Considerations for Bariatric Patients in Pressure Injuries and Wound Care. April 27, 2017

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Considerations for Bariatric Patients in Pressure Injuries and Wound Care April 27, 2017 Susan S Morello BSN RN CWOCN CBN Clinical Consultant s-morello@hotmail.

1 Considerations for Bariatric Patients in Pressure Injuries and Wound Care April 27, 2017 Susan S Morello BSN RN CWOCN CBN Clinical Consultant s-morello@hotmail.com 2017 National Pressure Ulcer Advisory Panel NPUAP Mission The National Pressure Ulcer Advisory Panel (NPUAP) serves as the authoritative voice for improved patient outcomes in pressure injury prevention and treatment through public policy, education and research. npuap.org 2017 National Pressure Ulcer Advisory Panel 1

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Injury Alliance (PPPIA) has worked to develop a pressure injury prevention and treatment the Clinical Practice

Purchase your copy today at www.npuap.org 2017 National Pressure Ulcer Advisory Panel www.npuap.org npuap.

Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and

The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special

2 Reduced Price for the International Guideline! NPUAP in collaboration with the European Pressure Ulcer Advisory Panel (EPUAP) and the Pan Pacific Pressure Injury Alliance (PPPIA) has worked to develop a pressure injury prevention and treatment the Clinical Practice Guideline and Quick Reference Guide. The price of these books have recently been reduced. Purchase your copy today at National Pressure Ulcer Advisory Panel npuap.org NPUAP Monograph Released in November 2012, the 254-page, 24 chapter monograph, Pressure Ulcers: Prevalence, Incidence and Implications for the Future was authored by 27 experts from NPUAP and invited authorities and edited by NPUAP Alumna Dr. Barbara Pieper. The monograph focuses on pressure ulcer rates from all clinical settings and populations; rates in special populations; a review of pressure ulcer prevention programs; and a discussion of the state of pressure ulcers in America over the last decade. Purchase the monograph today at E-version $49 Individual Chapters $19 npuap.org 2017 National Pressure Ulcer Advisory Panel 2

NEW Educational Slide Sets Pressure Injury Definition and Stages Prevention of Pressure Injury Treatment of Pressure Injury Each downloadable slide set includes presentations, speaker

3 NEW Educational Slide Sets Pressure Injury Definition and Stages Prevention of Pressure Injury Treatment of Pressure Injury Each downloadable slide set includes presentations, speaker notes and handouts Purchase the slide sets today at npuap.org 2017 National Pressure Ulcer Advisory Panel National Pressure Ulcer Advisory Panel 3

4 THANK YOU to the following companies that have provided support for this webinar! Acelity American Medical Technologies ArjoHuntleigh Coloplast Dabir Surfaces Leaf Healthcare Medline Mölnlycke The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation. THANK YOU to the following companies that have provided support for this webinar! Permobil Position Health Select Medical Sizewise Span America Stryker Tamarack Habilitation Technologies Wellsense The NPUAP webinar commercial supporters did not have any input regarding the content of this presentation. 4

5 Faculty Disclosure The faculty member has listed no financial interest/arrangements that would be considered a conflict of interest. Susan S Morello BSN RN CWOCN CBN Planning Committee Disclosures Jeffrey Levine, MD Mary Litchford, PhD, RD, LDN Sally O Neill, PhD Mary Sieggreen, MSN, CNS, NP, CVN The planning committee members have listed no financial interest/arrangements that would be considered a conflict of interest National Pressure Ulcer Advisory Panel 5

6 Objectives Examine the factors which have an impact on skin issues of the bariatric patient Discuss prevention and treatment of skin injuries when caring for a bariatric patient Describe factors to be considered when selecting a support surface, seat cushion and/or other specialty equipment for a bariatric patient International Guidelines Recommendations for Organizations 1. Provide safe, respectful care and avoid injuries to both the individual and health professional. C 2. Maximize workplace safety by implementing organization-wide bariatric management strategies that address manual handling techniques. C 3. Provide pressure redistribution support surfaces and equipment appropriate to the size and weight of the individual. C 6

7 Basic Considerations for the Bariatric Population There is nothing that makes an obese person ordinary when it comes to being a patient or a resident. BMI is not a way to evaluate the size of a person. It is an instrument for evaluating the at risk status of the individual. Sensitivity and respect are paramount when caring for persons of size. Skin Changes in the Bariatric Person Reduced tissue perfusion Compromise of moisture barrier Trans-epidermal Water Loss (TEWL) Lipid release Friction Chronic inflammation Pro-inflammatory cytokines Thinning of skin Aggressive prevention is mandatory! 7

8 Prevention of Skin Injuries Assessment Proper support surface Skin care Skin injury prevention protocols Assessments Skin Assessment Skin Risk Assessment Tool Skin folds Look inside the folds all places there is skin on skin Pressure areas Not just bony prominences Differentiate Moisture Associated Skin Damage (MASD) Identify area Lymphedema and Lipedema Nutritional Assessment 8

9 Support Surface Selection Weight capability is only one factor Important that those who make purchase and rental decisions understand this. Width measurement At widest point of body standard surfaces are in. or cm. Address pressure redistribution Active or passive Cells vertical or horizontal Selection cont. Addressing microclimate How does one remove excess moisture, control the temperature Address friction/shear What will reduce or increase friction? What will reduce or increase shear? Address egress and ingress Consider hi-low bed Is the bed self-propelled? 9

10 Seating Wheelchairs should be properly sized for patient/resident and single patient use. Sides should not bind. Adjustable parts should have proper padding to avoid any sharp edges. Seat cushions should be specific for patient and, properly fitted and prescribed by a professional and reevaluated at least yearly better every 6 months. Skin Care Cleanse Daily cleansing in all problem areas skin folds, under breasts, perineal area and any other areas of excessive moisture ph appropriate products Pat dry Moisturize Humectants or emollients or combo of both Protect Moisture barrier crème 10

11 Skin Injury Prevention Protocols Assessment: Skin daily in all settings, ICU and post-op require at each shift or more often Nutritional on admission, then monitor and re-evaluate at any condition change Support surface: Use of bariatric bed and mattress Established algorithm for support surface selection, unit specific and based on individual needs Prevention Protocols cont. Support surface cont. Should be available on admission Available in E.D., radiology, interventional radiology, pre-op, OR, post-op Skin Care Areas of excessive moisture may need to be cleansed several times daily Apply moisturizer frequently during the day Use of wicking products should be used in skin folds 11

12 Prevention Protocols cont. Pressure Injury Turning and repositioning schedule based on individual need.bed and chair. Select positioning devices with care. Monitor HOB Early and often mobilization Consider use of a prophylactic dressing Consider use of friction/shear reducing linens, bed linens and gowns Monitor adequate hydration and nutrition Moisturize, moisturize, moisturize Prevention cont. Medical devices Monitor sites frequently and address any reddened or irritated area immediately Obtain bariatric trach ties, bed pans, catheters Tubes and tubing Keep them where you can see them 12

13 Treatment Protocols All of the preventions listed above, and Turning and Positioning Avoid positioning on pressure injury site(s) Avoid positioning devices that create heat May need to reposition and/or turn more frequently Dressings pressure and other skin injury Often curl when used, monitor carefully and replace as needed. Moisture may prevent adherence. Skin is already fragile avoid tape when possible Treatment cont. Skin Injuries MASD Intertriginous dermatitis Wound dehiscence Skin tears Medical devices Use bariatric appropriate size Monitor sites frequently during the day Reposition devices if irritation or injury occurs 13

14 Bariatric Equipment Safety for patient Always obtain proper bariatric equipment both size and durability appropriate Beds, chairs, wheelchairs, stretchers, canes, lifts, slings, transfer devices, OR tables, seating cushions bariatric only Slings must be in good condition and compatible with lift Have any device brought from home checked Bariatric Equipment Safety for patient and caregiver Caregiver should not lift, turn or transfer a bariatric patient manually. Use of equipment is needed. Equipment must be in proper working condition, inspected frequently and removed if damaged in any way. Proper instructions for use of equipment should accompany equipment and in-service provided for its use. 14

15 Bariatric Equipment Proper equipment provides best measure of safety and care for patient as well as caregiver See Safe Patient Handling Guidelines for information tient-handling/ ***Documentation*** Sensitivity Respect for every patient Reconsider the use of terms like big bed, large chair.use another or better or more comfortable Recognize that obesity is not just a personal problem. It is a universal health problem with major health consequences. 15

16 Thank you for listening! References 1. Bergman, R., Stefanovski, D., Buchanan, T., et al. (2011). A Better Index of Body Adiposity. Retrieved June 5, 2014 from 2. Black, J., Gray, M., Bliss, D., et al. (2011). MASD Part 2: Incontinence-associated dermatitis and intertriginous dermatitis. Journal of Wound, Ostomy and Continence Nursing, 38(4), Gray, M., Black, J., Baharestani, M., et al. (2011) MASD Part 1: Overview and pathophysiology. Journal of Wound, Ostomy and Continence Nursing, 38, Guo, S. & de Pieto, L. (2010). Factors affecting wound healing. Journal of Dental Research, 89(3), Kennedy-Evans, K., Henn, T., & Levine, N. (2007) Skin and wound care for the bariatric patient. In Chronic wound care: a clinical sourcebook for healthcare professionals (4 th ed. pp ). Malvern, PA: HMP Communications 6. Lowe, J. (2008) Skin integrity in in critically ill obese patients. Critical Care Nursing Clinics of North America, 21(3), Morello, S. (2016) Skin and wound care for the bariatric population. In Wound, Ostomy and Continence Nurses Society Core Curriculum Wound Management. (pp ). Philadelphia, PA: Walters Kluwer. 8. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osbourne Park, Western Australia; O Lenick, A. (2009). Comparatively Speaking: Humectants vs Emollients vs Occlusive Agents. Retrieved July 11, 2014 from 16

17 CE Test Information To earn the 1.0 CE credit for today s webinar please visit the link below. This information will also be ed out to webinar registrants ONE HOUR after the conclusion of the webinar. _3kikc9vFZ7S6H3f 17

OR Positioning and Pressure Injury Prevention. September 13, Ann N. Tescher, APRN CNS, PhD, CCRN, CWCN Debra L.

OR Positioning and Pressure Injury Prevention September 13, 2017 Ann N. Tescher, APRN CNS, PhD, CCRN, CWCN Debra L. Fawcett, PhD, RN 2017 National Pressure Ulcer Advisory Panel www.npuap.org NPUAP Mission