Identifying Identifying and Reporting and Reporting changes in changes in skin conditionskin condition

Presented byPresented by

Lizeth Flores, RHIT Lizeth Flores, RHIT Anderson Health Information Anderson Health Information

Systems, IncSystems, Inc

940 W. 17940 W. 17thth Street, Suite B Street, Suite B

Santa Ana, CA 92706Santa Ana, CA 92706

(714) 558-3887(714) 558-3887

office@ahis.netoffice@ahis.net

Today’s TopicsToday’s Topics

• Pressure Ulcer risk factors Pressure Ulcer risk factors • Checking for pressure ulcers Checking for pressure ulcers • Pressure ulcer prevention Pressure ulcer prevention • Facility protocols for skin Facility protocols for skin

assessments assessments • Facility protocol for Facility protocol for

communicating changes in skin communicating changes in skin integrityintegrity

What is a pressure ulcer?What is a pressure ulcer?

• A pressure ulcer (a bedsore or pressure sore) is skin breakdown caused by pressure on bony prominences from being in one position for too long.

What are pressure What are pressure points?points?

•Bony parts of the body such as the tailbone, hips, heels, elbows, shoulders.

What can contribute What can contribute pressure ulcers?pressure ulcers? •

– Impaired/decreased mobility/functioningImpaired/decreased mobility/functioning– Co-Morbid Conditions (e.g. ESRD, DM)Co-Morbid Conditions (e.g. ESRD, DM)– Drugs (Steroids)Drugs (Steroids)– Impaired blood flow from sitting or lying Impaired blood flow from sitting or lying

too long in one place too long in one place – Resident refusal of treatment/careResident refusal of treatment/care– Cognitive ImpairmentCognitive Impairment– Urinary/Fecal incontinenceUrinary/Fecal incontinence– Wet clothing or a wet bed Wet clothing or a wet bed – Under-nutrition, malnutrition, dehydration Under-nutrition, malnutrition, dehydration

– not getting enough food or water – not getting enough food or water – History of/healed ulcerHistory of/healed ulcer– Use of physical restraints Use of physical restraints

OTHER RISK FACTORS……OTHER RISK FACTORS……

• Tubing such as catheters that Tubing such as catheters that the resident may lay on will the resident may lay on will cause unnecessary pressure and cause unnecessary pressure and friction that could lead to skin friction that could lead to skin breakdown breakdown

Are Pressure Ulcers the Are Pressure Ulcers the only type of ulcers?only type of ulcers?

• NO – NO – • There are many types of ulcers There are many types of ulcers

that can develop from disease that can develop from disease process process

• ExampleExample• Stasis Ulcer Stasis Ulcer • Diabetic UlcersDiabetic Ulcers

WHY IS IT IMPORTANT WHY IS IT IMPORTANT TO MONITOR AND TO MONITOR AND

REPORT CHANGES IN REPORT CHANGES IN RESIDENT’S SKIN RESIDENT’S SKIN

CONDITION ?CONDITION ?

It’s The LawIt’s The Law

• The law states that each resident The law states that each resident must receive necessary care and must receive necessary care and services to attain or maintain the services to attain or maintain the highest practicable physical, highest practicable physical, metal and psychosocial well-metal and psychosocial well-being in accordance with the being in accordance with the comprehensive assessment and comprehensive assessment and plan of careplan of care

F309 - §483.25 Quality of F309 - §483.25 Quality of Care Care -2-2

• Expands Definition of Skin Expands Definition of Skin Ulcer/WoundUlcer/Wound– Clinician expected to document the Clinician expected to document the

clinical basis* which permit clinical basis* which permit differentiating the ulcer type differentiating the ulcer type ESPECIALLY ESPECIALLY if the ulcer has if the ulcer has characteristics consistent with a characteristics consistent with a pressure ulcer but is determined pressure ulcer but is determined NOT NOT to be oneto be one

I’m a CNA what can I do?I’m a CNA what can I do?

• CNAs are the first line of defense CNAs are the first line of defense when it comes to identifying skin when it comes to identifying skin breakdownbreakdown

• You provide direct care to the You provide direct care to the residents daily and will usually be residents daily and will usually be first to notice changes in skin color first to notice changes in skin color or integrityor integrity

When will I check the skin?When will I check the skin?

• During daily activitiesDuring daily activities• During showers, bed baths, During showers, bed baths,

bedside care bedside care • Throughout the day as you carry Throughout the day as you carry

out your job duties out your job duties

What do I need to look What do I need to look for?for?

These are the signs that there These are the signs that there may be an issue with the may be an issue with the

resident’s skinresident’s skin

• Changes in skin color / discolorationChanges in skin color / discoloration• Changes in skin temperature – some Changes in skin temperature – some

breakdown may not be readily breakdown may not be readily visible on darker skin tones so visible on darker skin tones so changes in skin temperature, skin changes in skin temperature, skin appearance may give you the clues appearance may give you the clues you need to identify a problem. you need to identify a problem.

More signs of More signs of compromised skincompromised skin

• Red areas on the skin that do not go away Red areas on the skin that do not go away even after the pressure is removed even after the pressure is removed

• Cracked, blistered, scaly, broken skin Cracked, blistered, scaly, broken skin • An open sore involving skin surface or An open sore involving skin surface or

tissue under the skin tissue under the skin • Yellowish stains on clothing, sheets, or Yellowish stains on clothing, sheets, or

chair (may be tinged with blood) chair (may be tinged with blood) • Painful or tender "pressure points" (back Painful or tender "pressure points" (back

of head, ears, back of shoulders, elbows, of head, ears, back of shoulders, elbows, buttocks, hips, heels, and any place a buttocks, hips, heels, and any place a bony part rests on the bed surface.) bony part rests on the bed surface.)

What to report…….What to report…….

• All changes in skin condition must All changes in skin condition must be reported to ensure that the be reported to ensure that the facility is in compliance with facility is in compliance with regulatory requirements regulatory requirements

Reposition vs Reposition vs RedistributionRedistribution

• Repositioning plans should be outlined Repositioning plans should be outlined in the plan of care consistent with the in the plan of care consistent with the INDIVIDUALINDIVIDUAL resident’s needs resident’s needs

• Pressure RedistributionPressure Redistribution– Function or ability to redistribute a load Function or ability to redistribute a load

over a surface or contact areaover a surface or contact area– Specific devices and surfaces are Specific devices and surfaces are

addressed and suggestions given for using addressed and suggestions given for using and evaluating effectiveness of such and evaluating effectiveness of such devicesdevices

DO YOU KNOW WHERE TO FIND DO YOU KNOW WHERE TO FIND INFORMATION THAT WILL INFORMATION THAT WILL

HELP YOU CARRY OUT YOUR HELP YOU CARRY OUT YOUR DUTIES EFFECTIVELY?DUTIES EFFECTIVELY?

You are a key player in You are a key player in pressure ulcer preventionpressure ulcer prevention – How do you know what pressure How do you know what pressure

relieving devices are being used for each relieving devices are being used for each resident? resident?

Special needs list (new form) Special needs list (new form) Must be reviewed at the beginning of Must be reviewed at the beginning of

every shift before waking rounds every shift before waking rounds

– Where is this information located? Where is this information located? In the front of each ADL flow sheet In the front of each ADL flow sheet

binder binder

– How is the information updated when How is the information updated when there are changes? there are changes?

DSD / DON will assign a staff member DSD / DON will assign a staff member to update the list to update the list

No need to worry, every time you No need to worry, every time you review the list you can trust that the review the list you can trust that the information is accurate and reliable. information is accurate and reliable.

Walking RoundsWalking Rounds

• What am I looking for during walking What am I looking for during walking rounds? rounds?

1.1. Current Patient Status Current Patient Status 2.2. Patient’s on B&B Patient’s on B&B 3.3. Bed Linen requirements Bed Linen requirements a. Fitted sheeta. Fitted sheet d. Top Sheet d. Top Sheet

b. draw sheet b. draw sheet e. Blanket e. Blanket c. 1 blue pad c. 1 blue pad

4.4. Fluids, restricted or NPO Fluids, restricted or NPO 5.5. New Skin issues New Skin issues 6.6. Feeders Feeders 7.7. Falls, Injuries Falls, Injuries

How can I remember all How can I remember all of that? of that?

• There will be a reference card There will be a reference card on the back of your name on the back of your name badge. badge.

• What is the facility policy for turning What is the facility policy for turning and repositioning? and repositioning?

Turn and Reposition every 2 hours Turn and Reposition every 2 hours

• How do you know which way to turn How do you know which way to turn the resident? the resident?

Reference card behind staff name Reference card behind staff name badge badge

• How do you document turning and How do you document turning and repositioning of residents? repositioning of residents?

It is documented every shift on the ADL flow It is documented every shift on the ADL flow sheet sheet

o What symbol do you use to document turning What symbol do you use to document turning and repositioning on the ADL flow sheet? and repositioning on the ADL flow sheet?

““P” P”

Restraints and DevicesRestraints and Devices

• How Often must you check and How Often must you check and release restraints or devices? release restraints or devices?

Every 2 hours Every 2 hours

o Where is this documented? Where is this documented?

In The ADL flow sheet In The ADL flow sheet

• During showers how do you document During showers how do you document skin assessment? skin assessment?

Using the Using the “Shower Day Skin Inspection” “Shower Day Skin Inspection” form form

o How often will we document skin checks How often will we document skin checks

Daily Daily

Who will be responsible for Who will be responsible for documenting skin documenting skin ’s’s

• CNA’s providing showers will document on CNA’s providing showers will document on the the “Shower Day Skin Inspection Form” “Shower Day Skin Inspection Form”

• Non-shower days – Non-shower days – skin condition will be documented using the skin condition will be documented using the

skin assessment on the back of the skin skin assessment on the back of the skin inspection form (new form) inspection form (new form)

Remember to indicate any skin Remember to indicate any skin issues using the body issues using the body assessment diagram assessment diagram

What do you do with that What do you do with that information? information?

• Report it to the charge nurse Report it to the charge nurse • Make sure the charge nurse Make sure the charge nurse

initials the body assessment initials the body assessment (picture) (picture)

• Form must be signed by CNA and Form must be signed by CNA and charge nurse charge nurse

Don’t take it for grantedDon’t take it for granted

• Just because a resident is on a Just because a resident is on a pressure relieving device does not pressure relieving device does not mean they do not need to be closely mean they do not need to be closely monitored and turned and monitored and turned and repositioned based on their specific repositioned based on their specific needs needs

What else do I need to What else do I need to know?know?

• There are many other important There are many other important aspects of CNA duties and aspects of CNA duties and documentation that affect resident documentation that affect resident assessment and care assessment and care

• It is critical that you document what It is critical that you document what your observations of the resident is your observations of the resident is during your shift and not refer back during your shift and not refer back to prior day’s charting to prior day’s charting

Documentation…….Documentation…….

• A decrease in resident’s intake of meals can A decrease in resident’s intake of meals can indicate a change in their condition, it does not indicate a change in their condition, it does not necessarily mean that they have pressure necessarily mean that they have pressure ulcers but the fact that they are not consuming ulcers but the fact that they are not consuming adequate nutritional amounts can be a adequate nutritional amounts can be a contributing factor to skin breakdown contributing factor to skin breakdown

• So remember….. It is extremely important that So remember….. It is extremely important that you document % of meal intake accurately and you document % of meal intake accurately and timely. timely.

This is the only way to know how This is the only way to know how much a resident is eating much a resident is eating

DocumentationDocumentation

• Low intake of fluids can result in Low intake of fluids can result in dehydration which can lead to skin dehydration which can lead to skin breakdown. breakdown.

Remember…. Always offer fluids Remember…. Always offer fluids when at bedside / chairside when at bedside / chairside

• Always document accurately and Always document accurately and timelytimely

Who needs to know….Who needs to know….

• If you identify a problem, who will If you identify a problem, who will you tell? you tell?

The Charge Nurse The Charge Nurse • How can you prove you reported the How can you prove you reported the

changes?changes? Using the skin inspection form “DAILY” Using the skin inspection form “DAILY” • Where can this information be found? Where can this information be found? In the Skin Check binder at the Nurses’ In the Skin Check binder at the Nurses’

stationstation

What is the nurse What is the nurse responsible for?responsible for?

• The licensed nurse is responsible for The licensed nurse is responsible for assessment of the resident, assessment of the resident, development of a comprehensive development of a comprehensive plan of care and for carrying out the plan of care and for carrying out the care as specified in the care plancare as specified in the care plan

Why am I being asked to Why am I being asked to check the resident for check the resident for

pressure ulcers?pressure ulcers?• You are part of the resident You are part of the resident

care team and you play a very care team and you play a very important part in ensuring important part in ensuring quality of carequality of care

• The nursing staff will use any The nursing staff will use any information you provide to information you provide to ensure patient’s receive the ensure patient’s receive the necessary care to ensure their necessary care to ensure their highest level of well beinghighest level of well being

Why is there such a Why is there such a focus on pressure focus on pressure ulcers in skilled ulcers in skilled

nursing facilities? nursing facilities?

• Prevention and treatment of Prevention and treatment of pressure ulcers is a focus in all pressure ulcers is a focus in all healthcare settings and not just healthcare settings and not just

nursing homes nursing homes • It is mandated by State and It is mandated by State and

Federal Regulations Federal Regulations

ConsequencesConsequences

– Pressure ulcers can be very painful Pressure ulcers can be very painful for the residentfor the resident

– Pressure ulcers can result in Pressure ulcers can result in complications such as infection and complications such as infection and in severe cases loss of body parts in severe cases loss of body parts (amputation) (amputation)

– Pressure ulcers can progress very Pressure ulcers can progress very rapidly if they remain untreated rapidly if they remain untreated

– Pressure ulcers sometimes result in Pressure ulcers sometimes result in death death

• Pressure ulcers can lead to Pressure ulcers can lead to complaints and investigation complaints and investigation

• Pressure ulcers can lead to Pressure ulcers can lead to lawsuits and can be very costly lawsuits and can be very costly

If the facility has If the facility has patients with pressure patients with pressure ulcers does that mean ulcers does that mean that the residents are that the residents are no properly care for?no properly care for?

NO NO Even with very good patient care Even with very good patient care

there can be unavoidable ulcers there can be unavoidable ulcers

This is based on the overall condition This is based on the overall condition of the patient and diagnoses that can of the patient and diagnoses that can contribute to poor skin integrity contribute to poor skin integrity

Example Example

• DiabetesDiabetes• Renal Failute Renal Failute • Dialysis Dialysis • Poor circulation Poor circulation

Even if the resident’s Even if the resident’s pressure ulcers cannot be pressure ulcers cannot be avoided, they should be avoided, they should be promptly identified and promptly identified and

treatments implemented to treatments implemented to ensure they achieve their ensure they achieve their

highest level of well being.highest level of well being.

•

You work hard…. Take You work hard…. Take credit for itcredit for it

It takes a very special person to provideIt takes a very special person to providequality caring services for residents in quality caring services for residents in

skilledskillednursing facilities nursing facilities

That makes you very special people, yourThat makes you very special people, yourparticipation in the overall monitoring of participation in the overall monitoring of

thetheresident’s condition is critical to ensure resident’s condition is critical to ensure

theytheyare provided with the best care possible- are provided with the best care possible-

Discussion & QuestionsDiscussion & Questions

Thanks for Thanks for attendingattending