Pressure Ulcers:
Putting Pressure on
Prevention
Karen Clay, RN CWOCN
Why are we failing?
• Insanity
– Doing the same thing & expecting different
result
• Changing policy not practices
• Looking at paper not people
Goals
• Respond to pressure ulcer needs
assessment questionnaire
• Share prevention “pearls”
• Identify a variety of prevention possibilities
• Encourage honest examination of facility
practices
• Plan prevention in the context of each
resident’s life, routine and preferences
Questionnaire Results
• 68% of facilities conduct weekly risk
assessment x 4 weeks after admission
• 85% have process for re-stocking personal
care products
– 44% randomly audit this
• 52% have process for checking MDS
coding accuracy for Section M
• 31% have “rule” to decrease HOB
elevation when picking up meal tray
Questionnaire Results cont’d
• 55% of weekly skin committees include
visual rounds of residents in their seating
or bed positioning
• 78% have permanent assignments for
CNAs
• 68% have PU prevention as part of
orientation
Assessing Risk
Activity
Mobility
Braden Scale
Norton Scale
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Incontinence
Sensory Perception
Moisture
Friction & Shear
Nutrition
Physical Condition
Mental Condition
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Other Risk Factors
• History of pressure ulcers, scarring
• Medical diagnoses
• Nutritional deficits - wt loss, low albumin or
pre-albumin
• “Behaviors”: non-compliance, selfdestructive behaviors
– Do we “create” non-compliance when not
including the resident preferences in the plan?
– Is the resident REFUSING or CHOOSING?
Complicating Illnesses
• Impaired cardiovascular or pulmonary function:
*Compromise perfusion and oxygenation
• Conditions with damage to capillary basement
membrane - radiation, PVD
*Tissue perfusion is restricted
• Systolic pressure <100 mm Hg and diastolic <60
associated with PU development
– may shunt blood flow away from skin to more vital
organs…..decreasing skin tolerance by allowing
capillaries to close at lower levels of interface
pressure
Pain Control
• Eliminate/control pain
– Affects mobility
– Affects mental status
– Affects motivation
– Affects blood flow/perfusion of tissue
– Affects nutrition
Sample Protocol
“At Risk”
Turn/reposition every 2 hours (if
mobility impaired)
Moderate
Risk
High Risk
Very High
Risk
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Turn/reposition every 2 hours AND
prevent direct contact between bony
prominences
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Protect heels
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If bedfast, provide pressure-reducing
support surface
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If in wheelchair, provide standard
pressure-reducing seat cushion
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If appropriate, initiate remobilization
program (ambulation, stand-pivot
transfers, etc)
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Manage moisture (from incontinence)
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Manage nutrition
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Reduce friction/shear
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“At Risk”
Moderate
Risk
Very High
Risk
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Supplement turning schedule with
small position shifts (hourly)
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Obtain rehab assessment to:
-determine need for pressure
relief cushion
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Provide wedges/repositioning aids for
30 degree lateral positioning
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High Risk
-assess correct seat
height and w/c
positioning
Consider a pressure relieving support
surface or powered mattress overlay

Sample risk reduction strategies:
Heel Protection – Friction: “gripper” socks, sheepskin at foot of bed, transparent dressings, moisturizers, “bunny” boots
Heel Protection – Pressure: elevate lower extremities on pillow, multi-podus boots, heel-lift boots, loosen bed linens at
foot of bed, foot cradle
Manage Incontinence: initiate bowel/bladder program or scheduled toileting, incontinent care every two hours,
incontinence barriers, briefs, absorbent under pads, fecal bag (if frequent stools)
Reduce friction/shear: draw sheet or lift pad for bed movement, trapeze, moisturize skin, limit head of bed elevation to
30 degrees (and only as required), long sleeve garments/elbow protectors, careful cleansing during incontinence/hygiene
care, gait belt transfers (as appropriate), mechanical lift
Frequency of Assessment
Minimally
– upon admission
– quarterly
– upon Significant Change in Condition
Ideally
– day 7, 14, 21, 28 (post admission) and as
above
– during acute illness
Risk Assessment
• Establish guidelines, protocols,
algorithms/decision trees based on risk
– Low risk does not equal no risk
• Don’t just treat the conglomerate of
score
– Intervene based on the risk assessment
• What risks can you modify?
EXTERNAL FACTORS
Pressure
Shear
Friction
Moisture
Manage Moisture
• B&B programs
• Briefs
• Open vs. Closed
system at night
• Cleansing and
Moisturizing
• Moisture barriers
• Sweat
Fecal Incontinence
• Maklebust and Magnan (1994)
– 56.7% of patients with PU were fecally
incontinent
– 22 times more likely to have PU than patients
without fecal incontinence
Cleansing & Moisturizing
• Perineal cleansers better than soap or
products for routine skin cleansing
– Soap can dry, raise pH and contribute to
epidermal erosion
• Perineal cleansers – most contain
humectants
– Help replace oils in the skin
Skin Barriers
• Creams = water based preparations
• Ointments = oil based, longer lasting
(more occlusive)
• Paste = Ointment with powder; more
durability and absorption
SHEAR
Tissue layers slide against each other, disrupts or
angulates blood vessels
Heels
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•
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2nd most common site
Subject to high interface pressures
Suspend versus cushion
Diligent positioning and assessment
– Don’t treat just one heel
• Be flexible in approach – two hrs in
position may not be tolerable
Address Risk Factors
• Skin care
• Repositioning
– 1 hour in chair; 15 minutes in chair by
resident; 1-2 hours in bed, lift devices
• Pressure relief
– Cushions, support surfaces, off-load heels
• Assess/address nutrition, toileting schedule?
Rehab? Positioning evaluations?
Support Surfaces
• Pressure reducing/relief devices
– foam, static air, alternating pressure, low
air loss, air, gel, etc.
– If foam is used it should measure 3-4” in
thickness
– Egg-crate foam overlays are inadequate
– Sheepskin booties do not relieve pressure
– Need to learn properties
Rule of 30
• Head of bed is elevated to 30 degrees or
less
• Body is placed in a 30-degree laterally
inclined position - when repositioned to
either side
– Hips and shoulders tilted 30 degrees from
supine
– Pillows or wedges to keep position without
pressure over trochanter or sacrum
Repositioning
• Every 1-2 hours in bed
– Pros/Cons of facility-wide “clocks”
• Positioning devices
– No direct contact of bony
prominences
– MPB and stablizing bars
– Individualized w/c “accessories”
• Encourage mobility
CREATE A CULTURE OF
MOVEMENT
Tissue Tolerance
Deep tissue ischemia can occur without observable
changes in skin but it can “sensitize” the skin.
After that small increments of pressure may result
in breakdown
Husain (1953) research with rat muscle
• pressure of 100 mm Hg 2 hours
• Three days later: 50 mm Hg pressure to same
tissue caused muscle degeneration in only 1 hour
Skin Check
To be completed during the resident’s 1st bath of the week.
Please check the appropriate box and indicate the location. .
 Skin tear _____________________________
 Bruise _______________________________
 Open area ____________________________
 Reddened area_________________________
Rash_________________________________
Blister_______________________________
 No skin concern
 Resident refused shower or bath
Comment:_______________________________________________________
_______________________________________________________________
The Charge Nurse will notify the DON when there is a pattern of resident
refusals.
Charge Nurse Signature______________________________ Date__________
Competencies
• Have staff been taught how to conduct a
skin assessment
• Competency testing initially and annually
– Follow-up when a “necrotic” area is
discovered
• If skin check during shower…..how can we
do a complete assessment if resident
sitting on a shower chair?
Recurrent PU – Why?
• Decreased tensile strength of skin
• Characteristics of scar tissue
– Difficulties in assessment
• Higher level of prevention strategies
stopped when wound closes
• Weekly assessments by team stop when
wound closes
– Analogy of active rehab and “functional
maintenance” programs
Wound Care Teams
• ?Focus wound progress vs. prevention
– Wound characteristics assessed
• Cushions may/may not be assessed
– Presence, condition
• Heel off-loading devices may/may not be assessed
– Is there foot drop/deformity, condition of device, any
evidence of pressure from device
• Posture in chair
– Feet firmly planted (on floor or foot rest)
– How is position overall? Need therapy?
Mini-Focus Studies
• Check all residents requiring mechanical
lifts
– What time does the person get up in a.m.?
– What time does the person go back to bed
• If interval greater than two hours – how is pressure
relieved? How is incontinence care given?
– Have we worked with the resident to design a
schedule that honors their preferences and
protects skin
• Discussing benefit vs. risk with residents
Assignments & Appointments
• Many facilities have 11-7 assist a group of
residents up in a.m.
– What is criteria for developing this list
– Is skin risk considered
• If high risk resident assisted by 11-7 resident may
be ready for position change, incontinent care/
toileting or back-to-bed at the beginning of 7-3 shift
• How are routines altered if it is hairdresser
day? Podiatry visits?
– Potential for prolonged waiting times
Facility Patterns and PU
• Retrospective review of residents using
restraint
– How many restrained residents had any stage
PU in the past 3 or 6 months?
• Referrals to therapy for bed mobility?
• Any program to teach/encourage
resident(s) how to use chair rail to stand
up?
Wheelchair: Standard Issue
• How is it decided who “keeps” a w/c at all
times?
– Versus out of room storage for those requiring
for long distances
• Honest evaluation
– Is there a culture of mobility or immobility
• Wheelchairs for mobility
– Not used as “furniture”
Pondering Points……
• When folding bedcovers back and
putting extra blankets at the end of the
bed
– Where is the weight?
• When we remove pillows from under the
heels to “boost” the resident
– What happens?
• When we don’t use foot rests on
wheelchairs when needed
– What happens?
Involving Residents & Families
• Education in Resident Council
• Educating families
– Ways they can help
– Prohibiting family-provided devices unless
assessed by the team (cushions from home,
etc.)
• Encouraging culture of mobility
Involve Everyone!
• “Adopt a Resident” program
• Every two hour “theme” music/signal
• “Rounds” aligning with area of expertise
– Therapy random rounds for positioning
– CNA cross-audits of another unit for presence of skin
care supplies at bedside (if appropriate)
– SDC random competency check of skin assessment
– Any employee: walk thru after b’fast/meals to confirm
HOB has been lowered (unless clinically
contraindicated)
– Activities: who needs more movement incorporated
into activities program
“Super CNA” or “Lead CNA”
• Lighter assignment
– Enhance skin prevention role
– Verifying position changes, presence/use of
devices
– Work with nurse to modify resident schedules
– Participate in rounds
– Update peers weekly on progress
Care Plans
• Identify modifiable and non-modifiable
risks
• Link assessment with interventions
• Understand rationales for care
• Continually re-assess and update
• Weigh benefit versus risk
– Document
Quality Improvement
• Look for problems that exist in the delivery
of care
– Systems versus individuals
• How will you identify the problem(s)?
• What steps will you take to correct them?
• How will you measure your success?
Reality Check
• Check the budget for treatment supply
allocations
Then……………..
• Check the budget for prevention
supplies, pillows, positioning devices,
cushions
What does it show?
Incentives and/or Recognition
• When goal is reducing staff sick time
– Incentives often provided
• When goal is reducing worker’s comp
– Incentives often provided
• Staffing shortages and recruitment plans
– Incentives often provided
• When goal is reducing PU
– “I wish our numbers would come down”
The Devil is in the Details
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Communication to staff
Equipment provision and condition
Resident and facility routines
Availability of positioning devices
Willingness/commitment to have a living,
breathing, changing POC
• Improving one step at a time
– Don’t try to solve everything – pick one and
start
QI Lessons Learned
• Systems improvement does not happen
from
– Writing a new program
– Providing education one time
– Having “weekly measurements”
– Good intentions
MOST IMPORTANT
The resident WILL get your time……
Either proactively with PREVENTION
Or
Reactively with TREATMENT
My Challenge to You
• For the State that has the greatest decline
in pressure ulcers in the next
measurement period………..
– I will provide a complimentary four hour
educational presentation on any pressure
ulcer or wound care topic chosen by that
State
– The facility within that State with the greatest
improvement will be honored at that
presentation
Thank you for your time &
attention!
Karen Clay, RN, BSN, CWCN
Clay & Associates
(formerly Kare N’ Consulting)
[email protected]