Prevention of Pressure Ulcers and Incontinence Care Education for Nursing Assistants Jeri Lundgren, RN, BSN, PHN, CWS, CWCN Director of Wound & Continence Services August 24, 2010 1:30-2:30 PM CST
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Prevention of Pressure Ulcers and Incontinence CareEducation for Nursing AssistantsJeri Lundgren, RN, BSN, PHN, CWS, CWCNDirector of Wound & Continence ServicesAugust 24, 2010 1:30-2:30 PM CST
Presenter
Presentation Notes
Prevention of Pressure Ulcers and Incontinence Care
• Nursing Assistants are the key to a successful pressure ulcer and incontinence management program
Pressure Ulcers• A pressure ulcer is a localized injury to the
skin and/or underlying tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear and/or friction
Pressure Ulcers
Pressure Ulcers
Pressure Ulcers
Contributing Factors
Contributing Factors: Shear
Contributing Factors: Shear
Contributing Factors: Shear• Raise the knees of the bed a little before
raising the head of the bed to prevent the resident from sliding down
• Lift, do not drag, residents when moving them in the bed or wheelchair
Prevention Interventions• Monitor skin
– Inspect skin daily • Inspect bony prominences by looking and FEELING• Look for discoloration or areas that feel mushy or hard• Look under medical devices (casts, tubes, orthoses,
braces, etc).• Look for bruises, skin tears, rashes, etc.• Notify the nurse of any concerns immediately (in writing if
possible)
– Weekly skin assessment by licensed staff, typically on the bath day
Prevention Interventions • Provide pressure-reducing surfaces when in
bed and sitting– Overall goal of any bed or wheelchair support
surface is to evenly distribute pressure over a large area
– Residents in wheelchairs should have a cushion– Should be listed on Nursing Assistant
assignment sheets– Not a substitute for turning schedules– Heels may be especially vulnerable, even
on low air loss beds
Prevention Interventions
Prevention Interventions
Prevention Interventions• Develop an INDIVIDUALIZED turning and
repositioning schedule• Current recommendations:
– Turn and reposition at least every two hours when lying down
– Reposition at least hourly in a sitting position (if residents can reposition themselves in wheelchair, encourage them to do so every 15 minutes)
– When possible, avoid positioning on existing pressure ulcer
Prevention Interventions• Tissue tolerance is the ability of the skin and
its supporting structures to endure the effects of pressure with out adverse effects
• An individualized turning and repositioning schedule should be done for each resident– If turning intervals are not on the assignment
sheet, notify the nurse
Prevention Interventions• Momentary pressure relief followed by a
return to the same position is usually NOT beneficial (micro-shifts of 5 to 10 degrees or a 10-15 second lift)
• Off-loading is considered one full minute of pressure RELIEF– Done when the resident is going to return to the
same position– If putting residents to bed from the wheelchair,
place on their side
Prevention Interventions• Pad and protect bony prominences (note:
sheepskin, heel, and elbow protectors provide comfort, and reduce shear & friction, but do NOT provide pressure reduction)
• Do not massage over bony prominences
Prevention Interventions
Prevention Interventions• Nutrition and hydration support
– Provide protein supplements and protein intake– Monitor intake– Ensure assistance to those who can not feed
themselves– Give fluids in small dosages throughout the day –
each time you interact with the resident
Moisture
Prevention Interventions• Keep skin clean and dry
– Peri-care after each episode of incontinence– Apply a skin barrier to all incontinent residents
(thick paste type of ointments should only be used with severe irritated skin)
– 4x4s or dry cloths in between skin folds– Bathe with MILD soap, rinse and gently dry– Moisturize dry skin– Keep linen dry and wrinkle free
Other Considerationsfor Prevention Interventions• Notify Nurse of:
– Any pain concerns– If a resident refuses to allow you to do any of the
interventions, notify your nurse immediately• Explain to resident and/or family members
why you are providing certain cares or special equipment
• Re-approach as appropriate
Managing Incontinence
F315 Urinary Incontinence Tips• OVERALL GOAL of a comprehensive
assessment: – Determine the type of urinary incontinence– Provide more individualized programming or
interventions – Enhance the resident’s quality of life and
functional status
Age-Related Changes in the Urinary Tract– Bladder capacity is diminished– Amount of urine left in the bladder after urinating
may be greater– Desire to void or urge sensation is delayed– Involuntary contractions– UI predominately affects 1 in 4 women
Urinary Incontinence should NOT beconsidered a normal part of aging!!
What is Urinary Incontinence• Urinary Incontinence can be described as any
involuntary loss of urine from the bladder, whatever the cause, that is not controlled by the individual
Complications of Urinary Incontinence• Urinary incontinence can contribute to:
– Falls (20-45% of incontinent women)– Fractures– UTIs– Depression– Social isolation– Pressure ulcers– Dermatitis
F315 Urinary Incontinence Tips• Three-Day Voiding Patterns
– Track the time, frequency, amounts of urine, and whether individuals are incontinent
– Communicate during and at the end of each shift with the Nursing Assistant and Nurse
– Ensure Interdisciplinary Team is aware of three-day observation
– Overall goal is to get an ACCURATE observation
Types of Urinary Incontinence• Types of incontinence include:
– Urge – Stress – Mixed– Overflow– Functional
Urge IncontinenceOveractive Bladder
Common Causes:• --Genitourinary conditions • (UTI, Tumor, stones,cystitis)• --CNS disorders • CVA,Parkinson’s,• spinal injury)• --Medical condition • (DM, fluid intake, habitual • frequent voiding)
Symptoms:• --Involuntary contractions• --Strong urge to urinate• --Urine loss on way to toilet • --Timing is unpredictable• --Key-in-lock syndrome• --Running water• --Nocturia
Failure to store related to bladder dysfunction
Presenter
Presentation Notes
With urge UI and/or an overactive bladder, patients have severe urgency and frequency and usually cannot hold or postpone urination! Detrusor over activity is a common cause of urge incontinence. This instability causes uninhibited bladder contractions, increasing the urge to void. Uninhibited detrusor contractions due to neurologic conditions are referred to as detrusor hyperreflexia. Detrusor hyperactivity with impaired bladder contractility (DHIC) is more common in the elderly. Overactive bladder is a common term that describes all those conditions listed under urge. Common causes include: ü Local genitourinary conditions such as cystitis, urethritis, atrophic vaginitis, tumors, stones, diverticula, outflow obstruction, UTI, impaired contractility ü Central nervous system disorders such as stroke, Parkinsonism, Alzheimer’s disease, brain tumor or aneurysm, and spinal cord injury. ü Medical conditions such as diabetes mellitus, inadequate fluid intake, habitual frequent voiding. ü A number of frail, elderly incontinent residents will have involuntary bladder contractions, but not empty their bladder completely. This can cause chronic urinary retention. That is one reason why the MDS requires bladder assessment of all residents with UI. These residents have an absence of normal bladder urge sensations. Many times this is referred to as reflex incontinence.
Stress IncontinenceSmall to moderate amount of leakage simultaneously with physical exertion
From increase in intra-abdominal pressure
Signs and Symptoms:Small losses of urine when:
• Coughing • Laughing• Exercising• Changing positions• Lifting/Straining
Presenter
Presentation Notes
The two most common causes of SUI are: Urethral hypermobility or significant displacement of the urethra and bladder neck during physical exertion when abdominal pressure is increased Intrinsic sphincter deficiency (ISD) is significant failure of the sphincter due to urothelial, myogenic or neurogenic dysfunction of the outlet. ISD may be seen with and without hypermobility of the urethra. Etiology ü sphincter dysfunction, due to relaxation and weakness of the pelvic floor muscles and reduction in urethral resistance ü in women, especially those with multiple childbirths, estrogen deficiency, or trauma to the external urinary sphincter in men due to pelvic trauma or sphincter damage during prostatectomy ü obesity ü smoking with chronic coughing can contribute to stress UI.
Mixed Incontinence• Combination of Urge and Stress• Mix of gotta go right now and small
amounts of leakage with coughing, laughing, exertion
Overflow Incontinence
• Bladder cannot contract properly and empty normally
• Causal Factors:• Urethral Obstruction• NeurologicCondition• Medications
Symptoms:• Bladder Distention• Weak stream/hesitancy• Dribbling• Frequency• Dysuria• Nocturia• Incomplete voiding• PVR > 200cc
Urinary retention with leakage of small amounts of urine when the bladder has reached its maximum capacity
Presenter
Presentation Notes
Overflow incontinence occurs when the bladder cannot empty normally and becomes overdistended, leading to frequent, sometimes nearly constant urine loss. Urine loss is usually in small amounts and patients will report dribbling or being unable to “empty my bladder”. Causes include neurologic abnormalities that impair detrusor contractile capacity, including spinal cord lesions, neuropathies (e.g. Diabetes) and any factor that obstructs outflow, e.g., medications, tumors, constipation/fecal impaction, urethral strictures, and prostatic hyperplasia or cancer.
Functional Incontinence
Conditions:Cognitive impairmentFunctional disability (physical weakness, pain, or impaired mobility)Psychological impairmentEnvironmental barriersMedications
Symptoms:Inaccessible toilet Nocturnal enuresisCombined fecal and urinary incontinence
Normal bladder control, but factors prohibit residents from getting to the toilet on time
Three-Day Void• Communicate to the Nurse:
– Dribbling– Dribbling with movement– Weak stream– Voiding small amounts frequently– Urge requests or frequent need to urinate– Pain with urination
Successful ProgramsA successful incontinence program includes:• Access to bathroom and appropriate
equipment• Adequate fluid intake (small amounts
overtime)• Muscle strengthening exercises• Carefully scheduled elimination
times/prompting • Avoiding the use of incontinence briefs if
possible
Treatment and Elimination Plan• Scheduled toileting plan
– Cognitively impaired, functionally disabled, caregiver dependent
• Check and change– Physically unable to sit on toilet or have behaviors making
difficult to use
• Retraining– Oriented, able to feel sensation, able to understand and
inhibit urge, toilet independently or with minimal assist
• Prompted voiding– Scheduled toileting, that requires the
caregivers prompting; able to use the toilet
Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.
This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organizations for under contract with the Centers for Medicare & Medicaid Services(CMS), an agency of the US Departments of Health and Human services. The contents presented do not necessarily reflect CMS policy. 9S0W-MN-6.2-10-73 081810
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