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

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

Causes of Pressure

Interventions

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

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

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

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.

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

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

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

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

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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Contact Information: Jody Rothe, RN, WCC Quality Consultant MetaStar, Inc. 2909 Landmark Place Madison, WI 53713 (608) 274-1940 or (800) 362-2320, ext. 8271 www.metastar.com jrothe@metastar.com 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-09-223.