What are 3 appropriate prevention strategies for maintaining skin integrity and pressure area care for this client?
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Once you have determined that you are ready for change, the Implementation Team and Unit-Based Teams should demonstrate a clear understanding of where they are headed in terms of implementing best practices. People involved in the quality improvement effort need to agree on what it is that they are trying to do. Consensus should be reached on the following questions:
In addressing these questions, this section provides a concise review of the practice, emphasizes why it is important, discusses challenges in implementation, and provides helpful hints for improving practice. Further information regarding the organization of care needed to implement these best practices is provided in Chapter 4 and additional clinical details are in Tools and Resources. In describing best practices for pressure ulcer prevention, it is necessary to recognize at the outset that implementing these best practices at the bedside is an extremely complex task. Some of the factors that make pressure ulcer prevention so difficult include:
3.1 What bundle of best practices do we use?Given the complexity of pressure ulcer prevention, with many different items that need to be completed, thinking about how to implement best practices may be daunting. One approach that has been successfully used is thinking about a care bundle. A care bundle incorporates those best practices that if done in combination are likely to lead to better outcomes. It is a way of taking best practices and tying them together in a systematic way. These specific care practices are among the ones considered most important in achieving the desired outcomes. The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers:
Because these aspects of care are so important, we describe them in more detail in the subsequent subsections along with helpful clinical hints. While these three components of a bundle are extremely important, your bundle may stress other aspects of care. It should build on existing practices and may need to be tailored to your specific setting. Whatever bundle of recommended practices you select, you will need to take additional steps. We describe strategies to ensure their successful implementation as described in Chapter 4. The challenge to improving care is how to get these key practices completed on a regular basis. ResourcesThe bundle concept was developed by the Institute for Healthcare Improvement (IHI). Their Web site includes a more detailed description of what is a bundle: http://www.ihi.org/ihi/topics/criticalcare/intensivecare/improvementstories/whatisabundle.htm. Additional InformationThe following article describes successful efforts to improve pressure ulcer prevention that relied on the use of the components in the IHI bundle: Walsh NS, Blanck AW, Barrett KL. Pressure ulcer prevention in the acute care setting. J Wound Ostomy Continence Nurs 2009;36(4):385-8. 3.1.1 How are the different components of the bundle related?Each component of the bundle is critical and to ensure improved care, each must be consistently well performed. To successfully implement the bundle, it is important to understand how the different components are related. A useful way to do this is by creating or following a clinical pathway. A clinical pathway is a structured multidisciplinary plan of care designed to support the implementation of clinical guidelines. It provides a guide for each step in the management of a patient and it reduces the possibility that busy clinicians will forget or overlook some important component of evidence-based preventive care. Some of the advantages of these clinical pathways are to:
Tools
Practice InsightsGiven the complexity of pressure ulcer preventive care, develop a clinical pathway that describes your bundle of best practices and how they are to be performed. Return to Contents 3.2 How should a comprehensive skin assessment be conducted?The first step in our clinical pathway is the performance of a comprehensive skin assessment. Prevention should start with this seemingly easy task. However, as with most aspects of pressure ulcer prevention, the consistent correct performance of this task may prove quite difficult. 3.2.1 What is a comprehensive skin assessment?Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences. As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include:
Additional InformationIt is important to differentiate MASD from pressure ulcers. The following articles provide useful insights on how to do this:
3.2.2 How is a comprehensive skin assessment performed?A comprehensive skin assessment has a number of discrete elements. Inspection and palpation, though, are key. To begin the process, the clinician needs to explain to the patient and family that they will be looking at their entire skin and to provide a private place to examine the patient's skin. Make sure that the clinicians' hands have been washed, both before and after the examination. Use gloves to help prevent the spread of resistant organisms. Recognize that there is no consensus about the minimum for a comprehensive skin assessment. Usual practice includes assessing the following five parameters:
ToolsDetailed instructions for assessing each of these areas are found in Tools and Resources (Tool 3B, Elements of a Comprehensive Skin Assessment). Practice Insights
3.2.3 How frequently should comprehensive skin assessments be performed?Comprehensive skin assessment is not a one-time event limited to admission. It needs to be repeated on a regular basis to determine whether any changes in skin condition have occurred. In most hospital settings, comprehensive skin assessment should be performed by a unit nurse on admission to the unit, daily, and on transfer or discharge. In some settings, though, it may be done as frequently as every shift. The admission assessment is particularly important on arrival to the emergency room, operating room, and recovery room. It may be appropriate to have more frequent assessments on units where pressure ulcers may develop rapidly, such as in a critical care unit; or less frequently on units in which patients are more mobile, such as psychiatry. Staff on each unit should know the frequency with which comprehensive skin assessments should be performed. Optimally, the daily comprehensive skin assessment will be performed in a standardized manner by a single individual at a dedicated time. Alternatively, it may be possible to integrate comprehensive skin assessment into routine care. Nursing assistants can be taught to check the skin any time they are cleaning, bathing, or turning the patient. Different people may be assigned different areas of the skin to inspect during routine care. Someone then needs to be responsible for collecting information from these different people about the skin assessment. The risk with this alternative approach is that a systematic exam may not be performed; everybody assumes someone else is doing the skin assessment. Decide what approach works best on your units. Action StepsAssess whether your staff know the frequency with which comprehensive skin assessment should be performed. 3.2.4 How should results of the comprehensive skin exam be reported and documented?In order to be most useful, the result of the comprehensive skin assessment must be documented in the patient's medical record and communicated among staff. Everyone must know that if any changes from normal skin characteristics are found, they should be reported. Nursing assistants need to be empowered and feel comfortable reporting any suspicious areas on the skin. Positive reinforcement will help when nursing assistants do find and report new abnormalities. In addition to the medical record, consider keeping a separate unit log that summarizes the results of all comprehensive skin assessments. This sheet would list all patients present on the unit, whether they have a pressure ulcer, the number of pressure ulcers present, and the highest stage of the deepest ulcer. By regularly reviewing this sheet, you can easily determine whether each patient has had a comprehensive skin assessment. This log will also be critical in assessing your incidence and prevalence rates (go to section 5.1). Nursing managers should regularly review the unit log. Action StepsAssess the following:
ToolsA sample sheet can be found in Tools and Resources (Tool 5A, Unit Log). Practice Insights
3.2.5 What are some barriers to practice?There are many challenges to the performance of comprehensive skin assessments. Be especially concerned about the following issues:
ToolsAn example of a notepad to be used for communication among nursing assistants, nurses, and managers can be found in Tools and Resources (Tool 3C, Pressure Ulcer Identification Notepad). 3.2.6 How can practice be improved?Comprehensive skin assessment requires considerable skill and ongoing efforts are needed to enhance skin assessment skills. Take advantage of available resources to improve skills of all staff. Encourage staff to:
ResourcesThis slide show illustrates how to perform a skin assessment: www.authorstream.com/Presentation/ann5844-150720-skin-assessment-nursing-1-curdeline-product-training-manuals-ppt-powerpoint/ Consult the European Pressure Ulcer Advisory Panel Web site (http://www.epuap.org) for useful advice on evaluating erythema and the proper staging of pressure ulcers. Practice InsightsA full-body skin inspection does not have to mean visualizing all aspects of the patient in the same time period.
Return to Contents 3.3 How should a standardized pressure ulcer risk assessment be conducted?As discussed above, one purpose of comprehensive skin assessment is to identify visible changes in the skin that indicate increased risk for pressure ulcer development. However, factors other than skin changes must be assessed to identify patients at risk for pressure ulcers. This can best be accomplished through a standardized pressure ulcer risk assessment. 3.3.1 What is a standardized pressure ulcer risk assessment?After a comprehensive skin examination, pressure ulcer risk assessment is the next step in pressure ulcer prevention. Pressure ulcer risk assessment is a standardized and ongoing process with the goal of identifying patients at risk for the development of a pressure ulcer so that plans for targeted preventive care to address the identified risk can be implemented. This process is multifaceted and includes many components, one of which is a validated risk assessment tool or scale. Other risk factors not quantified in the assessment tools must be considered. Risk assessment does not identify who will develop a pressure ulcer. Instead, it determines which patients are more likely to develop a pressure ulcer, particularly if no special preventive interventions are introduced. In addition, risk assessment may be used to identify different levels of risk. More intensive interventions may be directed to patients at greater risk. Action StepsAsk yourself and your team:
3.3.2 Why is a pressure ulcer risk assessment necessary?Pressure ulcer risk assessment is essential for a number of reasons:
Action StepsAsk yourself and your team:
3.3.3 How is risk assessment performed?Pressure ulcer risk assessment is a standardized process that uses previously developed risk assessment tools or scales, as well as the assessment of other risk factors that are not captured in these scales. Risk assessment tools are instruments that have been developed and validated to identify people at risk for pressure ulcers. Typically, risk assessment tools evaluate several different dimensions of risk, including mobility, nutrition, and moisture, and assigns points depending on the extent of any impairment. Clinicians often believe that completing the risk assessment tool is all they need to do. Help staff understand that risk assessment tools are only one small piece of the risk assessment process. The risk assessment tools are not meant to replace clinical assessments and judgment but are to be used in conjunction with clinical assessments. Many other factors might be considered as part of clinical judgment. However, many of these factors, such as having had a stroke, are captured by existing tools through the resulting immobility. Several additional specific factors should be considered as part of the risk assessment process. However, also remember that patients who are just "not doing well" always seem to be at high risk for pressure ulcers.
Practice InsightsComprehensive risk assessment includes both the use of a standardized scale and an assessment of other factors that may increase risk of pressure ulcer development. 3.3.4 What risk assessment scales are used most often?Remember that risk assessment scales are only one part of a pressure ulcer risk assessment. These scales or tools serve as a standardized way to review some factors that may put a person at risk for developing a pressure ulcer. Research has suggested that these tools are especially helpful in identifying people at mild to moderate risk as nurses can identify people at high risk or no risk. All risk assessment scales are meant to be used in conjunction with a review of a person's other risk factors and good clinical judgment. While some institutions have created their own tools, two risk assessment scales are widely used in the general adult population: the Norton Scale and the Braden Scale. Both the Norton and Braden scales have established reliability and validity. When used correctly, they provide valuable data to help plan care. The Norton Scale is made up of five subscales (physical condition, mental condition, activity, mobility, incontinence) scored from 1-4 (1 for low level of functioning and 4 for highest level of functioning). The subscales are added together for a total score that ranges from 5 to 20. A lower Norton Scale score indicates higher levels of risk for pressure ulcer development. Scores of 14 or less generally indicate at-risk status. The Braden Scale is made up of six subscales (sensory perception, moisture, activity, mobility, nutrition, friction/shear) scored from 1 to 4 or 1 to 3 (1 for low level of functioning and 4 for the highest level or no impairment). Total scores range from 6 to 23. A lower Braden Scale score indicates higher levels of risk for pressure ulcer development. Scores of 18 or less generally indicate at-risk status. This threshold may need to be adjusted for the specific patient population on your unit or according to your hospital guidelines. Other scales may be used instead of the Norton or Braden scales. What is critical is not which scale is used but just that some validated scale is used in conjunction with a consideration of other risk factors not captured by the risk assessment tool. By validated, we mean that they have been shown in research studies to identify patients at increased risk for pressure ulcer development. Action StepsAsk yourself and your team:
ToolsCopies of the Braden and Norton scales are included in Tools and Resources (Tool 3D, Braden Scale , and Tool 3E, Norton Scale ). ResourcesAdditional information on the Braden and Norton scales may be found at the following Web sites:
3.3.5 What risk assessment should be used in special populations?The risk assessment tools described above are appropriate for the general adult population. However, these tools may not work as well in terms of differentiating the level of risk in special populations. These include pediatric patients, patients with spinal cord injury, palliative care patients, and patients in the OR. Risk assessment tools exist for these special settings but they may not have been as extensively validated as the Norton and Braden scales. ResourcesConsider the following resources for risk assessment in special populations:
3.3.6 What information do you get from using a risk assessment scale?Overall scale scores provide data on general pressure ulcer risk and help clinicians plan care according to the amount of risk (high, moderate, low, etc). Subscale scores provide information on specific deficits such as moisture, activity, and mobility. These deficits should be specifically addressed in care plans. Remember, even a score that indicates no risk does not guarantee that a person will not develop a pressure ulcer, especially as their condition changes. 3.3.7 How often is a pressure ulcer risk assessment done?Consider performing a risk assessment in general acute care settings on admission and then daily or with a significant change in condition. However, pressure ulcer risk may change rapidly, especially in acute care settings. Therefore, recommendations for frequency of risk assessment will vary. In settings where patients' status may change quickly, such as in critical care, risk assessment should be performed more frequently, such as every shift. In the OR, recommendations exist to assess on admission, at discharge to the recovery room, and periodically for operations lasting longer than 4 hours. (Consider the time in the holding and recovery rooms when assessing the time). For patients with more stable conditions, such as acute rehabilitation, pressure ulcer risk assessment may be less frequent. What is important is that the frequency of pressure ulcer risk assessment be individualized to the person's unique setting and circumstances. Action StepsConsidering the specific patient situation, ask yourself and your team:
ResourcesFor more information on risk assessment in the OR, see the recommendations from the Minnesota Hospital Association Safe Skin Campaign: http://www.mnhospitals.org/inc/data/tools/SafeSkin-Toolkit/OR-pressure-ulcer-recommendations.pdf. 3.3.8 How should pressure ulcer risk assessment be documented and communicated?Documenting pressure ulcer risk is essential to ensure that all staff are aware of patients' pressure ulcer risk status. While documenting in the medical record is necessary, documentation alone may not be sufficient to ensure that all staff know the level of risk. Among the options to consider for complete documentation are:
Remember that in documenting pressure ulcer risk, you want to incorporate not only the score and subscale scores of the standardized risk assessment tool, but also other factors placing the individual at risk. This information is often included in narrative text. Risk status should be communicated orally at shift change or by review of the written material in the medical record or patient care worksheet. Consider innovative approaches to conveying level of risk. For example, some facilities have color-coded the patient wristband, placed stickers on the patient chart or worksheet, or used picture magnets on the doors to indicate risk status. 3.3.9 How can we improve the accuracy of pressure ulcer risk assessment?The accuracy of a risk assessment scale depends on the person completing it. Experience has shown tremendous variability among staff even when evaluating the same patient. Therefore, training in how to use the scale is needed to ensure consistency. Action StepsIt is important to check how risk assessment is being performed on each unit.
ResourcesInformation may be found in the Hartford Institute for Geriatric Nursing's Try This Series at http://www.consultgerirn.org/uploads/File/trythis/issue05.pdf. Refer to Issue 5 under the General Assessment Series. Lindgren M, Unosson M, Krantz AM, et al. A risk assessment scale for the prediction of pressure sore development: reliability and validity. J Adv Nurs 2002;38(2):190-9. Additional InformationLearn more about risk assessment:
Which 3 ways can you prevent a client from getting a pressure ulcer?Tips to prevent pressure sores. change position and keep moving as much as possible.. stand up to relieve pressure if you can.. ask your carer to reposition you regularly if you can't move.. change position at least every 2 hours.. use special pressure relieving mattresses and cushions.. How can you maintain skin integrity to prevent a pressure sore?Skin care in hospital. Keep your skin clean and dry.. Avoid any products that dry out your skin. ... . Use a water-based moisturiser daily. ... . Check your skin every day or ask for help if you are concerned. ... . If you are at risk of pressure sores, a nurse will change your position often, including during the night.. What are the best ways to prevent pressure areas developing?Preventing pressure ulcers
regularly changing your position – if you're unable to change position yourself, a relative or carer will need to help you. checking your skin every day for early signs and symptoms of pressure ulcers – this will be done by your care team if you're in a hospital or care home.
What are three nursing interventions to prevent pressure ulcers?The pressure ulcer bundle outlined in this section incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment. Standardized pressure ulcer risk assessment. Care planning and implementation to address areas of risk.
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