Gauging Pressure Ulcers: A Nursing Home’s Guide to Prevention and Treatment

Gauging Pressure Ulcers: Introduction Pressure ulcers are a significant problem across all ages and health care settings. Multiple factors put residents at risk for developing a pressure ulcer, including immobility, chronic illness, incontinence, poor nutrition, altered level of consciousness, altered sensory perception and a history of having pressure ulcers.1 Pressure ulcers come at a high cost to everyone. They result in pain, suffering, diminished quality of life and even death for some residents. For a nursing home, they represent extra staff hours and medical supplies spent caring for a preventable condition, as well as more residents hospitalized. The cost of treating a single full-thickness pressure ulcer can be as high as $70,000, with the total treatment cost for pressure ulcers in the US surpassing $11 billion per year.2 Although pressure ulcers are preventable, more than one in every 10 of Missouri nursing home residents developed a pressure ulcer in 2007. The Centers for Medicare & Medicaid Services has long focused on helping nursing homes prevent pressure ulcers, but in 2008 they extended this effort across care settings. Hospitals now have a payment incentive to partner with nursing homes on pressure ulcer prevention – a good thing since 20 percent of nursing home pressure ulcers originate outside the nursing home, generally in the acute hospital setting. No matter where you are in your prevention efforts, now is the time to take a look at your care processes with fresh eyes. First, review what the law says about pressure ulcers. See this toolkit’s summary of the federal guidelines – Understanding CMS Interpretation of Tag F314. Then, use the included Pressure Ulcer Facility Assessment Checklists to take a critical look at your current practices. Every one of these systems is crucial to pressure ulcer prevention, so take your time completing this assessment. As you assess, call on other staff to help you answer questions completely and honestly. Once you’ve completed the assessment and identified key areas for improvement, review the clinical reference tools, reminder tools and sample forms included in this toolkit. Feel free to adapt them to meet your individual needs.

1 2

Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review. JAMA. 2006; 296: 974-984. Reddy M, Gill SS, Rochon PA. Preventing pressure ulcers: A systematic review.  JAMA. 2006;296:974-984.

Pressure Ulcers: Table of Contents This table of contents provides an overview of the assessment and clinical reference tools for pressure ulcers contained in this document. For further information, see the following pages for tool descriptions organized by section. If you’re viewing this document on your computer, click on the tool name in the table of contents below, and you will be taken directly to the resource. To download and print tools individually, go to www.primaris.org. I. Guidelines and Example Policies a. Understanding CMS Interpretation of F314 b. MDS Skin Condition Coding Tip Sheet II. Facility Assessment and Protocols a. Facility Assessment Checklists b. Sample Protocol III. Resident Assessment and Monitoring Tools a. Braden Scale b. Skin Tear Risk Assessment c. LTC Dehydration Risk Assessment d. Comprehensive Admission Skin Assessment e. Licensed Nurse Weekly Skin Assessment f. CNA Shower Assessment g. Daily Skin Monitoring Tool h. Systems Investigative Audit Tool IV. Prevention Tools a. Pressure Ulcer Prediction, Prevention and Treatment Pathway b. Tissue Tolerance and Individualized Turning Schedule c. Managing Tissue Loads d. Support Surface Characteristics and Considerations V. Treatment Tools a. Treatment Product Categories b. Nutritional Wound Healing Guidelines c. Selected Characteristics for Support Surfaces VI. Communication Among Providers a. SBAR Skin Care Instructions VII. Facility/Staff Education a. Staging Guidelines from National Pressure Ulcer Advisory Panel b. Pressure Ulcer Classification Pocket Cards (see www.primaris.org) c. CNA Knowledge and Attitude Survey

Pressure Ulcers: Tool Descriptions I. Guidelines and Example Policies Understanding CMS Interpretation of F314: Summarizes the changes that CMS put into place with the revision of F-Tag 314. Any time you make changes, quickly review this summary to ensure that you are meeting federal guidelines. MDS Skin Condition Coding Tip Sheet: Use this tip sheet to see, at a glance, how your coding questions might be addressed by the RAI manual.

II. Facility Assessment and Protocols Facility Assessment Checklists: Complete this checklist as you review your approach to pressure ulcer prevention and treatment. It will help determine your plan’s comprehensiveness, its alignment with F-Tag 314 and good clinical practice. Sample Protocol: Use this protocol as a guideline for establishing a comprehensive Pressure Ulcer Prevention and Management Policy. Download the file as a separate Word document and modify it to suit your practices and materials.

III. Resident Assessment and Monitoring Tools Braden Scale: The Braden Scale is a research-based risk assessment used widely in the nursing community. The format allows for four separate assessments to aid in monitoring change over time. Skin Tear Risk Assessment: Evaluating for skin tear risk and interventions is different than evaluating for pressure ulcer risk. The skin is our first line of defense, and we must protect the skin not only from pressure ulcers but from skin tears as well. This assessment helps determine if a resident is at risk for skin tears and offers potential interventions and a chart review audit, encouraging staff follow-through. LTC Dehydration Risk Assessment: Inadequate fluid intake can place residents at increased risk for pressure ulcers. This tool will help determine resident dehydration risk, enabling staff to take a proactive approach. Comprehensive Admission Skin Assessment: Conducting a baseline comprehensive assessment of the skin is vital. Staff may use this form to guide them through the assessment. Licensed Nurse Weekly Skin Assessment: All residents should have their skin assessed weekly by a licensed nurse. This form encourages continuity in this documentation. CNA Shower Assessment: This form recognizes the important role CNAs play in pressure ulcer prevention and empowers them to do regular skin checks. It provides a formal method of communication to the licensed nurses of their review of residents’ skin, which then would be followed up by the licensed staff. Daily Skin Monitoring Tool: This tool provides a formal approach for CNAs to report areas of concern with the resident’s skin daily. The licensed staff would then follow-up on noted areas of concern to provide a complete assessment. Systems Investigative Audit Tool: Use this tool as a guide during a chart review to ensure all appropriate steps are being taken for pressure ulcer prevention and management.

continued on next page >

Pressure Ulcers: Tool Descriptions IV. Prevention Tools Pressure Ulcer Prediction, Prevention and Treatment Pathway: This pathway assists staff in determining the appropriate care for the individual resident. It aids in staff critical thinking skills to ensure all areas of concern are met. Tissue Tolerance and Individualized Turning Schedule: This form can be used to document the assessment that led to the individualized turning schedule. Managing Tissue Loads: Use this tool to systematically choose the right mattress or wheel chair cushion, based upon a resident’s level of need. Support Surfaces: Characteristics and Considerations: Use this in-depth reference to learn more about the different support surfaces available for pressure ulcer prevention or treatment.

V. Treatment Tools Treatment Product Categories: Use this list outlining the major types of products to ensure your nursing center carries an appropriate range of materials for pressure ulcer treatment. Nursing staff should choose the most effective dressing type based on wound stage, characteristics and potential concerns. Nutritional Wound Healing Guidelines: This sample procedure helps enhance pressure ulcer healing by providing recommendations for nutritional intervention whenever possible. These are guidelines only. Individual patient and resident needs must be taken into consideration before implementation. Selected Characteristics for Support Surfaces: This quick visual reference compares the characteristics of the different types of support surfaces.

VI. Communication Among Providers SBAR Skin Care Instructions Form: Provides a standardized format for communication using the SBAR (Situation, Background, Assessment, Recommendations) model. This form would be used in communication from wound care nurse to unit nurse for the prevention and/or management of pressure ulcers.

VII. Education Resident and Family Education Brochure (PUP): Use this brochure to proactively inform residents and families about individual risk factors and prevention techniques associated with skin breakdown so they can be be involved in prevention. Staging Guidelines (National Pressure Ulcer Advisory Panel): These are the most up-to-date guidelines for assessing the state and the subsequent documentation of pressure ulcers. Pressure Ulcer Classification Pocket Cards: Two double-sided reference cards were designed to assist clinical staff in the assessment, measurement and documentation of wounds. Go to www.primaris.org to download a pdf of the cards. Primaris partner homes may order laminated copies. CNA Knowledge and Attitude Survey: CNAs’ participation is vital for the prevention of pressure ulcers. This survey will assess what your CNAs know about pressure ulcers and discover areas in which they could benefit from further education.

Understanding CMS Interpretation of F314 This document summarizes key points of CMS guideline Tag F314, which state surveyors use as guidance to help them assess nursing homes’ pressure ulcer prevention and treatment. Use this as guidance for assessing the processes in place at your home with regard to pressure ulcer prevention, assessment, intervention, monitoring and care planning. Regulations: Pressure Ulcers F314 42 CFR 483.25 (c) Pressure sores

Based on the comprehensive assessment of a resident, the facility must ensure that – • A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable; and • A resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing” F314 Intent

• Promote the prevention of pressure ulcer development • Promote healing of pressure ulcers that are present • Prevent development of new pressure ulcers Survey: Pressure Sore Investigative Protocol

Objective: • To determine if the identified pressure sore(s) is avoidable or unavoidable • To determine the adequacy of the facility’s pressure sore treatment interventions Risk Management • Identify and manage resident and facility risks • Prevention of pressure ulcers benefits everyone • Educate all staff on an ongoing basis • Provide care based on accepted standards of practice (WOCN, AHQR, NPUAP) • Document care based on accepted standards • Make Care plans realistic especially when discussed with family in care plan conferences • Watch for indicators of major system failures and initiate quality improvement activities • Document facts, not assumptions • Rising litigation –– What happens when the treatment sheet is not signed off? –– What happens when one lapse in weekly assessment occurs in a period where the wound declines? –– *Careful with dressings that stay on several days: What happens with weekly assess? –– Carefully consider policies on wound photography: may be “double-edge” sword

Understanding CMS Interpretation of F314: page 2 Three Key Factors for Risk Management

• Medical record must show standard of care for pressure ulcers was adhered to • Medical record must have documentation of resident complications, risk factors, and/or underlying disease that made the pressure ulcer unavoidable (if it is indeed) • You must provide a comprehensive and aggressive program to prevent and treat the pressure ulcer (within the parameters of resident advance directives) Prevention • What systems are in place in your facility? –– How is risk communicated to staff? –– Are there protocols for repositioning and pressure relief products that are understood by staff? –– How are you sure this is done for new admissions or those with change in status? –– Residents cannot afford to wait! • How are moisturizers/barriers stocked? • During “off-hours,” do staff know how to access pressure-reducing devices? • Are tracking and assessment forms stocked? • How are disposable briefs and underpads stocked and used? Assessment Avoidable vs. Unavoidable Pressure Ulcers

• Avoidable – Pressure ulcer developed and facility failed to do one or more: ▷▷ Defined/implemented interventions CONSISTENT with resident needs, goals ▷▷ Recognized standards of practice (AHCPR, AMDA, WOCN, current literature) ▷▷ Monitor and evaluate impact of interventions ▷▷ Revise interventions appropriately • Unavoidable – Resident developed pressure ulcer although facility: ▷▷ Evaluated clinical condition and risk factors ▷▷ Defined and implemented interventions consistent with resident’s needs, goals, standards of practice ▷▷ Monitored and evaluated impact of interventions ▷▷ Revised approaches appropriately Frequency of Risk Assessment (Braden or Norton most common)

• Minimally ▷▷ upon admission ▷▷ quarterly ▷▷ upon Significant Change in Condition • Best Practice ▷▷ day 7, 14, 21, 28 (post-admission) then as above ▷▷ during acute illness

Understanding CMS Interpretation of F314: page 3 Wound Assessment

• • • •

Assessment includes a full description of the wound and peri-wound Measurements alone do not constitute an assessment Reassess weekly at a minimum Reassess daily if pressure ulcer is deteriorating

Staging Assessment

• • • •

Does your facility policy address your process for staging? Who does initial staging? How is it confirmed? What are you staging? All open areas or only pressure ulcers? Is there a facility tool for documenting staging?

Risk Assessment – Facility Wide

• • • •

Establish written guidelines, protocols, algorithms/decision trees based on risk Low risk does not equal no risk Let low scores trigger your mind clinically: don’t just treat the conglomerate of score Use appropriate interventions based on the risk assessment

Interventions Address Risk Factors

• • • • • • •

Skin care: routine inspections, cleansing, moisturizing, avoid massage Repositioning: 1 hour in chair by staff, 15 minutes in chair by resident; 2 hours in bed Pressure relief for heels Pressure reduction devices Address nutrition Address incontinence Toileting schedule? Rehab? Positioning evaluations? Incontinence products?

Combination of Prevention Interventions

• • • •

Adequate nutrition and hydration Repositioning schedule and positioning Appropriate support surfaces Care of skin

Monitoring Wound Status Is It Better or Worse?

• Objectively review wound progress: measurements, type of tissue, PUSH tool • Subjective assessments are problematic: –– “I don’t think this treatment is working. I’m calling the MD to change the treatment…” –– “The pressure ulcer is deeper than last week - of course it is worse” - not necessarily true

Understanding CMS Interpretation of F314: page 4 Monitoring Treatment Plan • Is there a process for monitoring treatment? • Is there a tracking tool to document response to treatment? • Does the tracking form monitor the appropriate wound variables? • Are there protocols for changing the treatment if it is ineffective? • Healing - a systemic process affected by systemic conditions - treatment is more than a dressing • When do you change the treatment? • What determines frequency of dsg change • How do you handle “non-traditional” recommendations or a product being used in a manner different than its intended use? Care Planning • Do care plans identify risk factors? • Are you treating the risk factors? • Is the resident and family aware of and in agreement with goals? • Goal must be a clear statement of intended progress and how it will be measured • Be REALISTIC!!!! • Determine what the goal is: –– Maintenance –– Improvement/Healing –– Comfort –– Many goals beyond healing… ▷▷ Resolution of periwound erythema in 2 weeks ▷▷ 25% reduction in amount of necrotic tissue by 1 week ▷▷ Decrease in intensity of pain during dressing changes from 6 to 3 (as reported by resident) by 1 week ▷▷ 1 cm reduction in wound dimensions by 2 weeks

Document available at www.primaris.org MO-08-11-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from CMS Provider Certification, Transmittal 4, November 12, 2004; HCPro Pressure Ulcer Materials, 2004; & Pressure Ulcers F-314 by Courtney Lyder, September 2004

MDS Skin Condition Coding Tip Sheet Definition According the RAI Manual “A skin ulcer can be defined as a local loss of epidermis and variable levels of dermis and subcutaneous tissue, or in the case of Stage 1 pressure ulcers, persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.” (RAI Manual, pgs. 3-159)

CodingM1 - recording of all skin ulcers if caused by pressure or circulatory problems. 1. M1 - recording of all skin ulcers if caused by pressure or circulatory problems.

4. M4 - records skin problems or lesions not caused by pressure or circulatory problems.

2. M2 - differentiates between pressure or venous stasis ulcers only; record highest level of each.

5. M5 - records any specific or generic skin treatments.

3. M3 - history of resolved/cured ulcers. Definition same as for M1.

6. M6 - records specific foot problems and care.

Process 1. Review the record and check with appropriate nursing staff for the presence of any skin problems. 2. Examine the resident for condition (stage, number) of any skin problems. Coding will be based on what is seen (i.e. visible tissue) during the look back period. NPUAP standards cannot be used for coding on the MDS. MDS defined staging is used for M1 and M2 only. 3. Determine the cause of the skin ulcer. If it is caused from pressure or circulation (venous or arterial) then it is coded in M1. All remaining skin ulcers then are documented in

M4. (See pg 3-159) Record the number of skin ulcers caused by either pressure or circulatory problems according to stage for M1. M2 is for coding the highest stage of pressure or venous stasis ulcers only. 4. Include in M4 all skin problems not caused by pressure, venous stasis, circulatory problems or not coded anywhere else in Section M. 5. Code all skin treatments in M5. 6. Code all foot problems and care in M6.

Clarification 1. Necrotic eschar prohibits accurate staging. Code the skin ulcer with eschar as Stage 4 until debrided. 2. Good clinical practice dictates that the ulcer be reexamined and re-staged after debridement. 3. If a skin ulcer is repaired with a flap graft, it is coded as a surgical wound and not as a skin ulcer.

4. Skin ulcers should be coded in either M1, with further clarification in M2, or in M4. Pressure or stasis ulcers coded in M2 should not be coded in M4. 5. If skin ulcers are captured in M1 or M4, good clinical practice would also have something documented in M5 under treatment. 6. For MDs coding, ankle problems are not considered foot problems.

Documentation 1. For clinical practice facilities need to follow the NPUAP standards in regards to pressure ulcer documentation (i.e. Healing stage 4 that has the appearance of tissue size and depth of a stage 2- the clinical record will state a healing stage 4, but the MDS would have Stage 2 in M1.)

2. Document weekly assessments of the wound healing progress or lack of. Documentation should include a thorough description of size, drainage, etc. 3. Care planning should identify risk factors and interventions based on the identified level of risk, as well as interventions to facilitate healing of existing skin problems.

Example 1. Mrs. B has impaired arterial circulation to her right foot. She has a Stage 3 in appearance on the top of her foot. She also has a superficial skin tear on her right forearm. M1 would be coded as a Stage 3 ulcer, M2 would be coded with 0 (zeros) and M4a would be checked for the skin tear. M5d, e and g may be checked, depending on specified interventions. M6c would be checked.

Document available at www.primaris.org MO-08-47-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Pressure Ulcers: Facility Assessment Checklists A facility system assessment is a starting point for a quality improvement project. The checklists included in this booklet will be most useful if you take a critical look at your current practices.

Directions for Pressure Ulcers: Facility Assessment Overview Questionnaire • To be completed by a direct care or interdisciplinary team. • Consult with appropriate staff in answering certain questions and completing checklists. • If you answer “No” to any of the questions below, please proceed immediately to the checklist referenced by the page after the question. • If you answer “Yes” to a question, the process is always complete and done so consistently. Please continue to the next question. • If you answer “In Progress” to any of the below questions, the need is being addressed but needs improvement.

Pressure Ulcers: Facility Assessment

Yes

No

In Progress

Does your facility have a process to screen residents for pressure ulcer risk? (page 2)

o

o

o

Does your facility have a process to develop and implement care plans for residents who have been found to be at risk or have a pressure ulcer? (pages 3-4)

o

o

o

Does your facility complete a comprehensive assessment for residents who are found to have pressure ulcers upon screening or, if there is no screening process in place, another time? (page 5)

o

o

o

For residents who have pressure ulcers, does your facility have a process for monitoring treatment and prevention? (page 6)

o

o

o

Does your facility have a policy for pressure ulcer prevention and management? (page 7)

o

o

o

Does your facility have initial and ongoing education on pressure ulcer prevention and management for all relevant staff? (page 8)

o

o

o

When completing each checklist on the following pages: • If you answer “Yes” to all of the questions, the process is always complete and done so consistently. Continue to the next checklist. • If you are not sure, or answer “No” to one of the questions, choose one or more elements on which to focus your quality improvement. • If you answer “Needs Improvement” to one or more of the questions, the process is not always complete and/or not always done consistently.

Pressure Ulcers: Facility Assessment Checklists: page 2 Pressure Ulcers: Screening for Pressure Ulcer Risk A screening assessment is a brief assessment or question that determines if the resident is at risk for pressure ulcers. It does not include a thorough assessment of the pressure ulcer or what needs to be done if the resident is found to have a pressure ulcer upon screening. Does your facility’s screening process include the following components? Do you screen all residents for pressure ulcer risk at the following times? Upon admission Upon readmission When change in condition With each MDS assessment If resident is not currently deemed at risk, is there a plan to rescreen at regular intervals? Do you use either the Norton or Braden pressure ulcer risk assessment tool? (If yes, STOP. If No, please continue to next question.) Note: Federal regulations (F-314) recommend the use of standardized risk assessment tools.

Yes

No

Needs Improvement

o o o o o

o o o o o

o o o o o

o

o

o

If you are not using the Norton or Braden risk assessment, does your screening address the following areas? Impaired mobility: Bed

o

o

o

Chair

o

o

o

Urine

o

o

o

Stool

o

o

o

o o

o o

o o

o o o o

o o o o

o o o o

Incontinence:

Nutritional deficits: Malnutrition Feeding difficulties Diagnosis of: Diabetes mellitus Peripheral vascular disease Contractures Hx of pressure ulcers

Completed by:________________________________________ Date:_______________________________

Pressure Ulcers: Facility Assessment Checklists: page 3 Pressure Ulcers: Developing Care Plans Does the resident care plan address the following interventions and risk factors (as they apply)? Impaired mobility Assist with turning, rising, position Encourage ambulation Limit static sitting to 1 hour at any one time Pressure relief Support surfaces – bed Support surfaces – chair Pressure relieving devices Repositioning Check for “bottoming out” in bed and chair (To determine if a patient has bottomed out, the caregiver should place his or her outstretched hand, palm-up, under the mattress overlay below the existing pressure ulcer or that part of the body at risk for pressure formation. If the caregiver can feel that the support material is less than an inch thick at this site, the patient has bottomed out.) Nutritional improvement Supplements Feeding assistance Adequate fluid intake Dietician consult as needed Urinary incontinence Cause identified and treated as appropriate Toileting plan Wet checks Treat causes Assist with hygiene Fecal incontinence Cause identified and treated as appropriate Toileting plan Soiled checks Skin condition check Check intactness Color Sensation Temperature

Yes

No

Needs Improvement

o o o

o o o

o o o

o o o o

o o o o

o o o o

o

o

o

o o o o

o o o o

o o o o

o o o o o

o o o o o

o o o o o

o o o

o o o

o o o

o o o o

o o o o

o o o o

continued on next page >

Pressure Ulcers: Facility Assessment Checklists: page 4 Pressure Ulcers: Developing Care Plans

Treatment Physician prescribed regimen Appropriateness to wound staging Treatment reassessment time frame Pain Screen for pain related to ulcer Choose appropriate pain med Provide regular pain med administration Reassess effectiveness of med Assess/treat side effects Change, increase or decease pain med as needed Infection Dressing containment Keep dressing dry/intact Assess for s/sx infection

Yes

No

Needs Improvement

o o o

o o o

o o o

o o o o o o

o o o o o o

o o o o o o

o o o

o o o

o o o

Completed by:________________________________________ Date:_______________________________

Pressure Ulcers: Facility Assessment Checklists: page 5 Pressure Ulcers: Assessment and Reassessment Does your comprehensive pressure ulcer assessment include the following components?

Do you have a tool available to document pressure ulcer assessment?

Yes

No

Needs Improvement

o

o

o o o o o o o o

o o o o o o o o

o o o o o o o o

o o

o o

o o

o o o o o o o o

o o o o o o o o

o o o o o o o o

o o o o

o o o o

o o o o

o

Does your current assessment of pressure ulcers include: Location Stage Size Undermining/tunneling Wound bed (tissue) Drainage/exudate Peri wound tissue (color, temp, bogginess, and fluctuation) Need for debridement Is the resident’s pressure ulcer reassessed: Weekly Daily if worsening or high risk Does reassessment include: Size Tunneling Sinus tracts Presence of necrotic tissue Exudate Granulation Epithelialization Color photos, diagram, or drawing Are the following related factors considered in your assessment/reassessment: Mechanical forces (shearing, friction, pressure) Pronounced bony prominences Poor nutrition Altered cutaneous sensation

Completed by:________________________________________ Date:_______________________________

Pressure Ulcers: Facility Assessment Checklists: page 6 Pressure Ulcers: Monitoring Treatment and Prevention Does your facility’s process for monitoring treatment and prevention include the following?

Yes

No

Needs Improvement

o

o

o

o o o o o o o

o o o o o o o

o o o o o o o

Does your facility have protocols to follow if current pressure ulcer treatment is ineffective?

o

o

o

Does your facility have protocols to follow if ulcers are found to be non-healing?

o

o

o

Does your facility monitor pressure ulcers for the presence of infection (e.g., foul smell, greenish drainage, cellulitis, osteomyelitis)? Is there a list of possible interventions for the resident at each level of risk (low, moderate, or high), that nursing staff may implement to prevent pressure ulcer development? Does your facility have a protocol for management of tissue loads (e.g., positioning, pressure relieving mattresses, dynamic mattress overlay)? Are there adequate supplies to provide preventive interventions to all residents who require them (e.g., adequate pressure reducing or relieving mattresses/chair cushions)?

o

o

o

o

o

o

o

o

o

o

o

o

Are pressure reducing or pressure relieving mattresses/chair cushions in good repair?

o

o

o

Are pressure reducing/relieving supplies available to staff on all shifts and whenever needed? Does your facility have protocols regarding pressure ulcer prevention that includes the following:

o

o

o

o o o o o

o o o o o

o o o o o

Does your facility use a pressure ulcer tracking tool to document treatment and healing? (If “No,” skip to question 3.) Does the tracking form include the following: Date Stage Current treatment Color photo, diagram, or drawing Size Depth Appearance (e.g., redness, presence of discharge, eschar formation)

Monitoring residents for incontinence Need for assistance with mobility and bed mobility Weight loss Nutritional deficiency Dehydration

Completed by:________________________________________ Date:_______________________________

Pressure Ulcers: Facility Assessment Checklists: page 7 Pressure Ulcers: Elimination Does the pressure ulcer elimination process include the following components?

Yes

No

Needs Improvement

Does your facility’s policy include a statement regarding your facility’s commitment to pressure ulcer prevention and management?

o

o

o

Does your facility’s policy include screening, assessment, and monitoring of residents for pressure ulcers?

o

o

o

Does your facility’s policy address measures that should be taken to prevent pressure ulcers in residents?

o

o

o

If the resident is not currently deemed at risk, does your facility’s policy state that residents should be screened for pressure ulcer risk at regular intervals?

o

o

o

o o o o

o o o o

o o o o

o

o

o

Does your facility’s policy address steps to be taken if pressure ulcer is not healing?

o o o o o o

o o o o o o

o o o o o o

Does your facility’s policy address a protocol for communication of reporting pressure ulcer staging/healing to the designated MDS personnel to ensure correct coding?

o

o

o

Does your facility’s policy state that residents who are at risk for pressure ulcers be screened at the following times: Upon admission Upon readmission When a change in condition occurs With each MDS assessment Does your facility’s policy state that residents at high risk for pressure ulcers should be screened daily?

Does your facility’s policy include who, how, and when pressure ulcer program effectiveness should be monitored and evaluated? Prompt assessment and treatment Specification of appropriate pressure ulcer risk and monitoring tools Steps to be taken to monitor treatment effectiveness Pressure ulcer treatment techniques that are consistent with clinically-based guidelines Optimize the resident’s ability to perform ADLs and participate in activities

Completed by:________________________________________ Date:_______________________________

Pressure Ulcers: Facility Assessment Checklists: page 8 Pressure Ulcers: Staff Training and Education Does your facility’s training and education program include the following components?

Yes

No

Needs Improvement

Are new staff assessed for their need for education on pressure ulcer prevention and management?

o

o

o

Are current staff provided with ongoing education on the principles of pressure ulcer prevention and management?

o

o

o

Does education staff provide discipline-specific education for pressure ulcer prevention and management?

o

o

o

Is there a designated clinical “expert” available at the facility to answer questions from all staff about pressure ulcer prevention and management?

o

o

o

Is the education provided at the appropriate level for the learner (e.g., CNA vs. RN)?

o

o

o

Does the education include staff training on documentation methods related to pressure ulcers (e.g., location, stage, size, depth, appearance, exudate, current treatment, effect on ADL’s, pressure relieving devices used, nutritional support)?

o

o

o

Completed by:________________________________________ Date:_______________________________

Document available at www.primaris.org MO-08-16-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Sample Protocol Implement a protocol and accompanying strategies such as those below to help guide th care of residents at risk for developing pressure ulcers. At Risk

Moderate Risk

High Risk

Very High Risk

Systematic skin inspection









Turn/reposition every 2 hours (if mobility impaired) or more often if needed

 





Turn/reposition every 2 hours and prevent direct contact between bony prominences Protect heels









If bedfast, provide pressure-reducing support surface









If in wheelchair, provide pressure-reducing seat cushion









If appropriate, initiate remobilization program (therapy if appropriate, ambulation, stand-pivot transfers, restorative nursing etc)









Manage moisture (from incontinence)









Manage nutrition









Reduce friction/shear















Supplement turning schedule with small position shifts (hourly)





Obtain rehab assessment to: • Determine need for pressure relief cushion • Assess correct seat height and w/c positioning





Provide wedges/repositioning aids for 30 degree lateral positioning

Consider a pressure relieving support surface or powered mattress overlay



Written plan of care









Staff education









Sample Protocol: page 2 Sample risk reduction strategies: Skin inspection: All residents should be inspected at least daily. This can be done with dressing, undressing, toileting, bathing, peri-care, etc. Pay particular attention to bony prominences. Minimize exposure to low humidity. Moisturize dry skin. Turning and repositioning: Keep bony prominences from direct contact using systematic turning and repositioning and positioning devices such as pillows or foam wedges. Avoid positioning directly on the trochanter. Determine tissue tolerance. Wheelchair Positioning: OT evaluate for proper fit to wheelchair and appropriate pressure relieving device. Reposition and off load eight hourly – stand if possible. Try to use at least three different chair types daily to alter pressure points. If residents are able, teach or cue them to shift their own weight every hour. Use a pressure-reducing device such as those made of foam, gel, air or a combination of the two. Do not use donut-type devices. Heel Protection – Friction: To prevent friction, use “gripper” socks, sheepskin at foot of bed, transparent dressings or skin sealants, protective dressings (such as hydrocolloids), moisturizers Heel Protection – Pressure: Keep ALL weight off residents’ heels. Elevate lower extremities with pillows length-wise under lower legs, multi-podus boots, heel-lift boots, loosen bed linens at foot of bed, foot cradle Manage Incontinence: Initiate bowel/bladder program or scheduled toileting, incontinent care every two hours, incontinence barriers, briefs, absorbent underpads (made with materials that absorb moisture & present a quick drying surface to the skin), fecal bag (if frequent stools). Avoid hot water, and use a mild cleansing agent that minimizes irritation and dryness. Manage Nutrition: Monitor for weight loss. Assess for chewing or swallowing problems. Provide a combination of: dietician consults, supplements, vitamin supplements, hydration, feeding assistance, adaptive equipment. Reduce friction/shear: Draw sheet or lift pad for bed movement, trapeze, moisturize skin, limit head of bed elevation to 30 degrees (and only as required), long sleeve garments/elbow protectors, careful cleansing during incontinence/hygiene care, gait belt transfers (as appropriate), mechanical lift Pressure relieving mattress/overlay: Pressure reducing mattress types include, foam, static air, alternating air, gel or water mattresses Written plan of care: Each resident’s care plan should be unique, including specific turning and repositioning plans. Indentify and address each factor noted in the Risk Assessment. Staff Education: Target prevention at all levels of health care, from providers to residents and families. Identify the role each plays in pressure ulcer prevention. Implement a comprehensive pressure ulcer prevention program.

References: Agency for Health Care Policy and Research (1994). Treatment of Pressure Ulcers. AHCPR Pub. No 95-0652.University of Iowa Nursing Interventions Research Center. Prevention of Pressure Ulcers American Medical Directors Association. Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA 2008 Source: QIPMO: University of MO-Columbia, Sinclair School of Nursing, April 2008

Document available at www.primaris.org MO-08-14-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Braden Scale for Predicting Pressure Sore Risk Resident Name (Last, First, Middle)____________________________________________________________ Room #:__________ Attending Physician:_________________________Date of Assessment:______________ Assessment Date: Risk Factor

Score/Description

Sensory Perception Ability to respond meaningfully to pressurerelated discomfort

1 = Completely Limited 2 = Very Limited 3 = Slightly Limited 4 = No impairment

Moisture Degree to which skin is exposed to moisture

1 = Constantly Moist 2 = Often Moist 3 = Occasionally Moist 4 = Rarely Moist

Activity Degree of physical activity

1 = Bedfast 2 = Chairfast 3 = Walks Occasionally 4 = Walks Freqeuently

Mobility Ability to change and control body position

1 = Completely Immobile 2 = Very Limited 3 = Slightly Limited 4 = No Limitations

Nutrition Usual food intake pattern 1NPO: Nothing by mouth 2IV: Intravenously 3TPN: Total parenteral nutrition

1 = Very Poor 2 = Probably Inadequate 3 = Adequate 4 = Excellent

Friction and Shear

1 = Problem 2 = Potential Problem 3 = No Apparent Problem

1

2

3

Total Score High Risk: Total score ≤ 12. Moderate Risk: Total score 13-14. Low Risk: Total score 15-16 if under 75 years old or 15-18 if over 75 years old

For Detailed Descriptions, see page 2 Assess

Date

Evaluator signature/title

Assess

1

3

2

4

Date

Evaluator signature/title

NOTE: This form is copyrighted. Permission to reproduce this form may be obtained at no charge by accessing www.bradenscale.com/copyright.asp

page 1 of 2

4

Braden Scale for Predicting Pressure Sore Risk: page 2 Sensory Perception

Nutrition

1 = Completely Limited. Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation OR limited ability to feel pain over most of body. 2 = Very Limited. Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness OR has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body. 3 = Slightly Limited. Responds to verbal commands, but cannot always communicate discomfort or the need to be turned OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. 4 = No impairment. Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.

1 = Very Poor. Never eats a complete meal. Rarely eats more than ½ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement OR is NPO1 and/or maintained on clear liquids or IV2 for more than 5 days. 2 = Probably Inadequate. Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feeding. 3 = Adequate. Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement if offered OR is on a tube feeding or TPN3 regimen, which probably meets most of nutritional needs. 4 = Excellent. Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.

Moisture 1 = Constantly Moist. Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. 2 = Often Moist. Skin is often, but not always moist. Linen must be changed at least once a shift. 3 = Occasionally Moist. Skin is occasionally moist, requiring an extra linen change approximately once a day. 4 = Rarely Moist. Skin is usually dry; linen only requires changing at routine intervals.

Activity 1 = Bedfast. Confined to bed. 2 = Chairfast. Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3 = Walks Occasionally. Walks occasionally during day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. 4 = Walks Frequently. Walks outside room at least twice a day and inside room at least once every 2 hours during waking hours.

Friction and Shear 1 = Problem. Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction. 2 = Potential Problem. Moves feebly or requires minimum assistance. During a move, skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down. 3 = No Apparent Problem. Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times.

Mobility 1 = Completely Immobile. Does not make even slight changes in body or extremity position without assistance. 2 = Very Limited. Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3 = Slightly Limited. Makes frequent though slight changes in body or extremity position independently. 4 = No Limitations. Makes major and frequent changes in position without assistance.

Document available at www.primaris.org

MO-08-12-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. © Copyright Barbara Braden and Nancy Bergstrom, 1988. Reprinted with permission.

Skin Tear Risk Assessment Resident:____________________________________________________________ Date:__________________ This form should be completed in conjunction with the Skin Risk Assessment, in accordance with facility policy (on admission, readmission, quarterly, and with a significant change in condition). Check “Yes” or “No” if the item reflects the resident’s assessment. If the answer is “yes” to three or more of the items listed below, consider implementation of the “Skin Tear Prevention Protocol.” Skin Tear Risk Assessment

Yes

No

Reduced mental status History of skin tears

o o o

o o o

Dehydration

o

Self-abusive behavior

o o

Poor nutritional status

Thin, translucent skin

Yes

No

Resistant to care

o o o

o o o

o

Bruises easily (If yes, total number of bruises:__________)

o

o

o o

Skin Tear Prevention Protocol To Be Implemented

o

o

History of syncope or unsteady gait History of aggressive behavior

Skin Tear Prevention Protocol When the Skin Tear Risk Assessment identifies that the resident is at risk for skin tears, the nurse will review this protocol and indicated pertinent interventions on the treatment record. The nurses on the unit, not the treatment nurse, manage this protocol, which includes: 1. Provide covering for legs, such as long pants, heavy stockings, tube socks, or stockinet 2. Provide covering for arms, such as, stockinet, long sleeved shirts, or gowns. 3. Application of Kling for arms or legs ensuring no tape on skin. 4. Send inappropriate clothing home with the family so that it is not put on the resident by mistake. If the resident has no family, put the clothing in storage with the resident’s name on it. 5. Re-evaluate the necessity of side rails and if still necessary pad the side rails on the bed. Care plan for potential isolation due to the use of padded side rails. 6. Notify activities not to place the resident very close to another resident. 7. Use two staff members for all care performed as appropriate. 8. If the resident becomes combative or resists care, stop the care and return after the resident calms down. Try to identify what triggered the behavior. Adjust the care plan as necessary to include potential interventions. 9. Provide lotion to the skin routinely. 10. Assess the resident’s overall skin condition on a weekly basis – mark completion of this task on the treatment record. 11. Maintain hydration for the resident. 12. Examine equipment (e.g. wheelchair, bed, bedrails) for sharp edges that could potentially harm the resident. Notify maintenance if appropriate. Consult therapy in assisting with appropriate padding when necessary. 13. Notify Dietician to adjust diet as necessary. Nurse Signature:___________________________________________ Date Protocol Initiated:___________________

Skin Tear Risk Assessment: page 2 Skin Tear Risk Assessment and Prevention Protocol—Audit Related Federal Standard: “Quality of Care” Audit Objectives: To evaluate the application and use of the facility’s skin tear risk assessment. To evaluate the application and use of the facility’s skin tear prevention protocol. To identify that identified residents receive care based on the skin tear prevention protocol. Resident Sample: All residents in the facility who have received a risk assessment and residents that have been identified to be at risk for developing skin tears. Audit Sample Size: _____ residents that were assessed for skin tear risk _____ residents that were placed on the skin tear prevention protocol Time Period of Evaluation: ___________________________________________through: _________________ Commencement Date of Study:_ ______________ Expected Completion Date of Study: _________________ Criterion No.

1

2

3

Audit Criteria The Skin Care Risk Assessment is used to assess for risk of skin tear: a. Upon admission b. Upon readmission c. Each quarter d. With a significant change in status The Skin Tear Risk Assessment is complete: a. Resident name b. Total score is indicated c. Indication if Skin Tear Protocol is to be implemented d. Date assessment completed e. Nurse’s signature If Prevention Protocol was indicated, it was implemented: a. Interventions were identified on the protocol form b. Interventions were placed on treatment record c. Interventions were identified on care plan d. Implementation date is indicated e. Nurse’s signature is present

Document available at www.primaris.org

Exceptions

Instructions for Data Retrieval

None

Skin Care Risk Assessment

None

Skin Care Risk Assessment

Residents at risk Skin Care Prevention for skin care Protocol

MO-08-08-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.

LTC Dehydration Risk Assessment Resident Name:_____________________________________________________ Date:_ __________________ Check all conditions that apply to this resident. The greater the number of items checked, the greater the risk for dehydration. Initiate a plan of care if necessary based on your findings.

Medical Conditions/History:

Medications:

o Diabetes o CHF o CVA o Dementia o Depression o Major Psychiatric Disorder o Renal Disease o > 4 Chronic Conditions

o ≥ 4 medications o Diuretics o Laxatives o Steroids o ACE inhibitors o Psychotropics/antipsychotics o Antianxiolytics o Tricyclic Antidepressants or Lithium

History of: o Repeated infections o Dehydration o Malnutrition o Constipation

Intake Ability Status

Current Status: o Age ≥ 85 o Female gender o Language/speech difficulties o Cognitive Impairment o Unable to request fluids o Unaware of thirst o Recent change in mental status o Any physical immobility o Recent change in ability to carry out ADLs o Restraints o Falling episodes o Urinary incontinence o Decreased urinary output o Constipation or diarrhea o Current fever and/or infection o Vomiting o Recent rapid weight loss (>3% / 30 days) o Draining wound o Lethargy/weakness o Increased combativeness/confusion o Readmission from > 1 day hospital stay o Lab/Studies involving NPO or dyes

o Swallowing difficulties o Refuses fluids o Dislikes fluids/foods offered o Fluid restriction o Requires assistance to eat/drink o Poor eater (eats < 50% of each meal) o Holds food/fluid in mouth o Drools o Spits out food/fluid o Spills fluids o Tube fed o IV fluid therapy

Laboratory Abnormalities:

(or steady increase even if within normal range) o Urine Specific Gravity o Urine color dare yellow > 4 o BUN/Creatinine > 20:1 -or o  in BUN + stable Creatinine level o Serum Sodium o Serum Osmolality o Hematocrit > normal o BMI < 2 or > 27

Knowledge Issues: o Lack of understanding about fluid needs o Lack of understanding about causes of dehydration o Cultural barriers about hydration, reporting thirst, end of life issues

Comments:_ _______________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ Nurse’s Signature:___________________________________________________________________________

Document available at www.primaris.org MO-08-05-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Comprehensive Admission Skin Assessment Resident:________________________________________________ Date:_____________________________ Perform a visual assessment of a resident’s skin upon admission. Report any areas of concern to the charge nurse immediately. Forward any areas of concern to the next shift. Initiate a plan of care to address the problem and alert the CNAs. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and chart all abnormalities by number. Indicate on the body chart any areas of concern: A = Abrasion(s)

ST = Skin Tear(s)

B = Bruise(s)

SU = Stasis Ulcer(s)

PU = Pressure Ulcer(s)

SW = Surgical wound(s)

S = Scar(s)

O = Other

Narrative Note: Note site, length, width, depth, drainage, odor, pain and any other defining characteristics. __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________

Nurse Signature:_________________________________________________________ Date:_ ____________________

Document available at www.primaris.org

MO-06-07-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.

o o o o o o o o

o o o o o o o

No

o

Yes

MO-08-09-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.

Document available at www.primaris.org

Licensed Nurse Signature: _________________________________________________ Date: __________________

8

7

6

5

4

3

2

1

Any reddened areas that remain after 30 minutes of pressure reduction? Comments: __________________ _____________________________________________ Any rashes? Comments: ________________________ _____________________________________________ Any bruises? Comments: ________________________ _____________________________________________ Any open lesions, cuts, lacerations, or skin tears? (Indicate even if being treated.) Comments: ________ _____________________________________________ Any blisters? Comments: ________________________ _____________________________________________ Any open ulcers (indicate even if being treated.) Comments: ___________________________________ _____________________________________________ Excessively dry or flaky skin? Comments: ___________ _____________________________________________ Any edema? Location: __________________________ _____________________________________________

Weekly Skin Assessment

If any questions are answered “yes,” indicate location on body outline with number of question.

Resident: ______________________________________________________________ Date: ____________________ Room #:_________________ This form should be completed weekly on all residents per facility policy. Any areas of skin requiring treatment should have a thorough record of documentation in addition to this form located elsewhere in the chart per facility protocol. Check “Yes” or “No” if the item reflects the resident’s assessment. If the answer is “yes” to 3 or more of the items listed below, consider implementation of the “Skin Tear Prevention Protocol.” Review the care plan to ensure skin care is included as necessary.

Licensed Nurse Weekly Skin Assessment

Skin Monitoring: Comprehensive CNA Shower Review Perform a visual assessment of a resident’s skin when giving the resident a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately. Forward any problems to the DON for review. Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. Resident:________________________________________________ Date:_______________________

Visual Assessment 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15.

Bruising Skin tears Rashes Swelling Dryness Soft heels Lesions Decubitus Blisters Scratches Abnormal color Abnormal skin Abnormal skin temp (h-hot/c-cold) Hardened skin (orange peel texture) Other:__________________________

CNA Signature:__________________________________________________________ Date:_ ____________________ Does the resident need his/her toenails cut? Yes

No

Charge Nurse Signature:__________________________________________________ Date:_ ____________________ Charge Nurse Assessment:____________________________________________________________________________ _________________________________________________________________________________________________ Intervention:_______________________________________________________________________________________ _________________________________________________________________________________________________ Forwarded to DON: Yes

No

DON Signature:__________________________________________________________ Date:_ ____________________

Document available at www.primaris.org MO-08-42-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.

Skin Monitoring: Daily Skin Check Skin checks are to be completed daily for residents. A good time to do them is during AM and PM care and during bathing time. List the resident name, type and site (as listed below) of observed impaired skin integrity.

Diagram Key Types

Sites

• Bruises (B) • Skin tears (ST) • Pressure ulcers (PU) • Scabs (S) • Other (O)

• Ears, RT or LT (E) • Shoulders (S) • Arms (A) • Back of Head (H) • Coccyx (CO) • Legs (L) • Shin (SH) • Knees (K) • Feet (F) • Heels (HE) • Hands, front (HF) • Hands, back (HB) • Other (O)

Resident Name

E

E H E

E

S A

A

S

A

A CO

HF

L K

L

HF

L

L

K

SH SH F F

Type

HE HE Site

Staff Name:_ _____________________________________________ Completion Date:___________________

Document available at www.primaris.org MO-08-43-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

1. Resident is screened within 24 hours of admission for risk of skin breakdown using a standardized risk-screening tool. 2. An appropriate pressure ulcer prevention or treatment care plan was put into place within the first 24 hours of admission for all residents whether high or low risk and according to current CPGs. 3. Skin/wound assessments/reassessment were done at appropriate intervals according to determined levels of risk and current CPGs, • Full skin assessment at least weekly with detailed documentation, according to CPGs, of wound condition, if present • At least daily monitor pressure sites and areas of skin changes • Progress of wound healing is reassessed q2-4 weeks and treatment plan re-evaluated if no evidence of progress noted 4. The care plan incorporated the following care needs as well as all identified risk factors: • Needs for turning/positioning were identified • Positioning/pressure relief product needs were identified and utilized consistently and properly • Nutrition assessment was completed and identified needs included in the care plan • Individualized skin care needs were identified and included in the care plan • Interventions were included from all disciplines for either pressure ulcer prevention or treatment 5. Care plan interventions were implemented as indicated.

Criteria:

6. Care plan was consistently evaluated and revised, based on current resident assessed needs. 7. Documentation of skin condition, intervention for risk factors, treatment of existing pressure ulcers and evaluation of effectiveness was timely, consistent, and follows recommended CPGs. 8. An appropriate system for communicating to all direct-care staff skin risk factors, interventions and changes in the plan of care was in place and functioned properly. 9. Responsibility and accountability was assigned for each phase of the pressure ulcer prevention/treatment process. • Those designated as responsible and accountable for monitoring the processes of pressure ulcer prevention/treatment carried out their responsibilities in a timely manner 10. Policy and protocols are updated and communicated to all staff according to current clinical practice guidelines. 11. The QA/CQI committee had processes in place to track and identify patterns and to determine the root cause of skin breakdown events. • Identified solutions were system-oriented • Content of staff education was determined by competency evaluations and identified areas of weakness 12. If resident self-determination was a contributing factor in pressure ulcer development, reasonable counsel, education and alternatives were provided.

• NOTE: the following audit criteria are broad. Select a current clinical practice guideline (CPG), or utilize the facility assessment tool for pressure ulcers to guide your detailed audit.

Purpose: To evaluate the decision-making process and adequacy of the facility’s process in the prevention of pressure ulcers and appropriateness of treatment protocols.

Systems Investigative Audit: Pressure Ulcer Prevention/Treatment

Skin needs care plan was in place within 24 hrs of admission

Assessments and reassessments done at appropriate intervals

Care plan incorporates all identified risk factors

Interventions are implemented as indicated

Care plan shows evidence of timely revisions based on assessed resident needs

Skin condition, interventions and evaluation of interventions documented

Staff demonstrates awareness/ understanding of care plan content.

Accountability is evidenced by those responsible for monitoring, assessment and follow-up

2.

3.

4.

5.

6.

7.

8.

9.

Chart 2

Chart 3

Chart 4

Chart 5

Chart 6

Comments

Date of review: _____________________________

MO-08-17-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Document available at www.primaris.org

12. Resident/family education provided

11. QA/CQI meetings focus on root-cause analyses

10. Skin policy/protocols are current & followed consistently

Admission risk assessment completed with appropriate tool

1.

Chart 1

Reviewer: ______________________________________________

Systems Investigative Audit: Pressure Ulcer Prevention/Treatment: Page 2

Pressure Ulcer Prediction, Prevention and Treatment Pathway Step One: Assess Skin Condition Resident is admitted or readmitted to SNF

Head-to-toe skin assessment (upon admission and weekly) Does the resident have a pressure ulcer? Yes

No

Pressure Ulcer Documentation

Overall Skin Condition Documentation

• Tunneling

• Color

• Incisions

• Width

• Necrosis

• Temperature

• Scars

• Depth

• Granulation

• Moles

• Intact skin

• Location

• Undermining

• Bruises

• Burns

• Stage

• Sinus tracts

• Exudate

• Pain

• Length

Report findings to physician

Report anything abnormal to physician

Obtain treatment order from physician

Obtain treatment order from physician if appropriate

Notify Family

Notify Family

Turn page Go to Step 2

Turn page Go to Step 2

Remember, if a patient is at risk or has a pressure ulcer, repeat Step One on a weekly basis.

Document available at www.primaris.org

Pressure Ulcer Prediction, Prevention and Treatment Pathway Step Two: Complete Risk Assessment to Identify Risk Factors and Care Plan Interventions Complete Skin Risk Assessment At Risk? Remember that those with a pressure ulcer are automatically at risk.

No

Repeat skin risk assessment at least every 90 days and significant change or per facility protocol

Yes

Yes

Care Plan Actual Skin Problem

Does the resident have a pressure ulcer?

No

Care Plan Potential Skin Problem

Complete Care Plan Problem Statement

Complete Care Plan Problem Statement

Skin integrity, impaired, actual as evidenced by (AEB) (Wound-specific description: Location, stage, and measurements)related to (R/T) identified risk factors

Potential for impaired skin integrity, as evidenced by (AEB), risk assessment indicates that the resident is at risk for skin breakdown related to (R/T) identified risk factors Possible Care Planning Interventions

Address Possible Risk Factors Bed/Chair Mobility

Yes

No Friction and/or

Yes

Shear No B/B Incontinence and

Yes

Moisture

Bed Chair • T/R schedule • Repositioning schedule • Pressure reducing/relieving • Pressure-relieving cushion device • Assessment of chair fit • Therapy consult Friction/Shear • Padding to prevent skin contact • Booties/heel protectors, elevate heels • HOB in lowest position possible, unless contraindicated by medical condition • Positioning devices Incontinence Moisture • Peri care after each incontinence • Remove incontinence • Clean as soon as possible after soiling brief while in bed • Barrier cream • Moisture barrier • Incontinent pads, incontinent briefs

No

Nutrition and body weight Nutrition and Body Weight

Perform Step Two at least every 90 days and with any significant change. Adjust care plan as needed.

Yes

No Other Residentspecific Risk Factors

Yes

• Weekly weight • Dietician consult • Labs • Food Supplements • Speech therapy

• Vitamin/medication supplements • Hydration • Feeding assistance • Assessment for chewing and swallowing problems

Other • Add any/all interventions related to identified specific risk factors

Document available at www.primaris.org MO-08-52-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

/

/

/

/

/

/

/

/

/

/

3:30 am

5:30 am

7:30 am

9:30 am

11:30 am

1:30 pm

3:30 pm

5:30 pm

7:30 pm

9:30 pm

Name

/

1:30 am

Initial

/

Desired position

Name

/

/

/

/

/

/

/

/

/

/

/

/

Actual position & initials

Check back after turned, red after 30 min? Indicate “no” or Location that is still red

Initial

Name

/

/

/

/

/

/

/

/

/

/

/

/

Check back after turned, red after 30 min? Indicate “no” Actual Desired position or Location that is still red position & initials

Initial

Desired position

Name

/

/

/

/

/

/

/

/

/

/

/

/

Actual position & initials

MO-08-13-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Adapted from Ratliff Care Center.

Initial

Check back after turned, red after 30 min? Indicate “no” Actual position or Location that is Desired still red position & initials

11:30 pm

Time

Date

Document available at www.primaris.org



Recommended times for change in position are noted with desired position. Codes: RS ( right side) LS ( left side) , B (back) OOB ( lift/shift in chair) W/C, HOB ( head of bed, raised seating) T (toileted) When repositioning check after 30 minutes to see if the bony prominence is still red. Report to nurse. Change every hour in W/C and at least ever 2 hours in bed. Do not raise HOB higher than 30 degrees unless directed by nurse.

Check back after turned, red after 30 min? Indicate “no” or Location that is still red

Resident: ______________________________________________________________ Date: ____________________ Room #:_________________

Tissue Tolerance and Individualized Turning Schedule

Managing Tissue Loads Appropriate Patient Positioning Key

Multiple large, truncal Stage III or IV ulcers?

Yes

Yes/No Decisions Interventions

No Able to keep ulcer off surface?

No Use device that moves air across skin

Yes

Yes

Patient at risk for additional ulcers?

No

No special surface needed

Yes

Skin moisture problem?

No Multiple turning spaces available?

Yes

Static device

No Dynamic overlay or mattress

Patient bottoms out?

Yes

Patient bottoms out?

Yes

No

No

Ulcer healing properly?

No Ulcer healing properly?

Yes Yes

Monitor

No Low air-loss bed

Yes

Ulcer healing properly?

No Air-fluidized bed

No

Reference: Quick Reference for Clinicians No. 15 Page 10 Developed by AHCPR

Ulcer healing properly??

Reevaluate plan of care

Document available at www.primaris.org MO-08-12-PUH August 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Yes Monitor

Support Surfaces: Characteristics and Considerations Specialty Beds Air-fluidized bed (also known as a “bead bed” or “sand bed ”) Product Characteristics: This is a bed frame containing silicone-coated beads incorporated in Gortex® covering. When air is pumped through the beads, they behave like a liquid, creating air and fluid support. The resident “floats” on a sheet with one third of the body above the surface and the remainder of the body immersed in the warm, dry, fluidized beads. When bed is turned off, the surface becomes firm to allow for repositioning. Helps manage copious wound drainage or incontinence by absorbing fluids into bed of silicone beads. Although there is some evidence that air-fluidized beds enhance pressure ulcer healing rates, surface interface pressure remains sufficiently high to occlude capillary perfusion. Occipital and heel ulcers have been reported to develop in patients while on an air-fluidized bed (Parish & Witkowski, 1980). Considerations: • Not recommended for mobile patients, patients with pulmonary disease or patients with unstable spine • Continuous circulation of warm, dry air may dehydrate patient or desiccate wound bed • Bed may get too hot or make room hot • Head of bed cannot be raised; semi-Fowler’s position achieved by using foam wedges or movable sling-type device • Coughing less effective in mobilizing secretions • Leakage of beads may irritate the eyes and respiratory track and make floor slippery • Width of bed may preclude care to obese patients or patients with a contracture • Height of bed makes some nursing care difficult, and a step is needed to facilitate care • Transfer of patient out of bed is difficult • Bed is heavy and not easily transferable • Some patients become disoriented or complain of feeling weightless while on surface • Dependent drainage of catheters may be compromised because the patient is immersed in the bed • Sharp objects may damage the surface • Size and weight may be too large for use in home setting •

Set up and maintenance provided by company

Low air-loss bed Product Characteristics: A bed frame with a series of connected air-filled pillows that can be calibrated for varying amounts of pressure to provide maximum pressure reduction for residents. Dry air flow between the patient and bed surface helps control moisture and heat buildup and prevents maceration and friction. Some models are designed to counteract the effects of immobility on pooling of respiratory secretions and urinary stasis by providing oscillation therapy. Other models feature kinetic therapy (rotating slowly side to side), although this is limited to a 20-degree rotation and does not have the same effect as manually rotating the resident side-to-side. Considerations: • Head and foot of bed can be raised and lowered • Transfers in and out of bed easily accomplished • Portable motor available to maintain inflation during bed transfers. • Motor may be noisy • Proper inflation essential to maintain effectiveness • Sharp objects may damage the surface

Support Surfaces: Characteristics and Considerations: page 2 •

Bed surface is slippery; patients may slide down or out of bed with being transferred

•

Heels need to be “floated” to totally relieve pressure

•

Set up and maintenance provided by company

Dynamic Overlays Alternating air-filled overlay Product Characteristics: Air is pumped through overlay chambers at regular intervals to provide cyclical pressure changes, creating a low-pressure and a high-pressure area. These surfaces constantly change pressure points and create pressure gradients that enhance blood flow. Cells with larger diameter and depth produce greater pressure relief over the body. A cell depth of not less than 3 inches is recommended. Considerations: • Surface is easy to clean • Assembly required • Sensation of inflation and deflation may bother patient • Electricity required • Motor may be noisy • Excessive or sudden surface movement may disturb sleep • Sharp objects may damage the surface • Bed surface is slippery; patients may slide down or out of bed with being transferred • Heels need to be “floated” to totally relieve pressure

Static Overlays Foam Overlay Product Characteristics: A foam surface applied over the surface of an existing hospital mattress. The following characteristics of foam influence the effectiveness of the overlay: base height, density and indentation load deflection (ILD). Base height refers to the height of the foam from the base to where the foam ridges begin and should be 3 to 4 inches to be effective in reducing pressure. Density refers to the weight per cubic foot and reflects the foam’s ability to support the person’s weight. Foam densities of 1.3 to 1.6 pounds per cubic foot are generally effective in supporting an average size adult. ILD is a measure of the firmness of the foam. It describes the foam’s compressibility and conformability. It also indicates the ability of the foam to distribute the mechanical load. Measurement of ILD is expressed as the number of pounds required to indent a sample of foam with a circular plate to a depth of 25% of the thickness of the foam. An ILD of approximately 30 pounds is recommended. Optimal support and conformability of foam is achieved when the relationship between 60% ILD and 25% ILD is 2.5 or greater (Krouskop & Garber, 1987; Whittemore, 1998). Considerations: • Plastic protective sheet is usually required for incontinent patients • Foam may trap perspiration and be hot • Washing removes flame-retardant coating • One-time charge, no reoccurring charges • No set up or maintenance fees • Cannot be punctured by needle or metal traction • Light weight

Support Surfaces: Characteristics and Considerations: page 3 •

Requires no maintenance

•

No electricity required to operate

•

May be hot and trap perspiration

•

Foam has a limited life

•

Lack of firm edge creates unsure surface when patient transferring on and off surface

•

Heels need to be “floated” to totally relieve pressure

•

Must be discarded when wet from drainage or incontinence

•

Adds height to the bed

Air Overlay Product Characteristics: Interconnected bubble-like cells that are inflated with an air blower to an appropriate pressure level. Optimum air level is defined as 1 inch or more of uncompressed support surface between bony area of the resident’s body and the caregiver’s hand when placed under the support surface. Cells with larger diameter and depth produce greater pressure relief over the body. A cell depth of 3 in. or greater is recommended. Considerations: • Easy to clean • Low maintenance • Repair of some products is possible • Durable • Can be damaged by sharp objects • Requires regular monitoring to determine proper inflation and need for reinflation • Heels need to be “floated” to totally relieve pressure • Adds height to bed • Lacks a firm edge, so transfer on and off surface may be difficult

Water Overlay Product Characteristics: A vinyl chamber that can be filled with water to appropriate level to distribute body weight evenly over the entire supporting surface. Recommended depth is 3 in. or greater. Some models contain a baffle system to control motion effects. Considerations: • Readily available in the community • Easy to clean • Requires water heater to maintain comfortable water temperature • Fluid motion makes procedures difficult (e.g. positioning) • Patient transfers may be difficult • Inadvertent needle punctures will create leaks • Maintenance is needed to prevent microorganism growth • Surface is heavy • Cannot raise head of bed unless mattress has compartments • Can be overfilled (causing too firm a surface) or underfilled (decreasing pressure reducing benefit)

Support Surfaces: Characteristics and Considerations: page 4 Gel Overlay Product Characteristics: A pad constructed of Silastic, silicone or polyvinyl chloride. Lack air-flow for moisture

control and friction control is variable depending on the surface of the gel. Recommended depth for effective support is 2 in. or more. Gel filled pads are particularly useful in wheelchairs. Considerations: • Low maintenance • Easy to clean • Multiple-patient use • Impermeable to punctures with needles • Surface is heavy • Expensive purchase price • Heels need to be “floated” to totally relieve pressure • Research on effectiveness is limited •

Some surfaces may be slippery; patient may slide down or out of bed during transfers

Replacement Mattress Product Characteristics: Mattress made of foam and gel combinations or layers of different foam densities. Some models have replaceable foam shapes and some have a replaceable foam core. Other replacement mattresses contain a series of air-filled chambers covered with a foam structure. All models are covered with a comfortable, water-repellent, bacteriostatic cover that can be maintained with routine cleaning. Mattresses with foam should be antimicrobial and have appropriate foam ILD with high resiliency. Evidence is increasing that replacement mattresses are superior to standard hospital mattresses and may be more effective than some overlays (Vyhlidal, et al., 1997). Considerations: • Reduce use of overlay mattresses • Reduce staff time • Do not add height to mattress • Provide certain level of pressure reduction automatically • Multiple-patient use • Easy to clean • Use standard hospital linens • Low maintenance • Initial expense is high • Some mattresses have removable sections which may be misplaced • May not control moisture • Potential for excessive delay in using other support surface • No objective method for determining when or if product loses effectiveness • Life of product is not known

Support Surfaces: Characteristics and Considerations: page 5 Additional References: Hess, CT: Wound care, Springhouse, Pennsylvania, 2000, Springhouse Corporation. Krouskop TA, Garber SL: The role of technology in the prevention of pressure sores, Ostomy & Wound Management, 16:45, 1987. Maklebust J, An Update on Horizontal Patient Support Surfaces. Ostomy & Wound Management, 45, No 1A (suppl) 70S to 77S, 1999. Maklebust J, Sieggreen M: Pressure ulcers guidelines for prevention and management, Pennsylvania, 2001, Springhouse Corporation. Parish IC, Witkowski JA: Clinitron therapy and the decubitus ulcer: preliminary dermatologic studies, Dermatology, 19:517, 1980. Vyhlidal S et al: Mattress replacement or foam overlay? A prospective study on the incidence of pressure ulcers, Applied Nursing Research, 10(3):111, 1997. Whittemore, R. Pressure reduction support surfaces: A review of the literature. JWOCCN, 25:6-25. 1998.

Source: National Nursing Home Improvement Collaborative Coordinated by Qualis Health, Learning Session Two, January 2004

Document available at www.primaris.org MO-08-48-PU June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Adhesive and transparent.

Adhesive wafers composed of gelatin, pectin, and carboxymethyl-cellulose

Glycerin or water based gels, wafers, sheets, and impregnated gauze with or without adhesive borders

Hydrophilic polyurethane foam, available in wafers, sheets, and pillow with foam covering

Non woven fibers containing calcium sodium salts of alginic acid, available in pads or ropes

Hydrocolloid DuoDERM® Replicare® Comfeel® Others

Hydrogels Hypergel® Carrasyn® DuoDERM® Elasto-Gel Sheet™ SoloSite◊ Others

Foams PolyMem® Allevyn◊ Lyofoam® Others

Alginates SORBSAN™ KALTOSTAT® Algisite M◊ Others

Description

Polyurethane Film Tegaderm™ Op-site◊ EpiVIEW™ others

Treatment Products

Stage 2 wounds with a lot of exudate Stages 3-4

Stages 2-4

Stages 2-4

Stages 1-4

Stages 1-2

Appropriate Wound Stage

Non-adherent Promotes moist wound healing Can be used on infected wounds

Non-adherent Easy to apply and remove Highly absorbent

Non-adherent Fills dead space Semi-occlusive Promotes moist wound healing Easy to apply & remove Minimally absorbent Retains moisture and rehydrates wound

Occlusive and waterproof Retains moisture Impermeable Promote moist wound healing Moderately absorbent Easy to apply

Occlusive and waterproof Retains water Impermeable to bacteria & contamination Promotes moist wound healing Nonabsorbent May be changed every 3 to 7 days May be used as a secondary dressing over a more absorbent product

Characteristics

Should not be used on dry or low exudate wounds, the wound may get dehydrated Secondary dressing required Typically requires daily application

Can be used on various levels of exudate Additional fixation is required unless has an adhesive border

May macerate surrounding tissues Secondary dressing required Daily application required unless applied with adhesive borders Dries out easily Risk of candidiases

Should not be used with heavy exudate wounds Should not be used if infection is present May have odor upon removal May be difficult to remove

Should not be used with moderate to heavy exudate wounds May macerate surrounding skin

Concerns

Pressure ulcers require consistency in treatment to promote healing. Use this list that includes the major types of products to ensure your nursing center carries an appropriate range of materials. Nursing staff then can choose the most effective dressing type based on wound stage, characteristics and potential concerns.

Pressure Ulcers: Treatment Product Categories

Description

System that uses controlled negative pressure to help promote wound healing. VAC system pulls infectious materials and excess interstitial fluid from the wound

Indications Pressure ulcers Traumatic wounds Post op-dehisced & surgical wounds

Concerns/Precuations

Moist to dry debridement can be painful, damaging healthy tissue Woven gauze is abrasive Requires frequent changes Packing may harden, causing further pressure injury

Do not use on dry wounds Do not use with patients sensitive to bovine products

Active bleeding Malignancy Difficult hemostasis Untreated osteomyelitis Unexplored fistulas into the body cavity or to an organ Anticoagulant therapy Necrotic tissue with eschar in the wound abed Exposed arteries or veins Uncontrolled pain

Contraindications

May be dampened with saline or water Inexpensive Facilitates moist to dry debridement Non-adherent when used as a wet to moist dressing Minimal to moderate absorbency

Promotes new tissue growth Wound debridement Pulls wound edges together

Concerns Do not use with a resident with a known sensitivity to silver. Iodine products should be avoided if known sensitivity, or thyroid disorder. Do not use in conjunction with topical antibiotics

MO-08-45-PUH June 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.

Document available at www.primaris.org

Characteristics Manages bacterial burden Non-cytotoxic

** Brands are listed for reference purposes only. We do not recommend use of one brand over another.

Vacuum Controlled Assisted Closure (V.A.C.) KCI VAC® Engenex™ EZCARE◊ V1STA◊

Treatment Products

Related Wound Treatments

Woven natural cotton fibers,; non woven rayon and plastic blends; available in pads and rolls, sterile and non sterile

Gauze, Dry or Wet Stages 2-4, especially if wound is deep or has tissue that needs debridement

Collagen provides the matrix for the body’s Wounds that have tissue structure. Stimulates wound healing stalled in healing Can be found in different delivery systems: Chronic wounds dried collagen matrix, hydrogel with collagen, hydrogel base.

Collagen Biostep◊ Prisma® Promogran® Puracol® Others

Stage 2 wounds when antimicrobial treatment is needed Stages 3-4

Appropriate Wound Stage

Ionic silver and cadexomer iodine that provides sustained antimicrobial barrier to multiple bacteria including strains of MRSA and VRE. Can be found in different types of products including alginates, gels and polyurethane film

Description

Antimicrobial ACTICOAT◊ SilvaSorb® IODOSORB◊ ALLEVYN Ag◊ Optifoam AG® Others

Treatment Products

Pressure Ulcers: Treatment Product Categories, Page 2

Nutritional Wound Healing Guidelines Policy: This sample procedure is to help enhance the healing of pressure ulcers by the use of nutritional intervention whenever possible. These are guidelines only and individual patient and resident needs must be taken into consideration before implementation. Procedure: The nursing department reports all pressure ulcers and their stage to food and nutrition services. • The available dietician is contacted and reviews each case to make an individualized nutrition care plan. • Food and nutrition services may implement the following interventions, based upon the stage of resident’s pressure ulcers. Note that vitamin and mineral supplementation would require a physician’s order. »» Stage 1: 4 Vitamin C-rich food, high protein afternoon snack and a daily MVI with minerals •

»»

Stage 2: Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day and MVI with minerals daily

»»

Stage 3: 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein

snacks twice a day and MVI with minterals

»»

Stage 4: 8 oz. Arginine-intensive nutritional supplement (8 oz. Arginaid Extra) twice a day, high-protein

snacks three times a day and MVI with minerals Other nutritional considerations: •

• • • •

• • •

Think about other options to enhance nutritional status, such as: »» Increase eggs, milk, meat and cheese for additional HBV protein »» Add protein powder to foods »» Add other foods high in Vitamin C if the resident or patient dislikes orange juice »» Use Arginaid powder in place of Arginaid Extra if the patient is obese Continue nutritional interventions until wound has been healed for two weeks Avoid zinc supplementation for more than two months at a time Goal caloric intake is 30-35 kcal per kg or BMR x 1.5 stress factor x 1.2 (bed) or 1.3 (out of bed) Goal protein intake with no renal considerations is as follows: »» Stage 1: 1.2-1.4 g. per kg. »» Stage 2: 1.4-1.6 g. per kg. »» Stage 3: 1.6-1.8 g. per kg. »» Stage 4: 1.8-2 g. per kg. Goal of fluid is 30-35 ml. fluid per kg. If on chronic antibiotic use, give yogurt or lactobacillus supplements If patient/resident has a compromised gut (intestinal mucosal atrophy or malabsorbtion from malnutrition, 10-20 mg. of glutamine supplementation should be considered

Note: 8 oz. Arginaid Extra provides the following: 10 g. protein, 250 calories, 20 mg. zinc, 1,000 IU vitamin A, 250 mg. vitamin C; MVI with minerals usually contain the following amounts: 15 mg. zinc, 3,500 IU vitamin A, 60 mg. vitamin C, 18 mg. iron and 2 mg. copper

Document available at www.primaris.org MO-08-46-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Selected Characteristics of Support Surfaces

Selected Characteristics for Classes of Support Surfaces Support Devices Performance characteristics

Air-fluidized Low Air-loss

Alternating Air

Static Flotation (air or water)

Foam

Standard Mattress

Increased support area

Yes

Yes

Yes

Yes

Yes

No

Low moisture retention

Yes

Yes

No

No

No

No

Reduced heat accumulation

Yes

Yes

No

No

No

No

Shear reduction

Yes

?

Yes

Yes

No

No

Pressure reduction

Yes

Yes

Yes

Yes

Yes

No

Dynamic

Yes

Yes

Yes

No

No

No

High

High

Moderate

Low

Low

Low

Cost per day

Reference: Quick Reference Guide for Clinicians, No. 15, page 11. Developed by the Agency for Healthcare Research and Quality (AHRQ).

Chair Support Surfaces Support Surface

Characteristics

Cost

Concerns

Foam Cushion

• Provides some pressure reduction, depending upon the thickness of the foam (a thickness of no less than four inches is recommended) • Resident still requires repositioning at least every hour

Low Cost

• After laundering, this surface is no longer useful for pressure reduction. A slip cover that can be separately laundered keeps the cushion clean and dry

Gel Cushion

• Reduces pressure by spreading pressure across the contact surface • Does not replace repositioning

Low to Moderate Cost

• Pressure reduction depends on the cushion’s condition (watch for breaks in the integrity of the cushion, which renders this product ineffective) • Do not attempt to mend any breaks in the cushion

Air-filled Cushion

• Reduces pressure by evenly distributing weight • Cells fill with air and deflate as pressure is applied. Does not replace repositioning

High Cost

• Compromised integrity can render this product ineffective. An ineffective airfilled cushion should be replaced

Document available at www.primaris.org MO-08-51-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

SBAR: Skin Care Instructions

S

Situation Resident Name: _____________________________________________Age: ________ Admit Date: ______________ Admitting physician/consulting physician: _____________________________________________________________ Diagnosis/reason for admission: _____________________________________________________________________

B

Treatment plan: __________________________________________________________________________________

Background (check all that apply) Past medical history: ______________________________________________________________________________ Allergies: _______________________________________________________________________________________ Diet type: _____________________________ q NG/G-tube feedings Medication

A

q TPN/PPN q Ostomy/drains q Foley

Medication

Assessment (check all that apply)

q Pressure ulcer present q Precautions:___________ q Completely immobile q Limited mobility q Fully mobile q Incontinent q Impaired sensation q Alert/oriented q Confused q Lethargic/unresponsive q Photos taken Braden Score:_______

Decubitus Key

q High Risk q Low Risk q No Risk

Stage I: Red/skin intact

Site Diagram Front

Back

Stage II: Superficial breakdown Stage III: Skin breakdown Sub Q involved Stage IV: Skin breakdown. Muscle/bone exposed

Right

Left

Left

Right

*Do no stage if base of wound not visible Date

R

Site #

Stage

Size (in cm)

Description (color, drainage, odor, sloughing, eschar, undermining)

Recommendation (check all that apply) Pressure Ulcer Prevention Measures

Pressure Ulcer Management

q Ulcer treatment: ______________________________ q Keep clean and dry q Avoid diaper/brief use q Apply cleanser/barrier lotions to ________ every ____ q Dressings (specify type and frequency): ____________ hours ___________________________________________ q Apply Nystatin powder to _____________ every ____ q Wound vac: __________________________________ hours q Consider Foley catheter: ________________________ q Use special bed/mattress (specify type): ____________ q Odor control: ________________________________ q Turn and reposition patient every ______ hours q Dietary/nutrition consult q Use chair cushion (specify type): _________________ q Other: ______________________________________ q Elevate heels q Use heel protectors/heel lift ___________________________________________ q Use elbow protectors q Dietary/nutrition consult q Other: ______________________________________ Comments: _____________________________________________________________________________________ ____________________________________________________________________________________________ Assessment and recommendations completed by (signature) _______________________ Date: _______________ Treatment protocol approved by (signature) _____________________________________ Date: _______________

Document available at www.primaris.org MO-08-52-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

Pressure Ulcer Definition and Stages D E F I N ITI O N A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure ulcers are staged using the system at right.

P R E S S U R E U LC E R STAG E S (SUSPECTED) DEEP TISSUE INJURY

STAGE III

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Further Description: Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.

STAGE I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Further Description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

STAGE II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serumfilled blister. Further Description: Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicated suspected deep tissue injury. National Pressure Ulcer Advisory Panel 1255 Twenty-Third Street NW, Suite 200 Washington, DC 20037 T: 202-521-6789 F: 202-833-3636 www.npuap.org

Further Description: The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

STAGE IV Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further Description: The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

UNSTAGEABLE Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further Description: Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed.

This staging system should be used only to describe pressure ulcers. Wounds from other causes, such as arterial, venous, diabetic foot, skin tears, tape burns, perineal dermatitis, maceration or excoriation should not be staged using this system. Other staging systems exist for some of these conditions and should be used instead.

Updated 02/2007 Copyright © 2007

Pressure Ulcer Classifications

Suspected Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Further description

Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue, even with optimal treatment.

Stage 1 Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Further description

The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).

Stage II Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.

Further description

Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury

Pressure Ulcer Classifications

Stage III

Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.

Further description

The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue, and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/ tendon is not visible or directly palpable.

Stage IV

Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Further description

The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/ tendon is visible or directly palpable.

Unstageable

Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Source: National Pressure Ulcer Advisory Panel, Pressure Ulcer Stages Revised, February 2007. Permission to use granted to Primaris, the Quality Improvement Organization for Missouri.

13

A

14

width at the widest point (B). Measure the depth (C) at the deepest point of the wound. All measures should be in centimeters.

This ruler is intended for use as a reference only. To prevent infection, do not use this ruler to measure an actual wound.

Measuring Wounds Measure the length “head to toe” at the longest point (A) and the

15

Documentation and Measuring

B

10

Using a clock format, descrive the location and extent of tunneling (sinus tract) and/or undermining.

11

12

C

3

8

9

sample

9

12

Tunneling/Sinus Tract Undermining Tunneling wound which begins directly under the wound edge.

1 CM

If the wound has many landmarks, you may want to trace it before measuring.

2

3

4

A narrow channel of passageway extending into healthy tissue.

5

The head of the patient is 12:00, the patient’s foot is 6:00

6

7

6

Pressure ulcer documentation includes Wound location Stage Size • Length • •

Width Depth

Tunneling/Sinus Tract Undermining Necrotic Tissue • Slough • Eschar

Pain Exudate/Drainage • Amount • •

Color Odor

Description of Surrounding Tissue Support Surface Wound edges • Round • Rolled •

Extended

Granulation

Note the following skin characteristics • •

Color Temperature

• •

Moles Bruises

• • • •

Incisions Scars Intact Burns

MO-08-49-PU July 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services, and adapted from LHCR. The contents presented do not necessarily reflect CMS policy.

Pressure Ulcers: CNA Knowledge & Attitude Survey We are interested in your individual answer. Please check the box to indicate “True” or “False” for each of the following statements. Position Title:______________________________________________________________________________ Department:________________________________Shift (check one): o Days o Evenings o Nights

Pressure Ulcers: CNA Knowledge and Attitude Survey

True

False

o o o o o o o o o o

o o o o o o o o o o

o

o

o

o

13. A bed ridden resident will not fully recover from a pressure ulcer without surgery.

o

o

Pressure ulcers are often viewed as a sign of poor care being provided by the nursing staff.

o

o

o o

o o

1. Identification and reporting of reddened or open areas of skin are part of my job. 2. Pressure ulcer prevention is part of my job. 3. Pressure ulcers should only be documented by RN or LPN staff members. 4. Immobility is a cause of pressure ulcers. 5. Incontinence is a cause of pressure ulcers. 6. Poor dietary intake is a cause of pressure ulcers. 7. Chronic illness is a cause of pressure ulcers. 8. Poor circulation is a cause of pressure ulcers. 9. Pressure ulcers are part of the aging process. 10. Pressure ulcers can be prevented by proper positioning of residents. Pressure ulcers begin with a reddened area of the skin that does not disappear after pressure is relieved. Residents who have had a pressure ulcer in the past are more likely to develop 12. one in the future. 11.

14.

15. Pressure ulcers lower a resident’s self-esteem. 16. Pressure ulcers can occur on any area of the body.

Pressure Ulcers: CNA Knowledge & Attitude Survey: page 2 CNA Knowledge and Attitude Survey Results A Guide to Action Ask staff to complete the CNA Pressure Ulcer Knowledge and Attitude Survey. Then, use the following as an answer key and a guide to action. You’ll notice that particular answers may be “True” for some staff and “False” for others. This sheet will show how you might revise overall nursing home practices to improve staff knowledge and residents’ care. Questions 1 & 2 All nursing home clinical staff should have identification, assessment, prevention, care and documentation of pressure ulcers identified as a part of their job duties. If your staff felt this statement was “False,” this may be an area you could focus on for additional training. Non-clinical staff’s answers may vary between “True” and “False.” If you have non–clinical staff who feel that prevention is not part of their job, consider additional training. It is important for all staff to recognize ways they can identify potential problems and inform appropriate clinical staff. Ideas for improvement: • Explain how and why you’re committed to pressure ulcer prevention and treatment • Describe you home’s overall pressure ulcer plan • Describe each team member and family member’s role in pressure ulcer prevention assessment and treatment Question 3 This question addresses pressure ulcer documentation. All staff is responsible for noting information as a part of the general pressure ulcer plan of care. Leaders must instruct how and where that information will be documented on the resident’s record. Non-clinical staff may answer “False,” but you need a process for nonclinicians to report their observations as well, ensuring this information is documented. Ideas for improvement: • Define pressure ulcer documentation guidelines for all disciplines. • Offer training on sharing work responsibilities among disciplines. For example, activities staff must reposition resident while attending activities and document this for staff sharing, dietary staff must know the resident with a pressure ulcer cannot sit up to eat • Identify pressure ulcer tools to increase documentation consistency throughout the facility and within clinical staff. For example: ulcer measurement guide, bedside turning schedule, staging guidelines or exudate documentation Questions 4, 5, 6, 7, 8 and 12 These question reference risk factors for pressure ulcer formation. Immobility, poor nutrition, incontinence and circulatory conditions are all risk factors. If your facility’s surveyed staff felt any of these statements were “False,” it may indicate that the pressure ulcer risk factors are not well known or their importance is not well understood. You may want to identify if one group of employees or employees in general need information regarding risk factors and the role they play in pressure ulcer formation. Questions to ask staff: • What are the identified pressure ulcer risk factors? • How do risk factors contribute to the formation of pressure ulcers? • When are residents assessed for risk factors in your facility? • What effect do risk factors have on residents’ plan of care?

Pressure Ulcers: CNA Knowledge & Attitude Survey: page 3 • Who is responsible for identification and care planning for residents with identified risk factors? • Why is this important? Question 9 This question addresses a common misconception. Pressure ulcers are not part of the normal aging process. Although loss of skin elasticity and thinning of the skin are normal with aging, pressure ulcer formation is not. If most of your staff answered “True” to this survey question, you need to provide them with information about the normal aging process, including: • How the factors of the normal aging process contribute to the risk for pressure ulcer formation. • What your facility is doing to address the care associated with the elderly. For example, nutritional and activity programs, support groups, association with community support group. • Your facility’s efforts to communicate with other health care facilities that you have direct interaction with, i.e. referring hospitals, senior citizen groups, physician’s offices, home health agencies. Question 10 This question addresses the role of proper positioning in pressure ulcer prevention. If the lower extremity were positioned with proper support to keep pressure off the heel, an ulcer due to pressure on the heel would be prevented. If staff felt positioning did not contribute to pressure ulcer prevention, as noted with a “False” answer, consider: • Instruction on and demonstration of basic positioning techniques. • Reviewing your home’s resident care plans to address proper positioning and repositioning, i.e. turning schedule, pressure reduction techniques, devices available at your facility to reduce pressure load. • Reviewing of the etiology of pressure ulcer formation with staff, such as prolonged pressure reducing the blood flow to the capillaries causing tissue damage. Question 11 This question addresses pressure ulcer development. Pressure ulcers begin with a reddened area of the skin that does not disappear after the pressure is relieved. This is identified as a Stage I pressure ulcer. A response of “False” to this question indicates your staff doesn’t have a good understanding of pressure ulcer formation. Consider the following actions: • Provide all staff with common consistent definitions of pressure ulcer stages, such as guidelines from the National Pressure Ulcer Advisory Panel. • Adopt standard facility procedures for describing, measuring and evaluating pressure ulcers. • Provide consistent tools – such as measurement guides and an assessment scale – throughout the home for staff to use consistently • Review and adapt your pressure ulcer plan of care Question 13 This question identifies the misconception that a bed-ridden resident’s pressure ulcer requires surgery to heal. Improved wound care products and pressure reduction devices have greatly increased the healing of pressure ulcers without surgical interventions. If staff responded “True,” to this statement, consider: • Demonstrating and discussing newer pressure-reduction products available to assist with wound healing and discussing clinical indications

Pressure Ulcers: CNA Knowledge & Attitude Survey: page 4 Question 14 If clinical staff answered “True” to this question they may need further education and information about why pressure ulcers occur. Consider offering training on: • Non-compliance with pressure ulcer plan of care • Disease progression • Poor nutritional intake • Other pressure ulcer risk factors For non-clinical staff additional information may include: • Training on the etiology of pressure ulcer formation • Reviewing the role of non-clinical staff in pressure ulcer prevention and treatment • Reviewing risk factors • Information on their specific role in the care process as it relates to pressure ulcers. Question 15 If staff answered “True” to this statement, it indicates they understand the emotional impact a physical condition can have on residents’ self-esteem. Pressure ulcers may limit the independence of the resident. They may also contribute to a resident feeling ‘sick’ and dependent on others for care. Additionally, many pressure ulcers occur in areas of the body that are emotionally uncomfortable for people to deal with, such as the buttocks. Dignity may be compromised if the resident feels embarrassed or ashamed over having a pressure ulcer. Family members may be angry at the facility or the resident. This could add to feelings of inadequacy the resident may already be experiencing. If anybody answered “False,” offer education to all staff, families and volunteers about pressure ulcers effect on residents’ psychosocial well-being as well as their physical discomfort. Question 16 Pressure ulcers may occur on any part of the body exposed to unrelieved pressure that decreased the flow of blood a sufficient length of time to cause underlying tissue damage. A “False” answer to this question may indicate that your staff does not understand the etiology of a pressure ulcer. Although pressure ulcers generally are noted over boney prominences of the body, they can occur at any location where unrelieved pressure is noted. Educational intervention may include: • Pressure ulcer definition and staging guidelines • Proper positioning and repositioning techniques • Proper use of pressure reduction devices • Frequent reinforcement that pressure ulcer prevention and treatment is everybody’s responsibility

Document available at www.primaris.org

MO-08-15-PU May 2008 This material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.