INT"— Presentation transcript:
1Pressure Ulcer Prevention and Treatment Kaleida Health Policy #TX. INT Pressure Ulcer Prevention and Treatment Kaleida Health Policy #TX.INT.1 and Clin.63The Purpose of this review is to provide the Kaleida Health Healthcare Provider information on the methods for preventing, identifying, reporting and treating pressure ulcers.
2Scope of PracticeAll RN’s, LPN’s, in all patient care areas.PCA’s, CNA’s, Monitor Technicians, Nursing Assistants – preventing, identifying and reporting only.
3PolicyPatients 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.
4ProtocolPressure 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.
5Protocol 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.
6Protocol 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.
7Staging DescriptionDEEP 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.
8Staging DescriptionSTAGE 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.
9Staging 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.
10Protocol 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
11Protocol 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.
12Protocol 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.
13Protocol 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.
14Protocol SafetyImplement pressure ulcer prevention measures as appropriate for allPatients scoring at risk with the Braden or Braden Q Scale and/or forpatients with existing pressure ulcer(s):(1) Reduce and relieve surface pressure by selecting appropriate chaircushion, mattress, overlay or low air loss therapy bed (refer to procedure section).(2) Utilize pillows and supportive devices (foam, troughs, booties, rolledtowels) to elevate heels off firm surfaces and support bony prominences.(3) Turn and reposition at least every two hours in bed and every hour inchair. A clock model may be used to facilitate turning schedules.(4) Carefully reposition tubes (ET tubes, N/G, chest, etc.) throughout shift.
15Protocol 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 creamsover 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.
16Protocol 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 whentransferring 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.
17Protocol 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 orout of bed in a chair.(c) Utilize barrier creams, do not aggressively massage skin or bonyprominences.(d) Utilize airflow draw pads to reduce surface moisture.
18Protocol 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 enhancewound healing unless otherwise medically contraindicated.
19Protocol Safety(9) Collaborate with physician/practitioner regarding consultation withphysical/occupational therapy/infectious disease as necessary(10) Incorporate age/development diversional activities to promotecompliance with mobility and pressure ulcer preventioninterventions.
20Protocol Infection Control a) Maintain standard precautions.b) Dispose of dressings in appropriate containers.
21Protocol 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/oradditional pressure ulcer incidence and any ulcer with a worseningappearance, stage or presence of necrotic tissue.b) Signs and symptoms of wound infection.c) Poor response to current treatment following one week of consistenttherapy per protocol.d) Signs and symptoms of systemic infection.
22Protocol 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).
23Protocol 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 willbe discontinued when no longer medically necessary to expedite the rehabilitative and discharge planning process.
24Protocol Documentation A. Use the appropriate documentation form to record: 1. Braden Risk score (see attached) upon admission and every 12hours thereafter (Once between 0700 and 1900 and once between1900 and 0700).2. Condition of skin per every eight  hours. (Once between the hoursof 2300 and 0700, once between the hours of 0700 and 1500 andonce between the hours of 1500 and 2300.3. If pressure ulcer present, complete all required information daily orwith each dressing change.
25Protocol Documentation 4. Measurement of pressure ulcer(s) in centimeters weeklyKey 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.
26Protocol 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.