Nh Pressure Ulcer Ppt

Telephone-Based Training Pressure Ulcer Management Dial-In Information Telephone Number: (888) 850-5066 Confirmation Code: 35193

Pressure Ulcer Assessment and Management Presented by: Beth Brizee, RN,C Director of Clinical Operations TriLine Medical 888-966-6662 ext 301 1

Pressure Ulcer Assessment and Management Objectives By the end of the course participants will be able to: † Classify pressure ulcers by stage and differentiate ulcers of non-pressure etiology. † Discuss current treatment practices and interventions for pressure ulcer management. † Review key documentation areas for the medical record management of pressure ulcers.

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Overview of the Layers of the Skin The skin is comprised of three major components: † Epidermis † Dermis † Subcutaneous tissue Though interrelated, each layer of skin has different structures, cell types and functions

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What is a Pressure Ulcer? Localized areas of tissue necrosis which develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time. Unlike other ulcerations, which have a disease process associated with their development or decline, pressure ulcers have heightened requirements around: risk assessment; proactive and therapeutic care giver interventions; assessment of response to interventions and medical record management. Most pressure ulcers occur over bony prominences, where combined with friction and shearing forces result in skin breakdown. 4

Most common sites in bedbound elderly Supine: 23% sacrococcygeal 8% heels 1% occiput; spine Sitting: 24% ischium 3% elbows Lateral: 15% trochanter 7% malleolus 6% knee 3% heels 5

Classification of Wounds The staging of pressure ulcers, as defined by national guidelines (NPUAP, CMS, AHCPR), allow for common understandings for healthcare professionals. The staging of a pressure ulcer reflects the amount of tissue damage. Outside of the MDS, only pressure ulcers are staged – stage I – IV, UTD and DTI. Any wound such as a pressure ulcer, neuropathic ulcer, etc., can be considered “partial thickness” or “full thickness” depending upon the amount of tissue involved.

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Pressure Ulcers

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Stage I Pressure Ulcer The ulcer appears as a defined area of persistent red, blue, or purple hues in lightly pigmented skin. In darker skin tones, the ulcer may appear with discoloration, warmth, edema, induration or hardness.

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Stage I Pressure Ulcer Treatment Options Stage I on Trunk of the Body – … Manage incontinence, keeping area clean and dry. … Use moisture barrier as needed. … Off load area were pressure ulcer is – pressure reducing surfaces

Stage I on Heels – … Ensure that heel(s) are floated at all times with frequent monitoring.

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Stage II Pressure Ulcer Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.

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Stage II Pressure Ulcer Treatment Options Dry Wound Bed – … Cleanse with normal saline, apply small amount of hydrogel and cover with dd every day. … Off load area were pressure ulcer is – pressure reducing or relieving surfaces.

Minimal Drainage – … Cleanse with normal saline, apply hydrocolloid dressing every three days and prn soiling or dislodging. Monitor placement every day. … Off load area were pressure ulcer is – pressure reducing or relieving surfaces.

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Stage III Pressure Ulcer Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

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Stage III Pressure Ulcer Treatment Options Minimal Drainage and Clean Wound Bed – … Cleanse with normal saline, apply small amount of hydrogel and cover with dd every day. … Off load area were pressure ulcer is – pressure relieving surfaces. Presence of Slough – … Cleanse with normal saline, apply Accuzyme and cover with dd every day. … Use Foam dressing instead of dd for heavy drainage. … Off load area were pressure ulcer is – pressure relieving surfaces. Heavy Drainage and Clean– … Cleanse with normal saline, apply foam dressing every two days and prn soiling or dislodging. Monitor placement every day. … Off load area were pressure ulcer is – pressure relieving surfaces – 13 preferable a low air loss mattress replacement.

Stage IV Pressure Ulcer Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g., tendon, joint capsule). Undermining and sinus tracts also may be present.

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Stage IV Pressure Ulcer Treatment Options Minimal Drainage and Clean Wound Bed – … Cleanse with normal saline, apply small amount of hydrogel and cover with dd every day. … Off load area were pressure ulcer is – pressure relieving surfaces –. Presence of Slough – … Cleanse with normal saline, apply Accuzyme and cover with dd every day. … Use Foam dressing instead of dd for heavy drainage. … Off load area were pressure ulcer is – pressure relieving surfaces – preferable a low air loss mattress replacement. Heavy Drainage and Clean– … Cleanse with normal saline, apply foam dressing every two days and prn soiling or dislodging. Monitor placement every day. … Off load area were pressure ulcer is – pressure relieving surfaces – 15 preferable a low air loss mattress replacement.

UTD (Unable to Determine Stage) Pressure Ulcer When a pressure ulcer wound bed is covered with non-viable tissue such as “slough” or “eschar” the pressure ulcer can not be staged as visualization of the amount of tissue damage / involvement is impossible.

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UTD Stage Pressure Ulcer Treatment Options Presence of Slough – … … …

Cleanse with normal saline, apply Accuzyme and cover with dd every day. Use Foam dressing instead of dd for heavy drainage. Off load area were pressure ulcer is – pressure relieving surfaces – preferable a low air loss mattress replacement.

Heavy Drainage and Clean– … …

Cleanse with normal saline, apply foam dressing every two days and prn soiling or dislodging. Monitor placement every day. Off load area were pressure ulcer is – pressure relieving surfaces – preferable a low air loss mattress replacement.

Note – intact eschar on the lower extremities (i.e. heels) should not be actively debrided but should have pressure managed – floating of the heels

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Deep Tissue Injury These wounds present as intact skin with dark purple shading almost to black area usually within a reddened area of skin. This represents a pressure injury of an unknown depth so this wound cannot be staged – also known as “Purple Pressure Injury” or “Pre-Eruptive Full-Thickness Pressure Ulcer.”

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Causative Factors for the Development of Pressure Ulcers † † † † † † † † † † †

Immobility or limited mobility Incontinence Shearing and friction injuries Advanced age Malnutrition or under-nutrition Significant obesity or thinness History of pressure ulcers Dehydration Contractures Use of orthotic devises or restraints Issues of resident compliance 19

Immobility and Pressure Ulcers – CMS Statements Some statements around tissue load management from CMS: †

“Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one.”

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“Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning.”

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“Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.” 20

Immobility and Pressure Ulcers – CMS Statements †

“Depending on the individualized assessment, more frequent repositioning may be warranted for individuals who are at higher risk for pressure ulcer development or who show evidence (e.g., Stage I pressure ulcers) that repositioning at two hour intervals is inadequate.”

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“Based upon an assessment including evidence of tissue tolerance while sitting (checking for Stage I ulcers as noted above), the resident may not tolerate sitting in a chair in the same position for one hour at a time and may require a more frequent position change.”

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Interventions for the Management of Immobility † † † † † † †

Individualized re-positioning schedules with thorough communication of needs and expectations Use of appropriate pressure relieving or reducing support surfaces Float heels Keep sheets free from wrinkles Avoid raising the head of bed more than 30 degrees As appropriate, perform active or passive range of motion exercises to relieve pressure and promote circulation Adjust or pad appliances, casts, or splints as needed to ensure a proper fit and to prevent pressure and impaired circulation 22

Interventions for the Management of Incontinence † † † † † † †

Implement as appropriate a bowel and bladder retraining program Ensure healthful hydration through adequate daily fluid intake Assess environmental issues – accessibility, manual dexterity (how easily can the resident manipulate their clothing) Regular reminders to void with prompt response to toilet Fiber rich diets Promote regular exercise Maintain effective hygiene care, cleaning the perineal area frequently with use of a moisture barrier 23

Shearing and Friction Shear … The gravitational pull of the body downward while the skin stays stationary on the surface of bed or chair. … This gravitational pull creates a change in the angle of capillaries. Friction – … Result from forces that tend to cause two opposing surfaces to slide and displace against each other.

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Shearing Injury

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Interventions for the Prevention of Shear and Friction Injuries Assuring that individuals are being repositioned and that nursing staff understand: … Use of proper transferring and positioning equipment … Teaming up to safely reposition residents … Limit HOB elevation

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Interventions for the Management of Malnutrition “Under-Nutrition” † † † † † † †

RD assessment and recommendations – should be at least every month if a pressure ulcer is present Monitoring intake and output with communication of any changes in patterns Provide needed dental care Follow prescribed diets – protein supplementation, thickened liquids Offer liquids as appropriate at each care giving activity Encourage intake Maintain accurate medical record information for MD and RD – weights and I/O’s 27

Overview of General Treatment Interventions for Pressure Ulcers General considerations for the treatment of pressure ulcers: † Manage the moisture. † Remove non-viable tissue.* „ Enzymatic „ Sharp debridement „ Mechanical debridement † Tissue load management – never placing resident directly on an existing wound – use appropriate support surfaces. † Protect the peri-wound tissue.

*Intact eschar on extremities should not be debrided in most cases 28

Classification of Wounds – Federal Guideline Statement At the time of the assessment, clinicians (physicians, advance practice nurses, physician assistants, and certified wound care specialists, etc.) should document the clinical basis (for example, type of skin injury/ulcer, location, shape, ulcer edges and wound bed, condition of surrounding tissues) for any determination that an ulcer is not pressure related, especially if the injury/ulcer has characteristics consistent with a pressure ulcer, but is determined not to be one.”

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Arterial Ulcerations Venous Stasis Ulcerations Neuropathic Ulcerations

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Arterial Ulcerations Cause – Inadequate circulation to the legs † Contributing Factors: „ Arteriosclerosis and atheroslerosis „ Micro thrombi „ Smoking „ Elevated cholesterol and lipids „ Hypertension „ Diabetes

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Arterial Ulcerations Clinical Presentation † † † †

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Small, deep, punched out lesions Well demarcated, smooth edges Often contain necrotic tissue and / or pale wound beds Ulcers frequently appear on tips of toes or fingers and over phalangeal heads Ulcers may also appear around heels and ankles, sides and plantar surface of the foot

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Treatment Interventions for Arterial Ulcers The only treatment for arterial ulcerations is surgical intervention, re-establishing circulation. Many of our LTC residents are not surgical candidates. In this case make sure to have the MD document the fact that the benefits of vascular surgical intervention are out weighed by the risk of the procedure. It is also important to have the resident (if appropriate) and the family members understand this as well.

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Venous Stasis Ulcerations † † †

Affect 3.5% of the population Have approximately 70% recurrence rate Anatomy and Physiology of Venous Stasis Ulcers „ Incompetent, malfunctioning valves: Contribute to backflow Result in increased pressure within veins Allow leakage of serum and blood cells into tissue Create edema Presents with hemosiderin staining Ulcerations 34

Venous Stasis Ulcerations Clinical Presentation … … … … … … …

Superficial Irregular in shape Usually not painful / sensitive Usually occur on medial aspect of leg Brawny edema, deep, ruddy red tissue Legs appear hard and wooden-like Often heavily draining ulcers

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Treatment Interventions for Venous Stasis Ulcers The treatment for venous stasis ulcers is surgical repair of the malfunctioning valves. As with arterial ulcerations, many of our LTC residents are not surgical candidates. In this case make sure to have the MD document the fact that the benefits of vascular surgical intervention are out weighed by the risk of the procedure. It is also important to have the resident (if appropriate) and the family members understand this as well. Also note, that it is very important to ensure that arterial insufficiency has been ruled out before elevating or applying compression therapy. 36

Diabetic Neuropathic Ulcer †

Requires that the resident be diagnosed with diabetes mellitus and have peripheral neuropathy.

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The diabetic ulcer characteristically occurs on the foot, e.g., at mid-foot, at the ball of the foot over the metatarsal heads, or on the top of toes with Charcot deformity.

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Medical Record Documentation for Wound Care

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Medical Record Risk Management for Pressure Ulcers †

Unlike other ulcerations, which have a disease process associated with their development or decline, pressure ulcers have heightened requirements around: risk assessment; proactive and therapeutic care giver interventions; assessment of response to interventions and medical record management „ „ „ „ „

Risk Assessment MD notification / participation in plan of care Actual and Potential care plans IDT interventions and notes Treatment records with response to interventions

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Assessment Parameters †

Wounds need to have the following assessed: „ „ „ „ „ „ „

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Etiology – if not pressure then the MD should document as well Stage if pressure Size – length by width by depth and tunneling if present Wound bed tissue characteristics Periwound tissue characteristics Signs and symptoms of infection Response to current interventions

It is imperative that all wounds be assessed: „ „ „ „

Immediately upon admission At least weekly Upon change of wound status (improvement or decline) Upon discharge 40

Miscellaneous Discussion Points on Wound Healing † †

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“Healed” vs. “Re-surfaced” Tensile strength at end of proliferation phase and the remodeling phase Regulatory risk of re-occurrence Assessment of scar tissue

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Closing Questions and Comments

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Quality Improvement Resources ƒ Lumetra

www.Lumetra.com

ƒ Advancing Excellence Campaign

http://www.nhqualitycampaign.org/

ƒ MedQIC

www.medqic.org

Setting Targets – Achieving Results (STAR) ƒ A password-protected Web site created for nursing homes ƒ View current performance trends for six Quality Measures (QMs): High-risk pressure ulcers Post acute pressure ulcers Chronic care pain Post acute pain Depression Physical restraints

ƒ Set annual performance targets. ƒ Set your QM targets at www.nhqi-star.org.

To Get Your CEU Credit Download the CEU Evaluation Form.

ƒ Go to www.lumetra.com/events. Scroll down and click on the link for the 02/15/07 – Pressure Ulcer Management teleconference to download the CEU evaluation form. ƒ Complete the form. Legibly Include License number. Fax the completed form to (415) 677-2091.

ƒ A CEU certificate will be mailed to you.