STGEC ~ Wound Care: Pressure Ulcer Prevention/Management (2013)

STGEC ~ Wound Care: Pressure Ulcer Prevention/Management (2013)

but someone at stories you hi everybody ready to start again everybody to end out on the braking scale if not raise your hand and Joe will give you one this week seminar takes a lot planning and it was several months in advance to do this so I like to recognize the planning committee members without without well it would have been possible without them I might recognize Mark Johnson he's from the south this is geriatric Education Center need to help Frank center field and these are what media specialists and he's joining me he's recording the seminar for us and if you would like to purchase a GED afterwards they're $5 for each day and technology for both days so we have a forum out there where registration is and just about that forum and I also like to recognize Scott Walters and she's not here today she's over at Audie but she did a very instrumental and exciting this program our next program thiner it is a Chevy love and she's one of our speakers she's right here and our next person is Joseph Anza and he's from South Texas geriatric Education Center he's there in the rear of dispersion cannon various okay great and in the course Diane Rudolph our previous teacher she's very wonderful and she's very French I like to introduce our next speaker the echo past 17 years as art in she started out as a student of English in here in the LVN and then are no no not Indian okay sorry this at the student was technician and then are they worked in the areas ICU surgery pack butyl Emma tree as she presently works in acute long-term care here at KCC to AIDS she became weaker certified last November with in Becker CW CN she did her weaker training at eastern Kansas va1 Academy in Leavenworth Kansas and silver very proud of her and let's give a warm welcome good morning I'm going to be talking to y'all about pressure whores officers I know Diane spoke about it but we're going to go a little more in-depth on this we're gonna look at identified causes pressure ulcers identified common locations where they're developed go to go through the stages again and then some treatment modalities we want to especially important in today's this hostile environment that we have a evidence-based best practice ultra Prevention Program and we're going to talk about what that would entail we want to be able to effectively and competently use a regular skilled but that's what the VA I know some of you are from facilities outside the VA but that's what the VA uses in so that's the one today and we want to be able to accurately assess and document pressure ulcers across a million classes the problem with pressure ulcers is international scope we have the national pressure ulcer advisory panel and then there's the European pressure ulcer advisory panel so this is not just a problem in the United States it's worldwide and it is addressed in the healthy people 2020 one of the goals is to reduce the incidence of pressure ulcers in long term care and also it's a Joint Commission National Patient Safety going pressure ulcers present a very significant threat to especially our geriatric population where they have decreased mobility where they have decreased nutritional problems sensory deficits all those types of things so in it can be seen in any hospital setting from the ER all the way through to long-term care I don't know video helped mark D yard but a lot of times you might have a patient that is on the gurney for a long period of time and that's why it's so important when they get into the unit that you assess their skin because in the time period that they've been laying on that gurney in ER they could have done a bell of depression ulster so one of the things that Joint Commission also is saying that we each facility needs to have a written plan for identifying the risk form and every plan for preventing crash answers part of that plan should include an assessment at the time of admission so that you can identify residents that would be at risk for pressure ulcers or once it already have an area pressure problem opponent amendments and that's why when Diane was talking about assessments it's so important that people look at and document appropriately the location the problem said so Medicare and Medicaid and have an insurance companies are following they will not provide reimbursement for pressure ulcers that develop during a hospital stay our residential stay in as I've mentioned as part of practice regulations that we have a process in place to assess identify people at risk into the family and then there's a big thing that happens in this litigation in a patient under your watch develops a pressure ulcer that was considered an avoidable pressure ulcer you may be subject to litigation so just what is a pressure ulcer the national pressure ulcer advisory panel defines it as a localized injury to the skin are the underlying tissue usually over bony prominence as a result of pressure our pressure in combination with Charenton friction pressure ulcers developed when the capillary supplying the skin and subcutaneous tissue are compressed to them that impedes the flow of the blood nutrients to the the tissue and causes necrosis for each individual that pressure that capillary closing pressure is different it can range from 20 millimeters of mercury to 40 millimeters of mercury 32 is considered the average so that's what when we talk about offloading pressure we want to reduce the pressure interface between the tissue and in the surface pressure ulcers are usually caused by prolonged and unwilling pressure but it doesn't have to be it can occur as short as one to two hours and they usually occur of affirming prognosis but they can occur other places and they can develop from the use of a medical device how many of y'all have had patients on oxygen that their ears develop ulcers that's a pressure ulcer how many of you have had patients that have glasses that don't fit well and they get pressure ulcers on the bridge of their nose those are pressure ulcers but not all ulcers are pressure ulcers this is a zebra and the unicorn and a pony are not a force a venous ulcer an arterial sir are the continents associated dermatitis those are not pressure ulcers so when you it's like Diane was saying when you identify something in the chart as a pressure ulcer one make sure it really is a pressure ulcer and that you're not miss identifying the cause the common pressure sites how many of you have patients and wheelchairs that stay in wheelchairs most of the time that are prone to ulcers where do you see those ulcers develop on people waters variation is the commonplace but they can also develop on their feet from the foot rest especially if the wheelchair may not be in the best of repair that's why you want to make sure that your equipment listed and there are cushions and stuff for wheelchairs that will offload the pressure to those areas on the back we are looking at the back of the head the scapula the spine especially if you have a patient that has a cutting back they will break down when their spine very quickly the sacrum the trochanter is the issue tuberosities the heels in the feet and then if they land on their side you have elbows in the shoulder the ears and anywhere along that there are external ease okay is this a pressure ulcer and I think about it look at the shape of that it's a bedpan as a medical device a patient was left on a bedpan too long prolonged unrelieved pressure and it developed depressions Diane went over the stages with you there are the suspected deep tissue injury the stage 1 stage 2 stage 3 stage for an unstageable your suspected deep tissue injury it should be right along the rim localized to a certain area it could be a blood filled list or the damage damage of the underlying tissue it may be painful it may be tender it may either be indurated or hard or it could be foggy it may be cooler than the adjacent tissue are warmer and it's suspected deep tissue injury it's most likely gonna involve even with treatment so where do you think you would see a suspected deep tissue injuries most okay we all know that we have specialty items for bariatric patients but we may not have specialty beds and stuff readily available for our above average and Heights patients have you walked into room and seeing a tall person over six-foot that rests their heel on the footboard of the bed yep the reason I bring this up we've had two cases just in the last year a patient that was too long for the bed and rested their bills on the foot of the bed and developed a pressure ulcer and both homes started out with just suspected deep tissue injury so you have to be vigilant everybody has to watch if you walk on it in a room and you see that happening you need to get a bed that's appropriate for the patient or find some way to relieve that pressure you know reminding them don't rest your your your heels on that footboard when it occurs you don't know how deep the injury is gonna go you see the discoloration but there's no way of telling until it does evolve where it's gonna go this is one on the hill and then one on the buttocks and as you can see the one on the buttocks is the deep maroon colored now most the ones that I've seen on the hills are also that deep maroon color and usually have a very large blister blood-filled blister on top of them the stage 1 pressure ulcers BET's intact skin non-flexible redness of a localized area usually over bony prominence it may or may not be painful again it may you have to assess by touching and feeling whether it's firm soft warm or cool and it may be difficult to detect in darker skin individuals and it's just superficial it does not not go any deeper it can involve if you don't take care of the stage 2 pressure officer is a partial thickness with the loss of the dermis presenting is shallow open ulcer with a red or a pink blue bed without sloth and it may also present as an intact or open ruptured serum field blister and again I think Diane hand is safe nature of the stage 2 you will see the edges a lot of times that have the wider carrying maceration on them so you're going to need to offload the pressure you're going to need to treat the wound what you see the stage three pressure ulcer is a full thickness tissue loss subcutaneous fat may or may not be visible but bone and tendon or muscle are not exposed the soft may be present but it does not obscure the depth of tissue loss you may have undermining you may have tunneling so as you see the stage Street that was deeper but you don't it's not to the level of the bone of the muscle the stage four you're going to have full thickness lost you're gonna have exposed bone tendon or muscle you may have sloth or eschar presence of the parts of the wounded and this kind of wood often has the tunneling and undermining and as you see in this wound in an unstageable ulcer that's one in which it's a pulpit in the city loss but the base of the officer is completely covered by sloth or eschar of the way bed and until enough of that slop RS far is removed so that you can see the wound base and establish the true depth you cannot stage the wound and this is large large area of Escobar you know when that opens up it's probably going to be a stage forward but at this point you can't determine what the depth of that will be so pressure ulcer prevention program includes six main areas and that skin inspection and assessment of risk pressure redistribute redistribution and offloading and maintaining skin health nutrition and hydration which Diane talked about that are very important and patient and Family Education we're going to go into to some of these deeper but I heard somebody earlier when they were Dianne was asking what impedes wound healing and somebody said compliance and in patient education that's that's a big part of your pressure ulcer prevention you have to you can't make them comply but you have to give them the knowledge so that they can make one choice avoidable pressure also an avoidable pressure ulcer is where an individual develops a pressure ulcer and the facility did not do one or more the following they did not evaluate the individuals clinical conditions are there pressure risk factors are they did not define and implement interventions that are consistent with the individuals needs and a goal with recognized standards of practice they did not monitor and evaluate the impact of the interventions and they did not revise an intervention C as appropriate so if you have a patient that comes in and they develop a pressure ulcer and you have not assess their risk by a tool either the brain skills a norton skill some kind of risk assessment tool and you have not done a document a well documented assessment of their skin to say that that ulcer was not present on admission this is an avoidable pressure ulcer so you're not going to get reimbursement from Medicare Medicaid any of those for the treatment of this ulcer into treat wounds it's a big business it is it is a very expensive proposition in time and money and staff interaction to heal a wound so it's very important that you have a facility wide program in place to prevent that what this means for the nurses is they have to do assessments on a timely fashion upon admission upon it's a daily thing you have to if there's a problem do you have resident in your CNA s or helping faith or whatever and they come to you and they say would you come look at this we need to take time to look at it and if you realize it's a problem with pressure you need to document it and then you need to treat it unavoidable pressure ulcers even though you've documented their risk assessment you've put in place interventions to prevent the altar and you've monitored and evaluated those those interventions and know that they're appropriate and the patient still develops an ulcer that is an unavoidable answer you see this mode mainly in palliative care where a patient comes in they are nutritionally deficient their mobility is limited and even though you've offloaded their body is it's just a tearing and that's where you see a lot of those anybody else have an example of an unavoidable pressure ulcer I'm not sure there wait playing the one the one the Hill ulcers that I was talking about before those were avoidable but in the one case we had interventions in place we had documented education that we wanted a mattress to offload the pressure the patient refused the mattress the mattress was too noisy we wanted to put preval on boots on he refused the prevalent votes because they were too hot he didn't want a month and so even though you've provided the education patient says they understand but they choose to do something anyway was it avoidable yes but not on our part it was the patient's choice not to use interventions that we will so skins sense man inspection inspection this is the most important part it requires the removal of all clothing into position the patient for optimal visualization how many of y'all when a patient submitted to unit makes them take all their clothes off so you can look at them all over I think this is where we fail a lot of times we don't do this and then all of a sudden one of your CNAs comes after bathing patients he's got a big red spot on his hip did somebody check it when he was admitted do we know was it there on admission or has it developed a sentencing you it involves static collection you have to look you have to document location description of any problems the assessment comes in when you take all those factors and you like you don't over the Brighton scale and you've assigned a risk to them then you you synthesize all that information beyond into a plan so that you can can look at do we need nutritional supplements do we need to maybe for perfusion do we need some Ted hose doing the SCV's are they diabetic do they have sensory loss when y'all it meant patients do any of y'all on your diabetic patients do y'all test their their sensory perception in their feet or their lower extremities anybody do that we need to be doing that because as part of the brain scale we need to know what their sensory level is so in front of y'all you have the brain scale and the just a minute they're also the norton skills the watermen skills they should be done by norian it should occur immediately upon admission it serves as a baseline for comparisons later and pressure ARS areas can develop it in as little as one hour do any of y'all work on a post surgical floor anybody get patients from surgery if you do one of the things you need to be looking at is when your patient comes from post anesthesia you better be checking them when they arrive to see if there are any pressure ulcers because a lot of times they've been in surgery for a long time and even though they've been positioned and have the gel cushions or the gel mats they could have developed a pressure area while they were in surgery so you need to look you need to inspect you need to disrobe them and that's part of our job as nurses sure II would sure you would if your your under anesthesia you're under stress and you've been laying in a position especially if it's a long surgery so yes and you should be inspecting when they come to your unit especially if they've been to surgery or they've been in the the ER even for a long time you need to inspect and assess okay my flight for the Braden scale didn't come out too well so I had to sue print off a better copy for you we're gonna go over what the different areas need sensory perception refers to the patient's ability to respond meaningfully to pressure related discomfort that means if they're uncomfortable can they move themselves can they reposition themselves do they have do they have the ability to respond to that that pressure related discomfort and sometimes they may not even have they might not have a as intense response to the discomfort that a normal person would and it's it's dependent upon their degree to be able to feel and to communicate that discomfort like I said you need to to check their their level of sensory ability especially in their lower extremities especially on our diabetics I think probably eighty percent of our patients are diabetic and not I think maybe one out of ten is even moderately well controlled so you know that it's affecting their sensory perception in their lower extremities moisture moisture is not just incontinence it increases the skins vulnerability to the different forces this year the friction do you have a patient that is dr. Etta quite a bit we have several that they sweat all the time we do a linen change at least once a shift because they have died freeze that much and the other thing is they may have a draining wound and even though you're doing the right dressings and everything sometimes the wound X today is not well contained and when it's not well contained it can can cause the skin to become macerated in full ability to moisture damage activity is a matter of degree you need to pay close attention to the sub skills even a little bit of increased activity the patient being able to get out of the beds of the chair even if it's just for short periods it equals a decreased risk I know a lot on our long-term care units patients will say they don't want to get out of bed you need to try to encourage them to get out of bed at least four meals you know just that movement of getting up out of bed and moving to a chair decreases their risk on a daily basis and mobility that refers to the patient's ability to change and control their body position it does not refer to their ability to emulate a lot of people confuse that window they're looking at the Brayden skill we have some people that are not able Tory but they can move themselves some bad they can turn themselves Abed we have others they can't turn so you need to establish a turning schedule for those people that are increased risk because of their mobility limitations and nutrition that refers to the person's usual food intake do they eat well do they 50 percent or do they do they the large do they eat 100% at breakfast and then don't eat for the rest of the day we have some of them that do that you also need to look at their lab work does their albumin or the pre-op human indicator malnourished status if or if their lab work indicates that they're malnourished then they're going to score lower on that and be at a higher risk and you want to at that point get your dietitian involved you want to work with this patient to find out their food preferences as Diane talked about earlier you would want to see if supplements or in order to help prevent because they're at a higher risk if they don't have any wound problems now but they're at a higher risk if you want to do everything you can to prevent that friction this year it occurs when skin rubs against the service and shear is when friction and gravity come together you know we slide people up and Bend all the time when we should be lifting and moving them up dragging them doesn't reduce friction or shear we have new aids to help us when we're the sage model I don't know if y'all seen it where it's a literacy as well as an incontinence pad works very well to reduce the friction this year what's another way we reduce friction is here what's that and where should the position of the bid be 30 degrees or less more than 30 degrees it puts a lot of friction this year on their model maintaining skin health we want to have interventions that are minimize it and they minimize the threats to the skin integrity those things are are like the the pad to lift pads the sideburns we don't want to use up on soaps because that destroys them the normal pH of the skin and it reduces the skins ability to act as a barrier you don't want to scrub your patients you know I know that sometimes we have patients that come in from home that need scrubbing very badly but you don't want to to do that you want to gentle you want to use a moisturizer and a lawyer to prevent cirrhosis that's dry skin how many of you have seen patients come in and your feet and lower legs or just dry big plaques of skin what works well to get rid of that anybody now two of the cheapest things after you cleanse it is you either use Vaseline or you use a in the ointment and within a week you'll see a huge difference in the way there you want to make sure your patients are giving the fluid you don't want to dehydrate you what do you look at look at in a patient to see if their fluid intake is is probably good the turgor what else would you look at exactly so what are some ways that we can make sure that our patients are we'll hydrated IVs are good but you know just on a daily basis a lot of our patients won't even reach for the cut but if you hand them effective down the whole thing so it's a it's just as small act as pouring them a cup of water and saying here would you like something to drink and most of times exactly most of our patients can tell us that whether they want their their water pitcher at bedside with ice or without it but we still have a lot of patients that are demented and they won't think to take a drink and it's our responsibility as nurses to look at this and check them and make sure that if you're taking I'm not saying he I knows on them because you know that's always indicated but just the simple act of getting them to do that if they're incontinent you want to use a moisture barrier or ointment I kind of what kind of barriers would you use yeah that's one what's another one see when you move use less sheets our lifts are the hover mats to avoid shear how many of y'all have hover mats or hover jacks on your unit anybody familiar with those yeah a lot of times if you send you a mobile patient down to x-ray and they have to go by gurney I know at our facility we have the hover mats and it's a very nice thing to put them on that and it's a very nice transfer form and it doesn't interfere with their x-rays okay nutritional deficiencies equal decrease muscle mass and let less padding over bony prominences so when they have less muscle mass they're going to break down quicker you see these little men and women that come in that they just they don't even have a place to give a subcu injection because they're so thin that makes them in high-risk there's twice as likely to develop skin breakdown I would say even more than that I would say it's a greater chance so as we mentioned earlier you want to monitor their food and their fluid intake and make sure you assist with if you notice if you notice if they're not eating well or the tray comes back and they're not even eating Harley then you you need to investigate why you need to ask them you know what what's the problem you're not hungry you know is you know you need to find out the reason is because like you said it may be a dental problem it may be something that we can help but we we need to know what the problem is and it just takes a few minutes extra to find those things out and you want to do a nutritional consult when they're they're compromised off you want to make sure that you get a dietitian to come up and talk to them because that way the then the dietitian can address there's their food preferences and custom design a plan that will help them the other part of the problem are the preventive measures is a pressure redistribution and offloading impression that's accomplished with different support services when you have a patient that qualifies you can get special specialty surface mattresses that will like low air loss mattresses those type of things that will offload the pressure you need to turn in reposition you know we used to say every two hours but you need to establish a turnin schedule and if they're more prone to break down the higher the higher risk they are the lower their braiding skill you want to turn them every hour I know that it says every two to four hours but when they're in a chair how do you reposition them so you baby then sometimes you can just tell them to move you know just ask them to wiggle their hips it's just but you want to make sure you have a support surface in a chair of a patient's confined to a wheelchair they need the support surface in that future repositioning techniques you're gonna turn them but is there anything to remember when you're turning a patient from side to side I'm even ours what else how far do you turn them right you limit that they have any bed about elevation does he can anybody tell me why we do that we talked about it while ago when you gather decide which is more important at the time but you're still going to even if they're COPD you can limit the time that they're up more than 30 degrees yeah you know we we feed patients in bed sometimes they're gonna be up but you still need to lower them after you know reasonable time after they've had their meal to less than 30 degrees you want to transfer without lateral shear that means you don't drag you lift are you used a slide sheet that that doesn't cause friction floating appeals how do we float heals anything pillows are good in the VA system what else do we have ex crevel on boons alright and see a lot of times when you go on a unit you see people in wheelchairs are in the jury tears how do you see him seated how does it posture a lot of them are slumped forward and they're putting pressure on the coccyx that's why I'm saying when they're up in a chair and they're at risk you need to have a support surface like a ROHO cushion even though a crate cushion although I I'm not real fond of a crate petitions because they don't last very long but that's better than nothing Diane talked about pain it does have a big effect on wound healing and it's part of your pressure ulcer prevention and assessment you have to assess their pain it affects their physical psychological and spiritual well-being a lot of times if a person is in pain they don't sleep they don't eat they become anxious or very irritable it limits their mobility it limits their ability to change positions you know we want to we want to relieve their pain pain causes stress stress releases cortisol cortisol impedes wound healing it also makes you more prone to skin pretty so you want to reduce the pain at all times but then what about painful dressing changes especially if you're gonna beauty frequent you need to think about what you can do to reduce the pain and if you manage the pain it enhances wound healing in a cellular level just because of the chemicals that are dumped into your body when you're in pain they impede the wound healing so if you can relieve the pain then your you have a better chance of patient and Family Education it must be an appropriate reading level does anybody know what the optimal reading level is for the majority of patients twenty fourth and fifth grade the teaching you given must be consistent with their goals and their needs you know their goal may be I just want to get out of here you have to say well you know if you want to get out of here there are some of the things we need to do along the way and you have to make sure they understand what you're telling them you have to get them to repeat back to your demonstrate a knowledge of what you've been teaching and you must document that you've taught them because that's part of your your pressure ulcer prevention if they come in here and a patient's developed an ulcer and they asked you what did you teach this patient about prevention would you know would it be in the chart because I know that his nurses were busy and I know we're always providing education but do we always take time to put it in the chart and that's something we need to do it's a really important part of the prevention program and that you have documented and you documented the response to your teaching whatever that may be okay when you're documenting you must document it they recommend as a pressure ulcer prevention program that you document in the medical record in a specific location so would you know where to look in the chart to look for the the assessment like the initial assessment on patient for for those of you in the VA system where would you look in the chart to find out their initial assessment for skin exactly you have to the this in assessment is the the assessment includes all the combination of your inspection and your nutritional you know your risk analysis everything your documentation has simply the assessments has to include the interventions has to include does this patient need a pressure prevention now some of our patients on the the brain skill they don't they don't we say they don't need a prevention program because if they're no risk or low risk how often do we update that assessment in that risk level I think it depends on what type of unit you're on I think most of the long-term care units its weekly for the first four weeks and then monthly but you can do it more often there's no regulation that says you can't do it more often and if there's a change you need to do it you have to document skin care what skin care are you providing you know that doesn't just include wound care that includes are you providing lotions for dry skin are you using a barrier cream because this patient has a problem with incontinence and then if they do have a crusher ulcer how are you managing that what kind of treatment are you providing for that we and we'll talk about this later in the morning boo use uniform descriptors they an refer to same egg-shaped or you know it was the size of a grapefruit that type of thing we need to all be on the same page using measurements metric measurements if it's oval if it's round of the square if it's an irregular shape whatever and when you provide wound care are you decide not to provide wound care that day for some reason you need to document it because how does the next day's nurse know that that one care was done how does he or she know what you did and also they want you to measure pressure ulcers at a set frequency per facility proper policy here we measure weekly we can measure out more often and sometimes we do measure more often now what is the purpose of measuring late so that way you know if you have a stalled moon orbits were Singh and it was worsening or stalled what do you need to do you've got to change your interventions and we talked about photography so far I don't think our facility allows us to photograph I kind of wish they would I think it would give everybody even though we can all describe it it's like the three men that we're blindfolded and describing the elephant you know when described ahead one described hotel one describe the years it was nothing like the other if you can see it you know in addition to the descriptors it's consistent across the board and you need to provide accurate and effective handoff communication anybody tell me what that means well what if you're getting a patient in from somewhere and from another VA facility and you've read the vein odd and it says they have a stage two and you're getting rapport and you ask you skin breakdown those and those skin breakdown and you see their last assessment it was done two days ago it says they have a stage two but yet they arrived and there's nothing you can't find you can't find the also they're talking about or conversely you know they say yeah they have a stage two and then they get here you know I mean they tell you report there's a stage two because they read it in the chart but when they get here you can't find it that's why it's so important that when you admit a patient or a patient comes to you that you do an inspection on admission so you know what was present on admission to your unit not what some other nurse documented you need to document exactly what was was there when you go and by the same token if you're sending a patient to an appointment somewhere and they have a wound you might want to make sure you communicate that to the clinic you're sending the patient to it's there that's a new document that you've communicated that to whoever the wouldn't assessment you're going to include the anatomical location that's what we're saying about using descriptors you need is it lateral is it medial is it coccygeal is a sacral you know is it a trochanter is an issue you have to to use those terms for your documents and then you know you need to extend the tissue involvement is it full thickness is it partial thickness if it's a pressure sir what stages event or what state you know is it a stage three that is healing you know you don't say well it was a stage three and today it's a stage two you don't reverse stage you want to describe what the wound base look like is it granule eyes is it is there s car is there sloth what color is it and you can express that that in percentages like if 30 percent of the wound is yellow then you need to document that and like Diane was saying on the head-to-toe basis you can use a clock face and say at 3 o'clock there's between 1:00 and 3:00 there's about 30% and then the tissue color the peri wound conditioned we've talked about the macerated edges the raw edge is you know is there redness is there there bruising what is it the one measurement in shape any extra day you want a description of the x-ray is it sanguine and Sarah singers is it creamy as it Pureland is it green and any odor you may not can describe the odor but if there's odor present you say malodor I mean most of us in here as nurses we know different smells I know the ones smell I can identify right off the back is Pseudomonas you just look at the color and you get that smell and you know when you're measuring the wind size you're going to measure the length at the point of the greatest length head to toe and the width is side to side the depth it's most humbly done there's Diane said by placing a cotton swab and then measuring that tunneling tunneling and undermining it's also measured with a swath and the location is documented like it is a clock face with 12 o'clock being the head of the patient this club being their feet the push tool and that's a pressure ulcer staging healing tool it was developed by the National pressure ulcer advisory panel to monitor change of pressure officers over time and I sorry I didn't have to print that but it's a week-to-week document that you document the size it's a measurement the size of the wound the exudate the wound bed and those three things are rated and you obtain a score and then you plot it on the graph to show improvement or worsening over time that's part of your pressure ulcer prevention program in the hospital not all all ulcers are pressure ulcers you have to assess the wound to make sure really is a pressure ulcer is it over bony prominence was it caused by medical device you know or is it a diabetic foot ulcer not all ulcers are pressure ulcers pressure ulcers for the most part of preventable but you have to make sure that you have prevention measures in place and then you follow those prevention measures you have to accurately document one of the things that we're trying to do on the unit I work on and I think throughout this facility is that at least to our ends weekly lay eyes on the wound and we both agree on what the wound is where it is in the measurements and we both sign the note that way there is consistency now is that realistic to somebody so we don't have to our is to do that so we can't always do it but we crying so in pain control you need to really be assessing your patients level of pain and is that pain coming from the wound is it worsening pain is it changed do you notice if you're the one that's consistently doing the wound care and you've been doing the wound care in this patient who's never complained of pain and all of a sudden you see them jumping and flinching when you're doing wound care you know something's changed and you need to to investigate that and find out what's going on pressure ulcer prevention is a team effort not just one person can do it you have to involve your your team and the team includes the the providers the physicians then there's practitioners includes RN C includes LV ins it includes the CNAs and you've got to make sure that you communicate with them that their input is important and that you want to know what's going on if they see something that you haven't seen you want them to be able to come and tell you the elements of a successful pressure ulcer prevention program include skin inspections on a daily basis because things can change on a daily basis you want to do a risk assessment and as I said you want to do that anytime things change you want to do it at least on a weekly basis on the long-term care unit for the first four weeks and then monthly thereafter on acute units I think the policy is you do it daily or every other day or not sure which you want to make sure that you if there they have a problem with pressure that you have if they need a support surface that you've got the ball rolling to get the specialty bad or whatever or that you're offloading like with Preble on boots you're offloading their heels our diabetics podiatry works real well with us here about getting rug boots to offload pressure on people's feet you want to maintain the skin health that means you know if your patient hasn't bathed in a week and they really don't want to bathe yes they have the right to refuse but you sometimes have to do what you can to talk them into it you need to assess their nutrition and hydration you need to remember that sometimes it's just as simple as which is just like a drink of water mr. Smith and pouring them a cup of water in handy too and then patient and family education they need to know what caused pressure ulcers they need to know they need to either be if they're able to be up out of the bed and moving not just lay around they need to know that that if they can move they should be repositioning themselves if they can't move we need to be in there repositioning and a family needs to be involved in in that as well see buddy got any questions before we take a short break yes ma'am for a minute okay I would rent them for the time that they're in there is that best you know because that truly is you're not going to let them get up and walk because if they're and I see you a lot of times they're like you said they're either intubated they're two different various machines so for that time period they're bad fast but then when they become you know they go down to like the PCU or to the floor then that assessment would change and their risk factors would change I'm gonna let Diane help me with this one because this this is a bone of contention among some of the nurses I work with – absolutely I think it's a it's a really it's tricky and I wish that I had we had actually developed an anatomical chart that we are trying to incorporate as part of our documentation so the nurses are consistent with what they're talking about probably the best way to think about it is coccyx if you think about where the where the crack stops that's your coccyx sacrum is the area surrounding that probably the best way I can pick up to describe down so the coccyx is actually sort of centered within the larger sacral area but think about coccyx you're really talking about the tailbone that's where the crack stops and then sacrum is the area around it above that have you seen the Leoben dressings that are to keep the one for the coccyx okay the sacrum is like she's saying the big area and then the little where it almost looks like a tailbone at the end that's the coccyx we'll also call that a signal so yeah I think the big thing is you know an accession especially to I think one of the things that Sri made a big point about that was really important is when you're assessing it you know especially for the initial assessment I have a couple of clinicians look at it at the same time and then agree ok well this looks like it's the sacral area so let's document in this was April or this is a right issue we've read that this is right in this show so we're gonna call it this so maybe you know even confirming that was another clinician can be really helpful so that way you have consistency how many of you are from the GA system ok I'm going to go I know that like Diane said we're working on a pocket chart that's laminated that have its marked with anatomical locations and it's marked with the descriptors and hopefully they'll be out sometime soon for everybody to have they won't pay for avoidable pressure ulcers is my understanding yeah the voidable and it's it's just like the other big thing right now after all it is urinary tract infections from Foley's you know that is a situation where they're they're limiting reimbursement because it occurred because of our our care or lack of care or whatever but why do we do all the care and still have that picture also because the patient refused to walk them so this many refused payment I would think that would be one that they I really don't know the answer to that question but I think that's one that you could fight because but you would have to have your documentation you would have to say this is what we talk to the patient this is our recommendations this is how the patient responded to those recommendations and it's refusing these things many of our patients that will go down and smoke exactly instead of think you should I think I think you very well should because as nurse you're going to be documenting your teaching that you're going to teach them that smoking interferes with their wound healing and it interferes with their circulation so this is what I'm saying it's very important to document that document what you a must of time you can get the doctor will say we have offered them you know the nicotine patches or we've offered them whatever smoking cessation classes and they choose not to do that and that is their choice they have rights as an individual we can't force these treatments upon them if this is not something they want every every time that you make an effort to educate it's always critical to document every single episode where you made that effort to educate them or to advise them or to counsel them document what you taught document their response that will help cover in response to you know what you were asking about with the with the issue of the hospital-acquired yeah that was a huge issue that came out in 2008 there are a series of what CMS calls never events they're basically hospital-acquired conditions for which CMS is saying no we're not going to pay you because we think that you could have prevented it catheter-associated urinary tract infections is one another one of course our stage three or greater pressure ulcers the thing that has become a real issue is it does help in your defense and also from a litigation perspective as well it helps in your defense if you have documentation that supports that you made efforts to address that non-compliance I don't know what the final rulings are for CMS when there are issues of non-compliance but I do know that from a litigation perspective in doing in doing you know med mal cases it is very defensible if you have documentation that supports that the patient was not compliant but I think that's where we fail a lot of times we our documentation we don't take credit for their education we've provided and we don't document the response and that's a very important part of the plan anybody else okay we're going to take about a ten minute break and then we'll go to the next one baby baby I know

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