Standards of Practice for Pressure Ulcer Prevention Policy for Prevention of Pressure Ulcers A recent review of databases in Canada estimated that one in four patients in acute care and one in three patients in long-term care had a pressure ulcer. The overall prevalence across all institutions was 26%. The Prevalence and Incidence of Pressure Ulcers within the Grey Nuns Community Hospital is as follows: Year 2007 2008 2009 Prevalence Rate 34.2% (Sample size=185) 23.9% (Sample size=184) 18.9% (Sample size=158) Incidence Rate 28.9% (Sample size=38) 12.9% (Sample size=70) 17.5% (Sample size=59) Prevalence: Refers to the proportion of a group possessing a pressure ulcer at a given point in time. Prevalence is a snapshot of how many people with pressure ulcers you have in your facility right now. These patients may have developed pressure ulcers in the facility, or may have been admitted from home or other facilities with existing pressure ulcers. Incidence: Refers to the proportion of a group initially free of pressure ulcers that develops a pressure ulcer over a given period of time. This is the percentage of people who have developed pressure ulcers within this facility. This number reflects how the facility is doing at preventing pressure ulcers from developing in our care. Pressure ulcer risk assessment is recognized as the first step in pressure ulcer prevention because it helps nurses gather information needed to identify who is at risk for developing a pressure ulcer, for the purpose of planning effective prevention interventions. On admission or within 24 hours, a risk assessment will be completed using the Braden Scale for Predicting Pressure Sore Risk and a preventative care plan will be documented for each patient.
Standard Practice Recommendations Interpretation of Evidence Levels of Evidence Ia Evidence obtained from meta-analysis or systematic review of randomized controlled trails. Ib Evidence obtained from at least one randomized controlled trial. IIa Evidence obtained from at least one well-designed controlled study without randomization. IIb Evidence obtained from at least one other type of well-designed quasiexperimental study without randomization. III Evidence obtained from well-designed non-experimental descriptive studies, such as comparative studies, correlation studies and case studies. IV Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Standards of Practice for the identification of pressure ulcer level of risk and management of patients presenting with pressure ulcers. A. Assessment Recommendation 1.1 A head to toe skin assessment will be carried out with all patients on admission, and daily thereafter for those identified at risk for skin breakdown. Particular attention should be paid to vulnerable areas, especially over bony prominences. Level of Evidence- IV Recommendation 1.2 Complete the risk assessment on admission and every 24hours. Complete a patient history and a targeted physical examination to determine general health and risk factors that may lead to pressure ulcer formation or that may affect healing of existing of existing ulcers. (Level of Evidence: Prevention IV)
It is suggested to complete the Braden Score near the end of the shift to improve the accuracy of the measurements. For example, you will be better able to document Nutrition status after the patient has eaten meals and you will be able to assess how many times moisture was managed. Match the sub-scales and cue into specific, appropriate interventions related to that specific subscale. For example, scored of 1 and 2 in the Nutrition category are suggested to have a referral to the Dietitian. Document an individualized preventative care plan for each patient based on the Braden Score and the standardized care protocol suggestions. Review this plan daily and communicate this plan of care with the Interdisciplinary team members. Recommendation 1.3 Maximize nutritional status. (Level of Evidence 1b-IV) Whenever possible, referral to and intervention by a registered dietitian should take place to thoroughly assess a patient who is at risk for the development of, or who presents with, a pressure ulcer. B. Management Recommendation 2.1 Assessment/Documentation of Pressure Ulcers All pressure ulcers are identified and staged using the National Pressure Ulcer Advisory Panel (NPUAP) criteria. Level of Evidence IV. Suspected Deep tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Recommendation 2.2 To measure and monitor the progress or deterioration of Stage IV pressure ulcers, especially with a Wound VAC (NPWT) in place, incorporate the PUSH Tool as a standard documentation tool. Observe and measure the pressure ulcer. Categorize the ulcer with respect to surface area, exudates, and type of wound tissue. Record a sub-score for each of these ulcer characteristics. Add the sub-scores to obtain the total score. A comparison of total scores measured over time provides an indication of the improvement or deterioration in pressure ulcer healing.
Example on Graph Date Jan 01/10 Length x 5x4=20 Width Scores 9 Exudate Amount Tissue type PUSH Total Score points Moderate Scores 2 points Slough scores 3 points 14 PUSH Total Score 17 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1 Healed Date Jan 01/10 Pressure Ulcer Healing Graph Recommendation 2.3 For high risk patients, the use of pressure-relieving therapeutic surfaces will be considered with the aid of a therapeutic surface algorithm. Therapeutic seated surfaces will be incorporated into care plans for at risk individuals or patients with a coccyx pressure ulcer. Consider Foam seated cushions or Ro-Ho cushions.
Recommendation 2.4 Maximize activity and mobility, reducing or eliminating friction and shear. (Level of Evidence IV) Ensure appropriate consults are in place for Physical Therapy and Occupational Therapy. Use transfer sheets to minimize the forces of friction and shear. Recommendation 2.5 Manage moisture and incontinence. (Level of Evidence IV) The skin should be cleansed gently at time of soiling with a mild ph balanced non-sensitizing agent. Exposure of skin to a variety of moist substances such as urine, feces, perspiration and wound drainage will increase the susceptibility to injury and wet skin is fragile and more susceptible to friction and tearing injuries, especially during cleansing. Recommendation 2.6 Assess and control pain. (Level of evidence IV) All patients should be assessed for pain related to the pressure ulcer or its treatment. Pain should be assessed routinely and regularly using the same validated tool each time. Recommendation 2.7 Assess and assist with psychosocial needs. A psychosocial assessment is necessary to collect information to develop a plan or care with the patient that is consistent with individual and family preference, goals and resources, especially when the understanding, co-operation and initiative of patients and their caregivers are required. The treatment plan should include interventions to address identified psychosocial needs and goals. C. Education Recommendation 3.1 Educational programs for the prevention of pressure ulcers will be organized, and comprehensive, and updated on a regular basis to incorporate new evidence and technologies. Programs will be directed at all levels of health care providers including patients, family or caregivers. Level of Evidence III-IV. Staff is expected to attend annual education updates about pressure ulcer prevention. Recommendation 3.2 Develop an interdisciplinary team specific to the needs of the patient. Involve the Physician, Nurse Practitioner, Dietitian, and Physical Therapist, Wound Care Nurse/ET or Occupational therapist
Complete the Braden Score and match the total number with the Standardized care Protocol based on Pressure Ulcer Risk as follows: At Risk (15-18) Moderate Risk (13-14) Frequent turning Maximal remobilization Protect Heels Manage Moisture (see A), Nutrition (see b) and friction, and shear (see C) Pressure-reduction support surface if bed-or chair bound. *If other major risk factors are present (advanced age, fever, poor dietary intake of protein, diastolic pressure below 60, hemodynamic instability), advance to next level of risk. High Risk (10-12) Turning schedule Use foam wedges for 30 degree lateral positioning Pressure-reduction support surface Maximal remobilization Protect heels Manage moisture (see A), Nutrition (see B) and friction, and shear (see C). * If other major risk factors are present, advance to next level of risk Very High Risk (9 or below) Increase frequency of turning Supplement with small shifts Pressure reduction support surface Use foam wedges for 30 degree lateral positioning Maximal remobilization Protect heels Manage moisture (see A) Nutrition (see B) and friction and shear (see C) All of the actions to the left under (10-12) plus Use pressure-relieving surface: If patient has intractable pain or severe pain exacerbated by turning or additional risk factors *Low air loss beds do not substitute for turning schedules. A. Manage Moisture Use commercial moisture barrier Use absorbent pads or diapers that wick and hold moisture Address cause if possible Offer bedpan/urinal and glass of water in conjunction with turning schedules
Practice Point: Consider toileting routines to manage incontinence. Low air loss beds aid in keeping skin dry. Commercial bed bath in a bag already contain moisture barriers, additional barriers may not be required. B. Manage Nutrition Increase protein intake Increase calorie intake to spare proteins Supplement with multi-vitamin (A, C and E) Act quickly to alleviate deficits Consult Dietitian Practice point: Administering applesauce with medications does not provide any additional protein or caloric intake. Consult the Dietitian as the patient may be appropriate for the Nutrition Medication Pass System for additional supplementation. Is there a Prealbumin or Albumin result on the chart? Is the Dietitian aware that a patient has a pressure ulcer? Communicate to the Dietitian the amount of drainage from the wound. C Manage Friction and Shear Elevate Head of bed no more than 30 degrees Use trapeze when indicated Use lift sheet to move patient Protect elbows and heels if being exposed to friction Practice point: Upgrading the bed surface will contribute to minimizing friction and shear. Use disposable lifting sheets. Elevate heels during transfers. Lower the head of bed after meals to reduce friction and shear. Other General Care Issues No massage of reddened bony prominences No doughnut-type devices Maintain good hydration Avoid drying the skin Practice Point: Consider using Heel boots. Hydrate skin with lotion daily. Refer to the updated Therapeutic surface algorithm to assist you in making decisions abut therapeutic surfaces. Quick Reference for NO ULCERS Bundle and SKIN Bundle
Nutrition and Fluid Status N= Nutrition and fluid status O= Observation of skin U= Up and Walking or turn and re-position L= Lift (don t drag) skin C=Clean skin and continence care E= Elevate heels R= Risk assessment S=Support surfaces for pressure redistribution S= Surface selection K= Keep turning I= Incontinence management N=Nutrition No Ulcers Assess the need for the following: Dietary consult Nutrition Medication Pass System Meal percentage documentation with 100% accuracy Prealbumin or Albumin level Is wound drainage being communicated to the Dietitian? Observation of Skin Head to toe skin assessments daily Pay close attention to bony prominences Up and Walking or turn and Re-position Is there a PT and/or OT consult needed? Is the patient mobilized daily? Small changes in position are required a minimum every two hours Lift and don t drag Skin Lift patient when re-positioning. Use a lifting sheet to decrease friction and shear Set up a monkey-bar so the patient can help Use 2 or more persons for re-positioning
Clean skin and continence care Use SAGE bath products appropriately Add Baza or Zinc Oxide as a barrier for additional barrier if needed Change incontinence pads as soon as possible Consider using a bowel management device (Actoflo) to contain stool and prevent further skin breakdown Elevate Heels Heel ulcers are 100% preventable Elevate heels off the bed with pillows If the pillows don t stay in place, use the SAGE Prevalon Heel boot bilaterally for prevention and management. Add moisturizer to dry feet and heels Risk Assessment Complete an accurate Braden Score Apply prevention strategies according to the care protocol based on risk assessment within the first 24 hours and reassess daily Support Surface for pressure redistribution Assess the patient and refer to the Therapeutic surface algorithm to make your decision as to what surface is appropriate. S= Surface Selection SKIN Assess the patient and refer to the therapeutic surface algorithm to make your decision as to the most appropriate surface for the patient. K= Keep turning Turn and reposition the patient a minimum of every 2 hours. Small shifts can make a big difference. I= Incontinence management
Manage incontinence as soon as possible. Consider the use of bowel management devices if appropriate (Actiflo) N= Nutrition Does the patient have a low score in the Nutrition category of the Braden Scale? Is there a prealbumin and albumin level? Would the patient benefit from the Nutrition Medication Pass System? Is wound drainage communicated to the Dietitian? When supplements are not ingested, is this communicated to the Dietitian? References 1. Varga M and Harland Gregoire M. 2009. Prevalence and Incidence Study Data. Grey Nuns Community Hospital. Unpublished. 2. Woodbury MG, Houghton PE. Prevalence of pressure ulcers in Canadian healthcare settings. Ostomy/Wound management. 2004;50(10):22-38. 3. Wound Care Canada 4:1 2006. Reprint Edition. Best Practice Recommendations. Canadian Association of Wound Care. 4. National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer Scale for Healing (PUSH) Tool. Copyright agreement form signed March 13 th, 2009. http://www.npuap.org. 5. Ayello, E and Lyder, C. 2008. A new era of pressure ulcer accountability in acute care. Advances in Skin and Wound Care 21 (3), pp. 134-140.