Myth

MythbustersThe Truth About Pressure Ulcer

Prevention

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Faculty Disclosure Statement

The speaker(s) do not have any financial interest or affiliation with any corporate organizations associated with the manufacture, license, sale, distribution or promotion of a drug or device.

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Objectives

Upon completing this session, participants will be able to:1. Identify three factors that increase a

resident’s/patient’s risk of developing a pressure ulcer.2. Describe multiple strategies to prevent pressure

ulcers.3. Discuss the importance of early detection.

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1. There is little a nurse or a STNA can do to prevent pressure ulcers; they just happen.

True or False?

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False.

FACT: Most pressure ulcers are preventable.

Suggested strategies1,2: Know who is at risk. Know what to look for (inspection). Know what needs to be done to prevent pressure

ulcer development. Know what you can do to promote pressure ulcer

healing.

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True or False?

2. Residents/patients who are in a chair or wheelchair don’t need to be repositioned; they only need to be repositioned when they are in bed.

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False.

FACT: Residents/patients in chairs and wheelchairs, as well as those in bed, need to be repositioned.

Suggested strategies3,4: Reposition sitting residents/patients to shift pressure

points at least every hour. If this schedule cannot be kept or is inconsistent with

overall treatment goals, return the resident/patient to bed.

Individuals who are able should be taught to shift their weight every 15 minutes.

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True or False?

3. Residents/patients should be repositioned no more than every 2 hours while in bed.

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False.

FACT: Residents/patients need individualized turning and repositioning plans for bed and chair.

Suggested strategies4: Create individualized plans that include:

– Turning every 2 hours for in bed– Repositioning every hour for in chair– OR more frequently as needed to prevent

pressure ulcer development

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True or False?

4. Poor nutrition and/or dehydration may increase the risk of developing a pressure ulcer.

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True.

FACT: Nutrition and hydration are key factors in pressure ulcer development.

Suggested strategies5: Assist in meals, snacks, and hydration. Allow residents/patients adequate time to eat. If appropriate, offer a glass of water when turning to

keep patient hydrated. Consider nutritional supplements. Monitor nutritional intake. Offer snacks and fluids between meals. Weigh residents and report any weight loss immediately.

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True or False?

5. Residents/patients who are incontinent have a greater risk of developing a pressure ulcer.

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True.

FACT: Incontinence puts residents/patients at higher risk for pressure ulcer development.

Suggested strategies6,7,8: Cleanse skin at time of soiling and at routine intervals. Use absorbent underpads. Use moisture barriers for incontinent residents. Treat dry skin with moisturizers. Follow individualized toileting plan. Toilet in advance

of need.

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True or False?

6. Once a pressure ulcer is healed, prevention measures can be discontinued.

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False.

FACT: History of a pressure ulcer can increase the risk of developing a new pressure ulcer.

Suggested strategies2: Continue implementing prevention measures to

prevent skin breakdown. Continue to develop and modify plans as appropriate

for each individual.

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True or False?

7. The resident’s/patient’s skin should be checked at least daily if they are at risk for developing a pressure ulcer, even if they don’t have one now.

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Sacrum Back Buttocks

Elbows Back of head Arms, legs, fingers – due to

contractures or deformities

FACT: Skin should be checked at least daily for residents/patients at risk for developing a pressure ulcer, even if they don’t have one now.

Suggested strategies2,9,10: Acute care: Inspect skin daily. Long-term care: Inspect high-risk patients daily; inspect

all residents weekly. Special attention should be given to high-risk areas:

Heels Device-related

Pressure

True.

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Pressure Points

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True or False?

8. A reddened area on the skin can be a pressure ulcer.

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True.

FACT: Reddened area on the skin may be an indication of a Stage I pressure ulcer.

Suggested strategies11: Look for:

– Intact skin– Non-blanchable redness (doesn’t go away when

pressure has been relieved) Stage I pressure ulcers:

– Are usually on bony prominences– May be painful, firm, soft, warmer or cooler

compared to adjacent tissue– May appear with consistent red/blue/purple hues

in darker skin tones

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Stage 1 Pressure Ulcer11

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True or False?

9. It is only the wound care nurse’s responsibility to detect and treat pressure ulcers.

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False.

FACT: Pressure ulcer prevention and detection is every caregiver’s responsibility.

Suggested strategies9,10: Incorporate skin inspections into daily routine care –

whenever a staff member has visual access to a resident’s skin.

Opportunities include:– Bath/shower time– Dressing time– Incontinence care– Therapy time– Activities

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True or False?

10. Once a resident/patient says they don’t want to be turned anymore, there is nothing more you can do to prevent pressure ulcers.

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False.

FACT: Effective pressure ulcer prevention plans are customized for individual needs.

Suggested strategies2: Consider the needs, concerns, and abilities of specific

residents/patients when developing individualized plans. Integrate resident/patient/family education into all plans

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True or False?

11. Medical devices and personal items on or around a resident can cause a pressure ulcer.

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True.

FACT: Many factors, including medical devices and personal items, can increase the risk for pressure ulcer development.

Suggested strategies2: Monitor residents with devices such as casts, orthoses,

cervical collars, tubes, splints, and pommel cushions. Assess routinely to ensure that shoes fit properly. Maintain wrinkle-free bed linens. Keep personal alarm pads as wrinkle-free as possible Keep personal items within reach – not under

residents/patients

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True or False?

12. A blister or reddened area on a resident’s patient’s heel is nothing to worry about.

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False.

FACT: A blister or reddened area on a resident’s patient’s heel may be an indication of a developing pressure ulcer.

Suggested strategies3,4: When indicated, provide pressure relief by eliminating

contact between the heel and underlying surface. Inspect heels daily. Report blisters/reddened areas immediately.

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True or False?

13. Massaging a bony prominence promotes circulation and prevents pressure ulcers.

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False.

FACT: Current evidence suggests that massaging over bony prominences may be harmful.

Suggested strategies3:Adopt prevention and treatment options such as:– Resident/patient education– Regular repositioning schedules– Frequent monitoring

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True or False?

14. Bony prominences should not have direct contact with one another.

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True.

FACT: Direct contact of bony prominences can increase the risk for pressure ulcer development.

Suggested strategies11: Use pillows or foam wedges to keep bony

prominences such as knees and ankles apart.

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True or False?

15. The head of the bed should be placed in the highest position possible.

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False.

FACT: Improper bed positioning can lead to friction and shear, and contribute to pressure ulcer development.Suggested strategies4: Maintain the head of the bed at the lowest degree of

elevation consistent with medical conditions and other restrictions.

Limit the amount of time the head of the bed is elevated. The shear forces generated when an individual slides down the bed contribute to ischemia and necrosis of sacrial tissue and undermining of existing sacrial ulcers.

Educate residents/patients and families about bed positioning.

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Friction And Shear

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True or False?

16. Simple, hands-on rolling is the best way to turn a resident/patient in bed.

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False.

FACT: Hands-on rolling is not advised as a method for turning residents/patients.

Suggested strategies3: Use lifting devices to move rather than drag

individuals during transfers and position changes. Protect skin from mechanical injury via slide board,

turn sheet, trapeze, and/or lubricant use.

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True or False?

17. Residents/patients who can shift their own weight and reposition themselves don’t need to know about pressure ulcer prevention.

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False.

FACT: Pressure ulcer education should be provided to all residents/patients, including those who can shift their own weight and reposition themselves.

Suggested strategies2: Provide supportive devices (trapeze, bad canes, etc.) to

facilitate position changes. Educate residents/patients/families about the importance

of repositioning and how to do it properly. Encourage residents/patients to change positions

regularly (as often as necessary to prevent skin breakdown).

Monitor frequency of repositioning.

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True or False?

18. Moisture on the skin will increase the risk of developing a pressure ulcer.

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True.

FACT: Moisture is a key factor in pressure ulcer development.Suggested strategies11: Minimize exposure of skin to moisture (incontinence,

perspiration, wound drainage). Individualize bathing frequency. Use mild cleansing agents; avoid hot water and

excessive rubbing. Use lotion after bathing, and avoid massaging over

bony prominences. Follow bowel/bladder/toileting plan. Cleanse skin at the time of soiling. Use topical barrier to protect skin.

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True or False?

19. Residents with the following conditions are more likely to develop a pressure ulcer: Recent weight loss Recent incontinence Limited mobility Taking more than 8 medications

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True.

FACT: These conditions may increase the likelihood for pressure ulcer development.Suggested strategies2: Monitor all residents/patients, especially those at high

risk for pressure ulcer development. Adopt appropriate preventive measures, such as

bowel/bladder/toilet plans and proper transfer methods.

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Clinical Characteristics of Residents with PrUs

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True or False?

20. The care I give to my residents/patients every day can help prevent them from developing a pressure ulcer.

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TRUE!

FACT: The care you provide every day can help residents/patients live happier, healthier lives.

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References

1. Brandeis GH, Berlowitz DR, Katz P. Are pressure ulcers preventable? A survey of experts. AdvSkin Wound. 2001; 14(5):244-248.

2. Department of Health and Human Services. F-314: Pressure Sores, State Operations Manual: Appendix PP-Guidance to Surveyors for Long Term Care Facilities (Rev. 36). August 1, 2008. Available at: http://www.cms.hhs.gov/manuals/downloads/som107app_pp_guidelines_ltcf.pdf. Accessed May 5, 2009.

3. Bergstrom N, Allman R, Carlson CE, et al. Pressure Ulcers in Adults: Prediction and Prevention: Quick Reference Guide for Clinicians, No.3. AHCPR Publication No. 92-0050. Rockville MD: Agency for Health Care Policy and Research; May 1992.

4. Bergstrom N, Bennett MA, Carlson CE, et al. Treatment of Pressure Ulcers. Clinical Practice Guideline, No.15. AHCPR Publication No. 95-0652. Rockville MD: Agency for Health Care Policy and Research; December1994.

5. Institute for Healthcare Improvement. Five Million Lives Campaign Getting Started Kit: Prevent Pressure Ulcers, How-To Guide. Available at www.ihi.org. Accessed January 4, 2007.

6. Ayello EA, Braden B. How and why to do pressure ulcer risk assessment. Adv Skin Wound. 2002; 15(3): 125-131.

7. Bergstrom N, Braden, BA. A prospective study of pressure sore risk among institutionalized elderly. Journal of the American Geriatric Society. 1992; 40(8): 747-758.

8. Gosnell SJ. An assessment tool to identify pressure sores. Nursing Research. 1973; 22(1): 55-59. National Pressure Ulcer Advisory Panel. Cuddigan J, Ayello EA, Sussman C, eds. Pressure Ulcers in America: Prevalence, Incidence, and Implication for the Future. Reston, VA: NPUAP; 2001.

10. National Pressure Ulcer Advisory Panel. Baharestani MM, Ratliff C, eds. Pressure ulcers in neonates and children: An NPUAP white paper. Adv Skin Wound Care. 2007; 20(4): 208-220.

11. National Pressure Ulcer Advisory Panel. Pressure Ulcer Prevention Points. Washington DC: NPUAP; 2007.

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Questions

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Ohio KePRO

Rock Run Center, Suite 100

5700 Lombardo Center Drive

Seven Hills, Ohio 44131

Tel: 1.800.385.5080

Fax 216.447.7925

www.ohiokepro.com

All material presented or referenced herein is intended for general informational purposes and is not intended to provide or replace the independent judgment of a qualified healthcare provider treating a particular patient. Ohio KePRO disclaims any representation or warranty with respect to any treatments or course of treatment based upon information provided.

Publication No. 922000-OH-284-08/2009. This material was prepared by Ohio KePRO, the Medicare Quality Improvement Organization for Ohio, 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.