Pressure ulcer prevention

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  1. Pressure ulcer prevention program 
    • risk assessment 
    • skin assessment and inspection 
    • nutritional assessment 
    • preventive skin care 
    • proper positioning 
    • use of support surfaces 
    • accurate documentation 
    • education 
  2. risk assessment for pressure ulcers 
    • Factors that place persons at risk: inability to perceive pressure,
    • exposure to incontinence/moisture,
    • decreased activity level,
    • inability to reposition,
    • poor nutrition intake,
    • friction and shear
  3. Assessment of Risk Factors for Pressure Ulcers 
    *Risk assessment allows for early and appropriate reduction of risk 
    • turning schedules
    • mattresses/overlays/bed
    • nutritional supplements 
    • skin protection during incontinence 
  4. Braden subscales 
    • sensory perception
    • moisture 
    • activity 
    • mobility 
    • nutrition 
    • friction and sheer 
  5. Study scale in notes.....examine braden scale 
    • highest possible score is 23 
    • lowest possible score is 6 
    • mild risk=15-18 
    • moderate risk=13-14
    • high risk =10-12
    • very high=<9
  6. When to measure risk of pressure ulcers 
    • licensed or trained staff asses on admission(form care plan based on risk) 
    • document findings 
  7. Pressure ulcer risk management 
    *develop a care plan based on subscale scores and other conditions 
    • immobile=reposition q 2 hours in bed 
    • inactive=reposition q 1 hr in w/c 
    • incontinent=protect skin from exposure 
    • malnourished=supplement oral intake
    • shearing=keep HOB as low as possible 
    • limited awareness=assess skin daily 
  8. Reassessment of Risk 
    • Frequent reassessment recommended: Daily if condition is changing rapidly(acute care, ICU) 
    • monthly/ quarterly for LTC or if significant change in condition 
    • Optimal frequency unknown: verify frequency with the regulatory agency for your setting
  9. Preventative Skin Care 
    • maintain skin health: keep skin clean and dry,
    • daily personal hygience,
    • clean skin with warm.tempid water,
    • moisturize skin 
  10. Preventive skin care 
    • reduce exposure to irritants : clean immediately after incontinence, apply skin protectants  
    • keep linens clean/wrinkle free 
    • check fit of braces, splits, medical devices(eg. oxygen tubing, NG tubing, stockings ) and skin underneath 
    • maintain environmental humidity 
    • individualize frequency 
    • document 

  11. Nutritional care 
    identify contribution factors 
    • impaired nutrition intake 
    • low body weight/unintentional weight loss
    • evaluate clinical signs of malnutrition 
  12. Nutritional Care 
    • Evaluate appropriate biochemical data:albumin, pre-albumin, hemoglobin, hematocrit
    • correct protein/calorie/fluid intake 
    • consider nutritional supplementation 
  13. Incontinence Management 
    • Bowel and bladder training 
    • indwelling catheters may be used for short periods of time but should be avoided whenever possible as they increase the risk of UTI 
    • incontinence pads/briefs(no diapers) 
  14. Incontinence Management 
    • use gentle soap or skin cleanser (prevent abrasion;do not scrub the skin) 
    • apply topical barrier to protect skin 
    • avoid plastic incontinence pads on low air loss beds 
  15. Avoid massage of red areas 
    massage may decrease rather than increase blood flow 
  16. Reduce shear 
    • shear diminshes blood supply to skin 
    • use position, transferring and turning techinques to minimize friction/shear injury
  17. Reduce Friction 
    • friction injuries involve the superficial skin layers 
    • occur when moving across coarse surface 
    • high risk persons (agitated, spastic, sliding down in bed) 
    • prevent with heel protectors, stockings, elevation of heels, skin protectants 
  18. Repositioning 
    • reposition bed-bound individuals at least every 2 hours
    • reposition chair-bound individuals every hour and encourage wt shifts every 15 min
    • reposition while on special beds /overlays
    • person must be turned 40 degrees to remove pressure from sacrum 
  19. positioning Devices 
    • teach ind. to reposition using the trapeaze 
    • use lifting devices to move individuals who cannot assist 
    • place pillows or wedges between knees and ankles 
  20. HOB Elevation 
    • limit amount of time head of bed is elevated to reduce friction and shear 
    • maintain the lowest possible elevation
    • avoid more than 30 degree HOB unless medically needed 
  21. Side lying postion 
    • avoid positioning directly on the trochanters 
    • use the 30degree lateral inclined position 
  22. elevate heels 
    • there must be space between bed and heels(float heels) 
    • use pillows to elevate heels of the bed surface
    • avoid hyper-extension of the knees 
    • check for injury from splints when used for heel elevation 
  23. No donuts 
    • don't use plastic rings or donuts for pressure relief
    • can can larger area of tissue injury because of intense pressure along the donut 
  24. rehabilitation programs 
    (consider various therapies if consistent with overall goals of care for the resident )
    • physical therapy for ambulation and strengthening 
    • occupational therapy for splinting and self care 
    • speech/language therapy for swallowing 
    • restorative care for maintenance 
    • (individualize program) 
  25. Change support surfaces 
    general info 
    most pressure reducing devices are more effective than standard hosptial mattress 
  26. support surfaces in chair 
    for ind. who spend a majority of thier time in wheel chair

    • use pressure reducing cushion 
    • instruct to also relieve pressure with hand 
    • lifts if possible every 15 min 
    • consider changing chair to tilt/recline for more pressure distribution 
  27. Monitor and Document 
    • document interventions and outcomes 
    • multidisciplinary approach 
    • periodic re-evaluation 
  28. Education
    • involve all levels of health care providers , the ind and the family 
    • structured, organized and comprehensive 
    • update content regularly
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Pressure ulcer prevention
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