11/7/2015 1 Director of Public Policy and Education American Medical Technologies Idaho Pressure Ulcer Prevention Coalition presents THE BRADEN AND BEYOND PRESENTER PAMELA SCARBOROUGH DPT, CDE, CWS, CEEAA Disclaimer The information presented herein is provided for the general well-being and benefit of the public, and is for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.
Transcript
11/7/2015
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Director of Public Policy and EducationAmerican Medical Technologies
Idaho Pressure Ulcer Prevention Coalitionpresents
THE BRADEN AND BEYOND
PRESENTER
PAMELA SCARBOROUGHDPT, CDE, CWS, CEEAA
DisclaimerThe information presented herein is provided for the general well-being and benefit of the public, and is for educational and informational purposes only. It is for the attendees’ general knowledge and is not a substitute for legal or medical advice. Although every effort has been made to provide accurate information herein, laws change frequently and vary from state to state. The material provided herein is not comprehensive for all legal and medical developments and may contain errors or omissions. If you need advice regarding a specific medical or legal situation, please consult a medical or legal professional. Gordian Medical, Inc. dba American Medical Technologies shall not be liable for any errors or omissions in this information.
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Learning Objectives The attendee will be able to report components
of the Braden Scale for pressure ulcer risk assessment
The attendee will be able to report three patient specific interventions related to Braden Scale prediction of risk
The attendee will be able to report three appropriate referrals to the IDT to promote reduced pressure ulcer risk in those patients at risk of pressure ulcer development
Why Prevention?
National priority
Decrease incidence
Survey Process
Reimbursement may be affected in future
Framework for identifying unavoidable PrUs
Facility reputation
IMPROVED QUALITY OF LIFE
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Essential Components
PRESSURE
ULCER
PREVENTION
PROGRAM
Skin Inspection Risk Assessment Pressure redistribution and
offloading Maintaining skin health Nutrition & hydration Patient & family education
Skin vs. Risk Assessment
Skin
• Skin health• Variations• Age/disease
related changes
• Skin health• Variations• Age/disease
related changes
PrU
Ris
k • Immobility• Nutrition• Sensation• Moisture
• Immobility• Nutrition• Sensation• Moisture
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Skin AssessmentBaseline for Comparison
Complete skin Assessment: Essential Part of Your PrU Prevention Program
• ANY associated pain or discomfort• Understanding changes associated with aging skin• Identifying threats to skin (endogenous, exogenous)• Recognizing residents comorbidities and their overall
health status
• Frequency of inspection may need to be increased if any deterioration in overall condition of resident
• Obtaining an initial skin assessment upon admission for EVERY RESIDENT OR PATIENT is crucial for developing an individualized PrU prevention program
Consider capillary refill exam of most common areas for pressure ulcers in those patients/residents with significantly impaired mobility, • Sacrum• Trochanter• Malleolus• Other risk areas associated
with bed positioning
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Prevention of PrU’s
• “A key to prevention is early detection of at risk patients with a valid and reliable PrU risk assessment instrumentand timely interventions”
• Intent: To predict risk of a chronic wound problem before it occurs
Prevention Risk Assessment Central component of Clinical Practice
Mobility Assessing accurately for mobility impairments and
implementing a mobility plan of care is probably the most important component of a pressure ulcer prevention program
Bed mobility
Roll side to side
Hold side lying position
Scooting up in bed
Lying to sitting
Sit to stand
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Rehab Can Help Ensure your rehab team involved with residents who
have mobility & activity issues OT & PT can assist in evaluating & treating residents
with mobility issues by improving: Strength Body movement strategies in bed & chair Sitting & standing balance Teaching residents, staff, & family members
how to use adaptive equipment (i.e., transfer/gait belts, walkers, canes)
Restorative program
Therapists also provide assessments & make suggestions or create proper seating interventions when sitting mobility issues
Nutrition
1. Very Poor
2. Probably Inadequate
3. Adequate
4. Excellent
1. Never a complete meal
2. Only ½ of any food offered
3. Eats > ½ of most meals
4. Eats most of every meal.
Nutrition How?
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Friction & Shear
1. Problem
2. Potential Problem
3. No Apparent Problem
1. Mod-Max assist
2. Min. assist
3. Moves independently & Maintains good position.
Friction & Shear How?
Braden Scale Scores
At Risk = 15 - 18
Moderate Risk = 13 - 14
High Risk = 10 - 12
Very High Risk = 9 or below
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If other major risk factors are present - e.g., age, fever, poor dietary intake of protein, diastolic pressure <60, and/or hemodynamic instability…
Advance Level of Risk
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Case Study Previously active independent 68 y/o female
with L-partial hip replacement 5 days ago due to femoral neck fracture after fall in home
Admitted to skilled services for nursing and rehab with goal of returning to daughter’s home for continued recovery rehab with home health.
Vitals: T=99.6, R=17, BP=92/58, P=100bpm Goal: return to highest level of functionality as
an independent community ambulator and return to her personal home to live alone
Let’s do the Braden together
New femoral head
Braden ParametersSensory Perception1. Completely
Limited2. Very Limited3. Slightly Limited4. No Impairment
Moisture 1. Constantly Moist2. Very Moist3. Occasionally
Moist4. Rarely Moist
Activity1. Bedfast2. Chairfast3. Walks
Occasionally4. Walks Freq.
Mobility 1. Completely
Immobile2. Very Limited3. Slightly Limited4. No Limitations
Clinicians performing the Braden should review methods for scoring correctly
Surveyors may check medical records for use & accuracy of the risk assessment with corresponding subscales
In-services on how to perform and use the risk assessment scale are important components of the pressure ulcer prevention program and should be required for all nurse managers and other individuals delegated the task of completing the risk assessment
In addition, a quality assurance (QA) review is recommended to ensure accurate determination of the subscales of the risk assessment tool being used 32
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Nutrition for PrU Prevention
Screen/ assess the nutritional status of everyone at risk for pressure ulcers in each health care setting.
Use a valid, reliable and practical tool
Have a nutritional screening policy in place along with recommended frequency of screening for implementation
Refer each person with nutritional and pressure ulcer risk to a registered dietitian
Refer to a multidisciplinary nutritional team
registered dietitian, a nurse specializing in nutrition, physician, speech/language therapist, occupational therapist, when necessary a dentist
Nutrition Issue Indicators What are some indicators that your
residents/patients may have nutrition impairments putting them at risk for a pressure ulcer?
Name 41. ?2. ?3. ?4. ?
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Nutrition Issue Indicators What are some indicators that your
residents/patients may have nutrition impairments putting them at risk for a pressure ulcer?
Name 41. ?2. ?3. ?4. ?
a. Little or no appetiteb. Problems with oral healthc. Swallowing issuesd. Refusing to eate. Eating inadequate servings of nutrientsf. Depressiong. Functional impairment in handling eating utensilsh. Medications that decrease appetitei. Medications that dry mouth tissuesj. Medications that change the taste of foodsk. Cognitive impairments
Hydration Issue Indicators
What are some indicators that your residents/patients may have hydration impairments putting them at risk for pressure ulcer and slowed wound healing?
Name 2
1. ?
2. ?
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Repositioning & Early Mobilization
Reposition all individuals at risk of, or with existing pressure ulcers, unless contra-indicated
Regular positioning is not possible for some individuals because of their medical condition, and an alternative prevention strategy such as providing a high-specification mattress or bed may need to be considered.
Repositioning Common, effective intervention
Person with PrU Person at risk for developing PrU Critical for immobile residents - those dependent upon staff
for repositioning Plan of Care
Risk of friction/shearing with repositioning May require the use of lifting devices
Positioning the resident on an existing pressure ulcer should be avoided Adds pressure to compromised tissue May impede healing
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REPOSITIONING FREQUENCY
• NPUAP discusses repositioning in-depth • Frequency of repositioning: influenced
by several variables
• Tissue tolerance• Level of activity or mobility• General medical condition• Overall treatment objectives• Assessments of skin condition
HIGH RISK AREAS
Consider: not all pressure ulcersare over bony prominences.
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REPOSITIONING TECHNIQUES Use 30-degree tilted side-lying position
alternate: right, back, left side Prone if individual can tolerate;
medical condition allows Avoid postures that increase pressure
90-degree side-lying Semi-recumbent
Who is teaching this to the CNA? How are you monitoring
repositioning in your facility?
REPOSITIONING TECHNIQUES
Avoid pressure / shear forces Use transfer aids Lift—don’t drag
Avoid positioning directly on medical devices Avoid positioning on bony prominences with existing
pressure ulcers or non-blanchable erythema Continue to turn and reposition
regardless of support surface used Do not use ring - or donut-shaped
devices Do not apply heating devices
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Seating Considerations
• Select posture acceptable for the resident
• Posture that minimizespressures and shear
• Ensure that the feet are properly supported either directly on the floor, on a footstool, or on footrests when sitting (upright) in a bedside chair or wheelchair.
• Limit time spent in chair without pressure relief
2014 NPUAP Guidelines for Heels
General Recommendations
Inspect the skin of the heels regularly. (SoE=C; SoR=)
Repositioning for Preventing Heel Pressure Ulcers
Ensure that the heels are free of the surface of the bed. (SoE=C; SoR=)
Ideally, heels should be free of all pressure — a state sometimes called ‘floating heels’.
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Heel Suspension Devices
Use heel suspension devices that elevate and offload the heel completely in such a way as to distribute the weight of the leg along the calf without placing pressure on the Achilles tendon.
Heel suspension devices are preferable for long term use, or for individuals who are not likely to keep their legs on the pillows.
2014 NPUAP Guidelines for Heels
The knee should be in slight (5° to 10°) flexion. Indirect evidence that hyperextension
of knee may cause obstruction of popliteal vein, which could predispose an individual to DVT.
Avoid areas of high pressure, especially under the Use a foam cushion under the full length of the calves to elevate heels.
Pillows or foam cushions used for heel elevation should extend the length of the calf to avoid areas of high pressure, particularly under the Achilles tendon.
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2014 NPUAP Guidelines for Heels
Apply heel suspension devices according to the manufacturer’s instructions. (SoE = C; )
Remove the heel suspension device periodically to assess skin integrity. (SoE= C; )
Separate and protect ankles Maintain heel suspension “floating heels” Prevent foot drop or planter flexion contractions Exterior slides over bed sheets
for freedom of movement Pressure distribution for
calf within device Works for left of right leg/foot Holds foot in neutral position without external rotation
(foot turning out putting pressure on lateral ankle)
Support Surfaces and Repositioning for Prevention of Pressure Ulcers
How many of you have a support surface team?
How are you matching your resident to the mattress overlay, bed or chair cushion?
WHAT IS A SUPPORT SURFACE? (Per the NPUAP)
• A specialized device for pressure redistribution • Designed for management of:• tissue loads• micro-climate,• and/or other therapeutic
functions• Any mattresses,
integrated bed system, mattress replacement, overlay, or seat cushion, or seat cushion overlay
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Immersion and envelopment reduce tissue stress
Increasing the contact area between the support surface and individual’s body
Allowing for pressure redistribution
HOW SUPPORT SURFACES WORK
www.npuap.org
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CMS Support Surface Groups
Group 1 Group 2 Group 3
Support Surfaces & Pressure Redistribution
• Match a device’s potential therapeutic benefit with the resident’s specific situation
– Multiple ulcers
– Limited turning surfaces
– Ability to maintain position
• Effectiveness is based on their potential to address
– Individual resident’s risk
– Resident’s response to the product
– The characteristics and condition of the product
• Examples of these surfaces or devices include:– 4-inch convoluted foam
pads
– Gel pads
– Low loss air mattresses
– Air fluidized beds
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CMS: Avoidable Pressure Ulcers
Resident developed a pressure ulcer and the facility DID NOT DO one or more of the following: Evaluate the resident’s clinical condition and pressure
ulcer risk factors Define and implement interventions that are
consistent with resident needs, goals, and recognized standards of practice
Monitor and evaluate the impact of the interventions
Revise the interventions if appropriate
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CMS: Unavoidable Pressure Ulcers
Resident developed a pressure ulcer even though the facility:
Evaluated the resident’s clinical condition and risk factors
Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice
Monitored and evaluated the impact of the interventions
Revised interventions as appropriate
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Documentation of Repositioning
“Record repositioning regimes, specifying frequency and position adopted, and include an evaluation of the outcome of the repositioning regime.
Documentation provides a written record of care delivery and, as such, serves as evidence that repositioning has occurred.”
Health Professional EducationRecommendations
1. Assess knowledge and attitudes of professional staff regularly using reliable and valid assessment tools appropriate to the clinical setting.
2. Develop an education policy for pressure ulcer prevention and treatment at an organizational level.
3. Provide regular evidence‐based pressure ulcer prevention and treatment education.
Evaluate learning outcomes before and after implementing an education program.
4. Tailor training and education on pressure ulcer prevention and treatment to both the needs of members of the healthcare team as well as the organization.
5. Utilize interactive and innovative learning in the design and implementation of a pressure ulcer prevention and treatment education program
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Summary Education of ALL care givers: First step in
prevention!!! Policy on Prevention – evidence-based &
best practice Individualized risk assessments Implement early interventions for ALL
risk levels Assess, reassess, reassess risk for PrUs Educate, educate and educate
again…ALL (IDT)
Team Effort
"Taking the Pressure out of Wound Care Since 1994."
“The strength of the team is each individual member. The strength of each member is the team.”
