Teaching and Learning to Care:

Teaching and Learning to Care: Training for Caregivers in Long Term Care Module Two When Pressure Persists: Prevention of Pressure Ulcers for Those at Risk written by Barbara Levine, PhD, CRNP Gerontological Nursing Consultant revised by Ingrid Sidorov, MSN, RN Gerontological Nursing Consultant for Institute on Aging Supported by a grant from the Health Resources and Services Administration, Bureau of Health Professions, United States Department of Health and Human Services

Table of Contents Tab 1. Presentation Materials for the Instructor Reference List Forms for administration at start of module Instructional materials Forms for administration at end of module Tab 2. Handout Materials for the Participants to Use and Keep Introduction to Module and Objectives Handout version of presentation Optional additional materials 2

Module 2: TAB 1. Presentation Materials for the Instructor Introduction Why this Module? Pressure ulcers are a serious and costly condition. The cost of treatment is about $2000-$40,000 per pressure ulcer depending on the stage of development. (1)Additional costs of hospitalization, survey penalties, potential litigation, pain and suffering, and marred public image are inestimable! Prevention of pressure ulcers is a clinical imperative. Nurses and CNAs provide the first line of defense in pressure ulcer prevention. This module is intended to assist you, the staff development educator and instructor, in assuring the knowledge and skill of direct care staff to meet these responsibilities. What is the content? Key content for you to teach in this module includes: 1. What pressure ulcers are and what happens to tissues when ulcers develop. 2. The causes of skin injury, including pressure, friction/shear, moisture, and suspected deep tissue injury (DTI). 3. Specific risk factors for pressure ulcers. 4. The specific contributions of various team members in prevention of pressure ulcers. 5. Specific preventive measures such as how to care for and inspect the skin, reduce pressure in bed and wheelchair, and maintain nutrition. 6. Staging of pressure wounds including unstageable wounds and suspected DTI. 7. Issues related to defining unavoidable pressure ulcers. What Are the Learning Objectives? This module has been designed to address the following learning objectives: Direct Care Staff will be able to: 1. Identify the risk factors, or causes, that are associated with pressure ulcers. 2. Discuss the common reasons for pressure ulcers. 3. Discuss strategies to prevent these wounds. 4. Describe a team approach to pressure ulcer prevention and care. 3

Module 2: 5. Describe a pressure ulcer prevention program for a nursing home, including: Education of residents, staff and residents families Routine assessment of skin Proper skin care Prompt response to early signs of pressure ulcers Frequent movement of residents Use of pressure relieving measures and devices Toileting schedule for incontinent residents Staff observation and reporting of risks and signs of pressure ulcers What Key Concepts Should Be Covered? Be sure to address at least the following: 1. Many pressure ulcers can be prevented. 2. Redness (dark skin appears as red, blue or purplish) that does not go away after pressure is relieved may be a stage I ulcer or deep tissue injury. 3. Causes include: Pressure (reduces blood flow to skin as in sitting or lying down) Friction (rubbing, as across a surface) Shear (sideways pulling on skin as in sliding down in bed or on a chair) Frequent moisture from incontinence or sweating 4. Risks include: immobility, inability to feel pain or discomfort from pressure, incontinence, being underweight, malnourishment, dementia and illness, such as diabetes or anemia. 5. Nurses, physicians, nurse practitioners, dieticians, physical, occupational and speech therapists and CNAs all contribute to the team. 6. Preventive care includes skin care, reduction of pressure in bed and wheelchair, and assessing skin and nutrition. How to Use this Module: The component elements are described in the order in which they appear in the body of the module. Attendance Form which can be duplicated for your use. Pretest, a brief test of True/False and multiple choice items. You should have sufficient copies for presenter and participants. An instructor version with correct answers is supplied and test-scoring instructions appear with the test. Have participants put an identifier (such as their mother s maiden name) which only they will recognize. You can use this identifier to match pre- and post-tests. 4

Your presentation materials include: PowerPoint presentation A paper copy of the PowerPoint with notes about the content for your use in teaching. Note: If there is more content than you can teach in the time available, consult with your staff development educator to select ahead of time what will be covered. All objectives and test item materials should be covered. Participant Post-test which is identical to the Pre-test but with the items in different order and with a Post Test heading. Have participants use the same identifier as on the Participant Pre-test so you can match pre-post scores. Program Evaluation form for completion by participants Program Evaluation form for completion by instructor Before Your Presentation: Because face-to-face contact time with staff is so limited, prior preparation is essential! Review all materials, paying special attention to the objectives, key concepts and test items. PRACTICE presenting the content using the PowerPoint and the Instructor Notes. We suggest that you practice the presentation two ways: a) straight through to make sure your presentation is consistent with the available time and b) pausing to practice when you feel dissatisfied with your delivery of content. Make sure you have sufficient copies of tests and handouts. At the Time of Your Presentation: After introductions, distribute the Participant Pre-test. Do not distribute handouts at the same time. Have participants put an identifier (like their mother s maiden name) on the test so that you can match pre-and post-test scores, then collect completed tests. Put the facility name and the date on the Attendance Sheet and have participants sign it. Distribute Participant Handouts. Make presentation using PowerPoint and the Instructor version with notes. Have participants complete Post-test using the same identification code. Have participants complete the Participant Evaluation form. 5

After Your Presentation: Please complete the Instructor Evaluation form. Score Pre- and Post tests using form provided. Return scored tests, completed evaluation forms and instructional materials to your staff development educator. References: 1 Panel for the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guideline Number AHCPR Publication No. 92 0047. Rockville, MD, May 1992: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services 2 Centers for Medicare and Medicaid CMS F-Tag 314 3 Park-Lee, E. and Caffrey, C., Pressure Ulcers Among Nursing Home Residents: United States 2004. NCHS Data Brief, No. 14 February,2009. US Department of Health and Human Services, CDC Additional Reference: Maklebust J & Sieggreen M: Pressure Ulcers: Guidelines for Prevention and Management, 3 rd edition. Springhouse, PA, 2001, Springhouse. AHCPR Clinical Practice Guidelines Pressure Ulcer Prevention and Therapy, 1992. http://www.ahcpr.gov/clinic/cpgonline.htm. Salcido, R; Chief Editor: Pressure Ulcers and Wound Care. http://emedicine.medscape.com/article/31984-overview. July, 2009. Capezuti, E. et. al.: Evidence Based Geriatric Nursing Protocols for Best Practice, 3 rd edition,. NYC, NY, 2008, Springer Publishing. http://npuap.org/ - National Pressur Ulcer Advisory Panel www.guideline.gov AHRQ (formerly AHCPR) Clinical Guidelines for Pressure Ulcers http://www.wocn.org/ Wound, Ostomy and Continence Nursing Society 6

Your ID Today s Date / / Participant Pre-Test Circle T if the statement is True, F if the statement is False Example: This is a test. T F 1. It is easier to prevent a pressure ulcer than to heal it. T F 2. As we age, our skin becomes drier, thinner, and more fragile. T F 3. Shearing occurs when skin is pulled sideways until it breaks. T F 4. Raising the head of the bed above 30 degrees will reduce the risk of pressure ulcers. T F 5. A pressure ulcer is any redness or break in the skin caused by too much pressure on the skin for too long a period of time. T F 6. A pressure ulcer may develop in just 2 hours. T F 7. You should massage the skin where it is tight over bones. T F 8. Older Adults who get out of bed can not develop pressure ulcers. T F 9. You should report any breaks or reddened areas on the skin. T F 10. Adequate protein and fluids are necessary to prevent pressure ulcers. T F Thank you. Please return to instructor. 7

Your ID Today s Date / / Participant Pre-Test: Instructor s KEY Correct answers are in Circled bold italic Circle T if the statement is True, F if the statement is false Example: This is a test. T F 1. It is easier to prevent a pressure ulcer than to heal it. T F 2. As we age, our skin becomes drier, thinner, and more fragile. T F 3. Shearing occurs when skin is pulled sideways until it breaks. T F 4. Raising the head of the bed above 30 degrees will reduce the risk of pressure ulcers. T F 5. A pressure ulcer is any redness or break in the skin caused by too much pressure on the skin for too long a period of time. T F 6. A pressure ulcer may develop in just 2 hours. T F 7. You should massage the skin where it is tight over bones. T F 8. Older Adults who get out of bed cannot develop pressure ulcers. T F 9. You should report any breaks or reddened areas on the skin. T F 10. Adequate protein and fluids are necessary to prevent pressure ulcers. T F 8

Attendance Form Facility Name: Date: Name Position/Title Degree (if any) 9

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Objectives are included in the participant handout and include the detail for the last objective: Describe a pressure ulcer prevention program for a nursing home, including: Education of residents, staff and residents families Routine assessment of skin Proper skin care Prompt response to early signs of pressure ulcers Frequent movement of residents Use of pressure relieving surfaces Toileting schedule for incontinent residents Staff observation and reporting of risks and signs of pressure ulcers Providing adequate fluid intake Ensuring proper nutrition 11

Pressure ulcers are areas of skin and or tissue death. When the tissue is exposed to prolonged pressure it does not get enough nutrients and cells die. In its earliest stage, the ulcer shows up as persistent redness in light-colored skin. In dark-colored skin the area may appear red, blue or purplish. Sometimes, damage to underlying soft tissue or muscle may cause skin to turn dark maroon or purple, or a blood blister to occur, which could indicate suspected deep tissue injury. The area may be painful, boggy or firm. This terminology should be used in the documentation to describe the area, and not the term pressure ulcer. (1,2) 12

As people age, the skin becomes drier, thinner and more fragile. The fatty layer under the skin becomes thin, resulting in more prominent bony structures, and increased risk for breakdown of the skin. The goal is to prevent ulcers whenever possible. Many, but not all, pressure ulcers are preventable. Pressure ulcers can be painful and may result in complications such as infection, including of the bone. Residents with pressure ulcers are likely to die sooner than those without them. The cost to heal a Stage III or IV pressure ulcer may be as much as $70,000 dollars, and for less serious wounds, $2000-$30,000.(3) The overall cost in terms of pain and suffering, bad survey citations, law suits, etc., cannot be determined. The cost of preventing pressure ulcers is, of course, much less that treating one. There are ulcers that are considered unavoidable due to various factors, such as chronic illness, etc. It is still the responsibility of the health care team to show that they have done everything possible to prevent the wound and to keep it from getting worse. 13

Sustained pressure is a major cause of pressure ulcers, but it is often a combination of pressure, friction/shear and sometimes moisture that results in pressure ulcers. Pressure, the amount of force exerted on an area, is measured in millimeters of mercury (mm of Hg). When external pressure is greater than 32 mm Hg, blood flow to the area is reduced. The area may not get enough oxygen and nutrients. Metabolic toxins may build up in the area. Cells may die. There is a relationship between time and pressure. Lower levels of pressure for longer periods of time are as damaging as high pressure for short periods of time. It can take as little as 2 hours for a pressure ulcer to develop. Friction occurs when two substances rub together. Pulling an individual across the chair or bed surface may rub away the outer skin layer. When the interface between the body and the bedding is moist, the force of friction is greater. Think about the friction associated with pulling on a wet, as compared to a dry, bathing suit. Friction can be decreased by using a draw sheet while in bed, and proper lifting techniques when in a chair. Shear is a mechanical force that is parallel rather than perpendicular to the area. When we elevate the head of the bed, the body skeleton actually slides down in relation to the skin. This especially affects the sacrum. Shear force is greatest when we drag an individual in bed. Use of a draw sheet and keeping the HOB down when able will help reduce shear. 14

Many factors contribute to the risk for pressure ulcers: Immobility is probably the greatest threat of all. Individuals who are unable to move independently in bed and to get in and out of bed must depend on those caring for them to change their position, especially residents with contractures. Loss of discomfort from pressure. Normally, when pressure on the skin reduces blood flow to an area a sensation of discomfort causes one to shift a little and relieve the pressure. Those who are unable to sense the discomfort will be at greater risk. This may include individu- als who had a stroke or have diabetes or neuropathies, but also those who are sedated or restrained. Incontinence increases the risk because it causes excessively moist skin and chemical irritation. Of the two types of incontinence, fecal incontinence makes a greater contribution to pressure ulcer risk probably because stool contains bacteria while urine is normally sterile. Poor oral intake affects the health of skin and ability to heal. Adequate protein, calories, and fluids are essential to prevent skin injury. Individuals who are underweight or who are losing weight are at higher risk. Changes in level of consciousness or being cognitively impaired, such as in dementia, also increase the risk of pressure ulcer development. If a resident is unable to participate in their care or communicate effectively they may not move effectively on their own, or may not be able to complain about discomfort related to a wound developing. Having a prolonged fever can affect hydration and skin health, as can having a low blood pressure over a prolonged period of time. Various acute and chronic illnesses may increase the risk for pressure injury. These include diagnoses like CHF, diabetes, and anemia. 15

Pressure ulcers occur over bony prominences. Common sites of pressure ulcers are over boney prominences and include the - back of the head - back of shoulders (scapula) - ischium - trochanter - sacrum - heels - ankle - lateral edge of the foot and Areas of skin-to-skin contact are susceptible (such as inner knees), especially in persons with muscle contractures. These can be prevented by putting a pillow between the points. Most pressure ulcers occur in the lower half of the body. (Overhead is in participant handout as a full-page illustration) 16

Preventing pressure ulcers requires a team approach. The nurse identifies those at risk on admission by using an assessment tool. Most facilities use the Braden Scale, although some use the Norton Scale. The dietician assesses the nutritional status of each individual and prescribes a diet that will assure adequate protein, calories, and fluid to maintain skin health. A speech therapist may be consulted to address swallowing issues to make sure the food is the right consistency. The physical or occupational therapist assists with mobility and positioning devices. The activity therapist conducts activities that encourage movement. He or she may also be responsible for recommending pressure relieving devices, such as a chair cushion or mattress. Despite the efforts of all of these providers, it is the direct caregivers who provide the first line of defense in protecting older adults from pressure ulcers. What you do for prevention: promote healthy, clean, skin protect against pressure and injury assure that adequate food and fluids intake encourage participation in activities inspect the skin to identify early signs of skin injury 17

The thin, fragile skin of older people needs special care. Gentle cleaning with warm water alone, or a gentle cleanser such as DOVE is generally sufficient for daily bathing. During cleaning and drying, use a soft towel and pat the skin dry. Do not rub the skin, especially over any reddened areas. Make every effort to prevent incontinence by toileting individuals promptly as needed. Older adults should not be left sitting on the bedpan or toilet for more than 10 minutes. Clean the skin whenever it becomes soiled. Incontinence products and underpads do not replace the need for awareness and immediate cleaning. For incontinence, absorbent briefs may be used. Briefs should be made of materials that absorb moisture and present a quick- drying surface to the skin. There is little good reason for wearing briefs in bed. When you use specialty surfaces, place a single layer of fabric between the individual and the surface. Do not place the older adult directly on plastic or paper linen savers because they hold moisture and irritate skin. Topical moisture barriers may be used to protect the skin from moisture. Protective films may also help to reduce friction injuries. 18

Clean and dry is not enough! Lubrication of skin is important. Apply lotions or creams to areas of dry, flaky skin. Skin that is water-logged (macerated) is easily eroded by friction, more easily irritable, and more readily colonized by germs than normal skin. 19

The easiest times to do a skin check are when getting the person up (such as to go to the bathroom) and returning him/her to bed. Be sure to inspect all surfaces. Look for red- ness, dryness, rashes or other breaks in skin integrity. Feel for changes in skin temperature damaged areas may feel warm to the touch. Pay special attention to areas that remain reddened after position change. By definition an area that is still red after 15 minutes is a Stage I pressure ulcer. Avoid positioning an individual on a reddened area (or on a pressure ulcer). For example, limit time out of bed, i.e., for meals only, if a resident has a sacral wound; and turn side to side only when in bed. Never massage over bony prominences or reddened areas. Massage may rupture capillaries and damage underlying tissues. If you notice: a rash or break, then wash the area with plain warm water (no soap). an area of red but intact skin, then position the resident to relieve pressure. In either case, tell the nurse describe what you saw, felt and did. Ask him or her if he/she would like to see the area. 20

Examine the skin for signs of pressure change (redness, change in color, temperature, or texture), moisture or dryness, and presence of rashes or skin breaks. Report any changes promptly to the nurse. Describe the area including color, temperature, location, and size. Recheck the area 15 minutes after repositioning; note any change. Check for temperature changes by placing the back of your hand against the area. Compare findings with the temperature of other skin surface areas. Investigate and report complaints of pain or discomfort. When sensation is intact, older individuals may complain of pain associated with being in one position for too long. Established pressure ulcers may be painful especially if pressure is sustained, and during dressing changes. It is imperative that any complaints of pain be reported, treated and re-evaluated. Pressure wounds are often very painful as are the dressing changes or wound care. Blisters, fluid-filled or broken, may be Stage II pressure ulcers. Friction usually causes blisters. If an area is weeping or draining, notice and report the color, amount and odor of the drainage. If a dressing falls off or gets wet or soiled, notify the nurse right away. 21

Remember the time pressure relationship. Less pressure for more time is as dangerous as more pressure for shorter time. Some older adults may need to be turned or repositioned more frequently than every two hours. No one should ever lay on skin that is already reddened by pressure. Heels are especially vulnerable and should be lifted completely off the bed with pillows or with the use of heel boots. Heels should be elevated even when the individual is on a specialty surface. The head of the bed should not be elevated more than 30 o to avoid sliding down in bed. If the head of the bed must be elevated to minimize risk for aspiration or aid with breathing or eating, monitor the skin in the sacral region carefully. Lift sheets or a trapeze should be used for at-risk residents to enhance mobility and reduce friction and shear. When an older adult is lying on the side, weight should never be directly on the hip bone (greater trochanter of the femur). A 30 o laterally inclined position relieves sacral pressure and prevents trochanteric pressure. 22

T C Turning and repositioning is essential even if the person is on a pressure-reducing surface. In the 30 laterally inclined position, weight is on the fleshy buttock muscle, suspended between the sacrum and the trochanter (hip bone). Bending the knees further reduces pressure on the trochanter. A pillow between the legs prevents skin-to-skin contact and reduces pressure between the knees; one under the lower leg reduces pressure on the ankle bone and outer aspect of the foot. 23

When an older adult is in the chair, more of the body weight is distributed to smaller surface, producing higher pressure. The pressure time relationship means that those in a chair should be positioned more frequently than those in bed. Older adults in a chair should be encouraged to reposition at least every 15 minutes or so. Those who are able should be taught and encouraged to make small weight shifts every 15 minutes. NEVER USE ring cushions as they are known to cause venous congestion and edema. In one study, they were found to be more likely to cause than to prevent pressure ulcers. 24

Older adults need to know that skin breaks down more easily and wounds won t heal unless nutrition and hydration are adequate. Protein is a major nutrient that helps protect skin and promote healing. Primary sources of protein in the diet include milk products (yogurt, cheese, ice cream), meat, poultry, fish, dry beans, and eggs. If residents are unable to complete their entire meal, these foods are especially important. 25

Not all pressure ulcers can be prevented, but many can. CNAs provide the first line of protection against pressure ulcers. You can make a difference! The best way to lower the risk of pressure ulcers is to keep older adults moving. If individuals cannot position themselves, turn and reposition frequently. Individuals who can change their position may need to be reminded to do so. Don t forget to help or encourage the person sitting in a chair to change position. Adequate nutrition and hydration are essential to prevent pressure ulcers. If you notice someone is not eating or drinking enough, report it to the nurse. Some may need vitamins or supplements added to their diet. Individuals who are incontinent have a five times higher risk of pressure ulcers than those who are continent. Establish a toileting schedule for those who are incontinent. Clean those with incontinence promptly after soiling. Use skin protective barriers. Always be on the lookout report redness, investigate complaints of pain or discomfort you may be the eyes and ears of the nurse, but the voice of the older adult. 26

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Your ID Today s Date / / Participant Post-Test Circle T if the statement is True, F if the statement is false Example: This is a test. T F 1. A pressure ulcer is any redness or break in the skin caused by too much pressure on the skin for too long a period of time. T F 2. You should massage the skin where it is tight over bones. T F 3. Adequate protein and fluids are necessary to prevent pressure ulcers. T F 4. You should report any breaks or reddened areas on the skin. T F 5. As we age, our skin becomes drier, thinner, and more fragile. T F 6. Raising the head of the bed above 30 degrees will reduce the risk of pressure ulcers. T F 7. Residents who get out of bed can not develop pressure ulcers. T F 8. It is easier to prevent a pressure ulcer than to heal it T F 9. Shearing occurs when skin is pulled sideways until it breaks. T F 10. A pressure ulcer may develop in just 2 hours. T F Thank you. Please return to instructor. 29

Your ID Today s Date / / Participant Post-Test: Instructor s KEY Correct answers are in Circled bold italic Circle T if the statement is True, F if the statement is false Example: This is a test. T F 1. A pressure ulcer is any redness or break in the skin caused by too much pressure on the skin for too long a period of time. T F 2. You should massage the skin where it is tight over bones. T F 3. Adequate protein and fluids are necessary to prevent pressure ulcers. T F 4. You should report any breaks or reddened areas on the skin. T F 5. As we age, our skin becomes drier, thinner, and more fragile. T F 6. Raising the head of the bed above 30 degrees will reduce the risk of pressure ulcers. T F 7. Residents who get out of bed can not develop pressure ulcers. T F 8. It is easier to prevent a pressure ulcer than to heal it T F 9. Shearing occurs when skin is pulled sideways until it breaks. T F 10. A pressure ulcer may develop in just 2 hours. T F Thank you. Please return to instructor. 30

Participant Evaluation Form Today s Date / / Facility: Please circle the best response: (e.g. Agree ) 1. I can describe what usually causes pressure ulcers in frail older people. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 2. I can describe how to prevent pressure ulcers. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 3. I can tell you how to check skin for signs of pressure ulcers. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 4. This program will help me in my care of older adults. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 5. This program will help me work better with other staff. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 6. Overall I rate this program: Poor Fair Good Excellent 1 2 3 4 7. Overall I rate this instructor: Poor Fair Good Excellent 1 2 3 4 8. This program would be better if: 31

Instructor Evaluation Form Please circle the best response: (e.g. Agree ) 1. Learning objectives for this module were appropriate. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 2. This module was well-designed to meet its objectives. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 3. Instructor materials for this module were easy to use. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 4. The content of this module was at the right level for participants. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 5. The videotape for this module helps to meet the objectives. Strongly Disagree Disagree Agree Strongly Agree 1 2 3 4 6. As an instructor, I rate this module overall as: Poor Fair Good Excellent 1 2 3 4 7. This module would be improved if: Instructor information: My most advanced degree is: Masters in, Bachelors in, Associate Degree in. I have been teaching in long-term care for years, months. My current title is: Please return to Staff Development Educator. Thank you! 32

TAB 2. Handout Materials for the Participants to Use and Keep When Pressure Persists: Prevention of Pressure Ulcers for Those at Risk PARTICIPANT OVERVIEW Why a module on pressure ulcers? Pressure ulcers are serious, happen to many, are costly to care for and a red flag for regulatory surveyors. Pressure ulcers can often be prevented if staff know the risks for them and how to care for those at risk. What should you learn in this module? At the end of this module you should know how to: 1. identify the risk factors, or causes, for pressure ulcers. 2. discuss the usual reasons for pressure ulcers. 3. discuss ways to prevent these wounds. 4. describe how a team would approach, prevent and care for pressure ulcers. 5. describe a pressure ulcer prevention program for a nursing home, including: Education of older adults, staff and residents families Routine assessment of skin Proper skin care Prompt response to early signs of pressure ulcers Frequent movement of residents Toileting schedule for incontinent residents Staff observation and reporting of risks and signs of pressure ulcers Pressure Ulcers: What you need to know 1. Many pressure ulcers can be prevented. 2. Redness (in dark skin, red, blue or purplish) that does not go away after pressure is relieved may be a stage I ulcer. 3. Causes include: Pressure (reduces blood flow to skin as in sitting or lying down) Friction (rubbing, as across a bedsheet) Shear (sideways pulling on skin as in sliding down on a bed) 33

4. Risks include: not moving, inability to feel hurt from pressure, incontinence, underweight and loss of weight, and illness. 5. Nurses, dieticians, physical and occupational therapists and CNAs all contribute to the team. 6. Preventive care includes skin care, reduction of pressure in bed and wheelchair, and assessing skin and nutrition. Pressure Ulcers: What you need to do 1. Keep your older adult moving. 2. Position immobile or dependent residents frequently and carefully. 3. Assist with meals and snacks. 4. Provide plenty of clear, cool water. 5. Keep incontinent residents clean and dry. 6. Be alert to changes and report them. 34

Pressure Points Back of the head Back of shoulders Elbows Hip Buttocks Contractures Heels 35

T L C When Pressure Persists: Prevention of Pressure Ulcers for Those at Risk written by Barbara Levine, PhD, CRNP Gerontological Nurse Consultant revised by Ingrid Sidorov, MSN RN Gerontological Nurse Consultant DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tioonn CCeennt teerr T L C When Pressure Persists: Learning Objectives Direct Care Staff will be able to: Identify the risk factors for pressure ulcers Discuss common reasons for pressure ulcers Discuss strategies to prevent these wounds Describe a team approach to pressure ulcer prevention and care Describe a pressure ulcer prevention program in long term care settings DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr 36

T L C Pressure Ulcer: Definition A pressure ulcer is localized injury to the skin and or underlying tissue, usually over a boney prominence, that happens as a result of pressure and/or friction/shear issues. (NPAUP, 2007) DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr T L C Pressure Ulcers Occur more commonly in older people Can be prevented in many residents Can be painful, lead to infection, and are a marker for increased risk of death Cost an enormous amount of money DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr 37

T L C What Causes Skin Injury? Pressure reduces blood flow to skin Friction repeated rubbing causes a break in the skin Shear sideways pulling on the skin layers until it breaks Moisture, especially from urine or stool increases the risk of wounds multifold DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr T L C Who s at Risk? Individuals who: are bed or chair-bound have contractures are unable to sense discomfort are incontinent are poorly nourished are dehydrated suffer from an altered LOC or CI are febrile or hypotensive are chronically ill 38

T L C Pressure Points Back of the head Back of shoulders Elbows Hip Buttocks Heels DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr T L C A Team Approach to Prevention Identify at-risk individuals Maintain and improve skin condition Protect against pressure and injury Assure adequate nutrition and hydration Encourage activity and mobility Educate older adults, families, and care providers Early identification of skin injury 39

T L C Clean and Dry Clean gently with warm water Prevent incontinence by maintaining toileting schedule Help person off the bed pan or toilet promptly Clean skin at time of soiling Absorbent under pads or briefs only as needed - try to keep off to promote healing Moisture barriers T L C Beyond Clean and Dry Look for and report any changes Clean skin and keep it well lubricated Minimize dryness and avoid excessive moisture Do not rub over reddened areas; this only increases damage to tissues DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr 40

T L C Skin Checks Check all surfaces at least twice a day Remove clothing and position for visibility Check pressure points with every position change If you note a reddened area, reassess in 15 minutes DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr T L C Abnormal Skin Changes Note location, size, and degree of: Areas of redness or warmth in fair skin Areas of duskiness, discoloration and warmth in dark skin Areas of pain or discomfort Blisters fluid-filled or broken Weeping or drainage DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr 41

T L C Reducing Pressure in Bed Turn at least every two hours Prevent skin- to- skin contact Complete pressure relief for heels Elevate head of bed as little as possible Use lift sheets or trapeze Do not position directly on hip bone Do not rub or massage reddened areas DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr T L C 30 Laterally Inclined Position T C Weight not on sacrum or trochanter Support with pillows or foam wedge Use pillows to protect vulnerable areas Head of bed as low as possible DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr 42

T L C Reducing Pressure in Chairs Reposition at least every hour Instruct to shift weight every 15 minutes May need cushion Do not use doughnuts or rings DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr T L C Nutrition Encourage residents to drink enough fluids Assist to eat enough protein and calories 43

T L C You can make a difference! Keep your older adults moving Position immobile or dependent individuals frequently and carefully Assist residents with meals and snacks Provide plenty of fluids Keep those with incontinence clean and dry Be alert to changes and report them T L C Objectives Review Can you now: Identify the risk factors for pressure ulcers? Discuss common reasons for pressure ulcers? Discuss strategies to prevent these wounds? Describe a team approach to pressure ulcer prevention and care? Describe a pressure ulcer prevention program for long term care? DDeel laawwaarree VVaal lleeyy GG eerri iaat trri i cc EEdduuccaat tii oonn CCeennt teerr 44