Prevention of Pressure Ulcers and Skin and Wound Management Programs Mary Beth Flynn Makic RN PhD CNS CCNS [email protected]Research Nurse Scientist, Critical Care University of Colorado Hospital Assistant Professor, Adjoint University of Colorado, Denver, College of Nursing Never Events: Pressure Ulcers • Pressure ulcers (PUs) can be identified, measured, and reported • Usually preventable • Result in adverse patient outcomes, prolonged/additional care, increased costs • Significant body of scientific evidence is available to guide practice and prevent PUs • October, 2008 : Stage III and IV PUs acquired after admission are not reimbursed www.cms.hhs.org April 14, 2008 fact sheet;www.qualityforum.org Serious Adverse Events Working Group March 19, 2008 Pressure Ulcer Facts Dorner, B., Posthauer, M.E., Thomas, D. (2009) www.npuap.org/newroom.htm •4 th leading preventable medical error in the United State • 3 million patients are treated annually • National acute care prevalence rates 7-15% • ↑LOS ~ 4 to 14 days • Cost to treat PU $43,000 per hospital stay
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Prevention of Pressure Ulcers andSkin and Wound Management
• IHI 5 Million Lives Campaign• http:/www.ihi.org/IHI/Programs/Campaigns
• National Pressure Ulcer Advisory Panel• www.npuap.org
• European Pressure Ulcer Advisory Panel• www.epuap.org
S.P.A.M.• Prevention of pressure
ulcers is nursingsensitive indicator– This means that prevention
of skin breakdown is a directreflection of care provided topatients by nursingprofessionals
• Nursing practice guided bybest-evidence is essential inthe prevention of pressureulcers (PU)
• At UCH our skinprogram logo isS.P.A.M.– Skin– Prevention– Assessment– Management
Positively Impacting Care:Skin Assessment on Admission
• Essential that nurses complete anddocument full assessment of skin toinclude alterations and pressure ulcerson admission and nutritional status
• Differentiate– Community acquired pressure ulcer:
Present on Admission (POA)
– Hospital acquired pressure ulcer (HAPU)
Risk Assessment On Admission, Daily,Change in Patient Condition
www,ihi.org; Macklebust,JA (2009) The Braden Scale reliable assessment toeffective interventions
• Use standard EBP risk assessment tool• Research has shown Risk Assessment Tools are
more accurate than RN assessment alone.• Braden Scale for Predicting Pressure Sore Risk
– 6 subscales• Rated 1-4
– Pressure on tissues• Mobility, sensory perception, activity
– Tissue tolerance for pressure• Nutrition, moisture, shear/friction
– Score 6-23
Evidence-Based RiskAssessment Tools
Bolton, L. Which pressure ulcer risk assessment scores are valid for use in clinical settings? JWOCN, 2007;34(4): 368. ; Kring, D., Reliability and validity of the Braden scale for predicting pressure ulcer risk.
Braden Q Acute care Pediatrics 6 subscales +tissue perfusion
Pressure Ulcer Prevention (PUP) Protocol Related Policies / Guidelines: Use of Therapeutic Surfaces/Bariatric Suites
Prevention and Treatment of Skin/Tissue Breakdown Skin Tear Management Guideline Pressure Ulcer Prevention / Treatment Guidelines Nursing Standard of Care of Prevention of Pressure Ulcers and Skin Breakdown
? Turning Schedule: turn patient every 2 hours and PRN ? HOB < 30 if pt does not have pulmonary risks; HOB>30 if pt has risk for pulmonary complications (increase tu rning frequency) ? Trapeze when indicated, “Waffle” cushion to all chair surfaces for Braden ‘ACTIVITY’ subscale ? 3 ? Moisturize skin daily and PRN using Dimethicone barrier cream ? Control moisture; determine and treat cause of moisture, add absorbent pads to bed surface, barrier cleansing wipes and Zinc Skin Paste as needed. ? Nutritional Consult if: Braden ‘NUTRITION’ subscale ? 3 and/or Albumin ? 3.4 g/dl and/or Pre -albumin ?20 mg/dl and/or Braden score ?16 ? Minimize Friction & Shear by use of turning sheet s and slide boards to move patient, protect heels and fragile skin of extremities ? Wound Care Consult if: DTI, Stage III, IV, Unstageable or hospital acquired pressure ulcer, prevention challenges or complicated wounds
Braden Score 15-18
At Risk
Braden Score 13-14
Moderate Risk
Braden Score 10-12
High Risk
Braden Score < 9 Very High Risk
INTERVENTIONS:
? Implement turning schedule ? Moisturize skin daily and PRN ? Out of bed, increase activity as
indicated ? Control moisture ? Assess nutritional status ? Minimize friction and shear ? Consider Advanta bed or ensure
Advance to next level of risk if other factors are present: Advanced age, Chronic Illness, Diastolic pressure below 60, Uncontrolled pain Bariatric patients with BMI>40 (www.rd411.com/tools ) should be placed on surfaces as per ‘Therapeutic Surfaces/Bariatric Suites’ policy References:
1. Ratliff, C.R. et al (2003). Guideline for prevention and management of pressure ulcers. Wound Ostomy and Continence Nurses Society. Lake Avenue, Glenview IL. 2. Ayello, E.A. et al (2004). By the numbers: Braden score interventions. Advances in Skin & Wound Care 17(3):150. 3. Nurse’s Association of Ontario . Nu rsing Best Practice Guideline: Assessment and Prevention of Pressure Ulcers. Toronto: RNAO (2005). Available online @ www.RNAO.org/Nursing best practice guideline. 4. Keast, David et al (2007) . Best Practice Recommendations for the Prevention and Treatment of Pressure Ulcers. Advances in Skin &Wound Care 20(8): 447 -462. 5. Magalhaes, MD et al (2007). Risk Factors for Pressure Ulcers in Hospitalized Elderly without Significant Cognitive Impairment. Wounds 19(1): 20 -24.