4/15/2019 Pressure Injuries – Prevent, Treat and Sustain Gains Joyce Black, PhD, RN, FAAN University of Nebraska Medical Center Omaha, NE April 18, 2019 Is it accurate? ◦ What does a circle around the buttocks indicate? ◦ What does excoriation mean? If skin it showing early signs of pressure injury --- what is done? Is resident or family shown the problem? 4 eyes in 4 hours is a reasonable approach to skin assessment 2 1
4/15/2019 High risk residents should have skin examined for 72 hours following admission ◦ Prior hospitalization, esp. if critically ill or in surgery ◦ Wearing elastic stockings, splits, bi-valved casts, braces ◦ Have injury in or surgery on the legs ◦ Significant peripheral vascular disease (PVD) hairless legs, thick nails, weak pulses ◦ Deep tissue pressure injury does not appear for 48 hours after the pressure was present If the resident is admitted in that 48 hour window the skin can be intact and not found until the following weekly assessment 3 Accuracy is important ◦ Is the immobile patient accuracy identified? When compared to PT notes? When compared to underlying disease state? ◦ Is malnutrition accurately identified? When compared to weight record/ nutritionist notes? Is the risk assessment simply a paper document? Is the plan of care derived from the total score? 4 2
4/15/2019 Heel risk factors ◦ Leg immobility Does the resident move the leg? Not can… ◦ Neuropathy Stroke, DM, MS ◦ Peripheral vascular disease Common in the aged Use of braces, splints, and stockings Chronic use of recliner chairs/slide boards Use of Geri-Chair 5 Long period of immobility/confinement to the chair Unable to move due to fear of dislodging the lines Often unable to eat Very weak at end of run, unable to move self Low protein intake makes healing of existing ulcers very difficult 6 3
4/15/2019 End stage co-morbid disease ◦ Marked dyspnea ◦ Anasarca with risk of tissue injury during movement ◦ Breakthrough pain with movement ◦ Odor from extruding head and neck and breast cancers ◦ Request not to move 7 If the resident arrives ◦ at high risk, does the care plan include turning rather than “assist to turn as needed”? ◦ at high risk, is the mattress upgraded? ◦ with early signs of pressure injury, is the area offloaded? ◦ with plans for rehab and need to sit, is the wheelchair padded? ◦ needing dialysis, is the overlay sent along? Offloaded when they return? ◦ What happens over the weekend and holidays? 8 4
4/15/2019 When intensity of pressure is high, duration can be short ◦ Dialysis run, unpadded chairs When intensity of pressure is moderate, duration can be moderate ◦ Not turned adequately in the bed, not turned often, presumed resident is moving self When intensity of pressure is low, duration can be fairly long…depending on tolerance of tissue for pressure ◦ Use of speciality bed can lengthen turning frequency 9 Study of residents in long term care on foam mattresses ◦ Well designed randomized controlled trial (RCT), well powered ◦ Residents turned randomly Q2, Q3 and Q4 hours ◦ Compliance with turning measured Outcomes ◦ Pressure injury formation varied by turning frequency Q2 hours = 2.5% Q3 hours = 0.6% Q4 hours = 3.1% Can we now get to a turning schedule we can live with? Bergstrom, m, et al, 2013 JAGS 10 5
4/15/2019 If head of bed (HOB) up to Use of pillows seldom holds 30 degrees, pressure is resident in 30 degree applied to sacrum position Resident must be turned to Use of wedges works, if the offload the sacrum when in wedge is placed properly bed ◦ Under the body, it should hardly be visible ◦ Use hand check to determine sacrum is clear https://mms.mckesson.com/product/875773/Sage-Products-7206 11 Bottomin oming g out t indicated ted by high gh inter terface pressure surface 12 6
4/15/2019 13 Expectation in long-term care (LTC) is not to note each position ◦ However, relying on the CNA documentation of the amount of assistance needed to move is difficult to follow and prove the case ◦ Nurses should document that turning is occurring, once a day in high risk patients Charting by exception (CBE)is especially difficult to defend ◦ Almost always the very thing to help provide evidence of care provided is missing ◦ If CBE, why are vitals charted (if normal?) 14 7
4/15/2019 One of the most common chronic wounds 15 Not fixing the problem that caused the wound ◦ Continued pressure ◦ Continued shear ◦ No improvement in arterial flow Not providing enough protein and calories to promote healing ◦ Body becomes catabolic Not reducing risk of infection in wound bed ◦ Exposure to fecal matter ◦ Prolonged inflammation The cells become senescent ◦ Biofilm develops 16 8
4/15/2019 Return to form and function ◦ Seen best in acute wound healing ◦ Scar prevents form and function in large wounds and chronic wounds ◦ Wound closure in patients at end of life or end stage disease is not the priority for care Patient engagement These ischial ulcers have little hope for ◦ Management of condition closure without a comprehensive plan ◦ Management of wound and patient engagement 17 Controlling or curing the cause ◦ Pressure redistribution ◦ Arterial bypass for heel wounds 3 legged stools tip over Shear reduction when any one leg is Wound care (From 2014 Guidelines) missing ◦ Debridement, dressings/packing, topicals ◦ Do not debride ischemic tissue or malnourished pts Nutrition (from 2014 Guidelines) ◦ Increased protein and calories ◦ Vitamin and zinc supplement if low 18 9
4/15/2019 Continued pressure ◦ makes the wound ischemic ◦ increases shear ◦ destroys deeper tissue in the wound ◦ injures healing tissues Why is everyone’s head of the bed elevated? 19 Education works for some patients Consider that all behavior has a reason ◦ Why does the patient want to lie on his back? ◦ Why won’t the patient keep her heel off of the bed? If the patient’s wound is deteriorating due to the patient not remaining off of the wound… ◦ Is the patient competent? Able to understand why? ◦ Let the POA know of the issues ◦ Inform the provider of the issues ◦ Consider a higher immersion surface 20 10
4/15/2019 A common issue in nonhealing wounds Again, why is the patient not eating? ◦ Is this an area where the family can help? If tube fed, is it possible to provide the ordered calories? ◦ How often is the tube feeding stopped in 24 hours? ◦ Would the provider consider ordering a daily volume of tube feeding and allow the staff to figure out the best timing? 21 Does the staff know what signs or symptoms in a wound indicate a need to change the treatments? Are these orders ever written in your facility? If so, how to you handle it? ◦ Wet to dry until healed? ◦ Collagenase until healed? ◦ Dakin’s packing with no stop order? ◦ Hydrocolloids over inflamed, or slough filled wounds? Are all wounds debrided? Should they be? 22 11
4/15/2019 Patient or family thought that wound could heal ◦ Thought it was minor or small until seen in ED ◦ Did not understand that débridements were for necrosis in the wound Does the family have assessment skills to determine if the wound is worse? ◦ What if they are taking pictures of the wound? 23 Even the sloth doesn't know how CONSERVATION INTERNATIONAL/PHOTO BY REBECCA FIELD he got into the wound bed 24 12
4/15/2019 25 Systematic review with both conclusions and root causes backed up with evidence An independent team is best ◦ All causes should be identified ◦ If more than one cause is found, solutions are more difficult to sustain A sequence of events is usually effective to understand relationships RCAs can be threatening to many cultures and environments ◦ Non-punitive policy for problem identifiers needed 26 13
4/15/2019 1. Define the problem or event factually 2. Gather data (chart and interview) as evidence 3. Create a time line of events ◦ Ask “why?” with each piece of data and each step in time line 4. Identify all causes of problem 5. Identify all possible solutions for each cause 6. Monitor effectiveness of solutions 27 64 year old female Past Medical Hx: Diabetes on insulin, hypertension on meds, overweight Had a left total knee done 3 days ago Has been wearing TEDs and using sequentials Purple heel found 2 days after admission 28 14
4/15/2019 Is this wound a pressure ulcer? ◦ Was it due to pressure? ◦ Was it due to shear? ◦ What is the role of poor perfusion? Is this a diabetic foot ulcer? When did it start? 29 What was the condition of the skin on admission? ◦ What happens to the RCA if the admission assessment: Is blank in skin assessment? Lists skin is intact? Were there any additional assessments? 30 15
4/15/2019 What was admission risk score? ◦ Was it accurate? Did a prevention plan stem from the score? ◦ Was the heel elevated from the bed? However, we are only at the physical roots….The symptoms What more information is needed? 31 What leg had surgery? What position was the leg/legs in on the table? What leg has the DTI? 32 16
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