Pressure Ulcer Facts Dorner, B., Posthauer, M.E., Thomas, D. (2009)

Transcription

1 Prevention of Pressure Ulcers and Skin and Wound Management Programs Mary Beth Flynn Makic RN PhD CNS CCNS Research Nurse Scientist, Critical Care University of Colorado Hospital Assistant Professor, Adjoint University of Colorado, Denver, College of Nursing Never Events: Pressure Ulcers Pressure ulcers (PUs) can be identified, measured, and reported Usually preventable Result in adverse patient outcomes, prolonged/additional care, increased costs Significant body of scientific evidence is available to guide practice and prevent PUs October, 2008: Stage III and IV PUs acquired after admission are not reimbursed April 14, 2008 fact sheet; Serious Adverse Events Working Group March 19, 2008 Pressure Ulcer Facts Dorner, B., Posthauer, M.E., Thomas, D. (2009) 4 th leading preventable medical error in the United State 3 million patients are treated annually National acute care prevalence rates 7-15% LOS ~ 4 to 14 days Cost to treat PU $43,000 per hospital stay

2 Pressure Ulcer Facts Russo, CA et al (2008). Hospitalizations related to pressure ulcers among adults 18 years and older ,300 PU related hospitalizations in ,5000 admissions with PU as primary diagnosis 1 of 25 admissions ended in death 457,800 admissions, PU secondary diagnosis 1 of 8 admissions ended in death Pressure Ulcer Prevention: A Nursing Sensitive Indicator National Database of Nursing Quality Indicators (NDNQI) National Quality Forum National Voluntary Consensus Standards for Nursing-Sensitive Care asp IHI 5 Million Lives Campaign National Pressure Ulcer Advisory Panel European Pressure Ulcer Advisory Panel Prevention of pressure ulcers is nursing sensitive indicator This means that prevention of skin breakdown is a direct reflection of care provided to patients by nursing professionals Nursing practice guided by best-evidence is essential in the prevention of pressure ulcers (PU) S.P.A.M. At UCH our skin program logo is S.P.A.M. Skin Prevention Assessment Management

3 Positively Impacting Care: Skin Assessment on Admission Essential that nurses complete and document full assessment of skin to include alterations and pressure ulcers on admission and nutritional status Differentiate Community acquired pressure ulcer: Present on Admission (POA) Hospital acquired pressure ulcer (HAPU) Risk Assessment On Admission, Daily, Change in Patient Condition www,ihi.org; Macklebust,JA (2009) The Braden Scale reliable assessment to effective interventions Use standard EBP risk assessment tool Research has shown Risk Assessment Tools are more accurate than RN assessment alone. Braden Scale for Predicting Pressure Sore Risk 6 subscales Rated 1-4 Pressure on tissues Mobility, sensory perception, activity Tissue tolerance for pressure Nutrition, moisture, shear/friction Score 6-23 Evidence-Based Risk Assessment Tools Bolton, L. Which pressure ulcer risk assessment scores are valid for use in clinical settings? JWOCN, 2007; 34(4): 368. ; Kring, D., Reliability and validity of the Braden scale for predicting pressure ulcer risk. JWOCN, 2007; 34(4): 399. Braden Acute care, home care, nursing homes Adult patient populations 6 subscales Scores 6-23 Norton Gosnell Acute care Rehab Acute care, nursing home Adult patient populations Neurology, orthopedic, medical, ICU, geriatric patients 5 subscales Scores subscales Scores 5-20 Braden Q Acute care Pediatrics 6 subscales + tissue perfusion

4 Pressure Ulcer Prevention (PUP) Protocol Related Policies / Guidelines : Use of Therapeutic Surfaces/Bariatric Suites Prevention and Treatment of Skin/Tissue Breakdown Skin Tear Management Guideline Pressure Ulcer Prevention / Treatment Guidelines Nursing Standard of Care of Prevention of Pressure Ulcers nd a Skin Breakdown? Turning Schedule: turn patient every 2 hours and PRN? HOB < 30 if pt does not have pulmonary risks; HOB>30 if pt has risk for pulmonary complications (increase tu rning frequency)? Trapeze when indicated, Waffle cushion to all chair surfaces for Braden ACTIVITY subscale? 3? Moisturize skin daily and PRN using Dimethicone barrier cream? Control moisture; determine and treat cause of moisture, add absorbent pads to bed surface, barrier cleansing wipes and Zinc Skin Paste as needed.? Nutritional Consult if: Braden NUTRITION subscale? 3 and/or Albumin? 3.4 g/dl and/or Pre -albumin?20 mg/dl and/or Braden score?16? Minimize Friction & Shear by use of turning sheet s and slide boards to move patient, protect heels and fragile skin of extremities? Wound Care Consult if: DTI, Stage III, IV, Unstageable or hospital acquired pressure ulcer, prevention challenges or complicated wounds Braden Score At Risk Braden Score Moderate Risk Braden Score High Risk Braden Score < 9 Very High Risk INTERVENTIONS: INTERVENTIONS: INTERVENTIONS: INTERVENTIONS:? Implement turning schedule? Implement turning schedule? Implement turning schedule? Turn every 1 hour as applicable? Moisturize skin daily and PRN? Moisturize skin daily and PRN? Moisturize skin daily and PRN? Obtain PT consult, out of bed as? Out of bed, increase activity as? Out of bed, increase activity,? Obtain PT consult for activity indicated indicated assess need for PT consult level, out of bed as indicated? Moisturize skin daily and PRN? Control moisture? Control moisture? Cont rol moisture? Control moisture? Assess nutritional status? Nutrition consult? Nutrition consult? Nutrition consult? Minimize friction and shear? Minimize friction and shear on? Minimize friction and shear on? Minimize friction and shear on? Consider Advanta bed or ensure bed and chair surfaces bed and chair surfaces bed and chair surfaces prevention mode activated? Advanta bed surface? Advanta bed surface? Order Low-Airloss bed per? Patient/Caregiver Education? Patient/Caregiver Education? Patient/Caregiver Education Therapeutic Surfaces policy? Patient/Caregiver Education Advance to next level of risk if other factors are present: Advanced age, Chronic Ilness, Diastolic pressure below 60, Uncontrolled pain Bariatric patients with BMI>40 ( ) should be placed on surfaces as per Therapeutic Surfaces/Bariatric Suites policy References: 1. Ratliff, C.R. et al (2003). Guideline for prevention and management of pressure ulcers. Wound Ostomy and Continence Nurses Society. Lake Avenue, Glenview IL. 2. Ayello, E.A. et al (2004). By the numbers: Braden score interventions. Advances in Skin & Wound Care 17(3): Nurse s Association of Ontario. Nu rsing Best Practice Guideline: Assessment and Prevention of Pressure Ulcers. Toronto: RNAO (2005). Available best practice guideline. 4. Keast, David et al (2007). Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers. Advances in Skin &Wound Care 20(8): Magalhaes, MD et al (2007). Risk Factors for Pressure Ulcers in Hospitalized Elderly without Significant Cognitive Impairment. Wounds 19(1): University of Colorado Hospital, 2008 Accuracy of RN Knowledge Assumptions of RN knowledge to correctly assess, treat, and stage pressure ulcers Little didactic knowledge in academic settings Little formal education in practice; reliance on specialists (CWOCN) Two skin conditions of greatest concern are: Deep Tissue Injury (DTI) and Incontinence Associated Dermatitis (IAD)

5 Staging Pressure Ulcers Deep Tissue Injury (DTI) Stage I Stage II Stage III Stage IV Unstageable?mucosal injury DTI consensus statement Fleck, C. (2007). Suspected DTI, FAQs. Advances in Skin & Wound Care. 20(7),413 Deep Tissue Injury (DTI) High risk patient population-icu Immobility Poor perfusion states Purple in color, blood blister Wound deteriorates quickly Usually progresses muscle, bone Heels are high risk areas

6 Treatment of Pressure Ulcer Guidelines: Deep Tissue Injury (DTI) Pressure Ulcers and Excessive Moisture incontinence Gray,M., Bliss, D., Doughty, D., et al., Incontinence-associated dermatitis: a consensus. JWOCN, 2007; 34(1): WOCN Image Files *Maklebust, J. & Magnan, M. Risk factors associated with having a pressure ulcer: a secondary analysis. Adv Wound Care 1994, 7: 25. Incontinence associated dermatitis (IAD) Fecal > urine incontinence Patients with fecal incontinence 22% > chance developing PU* Immobility + fecal incontinence = risk Evidence-Based Management of IAD Wishin, J., et al. Emerging options for the management of fecal incontinence in hospitalized patients. JWOCN, 2008; 35(1): st identify the source of IAD In ICU frequently it is antibiotics or tube feeding Consult nutritionist: evaluate osmolarity of tube feeding; add fiber to diet Consider medications to slow diarrhea Evaluate medications that may be causing diarrhea Ace inhibitors, betablockers, digoxin, lasix, mannitol, octreotide, lactulose Absorbent underpads, changed frequently Low airloss therapeutic mattress

7 Evidence-Based Management of IAD Gray, M. Incontinence-related skin damage: essential knowledge. OWM, 2007; First, do no harm Soaps skin ph Wash clothes rough-up already fragile skin Diapers/briefs keep moisture, enzymes in Cleans frequently and avoid scrubbing Apply barrier creams that: moisturize and protect skin Polymer-based underpads; limit linens What is the evidence for rectal tubes? Rectal tubes Mushroom and balloontipped catheters No evidence to support use Not intended use of device Increased risk of liability Sphincter and mucosal injury Rectal trumpet (Grogan, 2002) Nasopharyngeal trumpet Rectal tubes BMS Evidence-based fecal incontinence management Palmieri, B et al. (2005). The anal bag: modern approach to fecal incontinence management. OWM, 51:44. Fecal containment devices FDA approved Research on effectiveness Requires two healthcare providers to apply Perineal skin must be intact Clean DRY skin Hold 1 minute for adhesive to bind to skin Careful removal of device

8 Evidence supporting bowel management systems (BMS) Benoit et al. 2007; Echols et al., 2007; Keshava, et al., 2007 Patient selection Indications Contraindications Placement: 29 days Practice realities Cost effectiveness Patient outcomes Evidence-Based Management of CAUTI and Skin Related Concerns? Newman,D. (2007) The indwelling urinary catheter, principles for best practice. JWOCN 34(6) What about CA-UTIs and urinary incontinence? How to prevent CA- UTIs? How was the foley placed Is foley secured Foley always below bladder Daily perineal care Metered bag Remove foley ASAP Bladder scan for bladder volume BEFORE patient can t void Intermittent catheterization for retention Excessive moisture? Treat cause/protect skin Therapeutic Surfaces National Pressure Ulcer Advisory Panel: Support Surface Standards Initiative. Terms and definitions related to support surfaces Accessed August 28, Rethinking beds as therapy Change in practice for all RNs Orderlies EVS Knowledge of surfaces is confusing Movement away from specialty beds except for specific indications Linen as a friend and foe

9 What Lies Beneath the Patient Brostrom, J. et al (1996). Preventing skin breakdown: nursing practices, cost, and outcomes. Applied Nursing Research Linen Linen increases entrapment of moisture Creates wrinkles May increase risk of skin compromise Limit linens on all beds Especially on pressure redistribution beds and low air loss beds Newer ICU beds are pressure redistribution surfaces _td position statement on bed surface terminology Williamson, R, et al (2008) Linen Usage Impact on Pressure and Microclimate Management. Hill-Rom Knowledge of Wound Assessment and Management Address healthcare provider knowledge of wound assessment Product knowledge There is more to wound management than hydrocolloids and wet to dry dressings. Partial or Full Thickness Wound Used to describe all wounds other than pressure ulcers Partial Thickness Involved epidermis and dermis Shallow Moist May be painful Pink-red color Full Thickness Total loss of epidermal and dermal layers Extends into subcutaneous tissue May involve muscle, bone or joint Undermining and tunneling may be present

10 How to Measure a Wound C Length Width Granulation A B Depth: measure at deepest point in the wound bed D Surrounding skin A is the wound bed B is the wound edge C is the surrounding skin UCH Resource Pocket Cards Wound Base Document assessment of wound base: Each dressing change Describe wound tissue Eschar or black necrotic Red Granulation Yellow slough Used with permission WOCN image library

11 Surrounding (periwound) Tissue Descriptors used to document the periwound Intact Erythema Macerated Blistered Indurated Used with permission NDNQI Assess for Signs and Symptoms of Infection Systemic Fever, chills, altered mental status Wound Necrotic tissue, erythema, warmth, poor wound healing, increased pain, increased exudate Immunocompromised Patient Vague symptoms Tack Your Success and Adjust Plan Pressure ulcer prevalence Quarterly (one day) Quarterly (billing chart audits) RN knowledge assessments Unit-based process improvement projects Unit skin rounds Journal clubs Evaluate products and processes related to products

12 Poisoning by the skin is no less certain than poisoning by the mouth only it is slower in its operation. ~Nightingale Nursing Driven Interventions to Prevent HAPU Assessment of risk The obvious factors Other factors: age, vasopressors, instability, severe agitation, comorbidities, obesity Optimize nutrition & hydration Albumin, prealbumin Fluid balance Frequent repositioning Manual turning Managing moisture Developing and implementing a pressure ulcer prevent protocol/rogram User friendly Products available RNs knowledge of protocol and products