Objectives are included in the participant handout and include the detail for the last objective: Describe a pressure ulcer prevention program for a

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2 Objectives are included in the participant handout and include the detail for the last objective: Describe a pressure ulcer prevention program for a nursing home, including: Education of residents, staff and residents families Routine assessment of skin Proper skin care Prompt response to early signs of pressure ulcers Frequent movement of residents Use of pressure relieving surfaces Toileting schedule for incontinent residents Staff observation and reporting of risks and signs of pressure ulcers Providing adequate fluid intake Ensuring proper nutrition 2

3 Pressure ulcers are areas of skin and or tissue death. When the tissue is exposed to prolonged pressure it does not get enough nutrients and cells die. In its earliest stage, the ulcer shows up as persistent redness in light-colored skin. In dark-colored skin the area may appear red, blue or purplish. Sometimes, damage to underlying soft tissue or muscle may cause skin to turn dark maroon or purple, or a blood blister to occur, which could indicate suspected deep tissue injury. The area may be painful, boggy or firm. This terminology should be used in the documentation to describe the area, and not the term pressure ulcer. (1,2) 3

4 As people age, the skin becomes drier, thinner and more fragile. The fatty layer under the skin becomes thin, resulting in more prominent bony structures, and increased risk for breakdown of the skin. The goal is to prevent ulcers whenever possible. Many, but not all, pressure ulcers are preventable. Pressure ulcers can be painful and may result in complications such as infection, including of the bone. Residents with pressure ulcers are likely to die sooner than those without them. The cost to heal a Stage III or IV pressure ulcer may be as much as $70,000 dollars, and for less serious wounds, $2000-$30,000.(3) The overall cost in terms of pain and suffering, bad survey citations, law suits, etc., cannot be determined. The cost of preventing pressure ulcers is, of course, much less that treating one. There are ulcers that are considered unavoidable due to various factors, such as chronic illness, etc. It is still the responsibility of the health care team to show that they have done everything possible to prevent the wound and to keep it from getting worse. 4

5 Sustained pressure is a major cause of pressure ulcers, but it is often a combination of pressure, friction/shear and sometimes moisture that results in pressure ulcers. Pressure, the amount of force exerted on an area, is measured in millimeters of mercury (mm of Hg). When external pressure is greater than 32 mm Hg, blood flow to the area is reduced. The area may not get enough oxygen and nutrients. Metabolic toxins may build up in the area. Cells may die. There is a relationship between time and pressure. Lower levels of pressure for longer periods of time are as damaging as high pressure for short periods of time. It can take as little as 2 hours for a pressure ulcer to develop. Friction occurs when two substances rub together. Pulling an individual across the chair or bed surface may rub away the outer skin layer. When the interface between the body and the bedding is moist, the force of friction is greater. Think about the friction associated with pulling on a wet, as compared to a dry, bathing suit. Friction can be decreased by using a draw sheet while in bed, and proper lifting techniques when in a chair. Shear is a mechanical force that is parallel rather than perpendicular to the area. When we elevate the head of the bed, the body skeleton actually slides down in relation to the skin. This especially affects the sacrum. Shear force is greatest when we drag an individual in bed. Use of a draw sheet and keeping the HOB down when able will help reduce shear. 5

6 Many factors contribute to the risk for pressure ulcers: Immobility is probably the greatest threat of all. Individuals who are unable to move independently in bed and to get in and out of bed must depend on those caring for them to change their position, especially residents with contractures. Loss of discomfort from pressure. Normally, when pressure on the skin reduces blood flow to an area a sensation of discomfort causes one to shift a little and relieve the pressure. Those who are unable to sense the discomfort will be at greater risk. This may include individuals who had a stroke or have diabetes or neuropathies, but also those who are sedated or restrained. Incontinence increases the risk because it causes excessively moist skin and chemical irritation. Of the two types of incontinence, fecal incontinence makes a greater contribution to pressure ulcer risk probably because stool contains bacteria while urine is normally sterile. Poor oral intake affects the health of skin and ability to heal. Adequate protein, calories, and fluids are essential to prevent skin injury. Individuals who are underweight or who are losing weight are at higher risk. Changes in level of consciousness or being cognitively impaired, such as in dementia, also increase the risk of pressure ulcer development. If a resident is unable to participate in their care or communicate effectively they may not move 6

7 Pressure ulcers occur over bony prominences. Common sites of pressure ulcers are over boney prominences and include the: the back of the head back of shoulders (scapula) ischium trochanter sacrum heels ankle lateral edge of the foot and Areas of skin-to-skin contact are susceptible (such as inner knees), especially in persons with muscle contractures. These can be prevented by putting a pillow between the points. Most pressure ulcers occur in the lower half of the body. (Overhead is in participant handout as a full-page illustration) 7

8 Preventing pressure ulcers requires a team approach. The nurse identifies at risk residents on admission by using an assessment tool. Most facilities use the Braden Scale, although some use the Norton Scale. The dietician assesses the nutritional status of each resident and prescribes a diet that will assure adequate protein, calories, and fluid to maintain skin health. A speech therapist may be consulted to address swallowing issues to make sure the food is the right consistency. The physical or occupational therapist assists with mobility and positioning devices. The activity therapist conducts activities that encourage movement. He or she may also be responsible for recommending pressure relieving devices, such as a chair cushion or mattress. Despite the efforts of all of these providers, it is the direct caregivers who provide the first line of defense in protecting older adults from pressure ulcers. What you do for prevention: promote healthy, clean, skin protect against pressure and injury assure that adequate food and fluids intake 8

9 The thin, fragile skin of older people needs special care. Gentle cleaning with warm water alone, or a gentle cleanser such as DOVE is generally sufficient for daily bathing. During cleaning and drying, use a soft towel and pat the skin dry. Do not rub the skin, especially over any reddened areas. Make every effort to prevent incontinence by toileting individuals promptly as needed. Older adults should not be left sitting on the bedpan or toilet for more than 10 minutes. Clean the skin whenever it becomes soiled. Incontinence products and underpads do not replace the need for awareness and immediate cleaning. For incontinence, absorbent b briefs may be used. Briefs should be made of materials that absorb moisture and present a quick- drying surface to the skin. There is little good reason for wearing briefs in bed. When you use specialty surfaces, place a single layer of fabric between the individual and the surface. Do not place the older adult directly on plastic or paper linen savers because they hld hold moisture it and dirritate itt skin. Topical moisture barriers may be used to protect the skin from moisture. Protective films may also help to reduce friction injuries. 9

10 Clean and dry is not enough! Lubrication of skin is important. Apply lotions or creams to areas of dry, flaky skin. Skin that is water-logged (macerated) is easily eroded by friction, more easily irritable, and more readily colonized by germs than normal skin. 10

11 The easiest times to do a skin check are when getting the person up (such as to go to the bathroom) and returning him/her to bed. Be sure to inspect all surfaces. Look for redness, dryness, rashes or other breaks in skin integrity. Feel for changes in skin temperature damaged areas may feel warm to the touch. Pay special attention to areas that remain reddened after position change. By definition an area that is still red after 15 minutes is a Stage I pressure ulcer. Avoid positioning an individual on a reddened area (or on a pressure ulcer). For example, limit time out of bed, i.e., for meals only, if a resident has a sacral wound; and turn side to side only when in bed. Never massage over bony prominences or reddened areas. Massage may rupture capillaries and damage underlying tissues. If you notice: a rash or break, then wash the area with plain warm water (no soap). an area of red but intact skin, then position the resident to relieve pressure. In either case, tell the nurse describe what you saw, felt and did. Ask him or her if he/she would like to see the area. 11

12 Examine the skin for signs of pressure change (redness, change in color, temperature, or texture), moisture or dryness, and presence of rashes or skin breaks. Report any changes promptly to the nurse. Describe the area including color, temperature, location, and size. Recheck the area 15 minutes after repositioning; note any change. Check for temperature changes by placing the back of your hand against the area. Compare findings with the temperature of other skin surface areas. Investigate and report complaints of pain or discomfort. When sensation is intact, older individuals may complain of pain associated with being in one position for too long. Established pressure ulcers may be painful especially if pressure is sustained, and during dressing changes. It is imperative that any complaints of pain be reported, treated and re-evaluated. Pressure wounds are often very painful as are the dressing changes or wound care. Blisters, fluid-filled or broken, may be Stage II pressure ulcers. Friction usually causes blisters. If an area is weeping or draining, notice and report the color, amount and odor of the drainage. If a dressing falls off or gets wet or soiled, notify the nurse right away. 12

13 Remember the time pressure relationship. Less pressure for more time is as dangerous as more pressure for shorter time. Some older adults may need to be turned or repositioned more frequently than every two hours. No one should ever lay on skin that is already reddened by pressure. Heels are especially vulnerable and should be lifted completely off the bed with pillows or with the use of heel boots. Heels should be elevated even when the individual is on a specialty surface. The head of the bed should not be elevated more than 30 o to avoid sliding down in bed. If the head of the bed must be elevated to minimize risk for aspiration or aid with breathing or eating, monitor the skin in the sacral region carefully. Lift sheets or a trapeze should be used for at-risk residents to enhance mobility and reduce friction and shear. When an older adult is lying on the side, weight should never be directly on the hip bone (greater trochanter of the femur). A 30 o laterally inclined position relieves sacral pressure and prevents trochanteric pressure. 13

14 Turning and repositioning is essential even if the person is on a pressure-reducing surface. In the 30 laterally inclined position, weight is on the fleshy buttock muscle, suspended between the sacrum and the trochanter (hip bone). Bending the knees further reduces pressure on the trochanter. A pillow between the legs prevents skin-to-skin contact and reduces pressure between the knees; one under the lower leg reduces pressure on the ankle bone and outer aspect of the foot. 14

15 When an older adult is in the chair, more of the body weight is distributed to smaller surface, producing higher pressure. The pressure time relationship means that those in a chair should be positioned more frequently than those in bed. Older adults in a chair should be encouraged to reposition at least every 15 minutes or so. Those who are able should be taught and encouraged to make small weight shifts every 15 minutes. NEVER USE ring cushions as they are known to cause venous congestion and edema. In one study, they were found to be more likely to cause than to prevent pressure ulcers. 15

16 Older adults need to know that skin breaks down more easily and wounds won t heal unless nutrition and hydration are adequate. Protein is a major nutrient that helps protect skin and promote healing. Primary sources of protein in the diet include milk products (yogurt, cheese, ice cream), meat, poultry, fish, dry beans, and eggs. If residents are unable to complete their entire meal, these foods are especially important. 16

17 Not all pressure ulcers can be prevented, but many can. CNAs provide the first line of protection against pressure ulcers. You can make a difference! The best way to lower the risk of pressure ulcers is to keep older adults moving. If individuals cannot position themselves, turn and reposition frequently. Those who can change their position may need to be reminded to do so. Don t forget to help or encourage the person sitting in a chair to change position. Adequate nutrition and hydration are essential to prevent pressure ulcers. If you notice someone is not eating or drinking enough, report it to the nurse. Some may need vitamins or supplements added to their diet. Individuals who are incontinent have a five times higher risk of pressure ulcers than those who are continent. Establish a toileting schedule for those who are incontinent. Clean those with incontinence promptly after soiling. Use skin protective barriers. Always be on the lookout report redness, investigate complaints of pain or discomfort you may be the eyes and ears of the nurse, but the voice of the older adult. 17

18 Can you now: Identify the risk factors for pressure ulcers? Discuss common reasons for pressure ulcers? Discuss strategies to prevent these wounds? Describe a team approach to pressure ulcer prevention and care? Describe a pressure ulcer prevention program for long term care? 18

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