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Pressure Injury - Prevention Marge Murphy Wound Care Nurse Specialist Residential Aged Care
Mrs Scott- RH resident • 91 admitted to hospital by GP/ low grade pyrexia/Ulcer below knee
2-3 months/MRSA on PO antibiotics 3 days – Mobility declining appetite poor
• Admitted diagnosed minor infection of lower limb. Secondary Diagnosis; acute on chronic renal failure /developed thrombocytopenia/ 2 units of blood/antibiotics changed to Vancromycin
• Stabilised but now deemed hospital level care/12 day admission.• Discharged to private hospital reported on Discharge Summary “in
a stable condition” On admission to PH she was assessed to have a Grade 111 pressure injury sacral area/ Haematoma Rt lower leg /Deep tissue damage Lt heel. Complaining of constant pain, discharged on Paracetamol
• Nil reference to any of the above on Discharge Summary• Not recorded as treatment injury
Lt lateral leg
Heel
Pressure injuries – Residential aged care • How do we prevent pressure injury (PI) with the best
available evidence
• The Waitemata experience
• Where are we at in NZ.
• What works and what are the next steps .
Presenter
Presentation Notes
RESEARCH HAS SHOWN They cause suffering and frustration to patients – pain, infection, delayed healing and wound characteristics (eg exudate and odour). They reduce quality of life –related to physical limitations and sleep deprivation and can have a psychological effect. Patients have reported negative emotions and mood alterations and issues related to body image, coping and acceptance. These factors contribute to personal suffering and impact on relationships with others including caregivers. They are associated with increased morbidity They are a huge financial burden on a health care system. They can be associated with feelings of anger and blame. They carry the underlying connotations of neglect mismanagement , feelings of failure and guilt on the part of the health professional
Recognising pressure injuries• Pressure ulcers can range from a discoloured or
reddened area of intact skin to full thickness skin loss, affecting muscle and bone. It is perhaps more correct to refer to them as pressure injuries as many are not open wounds
• A pressure injury is a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure in combination with shear and/or friction (Pan Pacific guidelines 2012).
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Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury. Produced by Australian wound management Association, New Zealand Wound Care Society and Hong Kong Enterostomal Therapist Association. Pressure injuries affect people who are largely immobile, most common amongst the elderly, but can affect anyone who is confined to a bed or wheel chair. On average 10% of hospitalised patients can develop a pressure injury during their stay. Prevalence rate of pressure ulcers can be between 5.4% and 15.6%.
Factors (localised) which determine if a pressure injury will develop
• duration of pressure– Time it takes before injury occurs.
• intensity of pressure– Boney prominences and surfaces and posture
• and ability of tissue to tolerate pressure (tissue tolerance) - (pressure, shearing, friction and moisiture).
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Presentation Notes
Intensity – the most vulnerable sites are heels, sacrum and ischial tuberosities. Heel pressure injuries has steadily increased over the last decade. Tissue tolerance – The ability of skin and underlying tissues to endure pressure without experiencing any adverse effects.When soft tissue is compressed between a bony prominence and a hard surface, the microcirculation is disrupted and local ischaemia occurs. In healthy individuals, a bright red flush over the pressure point will be visible on the skin (BLANCHING ERYTHEMA) due to local dilation of the blood vessels. This skin redness will resolve without tissue loss or damage. Non-blanching erythema is a sign that there is impaired blood supply and is suggestive that tissue damage is imminent or has already occurred. Shearing – Dragging skin accross support surfaces in the opposite direction to the skeleton and deep muscle. This can lead to stretching, kinking and tearing of the blood vessels, leading to deep necrosis. (Imagine a person sitting in a chair. The effect of gravity is to pull the patient downwards. However the skin, because of the resistance generated by the bed surface stays put and the skeleton and the deep muscle slides downwards) Friction – When the skin is pulled or slides over the surface. Damage tends to be superficial and moisture increases the risk.j
Risk Factors• Reduced mobility or immobility• Malnutrition and / or dehydration, recent weight loss.• Continence• Sensory impairment • Vascular disease• Advancing age. • Severe chronic or terminal illness • Previous history of pressure injury• Cognitive impairment
Presenter
Presentation Notes
If tissue tolerance is low in a patient with multiple risk factors, it is likely that the person will develop pressure damage sooner than someone with a higher tissue tolerance. Identifying risk factors is essential in order to develop a comprehensive PI prevention plan. Ptns aged over 65 years are at a greater risk, and the risk increases in those aged over 75 years.
Prevention and Management - Assessment• Conduct a comprehensive holistic assessment taking
into account: (CBR)Risk factorsMobility and activityNutritionContinenceCognitive assessmentPain
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1.Patients needs change on a daily basis, when there is acute illness ie UTI Chest infections , reassessment is vial Environment factors – eg shear and microclimate such as local heating, airconditioning, electric blankets, call bell etc.
Assessment1. Assessment of environmental factors.2. Use a validated pressure injury risk assessment scale
• Within 6 hours ? and ongoing daily e.g. showering.
• And when condition changes
Presenter
Presentation Notes
Environmental factors - Seating adequate hight, arm rests, bell is in reach, lighting, obstacles, walking aids, monkey bars, comodes. Risk assessment scales offers a structured approach to assessment but does not replace a comprehensive risk assessment. Lots of discussion around different tools they are only an aid to the prevention process. If a patient is identified to be at risk , it is vital that timely action is taken, These tools only comprise of part of what should be a complex prevention strategy and can only be effective if used in conjunction with clinical judgment. Reassessment as needs may change, not needing a alternating mattress forever kin assessment ; Skin status is the most significant early indictor of the skins response to pressure exposure and the ongoing risk of PI. Ongoing ( at shower turning patients) and BLANCHING ERYTHEMA. Importance of Care staff , identifying and reports to RN U HAVE DONE ASSESSMENT WHAT DO YOU DO ? Also assessing for localised heat, oedema, induration and skin breakdown. Identify areas of discomfort and pain.
Interventions - Repositioning
• Frequent repositioning reduces the amount of pressure over vulnerable areas, such as bony prominences and heels. (A)
• Frequency of repositioning should consider the patient’s risk of pressure injury development, skin response, comfort (pain relief), functional level, medical condition and the support surface used.
• Evidence that the 30 degree tilt is most effective (A)
Presenter
Presentation Notes
Repositioning – Reposition patients to reduce duration and magnitude of pressure over vulnerable areas, including bony prominences and heels. Frequency of repositioning should consider the patients risk of pressure injury development, skin response, comfort, functional level, medical condition and the support surface used. Change of position ie turning, education of patient , surfaces, education staff Frequency of repositioning to prevent ischaemia varies. The US / Europeen / British/ Australian guidelines all state the maximum period between repositioning at risk patients should be no longer than 2 hours. Frequency of repositioning should be documented so that all staff are aware of the patients status and no excuses for missing turns Reducing chair nursing to a maximum of two hours ( even with the use of pressure relieving devises) is recommended in International guidelines Patietn may be able to do with reminding. Pain- prescribed analgesia is given as prescribed and its effect is monitored and frequently reassessed. PAIN STOPS PEOPLE MOVING INCREASING RISK OF PRESSURE INJURY.
30 degree tilt
Pressure reducing
• Pressure reducing or static support surfaces, redistribute body weight and hence pressure over as great an area as possible, thereby reducing the amount of pressure at any one point. (A)
Presenter
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Support surface is a surface on which the patient is placed to manage pressure load, shear, friction and microclimate. This also includes seat cushions.
Pressure relievingActive support surfaces produce an alternating pressure
through mechanical means regardless of the pressure load. This is usually achieved through alternation of air pressure in support air cells on a programmed cycle time. This mechanism continually changes the part of the body supporting higher pressure loads.(A)
Support Surfaces
Skin Protection
Practice points (CBR)• Appropriate manual handling techniques with use of
hoist and sliding sheet etc• Provide transfer assistant devices e.g. overhead
handles to promote independent patient transferring• Do not vigorously rub the patients skin • Continence management plan • PH appropriate skin cleansers and barrier cream• Dressings or pads may be appropriate for pts at risk of
friction or shear
Presenter
Presentation Notes
Elimination of sheer friction and moisture are primary considerations in protection of the skin. Continence- Barrier creams . Frequent Toileting (maintaining patients mobility reduces risk).h Appropriate use of continence products and changing as per manufacturing (Ensure patients are assessed to need continence products).
NutritionAt risk patients are identified (MUST tool) (B)Interventions • High protein and calorie diet • Document fluid and food intake • Weekly weigh.• Assist with food intake • Patient preference• Consider Dietician referral
Presenter
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On the basis of 1 RCT, it appears that use of nutritional supplements may be of benefit in the prevention of pressure ulcers, though which specific nutrients offer the best protection remains unclear
Education• Provide patients with education on the prevention and
management of pressure injuries.• Involve patient and family.• Staff education (CBE
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Take in to account mental status, psychological symptoms including depression, ptn preferences, goals of care, quality of life(palliative care patients may have a stronger focus on managing symptoms, comfort and quality of life, culture and ethnicity, educational requirements. Ptn should have a clear understanding of the impact of PI and strategies that assist in reducing or eliminating the risk.
Staging • The most commonly used systems are National
Pressure Ulcer Advisory Panel (NPUAP) and European Pressure ulcer advisory panel (EPUAP)
• Superficial lesion are usually due to moisture and friction, should they be included in our statistics?
• Different tissue has different susceptibility to pressure, muscle is most susceptible followed by subcutaneous fat then dermis. Deep tissue damage can occur with little or no evidence of superficial damage. The first signs could be a deep necrotic wound. Seen frequently on the heel.
• Do PI on the sacral area follow a different physiological process to the heel area?
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Does one size fit all
Waitemata experience• First do no harm – voluntary reporting of all grade 111,
1V, Unstagable and all suspected deep tissue injury• Sep 2013, approx 20 facilities submitted data ( total 60)• Difficult to trend due to low numbers both in terms of
facility numbers and patient numbers • Records prevalence• In patient setting unable to get hold of data
Presenter
Presentation Notes
Try to encourage more facilites to submit data- It has to be useful to them Have to get something back 2. Recording needs to be consistant – Example a grade 111 is always a grade 111 As with falls data it should be more meaningful when all four dhbs report as one and faciltes will be able to bencch mark Unsure if in reports facilities are down grading as they heal / ( one data base across the dhbs )
NZ • Global Trigger tool - Measuring adverse events • First do no harm – intervention to reduce falls and grade
111, and 1V- Collection of data from RAC sector/Voluntary
• Pressure Injury prevalence surveys on an ad hoc basis • Some of the worst cases of pressure injury surface as
complaints to the Health and Disability Commissioner, and increasingly, claims are being made to ACC for treatment injury costs as a result of developing a debilitating pressure ulcer.
• But unlike most other OECD nations, New Zealand does not collect national annual data on PIs
Presenter
Presentation Notes
Global Trigger tool - Measuring adverse events First do no harm – intervention to reduce falls and grade 11, 111, and 1V- Collection of data from RAC sector/Voluntary Pressure Injury prevalence surveys on an ad hoc basis Some of the worst cases of pressure injury surface as complaints to the Health and Disability Commissioner, and increasingly, claims are being made to ACC for treatment injury costs as a result of developing a debilitating pressure ulcer. But unlike most other OECD nations, New Zealand does not collect national annual data on PIs 2739 pressure injury events were recorded for hospital patients discharged in the six months to the end of July 2011.* (National Minimum Data Set and Chief Nurses Office ) 143 claims for pressure injuries were accepted by ACC in 2010-11 (compared with 35 in 2005-2006). (ACC treatment Injury Statistics) 91% of the claims related to events in DHB facilities. (Serious and Sentinel Events reported by DHB to Health Quality and Safety Commission in 2010-2011
The Future • Multipronged, multidisciplinary interventions to prevent
PI in acute care settings and long-term-care facilities• Grading ulcers at any one point in time is problematic• We need to get out of our Silos, Is skin care only a
nursing problem ?• Avoidable?• Reflection of quality of care• League tables and benchmarking • Funding being cut when injury has been deemed
avoidable
Presenter
Presentation Notes
MULTIPRONGED approach; ie Outcomes reported in these studies suggest that such programs can be successful in reducing PrU prevalence or incidence rates. However, to strengthen the level of evidence, sites should be encouraged to rigorously evaluate their programs and to publish their results Grading. What appears as For example, someone with a black mark on their heel might simply have a blister with hard skin that will fall off, or they could have deeper damage which, in a diabetic, might mean losing a leg. The grading system could be interpreted as a continium , 3. It’s not just a nursing problem The doctors who clerk the patient in should be looking at the skin, the physio should be looking at the skin. At the moment we have people in silos - skin is ‘nurse’, ankle rotation is ‘physio’ and medication is ‘doctor’,” she says. Examine or nursing training programmes , is pressure injury prevention and management interwoven in all disciplines It is imperative to have management on board, yes figures are important but so are pictures What about technology to assist with assessment There is a mismatch between the high prevalence and costs associated with pressure ulcers and the amount of good-quality research focused on their prevention
