SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY

Transcription

1 SARASOTA MEMORIAL HOSPITAL NURSING DEPARTMENT POLICY TITLE: PRESSURE INJURY PREVENTION POLICY EFFECTIVE DATE: REVISED DATE: (Patient care) 4/18 Job Title of Responsible Owner: Director, Education PAGE: 1 of 12 PURPOSE: EXCEPTIONS: To establish guidelines for Pressure Injury Prevention, including procedure for recognition and identification of patients at risk for skin breakdown and/or developing pressure injuries, prevent progression of existing pressure injuries, and to maintain skin integrity. Patients will be identified for risk for developing pressure injuries by visual assessment, Braden Score, and medical conditions/co-morbidities. The following nursing units/areas will follow pressure injury prevention practices specific to their patient population and Standards of Care: Neonatal Intensive Care Unit (NICU), Nursery, Pediatrics, and Perioperative Services. For the Pediatric unit, refer to Nursing Policy Pediatric Unit Standards of Care ( ). For the NICU refer to Nursing Policy Neonatal Intensive Care Unit: Admission and Transfer Procedure and Acuity Criteria ( ). In Perioperative Services, refer to Policy Preoperative Admission Criteria, Patient Assessment and Preparation for Surgery ( ), Procedure: Positioning Patients for Surgery (PAT.01) and Department policy Post Anesthesia Unit (PACU) Standard of Care ( ). Outpatients are an exception. KNOWLEDGE BASE: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. (NPUAP)

2 TITLE: PRESSURE INJURY PREVENTION POLICY Page 2 of The most common pressure injury areas are the sacrum, coccyx, elbows, and heels. Pressure is greatest at the bony tissue interface and there may be significant subcutaneous tissue damage underneath unbroken skin. Prevention including off-loading pressure, ensuring mobility, and maintaining adequate nutrition is the key to avoiding extensive therapy. DEFINITIONS: Pressure Injury: localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device occurring as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 1: Intact skin with a localized area of non-blanchable erythema. Stage 2: partial thickness loss of dermis. The wound bed is pink or red, moist, and may also present as an intact or ruptured blister. Stage3: Full thickness tissue loss, exposing subcutaneous fat. No muscle or bone is exposed. Stage 4: Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes tunneling and undermining. Deep Tissue Injury: Intact or non-intact skin with non-blanchable purple to maroon skin discoloration, or a blood- filled blister, caused from pressure and /or sheer. Affected area feels soft and sponge-like to the assessor s finger tips. Unstageable: full thickness tissue loss where the wound base is covered with eschar or slough, so that the wound cannot be assessed accurately until it is debrided. Medical Device Related Pressure Injury: pressure injuries that are caused from the use of medical devices designed and applied for diagnostic or therapeutic purposes. Mucosal Membrane Pressure Injury: pressure injuries found on mucous membranes with a history of medical device in use at the location of the injury. These cannot be staged. Four (4) eyes within 4 hours: Two nurses assess a patient s skin upon admission to the unit (which includes ECC admits, direct

3 TITLE: PRESSURE INJURY PREVENTION POLICY Page 3 of admits, and transfers to the unit) and document findings. PROCEDURE: Skin Assessment/Reassessment 1. Perform a head to toe skin assessment on each patient at the time of admission, transfer, and at least once a shift. Document all findings. a. Upon admission and/or transfer to any unit, four (4) eyes within 4 hours should be performed. b. Inspect and measure all wounds upon admission/transfer and then weekly after that. Dressings are to be removed for skin inspection. c. If patient is admitted with a wound vac, Remove wound VAC dressing- cleanse wound, measure and document. Pack wound with wet to moist saline gauze. Change every shift until evaluated by MD. Physician order necessary to reapply wound vac. EXCEPTION: If a wound VAC is applied over a skin graft, contact MD who performed the graft for further orders. Do not remove unless directed by the physician who performed the skin graft. Refer to nursing procedure Vacuum-Assisted Closure (VAC) Therapy (wou08) d. For skin tears, refer to nursing procedure Treatment for the Care of Skin Tears (skc06). e. For all non-pressure wounds, report to physician and obtain treatment orders. f. For all pressure injuries noted, report to physician, follow protocol orders, and document all findings (See Appendix C) g. For prevention of medical device related pressure injuries, assess the skin under or directly affected by the medical device (ie trach collar, oxygen tubing, etc) 2. Utilize the Braden Risk Scale on all patients at admission, transfer, and at least once per shift to predict risk of patients developing a pressure injury. a. Score is calculated upon assessment of sensory perception, moisture, activity, mobility, nutrition, and friction and shear.

4 TITLE: PRESSURE INJURY PREVENTION POLICY Page 4 of b. Patients with a Braden Score of 18 or less should have preventative measures in place. NOTE: Other factors to be considered and assessed include age, diabetes mellitus, Peripheral Vascular Disease (PVD), use of vasopressor agents, Coronary Artery Disease (CAD), edema, renal failure, obesity, paralysis, contractures, and pain. 3. The following pressure injury prevention interventions are recommended for all patients: a. Consider all bed or chair -bound persons or whose ability to reposition themselves is impaired, to be at risk for pressure injuries regardless of Braden Score. b. Reposition bed- bound persons at least every two hours. Encourage patient sitting in a chair to shift weight every 15 minutes if they are capable of doing so themselves. c. Consider using a specialty bed mattress for patients that meet criteria. Refer to nursing procedure Specialty Beds and Surfaces (skc15). (See Appendix B). NOTE: Regular non-specialty mattresses have a life expectancy of approximately 5 years. There is a process in place for OPL and EVS to identify mattresses nearing their 5 years to assess for integrity. All staff should visually inspect mattresses for rips/tears, compromised mattress cover material, and/or extreme sagging. Call to deliver a new mattress or off hours VOALTE EVS. d. Utilize lifting devices (maxislide/trapeze/lift sheet to move and turn patients to avoid friction and shear. e. Utilize devices to relieve pressure on the heels (pillows, splints) and to keep bony prominences from contact with each other. Use pillows under calves to elevate legs from above the knees to ankles. Alter the angles of arms and legs. f. Avoid positioning patient directly on trochanter (use 30 -degree lateral position). g. Keep head of bed elevation at or less than 30 degrees, as tolerated. h. Protect patient s skin from excess moisture and keep clean if any incontinence or loose stool. i. Avoid massage over bony prominence.

5 TITLE: PRESSURE INJURY PREVENTION POLICY Page 5 of The following interventions are recommended for patients identified at risk for developing a pressure injury (Braden Score of 18 or less): NOTE: Implement above recommendations for all patients plus the following: a. Initiate Skin Care Prevention order set in the electronic medical record. b. Consider consult to dietician c. Consider use of Mepilex dressing for prevention d. Consider specialty bed consult to determine need of specialty surface 5. For patients that are determined to be too unstable to turn, a consult to the wound nurse should occur to evaluate all other prevention initiatives are in place. 6. Upon documentation of a pressure injury on the Skin Wound Flowsheet, protocol orders will be entered as per Appendix C 7. Physician must be notified if the patient has a pressure injury. 8. Consider a Wound Care Nurse Consult if not already completed. This consult order is automated on any Stage 2, Stage 3, Stage 4, DTI, and/or Unstageable pressure injury. 9. Consider a wound photography order for pressure injuries. This consult order is automated on any Stage 3, Stage 4, DTI, and/or Unstageable pressure injury. 10. Pressure Injuries should be assessed and documented at least once a shift to monitor progression or healing. 11. Educate patients on their pressure injury risk and prevention interventions. DOCUMENTATION: EMR: Document all assessments in the electronic medical record. REFERENCE(S): Bergstrom, N., Braden, B., Laguzza, A. & Holman, A. (1987). The Braden Scale for predicting pressure sore risk. Nursing Research. 36(4),

6 TITLE: PRESSURE INJURY PREVENTION POLICY Page 6 of Lippincott. (2015). Lippincott s Nursing Procedures. 7th edition. (pp ). Lippincott, Williams and Wilkins. Philadelphia: PA. National Pressure Ulcer Advisory Panel (NPUAP) Fowler, E. & McGuire, J. B. (August 2008). Practice Recommendations for Preventing Heel Pressure Ulcers. Ostomy Wound Management. 54(10), Wound, Ostomy and Continence News 2008, issue 3. AUTHOR(S): Jackie Garabito, MSN, RN-BC, Clinical Manager, Clinical Programs Pamela Jackson, BSN, RN, CWOCN, Wound/Ostomy Jovan Huss, BSN, RN, WCC, Wound/Ostomy Sandy Davis, MSN, RN, Wound/Ostomy Karen Rinehart, RN, Wound/Ostomy ATTACHMENTS: Appendix A: Pressure Injury Prevention and Wound Treatment Pathway (2018) Appendix B: Specialty Surfaces (2018) Appendix C: Order Set protocols (2018)

7 TITLE: PRESSURE INJURY PREVENTION POLICY Page 7 of APPROVALS: Signatures indicate approval of the new or reviewed/revised policy Date Committee/Sections (if applicable): Pressure Injury Prevention Steering Committee Clinical Practice Council March /5/18 Signature: 4/11/18 Title: Jean Lucas, ACNO Signature: Title: Signature: Title: Signature: Title: Vice President/Administrative Director (if applicable): 4/16/18 Signature: Name and Title: Connie Andersen, VP/CNO

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