“Nurse, I See RED…..” Maintaining skin integrity, it can be done! Developed by: Carol Balcavage, RN, WOCN, 2004
The Audience This education program was designed for the caregiver who spends the most time at the patient’s bedside . . . “The Nursing Assistant”
Objectives • The learner will identify the cause of pressure ulcers. • The learner will identify factors that contribute to the development of a pressure ulcer. • The learner will identify the role of the Nursing Assistant in prevention of pressure ulcers.
The Patient’s Skin • Largest organ in the body, equals 12-15% of body weight and receives one third of the body’s circulating blood volume • Functions • Protection • Thermoregulation • Sensation • Metabolism
Maintaining Skin Integrity • Is everyone’s responsibility • Patient’s first line of defense from infection • Many forms of skin integrity issues • Bruises, skin tears, cracks, shearing, erosions, scratches, blisters, pressure ulcers • Hospital acquired pressure ulcers are of great concern
What is a Pressure Ulcer? • Any injury caused by unrelieved pressure that damages the skin and underlying tissue (fat, muscle, bone). Also called decubitus ulcers, pressure sores or bed sores • Severity ranges from reddening of skin to deep craters extending to muscle and bone
Why are Pressure Ulcers a Problem? • Pressure ulcers can produce poor outcomes for patients including loss of a limb or even death • Pressure ulcers are costly • Increased length of stay • Added hospital costs • Additional recovery time • Pain • Potential for litigation
Risk Factors • Moist skin • Perspiration • Incontinence • Wound drainage • Limited activity and mobility • Inability to change position independently in bed or in chair • Assistance required to get out of bed • Assistance required to walk
Risk Factors Loss of sensory perception • Paralysis (loss of voluntary motion and/or sensation) • Neuropathy (“pins & needles” sensation in affected limb, decrease in sensation) • Decrease in mental awareness
Risk Factors • Altered blood flow • Decreased flow of blood to extremities • Vascular patients • Diabetic patients • Edema • Hypotensive episode (low BP)
Risk Factors • Friction and Shearing • Friction – abrasion of the top layer of skin • Shearing – the skin separating from underlying tissues
Risk Factors • Poor nutrition • Poor hydration
What Does a Pressure Ulcer Look Like? • There are four stages of pressure ulcer plus unstageable • Stage I: the ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues
Special Consideration for Pigmented Skin • Check skin compared to an adjacent or opposite area on the body • Skin temperature (warmth or coolness) • Tissue consistency (firm or boggy feel) • Sensation (pain or itching)
What Does a Pressure Ulcer Look Like? • Stage II: ulcer is superficial and presents clinically as an abrasion, blister or shallow crater • Stage III: full thickness of skin is lost, exposing the subcutaneous tissue • Stage IV: full thickness of skin and subcutaneous tissue is lost, exposing muscle or bone
What Does a Pressure Ulcer Look Like? Unstageable: ulcer is covered with dead tissue which may be black, brown or yellow
What Can You Do to Prevent Pressure Ulcers? • Each person plays an important role • Communication and timely reporting is critical • Other resources are also available such as the patient’s family and friends, the chaplain, volunteers and the WOC/ET nurse • However, it is the “Nursing Assistant” who spends the most time with the patient and who can make the biggest difference in preventing pressure ulcers
Prevention: Decrease Excessive Moisture • Good skin care • Bathe patient daily paying particular attention to skin folds and perineal tissues • Use skin cleansers with a low pH and skin protectant on all incontinent patients and patients who use a bedpan • Place absorbent material between the skin folds of obese patients
Prevention: Decrease Moisture • Good Skin Care • Limit use of diapers to patients who are out of bed or who have large amounts of urine or diarrhea at one time • Check incontinent patients frequently • Discuss a toileting schedule with the RN • Avoid plastic barriers and sheepskin • Communicate any signs of rednessto RN
Prevention Sensory Perception • Inspect patient’s skin for areas of redness with every position change • Avoid massaging or rubbing bonyprominences (Use a gentle touch when cleansing skin and applying ointments) • Turn and reposition every two hours (minimum) • Elevate heels off of bed surface • Check position of foot in the heel protection device and reposition as necessary
Prevention Sensory Perception • Remove compression stockings for ½ hour twice each day and check heels. If patient is at risk for heel breakdown, check more frequently • Perform active and passive range of motion (ROM) of all involved extremities
Prevention: Activity/Mobility • Encourage patient to change position frequently or turn and reposition patient every two hours • If patient is not moving because of poor pain control, discuss with the RN • Promote ambulation at regular intervals (consider PT consult if patient has difficulty with mobility)
Prevention: Activity/Mobility • Out of bed to chair no longer than two hours at one sitting • Reposition in chair after one hour. If patient is able to do so, remind to shift position every 15 minutes Hint: Suggest that position be shifted each time there is a commercial on TV • Use chair cushion if patient is at risk
Prevention: Altered Circulation • Report the following unexpected changes to the RN: • Change in vital signs and color • Change in temperature of skin surfaces • Decrease in urine output • Swelling in any body tissues
Prevention: Altered Circulation • Keep in mind that patients with altered circulation are susceptible to skin damage from heat and cold from items such as: • Heating pads • Hot packs • Cold packs
Prevention: Friction/Shearing • Use moisturizers on dry skin surfaces where applicable and use a bathing system that incorporates emollients like Vitamin E and Aloe • Assess need for assistive devices (heel protectors, extra pillows) • Use turning and transfer aids (i.e., lift sheets, trapeze)
Prevention: Friction/Shearing • Prevent shearing by maintaining bed at 30 degrees or less and gatch knees when possible • Have patient use a trapeze when indicated • When using lift sheet to move patient to top of bed • Avoid dragging any part of patient’s body • Put socks on patient’s feet • Ask patient to bend knees and to push against bed surface
Prevention: Friction/Shearing • Powder bedpan edges before placing patient on bedpan • Pad patient’s buttocks and or transfer board when getting patient in and out of bed with transfer board • Use elbow protectors when indicated • Maintain proper positioning in chair
Prevention: Nutrition & Hydration • Monitor weight on admission and weekly • Monitor fluid status, I & O as appropriate • Monitor/encourage nutritional intake recommendations (target: meal completion over 75%) • Accurately record calorie counts • Give patient nutritional supplements as ordered
Prevention: Nutrition & Hydration • Provide patient with hand wipes before and after meals. Also provide opportunity to brush teeth • Whenever possible, get patient out of bed for meals
Review Now let’s test your knowledge
Select the best answer • A pressure ulcer is a surgical wound. • A patient with poor circulation is not at risk for developing a pressure ulcer. • Pressure ulcers are caused by unrelieved pressure. • No one develops a pressure ulcer at my hospital.
Select the best answer • A patient with reduced sensation in his feet is at risk for developing a heel ulcer. • Good nutrition leads to bedsores. • Moist skin due to perspiration is not a risk factor. • A patient who is paralyzed is not at risk for developing a pressure sore.
Select the best answer • I really don’t worry about pressure ulcers, that’s the nurse’s job. • All patient’s have red heels. • I report any reddened area to the RN. • I check my incontinent patients every four hours.
Select the best answer • I do not need to report every red mark that my patient gets on his skin to the RN. • The RN is the only one who can prevent pressure ulcers. • A little pressure sore on my patient’s foot is not very important. • It takes team work to prevent pressure ulcers and I’m a key player on that team.
Answer Key C. Pressure ulcers are caused by unrelieved pressure. A. A patient with reduced sensation in his feet is at risk for developing a heel ulcer. C. I report any reddened area to the RN. D. It takes team work to prevent pressure ulcers and I’m a key player on that team.
References Ayello EA, Baranski S, Lyder CH, Cuddingan J. Pressure ulcers. In:Baranski S and Ayello EA. Wound Care Essentials: Practice Principles. Springhouse, PA: Lippincott Williams & Wilkins: 2004. p 240-70. Calianno C, Assessing and preventing Pressure Ulcers. Adv Skin Wound Care; 2000; 13(5):244-246. Hess CT. Skin Care Basics..Adv Skin Wound Care 2000; 13(3):127-129. Panel on the Prediction and Prevention of Pressure Ulcers in Adults. Pressure Ulcers in Adults:Prediction and Prevention. Cliical PracticeGuideline,No.3 AHCPR Publication No. 92-0047. Rockville,MD:Agency for Health Care Policy and Research; May 1992. Ratcliff CR,WOCN’s Evidence-Based Pressure Ulcer Guideline. Adv Skin Wound Care 2005; 18(4):204-207. Zulkowski,KM, Tellez R, van Rijswijk L. Documentation with MDS Section M: Skin Condition. Adv Skin Wound Care 2001; 14(2):81-89.
Lehigh Valley HospitalAllentown, PA Developed by: Carol Balcavage, RN, WOCN, 2005