Presented by: Shawneen Schmitt , RN MSN MS CWOCN CFCN August 27, 2009 Statewide Pressure Ulcer Project

1. Treatment and Management of Conditions to Prevent Pressure Ulcer DevelopmentorIs Your Agency’s Compass Set for Directions on Interventions for PU Prevention? Presented by: Shawneen Schmitt, RN MSN MS CWOCN CFCN August 27, 2009 Statewide Pressure Ulcer Project

2. OBJECTIVES • Identify appropriate interventions using the case study from previous teleconference. • Summarize options for treating conditions that place person at high risk for developing pressure ulcers. • Evaluate and document effectiveness of appropriateness of interventions.

3. Let’s Review Previous Teleconference • Pathophysiology of a Pressure Ulcer • Tissue Injury • Tissue edema/inflammation • Impaired circulation (micro-vasoconstriction) • Impaired tissue perfusion • Impaired tissue oxygenation • Capillary thrombosis • Tissue ischemia • Tissue death

4. Let’s Review Previous Teleconference • Contributing Factors • Aging Skin • Medications • Lifestyle • Low Braden/Norton Scores • Chronic Diseases R/T to Physiological Systems • Other Contributing Conditions • Pain/Stress • Nutritional Status • Cancer • Abnormal Labs • Dementia/Depression • Isolation • Devices/Tubes

5. Let’s Review Previous Teleconference • Risk Assessment • With every added contributing condition there is an added risk for pressure ulcer development • Need to look at the sub-scores on the Braden/Norton Scales for appropriate interventions • Added “risks” • Male gender • Darkly pigmented skin • Institutionalization • Length of Stay • Transportation • Frequent Admissions • Crisis situations…ED visits, extensive surgery, ICU admission • Physiological/hemodynamically unstable

6. Case Study • An 82-year old African American male was admitted to your unit for diarrhea, UTI and altered mental status times two days. He has a history of Diabetes –type 2 with peripheral neuropathy, COPD, HTN, CAD and Anemia. He weighs 252# with a BMI of 43. He smokes 3-4 cigarettes a day and takes 2.5 mg of corticosteroid daily for his COPD and a beta blocker for his HTN. He rates his pain as 6/10 “hurts all over” He stated that he has tried to eat “but nothing tastes good for the last week”. His admitting HGB was 10.2 and HCT was 33, WBC are normal but lymphocytes are 11, Albumin level is 3.0, Blood glucose is 189, Potassium is 3.4, Sodium is 147. All other tests are within normal range. Stool cultures pending. His temperature is 99.8 orally, pulse is 72 and regular, blood pressure is 162/90 and respirations are 16 and shallow. Pulse ox is 89% on room air. Ambulation he states is difficult at times because he gets short of breath. Braden score overall was 13 with low scores for moisture, nutrition, sensory perception and friction/shear. Skin assessment shows no pressure ulcers on admission. • How would you rate his overall risk for development of a pressure ulcer? Why? What are his contributing factors? What preventive interventions would you put into place?

7. Case Study • An 82-year old African American male was admitted to your unit for diarrhea, UTI and altered mental status times two days. He has a history of Diabetes –type 2 with peripheral neuropathy, COPD, HTN, CAD and Anemia. He weighs 252# with a BMI of 43. He smokes 3-4 cigarettes a day and takes 2.5 mg of corticosteroid daily for his COPD and a beta blocker for his HTN. He rates his pain as 6/10 “hurts all over” He stated that he has tried to eat “but nothing tastes good for the last week”.His admitting HGB was 10.2 and HCT was 33, WBC are normal but lymphocytes are 11, Albumin level is 3.0, Blood glucose is 189, Potassium is 3.4, Sodium is 147. All other tests are within normal range. Stool cultures pending. His temperature is 99.8 orally, pulse is 72 and regular, blood pressure is 162/90 and respirations are 16 and shallow. Pulse ox is 89% on room air. Ambulation he states is difficult at times because he gets short of breath. Braden score overall was 13 with low scores for moisture, nutrition, sensory perception and friction/shear. Skin assessment shows no pressure ulcers on admission.

8. How would you rate his overall risk for development of a pressure ulcer? • Braden Score overall is 13 = moderate risk for pressure ulcer development • Is this accurate? • Could the patient be even at a higher risk for a possible agency required (nosocomial) pressure ulcer? • Remember the additional “risks” • Gender • Race • Specific sub-scores • Moisture • Sensory Perception • Nutrition • Friction/Shear • Contributing Factors

9. Age Gender Race Diagnosis Diabetes CAD HTN COPD Anemia Peripheral Neuropathy Smokes Pulse Ox = 89% Poor Appetite Obesity Medications Steroids Beta Blocker Pain/stress Diarrhea Admission to Health Care Agency Abnormal Labs Low Hemoglobin Low albumin Low Lymphocytes Elevated Blood Glucose Moderate Risk Braden Score What are the Contributing Factors?

10. What preventive interventions would you put into place? • Before you can answer the question you need to first look at the Braden/Norton sub-scoresNOT its overall score. • Reason to Do This • To individualize a plan of care/action/interventions to the existing situation/circumstances with a score of 1 or 2 • As the sub-score changes, the plan of care/actions/interventions need to change as well • Look at all risks/contributing factors because the overall score may need to go to the next higher risk level • Preventive interventions need to be evidence based practices that relate to the sub-score

11. Evidence Based Interventions for at Risk Persons • The following is for everyone no matter what the overall Braden score/risk level (under 18) • Skin Assessment every day especially look at coccyx, sacrum, buttocks and heels • Turn & reposition every two hours or more often when in bed • Minimizes muscle spasticity • Improves respiratory function • Prevents moisture accumulation • Reduces pressure points hyperemia • Reposition every 30 minutes when up in chair • Do chair lifts & use a chair cushion • Elevate heels off the bed • Maintain muscle tone/conditioning

12. Evidence Based Interventions for at Risk Persons • Manage Moisture • Incontinence protocol (skin protectant) • Minimal to no use of diapers • Toileting schedule/condom catheter • Stool/fecal pouching • Limiting multiple layers of underpads • Remember: patient has diarrhea and C-Diff is being R/O

13. Evidence Based Interventions for at Risk Persons • Manage Nutrition • Provide adequate hydration • Determine foods likes and dislikes • Increase calories if malnutrition is suspected • Increase protein intake • Supplement with MVI (vitamins A & C, Zinc) • Dietician/nutritionist consult • Remember: Patient hasn’t been eating and has an Albumin level of 3.0 and has pain

14. Evidence Based Interventions for at Risk Persons • Manage Friction & Shear • Elevate bed no higher than 30 degree unless contraindicated • Use trapeze, lift sheet, hover mat, Hoyer lift • Protect heels and elbows • Keep skin moisturized • Avoid devices that increase pressure such as donuts • Avoid messaging over bony prominences • Use a pressure redistribution mattress overlays and/or chair cushion for high to very high risk scores • Remember: Patient weighs 252# (obese), on oral steroid drugs, incontinent, smokes, is diabetic

15. Evidence Based Interventions for at Risk Persons • Managing Sensory Perception • Elevate heels • Increase the frequency of turning and repositioning • Consider the use of a pressure redistribution mattress/chair cushion • Remember: Patient has a history of peripheral neuropathy, diabetes, smokes, and pain

16. Evidence Based Interventions for at Risk Persons • What are the other Braden sub-scores? • Mobility • Activity • What additional information would you need to be sure patient does not have a score of 1 or 2? • What other factors need to be considered for putting in place interventions? • Age • Race • Alterations in tissue perfusion • Anemia, HTN, CAD • Alterations in tissue oxygenation • COPD, Low pulse ox, short of breath when walking • What would be the intervention (s)? • Increase monitoring/evaluating of patient (checking lab work and vital signs) • Appropriate documentation

17. Evaluation & Documentation • Evaluation is the last step in the nursing process that determines if goals, outcomes were met and/or treatments were effective and/or standards of care were maintained • Documentation is a written or printed paper that substantiates an evaluation, claim or data • Written validation using standardized/acceptable terminology • Constructs detail by reproducing the authentic situation • Communicates information in its original or official/legal format • Used as a basis for reimbursement

18. Red Flagsin Documentation • Things don’t add up • Incorrect Braden scores • Terms are unclear “fair”, “encourage” • Things that are too good to be true • Inconsistent variations in change/status • Inconsistencies in the medical record • Flow sheets • Nurse’s notes Baranowski, S. 2004

19. Avoid Documentation Negligence • Use only the “FACTS” • F = factual • A = accurate • C = complete • T = timely • S = specific • Use patient/family quotations whenever possible • Follow agency’s policy and procedures • Know your nurse practice act and standards of care • Identify administrative codes & guidelines • Maintain competency • Use appropriate current resources

20. Pearls to Remember • Remember it is always “back to the basics” with nursing care practice • Do critical thinking with clinical reasoning • View the patient holistically • Be a proactive advocate • Communicate and collaborate effectively with health care team • Document accurately & completely • Knowledge is the power for change • Use appropriate resources to validate care • Standards of practice • Current nursing/wound care textbooks • Barnowski, S & Ayello, E. (2004) Wound care essential. Philadelphia; Lippincott Williams & Wilkens • Evidence based research • Guidelines from WPUC • Reliable Internet Websites such as • http://www.globalwoundacademy.com/ • http://www.npuap.org/ • http://www.thewoundinstitute.com

21. In conclusion…..Where is your agency’s compass set for directions regarding interventions for the prevention of pressure ulcers? • Thank you for your attention …..If you have any question(s) after this presentation, contact me by E-mail at: cwocn4u@gmail.com