MA DDS Identifying, Healing and Preventing Pressure Ulcers (26 min)

MA DDS Identifying, Healing and Preventing Pressure Ulcers (26 min)


Hello and welcome to today’s webinar. My
name is Courtney Dutra and I’m from the Center for Developmental Disabilities
Evaluation and Research at UMass Medical School. Working in conjunction with the
Massachusetts Department of Developmental Services, we are pleased to
present today’s topic on Identifying, Healing and Preventing Pressure Ulcers:
It Really Does Take a Village. I’d like to introduce our speaker today. Donna
Morrow is an RN and wound care manager for Nozomi Health in Somerville,
Massachusetts. She has over 30 years of experience
working in nursing and specifically in wound care and wound management. Donna is
a certified wound care and ostomy nurse. She’s presented nationally on pressure
ulcers and published research articles on prevention and care. So without
further ado, I’m going to turn this over to Donna so she can begin.

>>Well thank you
very much Courtney. I am very happy to be here today and to
talk to you about pressure ulcers. This is a topic that I do hold near and dear
to my heart and I spent much of my career treating patients or people with
that. I want people to understand that pressure ulcers, so that they can give
good care to the people that they love and to their clients. Today’s objectives will
include identifying what pressure ulcers exactly are and what caused them.
Identifying those most at risk for a pressure ulcer, and recognizing pressure
ulcers, especially in different skin tones. We need to know how to prevent and
treat those ulcers and a few case studies and resources. A word of
warning. I just just want to let people know that today’s presentation is very
straight forward, as much so as possible and it’s not going to be very clinical.
This webinar is primarily for direct support professionals and others who
work directly with people with disabilities. It is not meant for
clinicians, however, we will show some clinical
images of what pressure ulcers look like in case you’ve never seen them before.
We’ll limit this to early in medium stages but you want to be aware that
this can be a little graphic. What is a pressure ulcer?

Sometimes we call them decubitus ulcers or bed sores and it’s an injury to
the skin and underlying tissue. There were two main causes, one being pressure
on one spot of the body for too long and the second being friction on that same
skin. Pressure occurs when someone is lying or sitting in one position for too
long. In the pressure of the body against that surface, like a chair seat, reduces
blood flow to the skin in nearby tissue. This stops the flow of oxygen. Pressure
can cause damage to the skin in the underlying tissue and serious damage to
the skin and muscle can occur in as little as one hour in a chair and as
little as two hours in a bed. So it’s so important to have those people that you
love that aren’t that mobile, help them to move even if it’s a little bit in a
chair or bed, you’ve succeeded in preventing that pressure ulcer.
Friction
Friction is a resistance to motion. It occurs when the skin is dragged across a
surface. When the person changes position or has moved or repositioned, if the skin
is moist or wet, the friction is worse and can cause significant skin and
tissue damage. This can worsen existing pressure ulcers. You’ll see the
highlighted red areas at the buttock and the heel are areas that frequently will
be affected by friction. Shearing. It’s similar to friction but it’s important
you understand how friction and shearing damage the skin. And when a person slides
down in their bed, the tailbone moves in one direction – downward – while the skin
over the tailbone stays in place. This pulls the skin in the opposite direction, and
the arrows in the picture show that the bone is moving away, one way, while
the skin is moving the other. This can cause tearing and damage to the skin. It
can also worsen existing pressure ulcers. Can you imagine if you had a pressure
ulcer and you were being pulled down in the bed like that? It’d be very painful. Other causes of pressure ulcers.
Any device or object that sits on the body and presses or rubs against it. A splint, a
roll of medical tubing, a g-tube, sheets, towels, or draw sheets. It’s very
important when placing anything under a client, a draw sheet, or anything, that
there are no wrinkles because this can add to the pressure.
This can cause a pressure injury. And when you’re checking the skin, to be
really careful. Check all of it, places you wouldn’t normally think a pressure
ulcer might occur. Behind the ears, if a patient’s wearing an oxygen tubing.
There’s not a lot of adipose tissue so this part of the body can break down
very quickly and can go right to a Stage 4 pressure ulcer. The Impact of Pressure Ulcers
At first the affected skin may be reddened or pink. A person may complain of
pain or itch, which is an extremely important indicator because that may be
your first clue that something’s wrong. In a darker toned skin patient, you may
not see the redness or pinkness but that pain can give you an indication to touch
or to feel that area for boggyness or a softness, firmness, warmth or
coolness. This can be an indicator that a pressure ulcer is forming. And if that
area was left untreated, the skin can open, become larger, deeper and much more
difficult to heal. And this goes into a great pain and can lead to bone
infection and sepsis. I’ll go into that a little more on the next slide but this
area can lead to death. Septicemia or sepsis infection.
It is a serious life-threatening condition. It occurs when the body has an overwhelming immune
response to that infection. As you can see in the picture, your client might
complain or have shivering, a fever, or feel very cold. They may have extreme
pain or general discomfort. They may be pale or have discolored skin. They may
complain of being sleepy or they may be difficult to wake up or be confused. And
they might state, “I feel like I might die.” That’s how bad sepsis would make your client feel.
They might not be able to explain it, that might be something they might
say. They also might be short of breath. These are some data from, umm, research
studies. As many as one-third of hospitalized patients with pressure
ulcers die during their hospitalization. More than half of those who develop a
pressure ulcer in the hospital will die within the next 12 months and about
60,000 patients die a year as a direct result of pressure ulcer each year. And
this translates to 6.85 deaths every hour, every single day, so
pressure ulcers are a huge impact on healthcare and the people we love.
Now that you know what a pressure ulcer is, what causes them? I’m going to cover
who is most at risk for developing these, and you can probably already think of
some situations where people would be more likely to develop a pressure ulcer.
People at risk are the elderly, people who have lost feeling or sensation in a body
part, cannot move themselves or are immobile, sit or lie down for extended
periods of time, or have a history of pressure ulcers. Also clients that have
bowel or urinary incontinence. And the elderly are more at risk because of the
skin loss elasticity as it ages. The skin can’t bounce back and they’re more
likely to suffer a skin injury or a tear. More people that are at risk are people
that take eight or more medications, have poor health or chronic health conditions,
especially diabetes and blood circulation problems, poor nutrition and
hydration. Making sure that your patient is getting a high-protein diet with lots
of water. They really need to be hydrated to keep that skin healthy. Fragile skin
that tears easily, skin tears or chronic skin problems, and excessively dry or
moist skin. Sometimes we use too much moisturizers or lotions, over the counter.
We need to have a balance because sometimes the moist skin can be just
as dangerous as having dry skin. People with a history of pressure ulcers.
They are five times as likely to develop another pressure ulcer. The
strength in that skin after you’ve had your pressure ulcer, when it’s healed,
goes down to 70%. So you’re never going to have that full strength skin that you
did after a pressure ulcer. So much more likely to break down again – we need to
really be aware when we have a patient that’s had a pressure ulcer. They
especially need to be repositioned off of that area. And even if the skin and
muscle heals, like I said, it will never be as strong as it once was. How to Recognize the Pressure Ulcer Now that you know what a pressure ulcer is and
what causes them, I’ll cover what a pressure ulcer looks like and where to
look for them. 95% of pressure ulcers develop in the
lower body. Common sites, as you can see on the picture, are the tailbone, the hip
bone, heel, ankles, elbows, and spine, as well as the back, back of the head, and
areas we don’t think of too much. Back of the ears. These are all in red on this
picture, you’ll notice. What your pressure ulcers look like?
These are both examples
of pressure ulcers in the pictures. Notice that the skin doesn’t have to be open
for a pressure ulcer to exist and for significant damage to be
occurring.
In the early stages, the skin can appear red or inflamed and the
person often complains of pain or an itch in the affected area. The skin may
be intact but it is red or spongy. And you need to be aware that pressure
ulcers can look different on different skin tones. The Stage 1 is where we
want to find the pressure ulcer. We want to see that we have a problem, get that
pressure away from it, and make sure it doesn’t go any further. This is where
it’s so important for you to check the skin and alert someone right away. A
charge nurse, your supervisor, your agency nurse, let them know and say “Hey, I see a
red spot on the client.” Okay, the next slide …
Finding Ulcers: Look, Listen, and Feel
Very important. You need to check your client’s skin at close range and at a distance, you’ll
be able to pick up differences in their skin tone. It can give you a heads up that
a pressure ulcer may be forming. You need to listen again to your client. If
they’re complaining of pain or soreness, very important and to feel, touch the
person’s skin. Check for warmth, coolness, if it feels mushy or firm, anything that
might feel different to you. It might be an indicator that something’s wrong and
to let someone know. Se Something, Say Something
Very important. It’s not gonna
help anyone if you see something and you go “I’m gonna keep an eye on that.” you
need to take the time, let somebody know whether it’s a doctor or nurse that
visits, the head of the group home, whatever it may be, you want to make sure
that patient is seen by a medical professional or wound nurse, somebody
that’ll know if that difference that you’ve seen, is something to really worry
about. Stages of Pressure Ulcers
The average person doesn’t need to know much
about the different stages. You don’t need to know the different stages to
identify a pressure ulcer. This is how medical professionals describe them. You’re probably going to hear these terms so it’s good to understand what
they mean. There are different stages of pressure ulcers. Stage 1 being the
least serious and 4, being the most. But medical professionals will use this word
“staging” so it’s important for you to understand that.
Stage 1, you notice that the skin is not broken but it is inflamed. The area may be red,
painful, soft, firm, warmer or cooler. Stage 2, the outer layer of skin,
epidermis, and the inner layer of skin, dermis, is damaged or lost. The wound may
be shallow, pinkish, or red. It may look like an abrasion, fluid
filled blister or a shallow crater. With Stage 2, the wound will be open. In a
Stage 3, the loss of skin usually exposes the fat layer. Bone, tendon, and muscle are
not exposed. Often times you’ll only see part of
the wound. It may be actually a lot deeper. There may be damage underneath.
Pressure ulcers start at the bone and work their way out ward towards the skin
and by the time you see it, it’s already been working its way out. A Stage 4 is
a pressure ulcer at a very deep, severe stage. It reaches into the muscle, the
bone, and it causes extensive damage. Damage to deeper tissue, tendons, and
joints may occur. What a pressure ulcers look like in different skin tones ?
Darker versus Lighter Skin Pigmentation The most crucial part of detecting the
pressure ulcer is understanding the changes in skin. Pressure ulcer may appear
bluish, purplish, or violet in darker pigmented skin. The same ulcer would look
red or pink in lighter skin. That’s why it’s so important to do a tactile exam
and feel the skin. You might not be able to see everything that’s below the skin
that’s happening. When you feel the skin, you might feel that the area feels boggy or
very soft. It will often be a different temperature from the surrounding skin. It
may be warmer or cooler. These are good indicators there’s a problem and to
alert someone. How to Check for Pressure Ulcers in Darker Skin Tones
The skin may be taunt, shiny, or hard, firm. Feel the area if you seek to see if it feels boggy or
very soft. It will often be a different temperature from the surrounding skin
and again, the person will likely be in pain. It’s important to identify these
areas before they develop into a larger pressure wound. How to Prevent Pressure Ulcers
A great way to prevent them is early detection. Inspect skin during
bathing or daily personal care and to report any and all changes in skin
appearance. Do not massage areas that are already red, especially if they are over
a bony part of the body, ankle, hip. We want to be able to pass that on to somebody in
charge, let them know. Reporting, I think, is the most important thing you can do.
To protect the skin, we want to make sure that we’re checking for urinary and
fecal incontinence so that a person is not sitting for long
periods of time. Feces and urine can be toxic to the skin. It can affect the pH
balance and it can definitely affect breakdown of skin. It also removes the
protective layer that the skin normally has so it’s so important to properly
clean the skin and then remoisturize after. We want to use only creams that
are ordered by the physician. Over-the-counter protectants are fine but
you really need to make sure that we have healthcare involved in choosing
which ones.

Good Hydration and Nutrition Again, protein is the key. It’s so
important when you’re helping your client to choose foods. We want to choose
a high protein, we want to make sure they’re drinking throughout the day. Protein is the biggest builder to skin and healing. We need to maintain that
hydration and nutrition. Clients need to drink enough, they need to be hydrated
and they need to choose things from a good diet. Good Positioning
When in bed, maintain the lowest possible head elevation appropriate for that person to
reduce the impact of shear. Position the patient to minimize pressure and
shearing forces over the heels, elbow, base of the head and the ears. Remember, positioning a patient is always appropriate for that person. You
need to follow guidelines as needed for that person. If a patient has a g-tube
and they’re getting a feeding, please follow the doctor’s orders and don’t put
the head of the bed down. We always want to maintain what the doctor suggests is
the safest possible position for that patient. When repositioning, we need to
help the person change position to relieve the pressure on that body part.
The person should change position at least every two hours and more often if they
are at risk for pressure ulcers. You can gently help your patient if they are in
a chair or in a bed. You can use pillows under one side of the back to offload
pressure, cushions under legs or between knees. And we need to follow all health
practitioners, physical and occupational therapists, and nursing
orders. There are reasons sometimes that we have to have a patient, again,
positioned at a certain level and we can’t change that without a doctor’s
order. We want to minimize friction and shearing, we want to avoid dragging those
heels, hips, or tailbone when we’re lifting someone in the bed. If they have
a device like a trapeze, please let them use that, let them assist you, because
that can cause a pressure area. Wheelchair Repositioning and Assessment
It is so important to encourage patients to shift their weight every 15 minutes
while seated and if you have a tilt feature on your chair, it’s very simple.
Move it a little bit. You’ve taken the pressure, you’ve changed it. That little
bit that you’re doing will help that pressure to be relieved and the patient
won’t develop that pressure area. We need to inspect the cushions for signs of
wear and proper inflation, proper placement. Wheelchairs, they need to be
inspected. This says “daily” -Absolutely! A sharp edge
could cause a brand new wound or injury and we don’t want to cause injury, we
want to prevent it. Providing Good Support
Specially ordered air mattresses or wedges, cushions, or pillows will relieve the pressure. If your
patient has a pressure injury, they may have an air mattress. Make sure that it’s
properly inflated. This support is needed to offload that pressure and they would
be recommended by a doctor a physical or occupational therapist. Skin Care
Very important. We need to keep that skin clean and dry.
We need to wash with mild soap and water, rinse thoroughly, and gently pat dry.
And we can apply over-the-counter lotions to prevent that dryness or skin
breakdown and again, never massage over the red skin. We want to make sure that
that’s left alone, we don’t want to add to any pressure on that area. Pressure Ulcer Management All wound care is to be managed or overseen by a certified wound and
ostomy nurse under the order of a healthcare provider.
An individualized protocol for the prevention and management of pressure
ulcers must be created for any person determined to be at risk. We want to make
sure that somebody that’s a professional, that works with wounds, or a physician
that works with wounds, makes that plan and lets us know what’s safe for this
patient. We don’t want to change anything without a doctor’s order.
This is the Braden Scale. It’s a way that healthcare professionals judge the risk of a person
having a pressure ulcer. You may see these in the home or hear them discussed.
Braden Scale assessments are not completed by direct care staff. It
is a tool for licensed staff only. Everyone has to be involved. As you know,
this is a team approach. Planning to provide evidence-based treatment
interventions is the responsibility of the whole team, whether you’re the nurse,
the case manager, a family member or direct caregiver. You’re important and
your input counts. We all need to be on board to prevent pressure ulcers. Pressure Ulcer Treatment
The treatment of a pressure ulcer will be done by a wound and ostomy nurse, not the provider nurses or direct care staff. However your
input is extremely essential. We need to know if there’s a new reddened area or
if the wound smells different, or looks different to you. Treatment and Monitoring A healthcare professional should evaluate a pressure ulcer at every dressing change to assess. But even though the wound and ostomy nurse is
managing the treatment of the wound, direct care staff probably play the most
essential role of all – that of noticing the beginning of a pressure ulcer and
reporting it immediately. You can stop the process. Treatment Goals

An open pressure wound needs to be covered by a dressing. We need to keep that wound
bed moist and the surrounding skin dry. We need to protect the ulcer from
contamination and promote moist wound healing. If you find a wound, it’s better
to cover it than leave it open. We don’t want to get an infection.
I have a couple of
case examples that I’d like to share with you. These are clients that I cared
for. Case 1: I had a 57 year old male who was admitted to the hospital with
pneumonia and sepsis. This person had to be intubated while in the hospital and
developed a Stage 4 pressure ulcer as a result. Normally this person was active
and not a person who we would think would develop a pressure related injury.
But because he was made immobile related to intubation and hospitalization, that
pressure wound developed rapidly. That wound changed his life and interrupted
it for over six months. He had difficulty sitting for prolonged period of time and
he was in a lot of pain. He was very self-conscious of this wound
and it could happen to anyone that’s hospitalized. That’s why we need to be
aware that if you have somebody in the hospital or even if you’re in the
hospital, make sure that we’re being positioned, even a little bit. We might be
able to prevent something like this. Statistically, hospitalizations
and illnesses increase that chance for every person for developing a pressure ulcer.
Case 2 – 61 year-old male with a history of diabetes, kidney failure, and
arterial disease. He had an amputated leg and he wears a prosthetic device.
Developed a blister on his right leg, above the knee amputation stump. Then
turned into a Stage 2 pressure ulcer. This was caused by wearing his
prosthetic device while his stump was edematous, or swollen.
And as you can see in the picture, because the stump was swollen, applying that
prosthetic device to it caused that pressure ulcer. You wouldn’t normally
think of a pressure ulcer developing in that area but a pressure ulcer can
develop anywhere it comes in contact with a hard surface, including a
prosthetic device or a brace. When doing a daily skin check, we need to check the
skin before we apply any braces or hardware because we can actually cause
pressure wounds and in this case, it may have started a red area that could
have been treated rather than it developing into a Stage 2 Pressure Ulcer. Thank You Donna.
This is Courtney Dutra again and I wanted to wrap up the webinar by sharing
some places where you can find more information. DDS, the Department of
Developmental Services, released guidelines for managing pressure ulcers
and these were released in June of 2017. Basically, the guidelines state that all
people with risk factors for developing pressure ulcers should be evaluated and
a protocol should be created for how best to manage that risk. Additionally,
all wound care should be managed by a certified wound and ostomy nurse. And
there we put the URL if you’d like to go read those guidelines more in
detail. Additionally DDS has developed a Signs
and Symptoms Sheet. This is a one or two page sheet that’s very basic and very
straight-forward and clear, and really gives good information about what is a
pressure ulcer, what does it look like, who is most at risk, and what should you
do if you suspect somebody has one. So I would really recommend that everyone
visit the DDS website – we put it there at the bottom – and and print off a copy of
that for yourself. We also have something called the Quality Is No Accident brief.
This is developed by my research center as well as DDS, and this is really
targeted towards house managers, risk managers, program supervisors, and it goes into just more detail about risk factors and so how to identify risk how to best
manage that risk as well as some treatment and prevention strategies. And
again, we put the website there if you’d like to get that.
And here we have a general resources about pressure ulcers and we will also
post this on our web page with this webinar. Lastly I just like to say thank
you for listening today. If you have any questions, Sharon Oxx, the director of
Health Services for DDS, has made herself available to answer questions by email.
Her email address is Sharon S H AR O N dot Oxx O X X at state dot ma dot us. Thank you
for listening.

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