1. Pressure Ulcer Prevention & Management
Presented by
Carol Compas, RN, BSN
Project Manager (AFMC)
Jeff Edwards,RN
MDS/RAI Coordinator (OLTC)

2. Outline Background Pressure Ulcer Prevention
Pressure Ulcer Treatment and Monitoring
Publicly reported PU Quality Measure
Partnering with the QIO to improve PU care

3. Pressure Ulcers Definition Can occur anywhere on body
Any lesion caused by unrelieved pressure resulting in damage of underlying tissue (AHCPR, 1994).
Can occur anywhere on body

4. Healing of Pressure Ulcers
Pressure Ulcer Staging (depth & tissue type)
Stage I Persistent redness (culturally sensitive)
Stage II Partial thickness skin loss
Stage III Full thickness skin loss (subcutaneous)
Stage IV Full thickness skin loss (fascia)
*NPUAP does not endorse reverse staging;however, the current RAI guidelines mandate reverse staging

5. Pressure Ulcer Stages

6. Pressure Ulcer Causes Prolonged pressure
duration and intensity of pressure
location of pressure on body
extended pressure that blocks flow to the tissue between the source of pressure & the bone
Shear
Friction

7. Pressure Ulcer Pressure Ulcer Etiology
pressure exerted by bony prominences on the body that stop capillary flow to the tissues.
Deprives tissues of oxygen and nutrients causing cell death.
Pressure greater than 32mmHg exerted by bony prominences to disrupt blood flow.

8. Pressure Ulcer Etiology
Function of both time and pressure (hyperbolic curve)
-70mmHg pressure for two hours produces irreversible injury
-greater pressure takes less time
-lower pressure takes more time
-obese may be much lower; emaciated may be much higher
-turning schedules must be individualized!!!!

9. Most Common Sites Sacrum (tail bone)- most common site
-Semi-fowlers’ position
-Slouching in bed or chair
-higher risk in tube fed or incontinent pts.
Heels- 2nd most common
-Immobile or numb legs
-Leg traction
-Higher risk with PVD & diabetes neuropathy

10. Other Bony Prominences
Trochanter (hip bone)
-Side lying
-Highest risk contractured residents
-Ulcers on lateral foot rather than heel itself
Ischium (sitting erect bone)
-highest risk paraplegics

11. Pressure Ulcers from other sources of pressure
Boots/boot straps
Heel protectors/protector straps
Oxygen tubing
Stockings
Any device that can lead to pressure induced ischemia on the skin

12. Morbidity & Mortality
Pain
Infection
Quality of life
Death
Cost

13. Mortality 40% die per year
60% die within 1 year after hospital discharge
sources: Thomas DR JAGS 1996; 44:1435.
Brandeis GH JAMA 1990;264:

14. Pain with Pressure Ulcers
59% report some degree of pain
Only 2% receive pain medication within 4 hours of dressing change
45% report pain as distressing or horrible

15. KEY Pressure Ulcer Risk Factors
Impaired bed or chair mobility
Urinary incontinence
Fecal incontinence
Poor nutritional status
History of pressure ulcer
PVD or Diabetes Mellitus

16. Risk of Pressure Ulcer by Number of Risk Factors
Number of risk factors present
Mor, V et al Canadian J of Quality of Care

17. Admission Assessment for Risk Factors
Mobility status
Urinary continence
Bowel continence
Feeding assistance needed
Pressure ulcer history
Recent weight loss
Height & weight
Skin exam

18. Impact of Risk Assessments
Implementation of risk assessment reduced development of new pressure ulcers each year in one hospital
18.7%  13.1%  11.7%  6.4%
Source: Bergstrom N. Nurs Clin North Am 1995;30:

19. Impact of Risk Assessments
Implementation of Braden scale reduced new pressure ulcers over 6 months in high risk patients
32.6%  9.1%
Source: Horn ., Clinical Practice Improvement. Faulkner & Gray Inc. 1994

20. Plan of Care to Address Risk Factors
Skin Care
Pressure Reduction
Incontinence Care
Nutritional Interventions

21. General Skin Care Daily skin inspections for high-risk individuals
Skin cleansing
Minimize drying & cracking
Minimize excess moisture
Avoid massage

22. Protect skin from moisture
Cleanse skin with warm water & mild soap
Cleanse skin after soiling
Use non-alcohol based moisturizers
Use skin protectants or barriers
Do not massage over bony prominences
Institute bowel or bladder training programs
Use briefs or absorbent underpads

23. Pressure Reduction Rehabilitation to improve mobility
Repositioning schedule (individualized)
Minimum turn Q2 hours in beds
Minimum shift Q1 hour in chair (15 mins)
Heel relief
Positioning
Pressure reduction devices
Beds
wheelchairs/chairs

24. Support Surface Selection
No one support surface ever has been shown to be the best for all users
Bed- consider the # of body surfaces available for support
Wheelchair- cushions are fundamentally different than horizontal support surfaces
Effectiveness is judged directly & indirectly
-Direct- clinical outcomes
-Indirect- interface pressure/IP, blood flow, etc. (never use 32 mmHg as the safe threshold for IP)

25. Pressure Reduction Helpful Hints
Static Devices
Air, gel, water, foam and combinations
No statistical significant differences have been noted between static devices
Key to static devices
Foam density of 1.3lbs/cubic foot
3 inches for solid foam, 4 inches for convoluted
Ability to assume variety of positions without bearing weight
Remember wear and tear factor (average life of foam overlay is years).

26. Pressure Reduction Helpful Hints Cont’d
Dynamic Surfaces
Alternating, low air loss and air fluidized
effective in maintaining < capillary closure pressures.
Few studies demonstrate variances between dynamic surfaces.
Must be operational (check instructions)

27. Pressure Reduction Helpful Hints Cont’d
Key to selection
Inability to assume variety of positions without bearing weight on pressure ulcer
“Bottoming out”
Absence of healing (wide variance on stages)
Resident has Stage IIIs and Stage IVs on multiple turning surfaces
Check Heels!

28. Pressure, friction and shear reduction
Reduce pressure over bony prominences
Individualized bed turning (min. q 2hrs)
Individualized chair repositioning (min. q1hr)
HOB < 30 degrees
Avoid positioning directly on great trochanter
Float heels off bed
Check devices for “bottoming out”
Avoid mechanical injury- use slide boards, turn sheet, trapeze, corn starch
Increase mobility/Consult PT/OT

29. Encourage optimal nutrition and fluid intake
Conduct nutritional consultation
Consider resident preferences and special needs
Provide assistance and adequate time
Offer snacks and fluids between meals
Consider administration of vitamins &/or protein supplements
Assess lab values

30. Pressure Ulcer Prevention
Risk Assessment upon admission
Admission interventions for each selected risk factor
Admit & daily skin exams documented for at-risk population
Risk
Early
Care Plan
Quality
Improvement/
Monitor Program
Daily skin
check

31. Pressure Ulcer Monitoring and Treatment

32. Description of Ulcers Stage Ulcer Location Size Wound bed
Granulation tissue
Necrotic tissue
Wound edges
Drainage
Infection
Pain

33. Healing of Pressure Ulcers
Pressure Ulcer Staging
Stage I Persistent erythema (culturally sensitive)
Stage II Partial thickness skin loss
Stage III Full thickness skin loss (subcutaneous)
Stage IV Full thickness skin loss (fascia)
*NPUAP does not endorse reverse staging; however, the current RAI guideline does

34. Identification Consider risk factors that are present
-Shortness of breath, weight loss, inability to eat, orthopedic surgery (hip, knee) diabetes
Consider if patient cannot move voluntarily
-Bedridden, chair ridden, coma, restrained, desaturation with movement, traction, pain
Consider the pattern of ulcer development
-High risk? Or acquired, trapped in one place for extended time?

35. Identification Consider location of the ulcer
-Bony prominence, in location of medical devices
Descriptions (photographs)
-crater like ulcers common
-do not rely on the use of staging, many people stage wounds of any etiology
Do not rely on the use of staging terms as evidence that a wound is a pressure ulcer

36. Management of Ulcers Wound Care Pressure reduction
debridement
wound cleansing
dressings
adjuvant therapies
Pressure reduction
Risk factors addressed
Continence care
Nutritional improvement
Mobility
Consider operative repair

37. Monitoring of Ulcers Maintain communication with treating physician
Physician and nursing documentation should correlate
Reassess ulcer weekly (skin daily)
PUSH Tool – see sample
Re-evaluate plan of care
if wound deteriorates
if no healing in 2-4 weeks

38. Healing the Heels Hints
Heel Pressure Ulcers
Account for 20% of all pressure ulcers
Easier to acquire, challenging to heal
Pressure relief on heels?
Moisturize heels
pillows
semipermeable membrane dressing for pre-Stage I
Hydrocolloid for Stage I

39. Healing the Heels Cont’d
Heel protector boots (check warranty, check wear and tears, usual heel protector last 1 year!)
Heel lift suspension (usually last 1-2 yrs)
“Good fitting” sneakers with cushion pads
Heels can be vulnerable independent of support surfaces on bed/wheelchair

40. Wound Cleansing Completed with each dressing change
Clean with saline or water
do not use skin cleansers or antiseptic agents
use appropriate irrigation pressure

41. Wound Cleansing Completed at each dressing change
Clean with saline or water
-Saline is considered the most appropriate solution
-Literature also supports use of tap water if quality
No skin cleansers or anti-septics
Use appropriate irrigation pressure between 4-15 psi
-35cc syringe with 19-gauge cath. (delivers 8 psi)
->15 psi may drive wound fluid & debris into wound
Consider availability, ease of use and cost

42. Wound Dressings Keep wound bed moist
Keep surrounding tissue clean & dry
Eliminate dead space
Do not use antiseptic agents

43. Types of Dressings Gauze Transparent films Hydrocolloid Hydrogel
Alginates
Foam
Composite

44. Keys to Selecting Dressings
Must use clinical judgement
Keeps ulcer bed continuously moist
Keeps surrounding periulcer skin dry
Controls exudate without dessicating (drying out) ulcer bed
Caregiver time

45. Debridement Techniques
All wounds with necrotic tissue should be debrided (except eschar on heels) as necrotic tissue delays wound healing and predisposes to infection.
Sharp
Mechanical (including dextranomers)
initial form of debridement
Enzymatic
Autolytic

46. Bacterial Infection Clinically Infected All wounds colonize!
redness of the skin around
purulent drainage
foul odor
edema
All wounds colonize!

47. Helpful Hints to Prevent Infection
Sterile vs. Clean Technique
Wounds are not sterile
Assure wound care products/dressing supplies do not become contaminated during storage and use
To Swab or not to Swab?
Has little value in determining whether wound is infected, not currently recommended

48. Monitor Nutritional Status
Track percent meals consumed
Monitor changes in weight
Monitor protein intake (< 90% RDA)
Consider laboratory tests

49. Nutritional Interventions
Supplements
Feeding assistance programs
Feeding assistance devices
Vitamins & minerals

50. Pressure Ulcer Treatment
Assessment upon admission
Admission treatment order based on current standards or product guidelines
Weekly ulcer assessments
Admit
assessment
Treatment
Plan
Quality
Improvement/
Monitor Program
Weekly
Re-assess

51. Section M. Skin Condition
Skin Ulcer Definition-
Local loss of epidermis and variable levels of dermis and subcutaneous tissue, or in the case of Stage I pressure ulcers, persistent area of skin redness.
Skin ulcers that may develop because of injury, circulatory problems, pressure, or in association with other diseases.

52. Section M. Skin Condition
M1 Ulcer
-Due to any cause
-7 Day look back
Intent is to record the number of ulcers, of any type at each ulcer stage, on any part of the body
M2 Type of Ulcer (only 2 choices)
a. Pressure Ulcer
b. Stasis Ulcer

53. Regulatory Compliance
F271- “At the time each resident is admitted, the facility must have physician orders for the resident’s immediate care”
“Orders at a min. should include routine care to maintain or improve functional abilities until staff can conduct a comprehensive assessment and develop a care plan”

54. Regulatory Compliance
F281- The services provided must meet professional standards of quality
“Professional standards of quality” means services that are provided according to accepted standards of clinical practice
Standards published by a professional organization
Pressure ulcer specific- AMDA & AHCPR
Manufacturer guidelines count as standards!
Ensure product is used accordingly

55. Regulatory Compliance
F272- “The scope of the RAI does not limit the facility’s responsibility to assess & address all care”
“The facility is responsible for addressing the residents’ needs from the moment of admission”

56. Regulatory Compliance
F314- “A resident who enters the facility does not develop pressure sores unless clinical condition demonstrates that they were unavoidable”
“A resident having pressure sores receives necessary treatment & services to promote healing, prevent infection and prevent new sores form developing”

57. Was the ulcer avoidable?
Avoidable: ulcers develop when all appropriate care was given, or in residents who cannot move, will not move, will not be fed, etc…
Documentation must support appropriate care, inability to move (e.g. unstable spinal cord injury), noncompliance, advanced directives
Support surfaces & pain control often are other aspects of determining if appropriate care was given

58. Investigative Protocol Task 5c, 6
Conduct a review of the assessment and care plan noting the facility’s interventions
Observe care delivery to determine if the interventions have been implemented, such as:
-incontinence care with frequency to keep skin clean & dry
-repositioning and evaluation of skin condition
-nutritional interventions
-treatment interventions
-changes in skin condition & healing

59. Investigative Protocol
Note: Regardless of the timing of the assessment, the facility is required to develop and implement a care plan to meet the needs of the resident
Evaluation of the assessment identified conditions that may put the resident at-risk for development such as:
-Diabetes
-Peripheral Vascular Disease
-COPD

60. Investigative Protocol
All related information and documentation will be reviewed to look for evidence of identified causes of the condition or problem
Inquiry should include interviews with appropriate staff, who by level of training and knowledge of the resident, should be able to provide information about the causes of a resident’s condition or problem

61. Investigative Protocol
Determination if the facility developed a care plan with interventions for the prevention of the development of an ulcer
Determination if an interdisciplinary care plan was developed for the conditions identified
Review documented interventions, such as pressure relieving devices, nutritional interventions and other measures, developed to provide an aggressive program of prevention and/or treatment

62. Case Scenario I
78 year old CVA immobile resident is admitted with recent weight loss. She is admitted on a regular diet and consumes <25% of each meal. She has a Stage I reddened area on her left heel and excoriated perineal area from urinary & bowel incontinence.

63. Case Scenario I Is she at-risk of developing a pressure ulcer?
Does she have a stage I pressure ulcer?
If so, how should it be coded on the MDS?
What should be considered for her plan of care?
When should the plan of care be implemented?
Who should implement the plan of care?

64. Case Scenario II
85 year old diabetic man was admitted to the facility with skin tear on his right shin that resulted from the stretcher transfer. His sacral area is reddened and he has a Stage 3 pressure ulcer on his left hip. His previous diet was regular with BID Ensure which he consumed between 25-50% . He is continent of bowel only.

65. Case Scenario II How many ulcers will be coded on M1?
Where should the ulcers be coded on the MDS?
What physician orders are needed for the resident’s immediate care upon admission?