1. Identifying and Reporting changes in skin condition

2. Presented by Lizeth Flores, RHIT Anderson Health Information Systems, Inc 940 W. 17 th Street, Suite B Santa Ana, CA 92706 (714) 558-3887 office@ahis.net

3. Today’s Topics Pressure Ulcer risk factorsPressure Ulcer risk factors Checking for pressure ulcersChecking for pressure ulcers Pressure ulcer preventionPressure ulcer prevention Facility protocols for skin assessmentsFacility protocols for skin assessments Facility protocol for communicating changes in skin integrityFacility protocol for communicating changes in skin integrity

4. What is a pressure ulcer? A pressure ulcer (a bedsore or pressure sore) is skin breakdown caused by pressure on bony prominences from being in one position for too long.

5. What are pressure points? Bony parts of the body such as the tailbone, hips, heels, elbows, shoulders.

6. What can contribute pressure ulcers? –Impaired/decreased mobility/functioning –Co-Morbid Conditions (e.g. ESRD, DM) –Drugs (Steroids) –Impaired blood flow from sitting or lying too long in one place –Resident refusal of treatment/care –Cognitive Impairment –Urinary/Fecal incontinence –Wet clothing or a wet bed –Under-nutrition, malnutrition, dehydration – not getting enough food or water –History of/healed ulcer –Use of physical restraints

7. OTHER RISK FACTORS…… Tubing such as catheters that the resident may lay on will cause unnecessary pressure and friction that could lead to skin breakdownTubing such as catheters that the resident may lay on will cause unnecessary pressure and friction that could lead to skin breakdown

8. Are Pressure Ulcers the only type of ulcers? NO –NO – There are many types of ulcers that can develop from disease processThere are many types of ulcers that can develop from disease process ExampleExample Stasis UlcerStasis Ulcer Diabetic UlcersDiabetic Ulcers

9. WHY IS IT IMPORTANT TO MONITOR AND REPORT CHANGES IN RESIDENT’S SKIN CONDITION ?

10. It’s The Law The law states that each resident must receive necessary care and services to attain or maintain the highest practicable physical, metal and psychosocial well-being in accordance with the comprehensive assessment and plan of careThe law states that each resident must receive necessary care and services to attain or maintain the highest practicable physical, metal and psychosocial well-being in accordance with the comprehensive assessment and plan of care

11. F309 - §483.25 Quality of Care -2 Expands Definition of Skin Ulcer/WoundExpands Definition of Skin Ulcer/Wound –Clinician expected to document the clinical basis* which permit differentiating the ulcer type ESPECIALLY if the ulcer has characteristics consistent with a pressure ulcer but is determined NOT to be one

12. I’m a CNA what can I do? CNAs are the first line of defense when it comes to identifying skin breakdownCNAs are the first line of defense when it comes to identifying skin breakdown You provide direct care to the residents daily and will usually be first to notice changes in skin color or integrityYou provide direct care to the residents daily and will usually be first to notice changes in skin color or integrity

13. When will I check the skin? During daily activitiesDuring daily activities During showersDuring showers Throughout the day as you carry out your job dutiesThroughout the day as you carry out your job duties

15. What do I need to look for? Changes in skin color / discolorationChanges in skin color / discoloration Changes in skin temperature – some breakdown may not be readily visible on darker skin tones so changes in skin temperature, skin appearance may give you the clues you need to identify a problem.Changes in skin temperature – some breakdown may not be readily visible on darker skin tones so changes in skin temperature, skin appearance may give you the clues you need to identify a problem.

16. What to look for……. Red areas on the skin that do not go away even after the pressure is removedRed areas on the skin that do not go away even after the pressure is removed Cracked, blistered, scaly, broken skinCracked, blistered, scaly, broken skin An open sore involving skin surface or tissue under the skinAn open sore involving skin surface or tissue under the skin Yellowish stains on clothing, sheets, or chair (may be tinged with blood)Yellowish stains on clothing, sheets, or chair (may be tinged with blood) Painful or tender "pressure points" (back of head, ears, back of shoulders, elbows, buttocks, hips, heels, and any place a bony part rests on the bed surface.)Painful or tender "pressure points" (back of head, ears, back of shoulders, elbows, buttocks, hips, heels, and any place a bony part rests on the bed surface.)

17. What to report……. All changes in skin condition must be reported to ensure that the facility is in compliance with regulatory requirementsAll changes in skin condition must be reported to ensure that the facility is in compliance with regulatory requirements

18. Reposition vs Redistribution

19. Repositioning plans should be outlined in the plan of care consistent with the INDIVIDUAL resident’s needsRepositioning plans should be outlined in the plan of care consistent with the INDIVIDUAL resident’s needs Pressure RedistributionPressure Redistribution –Function or ability to redistribute a load over a surface or contact area –Specific devices and surfaces are addressed and suggestions given for using and evaluating effectiveness of such devices

20. DO YOU KNOW WHERE TO FIND INFORMATION THAT WILL HELP YOU CARRY OUT YOUR DUTIES EFFECTIVELY?

21. You are a key player in pressure ulcer prevention –How do you know what pressure relieving devices are being used for each resident? –Where is this information located? –How is the information updated when there are changes?

22. What is the facility policy for turning and repositioning?What is the facility policy for turning and repositioning? How do you track turning and repositioning of residents?How do you track turning and repositioning of residents? During showers how do you document skin assessment?During showers how do you document skin assessment?

23. What do you do with that information?

24. Don’t take it for granted Just because a resident is on a pressure relieving device does not mean they do not need to be closely monitored and turned and repositioned based on their specific needsJust because a resident is on a pressure relieving device does not mean they do not need to be closely monitored and turned and repositioned based on their specific needs

25. What else do I need to know?

26. There are many other important aspects of CNA duties and documentation that affect resident assessment and careThere are many other important aspects of CNA duties and documentation that affect resident assessment and care It is critical that you document what your observations of the resident is during your shift and not refer back to prior day’s chartingIt is critical that you document what your observations of the resident is during your shift and not refer back to prior day’s charting

27. Documentation……. A decrease in resident’s intake of meals can indicate a change in their condition, it does not necessarily mean that they have pressure ulcers but the fact that they are not consuming adequate nutritional amounts can be a contributing factor to skin breakdownA decrease in resident’s intake of meals can indicate a change in their condition, it does not necessarily mean that they have pressure ulcers but the fact that they are not consuming adequate nutritional amounts can be a contributing factor to skin breakdown So remember….. It is extremely important that you document % of meal intake accurately and timely.So remember….. It is extremely important that you document % of meal intake accurately and timely.

28. Documentation Low intake of fluids can result in dehydration which can lead to skin breakdown.Low intake of fluids can result in dehydration which can lead to skin breakdown. Always document accurately and timelyAlways document accurately and timely

29. Who needs to know…. If you identify a problem, who will you tell?If you identify a problem, who will you tell? How can you prove you reported the changes?How can you prove you reported the changes? Where can this information be found?Where can this information be found?

30. What is the nurse responsible for? The licensed nurse is responsible for assessment of the resident, development of a comprehensive plan of care and for carrying out the care as specified in the care planThe licensed nurse is responsible for assessment of the resident, development of a comprehensive plan of care and for carrying out the care as specified in the care plan

31. Why am I being asked to check the resident for pressure ulcers? You are part of the resident care team and you play a very important part in ensuring quality of careYou are part of the resident care team and you play a very important part in ensuring quality of care The nursing staff will use any information you provide to ensure patient’s receive the necessary care to ensure their highest level of well beingThe nursing staff will use any information you provide to ensure patient’s receive the necessary care to ensure their highest level of well being

32. Why is there such a focus on pressure ulcers in skilled nursing facilities?

33. Prevention and treatment of pressure ulcers is a focus in all healthcare settings and not just nursing homesPrevention and treatment of pressure ulcers is a focus in all healthcare settings and not just nursing homes

34. Consequences –Pressure ulcers can be very painful for the resident –Pressure ulcers can result in complications such as infection and in severe cases loss of body parts (amputation) –Pressure ulcers can progress very rapidly if they remain untreated –Pressure ulcers sometimes result in death

35. Pressure ulcers can lead to complaints and investigationPressure ulcers can lead to complaints and investigation Pressure ulcers can lead to lawsuits and can be very costlyPressure ulcers can lead to lawsuits and can be very costly

36. If the facility has patients with pressure ulcers does that mean that the residents are no properly care for?

37. NO Even with very good patient care there can be unavoidable ulcers This is based on the overall condition of the patient and diagnoses that can contribute to poor skin integrity

38. Example DiabetesDiabetes Renal FailuteRenal Failute DialysisDialysis Poor circulationPoor circulation

39. Even if the resident’s pressure ulcers cannot be avoided, they should be promptly identified and treatments implemented to ensure they achieve their highest level of well being.

40. You work hard…. Take credit for it It takes a very special person to provide quality caring services for residents in skilled nursing facilities That makes you very special people, your participation in the overall monitoring of the resident’s condition is critical to ensure they are provided with the best care possible-

41. Discussion & Questions

42. Thanks for attending