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NDNQI: Preventing Pressure Ulcers

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Tam Amberg

on 17 April 2014

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Transcript of NDNQI: Preventing Pressure Ulcers

NDNQI: Assessing & Preventing
Pressure Ulcers

http://www.nursingquality.org/
Braden Skin Scale
Website: http://bradenscale.com/index.htm

Copyright Permission: http://bradenscale.com/copyright.htm

Braden Scale for Assessing Pressure Sore Risk: http://bradenscale.com/images/bradenscale.pdf

Protocols for Level of Risk: http://bradenscale.com/images/protocols_by_level_of_risk.pdf

Skin Assessment Tool: http://bradenscale.com/images/skinassessmenttool.pdf

Tools
1. Sensory Perception
2. Moisture
3. Activity
4. Mobility
5. Nutrition
6. Friction/Shear

Modifiable risk factors of PUs

* Prolonged pressure to
bony prominences

* Tolerance of tissue to
continued pressure
Buttocks
Ischium
Heels
Toes

Occiput
Ears
Scapulae
Sacrum
Olecranon
Common Areas for PUs

* Subscales ranked 1 to 4, except friction/shear ranked 1 to 3

* Total possible score 6 to 23

* Higher scores = less risk for PUs

* Lower scores = greater risk for PUs

* 19-23 (low risk)
* 15-18 (at risk)
* 13-14 (moderate risk)
* 10-12 (high risk)
* < 9 (very high risk)
Levels of Risk
* Assess risk within 24 hrs of admission
* Reassess risk at each assessment
* Frequent turning - every 2 hours
* Maximize remobilization
* Protect heels from bed surface
* Minimize moisture
* Promote nutrition and hydration
* Reduce friction/shear forces
Interventions to Prevent PUs
* 1 = Completely limited
* 2 = Very limited
* 3 = Slightly limited
* 4 = No impairment
1. Sensory Perception
“ Ability to respond meaningfully to pressure-related discomfort”
Sources of moisture:
* Urinary incontinence
* Fecal incontinence
Draining wounds
Diaphoresis
2. Moisture
“The degree to which skin is exposed to moisture”
* Urinary and fecal incontinence represent the most common sources
of moisture exposure, estimated at 19.7% in the acute care setting.
Scale: 1 to 4
* 1 = Constantly moist
PU 10X more likely!!
* 2 = Very moist
* 3 = Occasionally moist
* 4 = Rarely moist
* 1 = Bedfast
* 2 = Chairfast
* 3 = Walks occasionally in room
* 4 = Walks frequently and far
3. Activity
“ Degree of Physical Activity”
* 1 = Completely immobile
* 2 = Very limited
* 3 = Slightly limited
* 4 = No limitations
4. Mobility
“ Degree of Physical Activity”
* 1 = Very poor
* 2 = Probably inadequate
* 3 = Adequate
* 4 = Excellent
“ Usual food intake pattern”
5. Nutrition
* 1 = Problem
* 2 = Potential problem
* 3 = No apparent problem
“The amount of assistance a client needs to move and the degree of sliding with movement”
6. Friction/Shear
Pressure Ulcer
Assessment Video
Wound Educators.com
Stage I
Stage II
Stage III
Stage IV
Skin Assessment Quarterly Survey
Questions
Reimbursement
Implications


INTACT skin with non-blanchable redness of a localized area usually over a bony prominence. Skin that is dark may not appear red, but may have a darker coloring.

ALSO:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.
WHAT IS A PRESSURE ULCER?

A pressure ulcer (PU) is an area of damaged skin and/or underlying tissue that generally occur at areas with a bony prominence. The injury is a result of sustained pressure and/or shearing force.

PRESSURE- Pressure is vertical or perpendicular force to an area of the body that compresses underlying tissue and small blood vessels. This force impedes blood flow and nutrient supply to the skin and tissues, and can cause ischemic damage and necrosis.

SHEAR - Shear is a horizontal force of one layer of tissue sliding over another. This motion can damage skin and underlying tissue as blood flow is disrupted.
PARTIAL THICKNESS loss of dermis. Appears as a shallow open ulcer with a red pink wound bed. ALSO may appear as an intact or broken serum-filled or serosangineous-filled blister.

NOTE:
This stage should not be used to describe skin tears, tape burns, incontinence skin irritation, maceration or excoriation.
FULL THICKNESS tissue loss. Subcutaneous fat may be visible but tendon, muscle, or bone are not exposed. Slough may be seen as well as undermining and tunneling.

ALSO:
Depth varies by anatomical location. Ulcer may be a shallow depression in areas with little or no subcutaneous tissue such as the bridge of the nose, ear, occiput and malleolus or very deep in areas with much adipose tissue.
FULL THICKNESS tissue loss WITH EXPOSED TENDON, MUSCLE, OR BONE. Slough or eschar may be present. These ulcers often include undermining and tunneling.

NOTE:
Ulcer can extend into muscle and/or supporting structures such as fascia, tendon or joint capsule. This makes osteomyelitis or osteitis a likely complication. Exposed bone/tendon is visible or directly palpable.
Tamara Amberg, IPPNS (ambets01@students.ipfw.edu)
Kelly Christophel, IPPNS (chrika02@students.ipfw.edu)
Paula Kushman, IPPNS (kushpd02@students.ipfw.edu)
INTERVIEWS
PAMELA REESE
*ParkviewSkin Care Team Organizer
JANET HUNTER
* Manager for Center of Nursing Excellence
AMBER VACHON
* Runs HAPU reports for Parkview
NDNQI
$$ REIMBURSEMENT $$
ANA
EDUCATION
Hospitals' participation achieves national reduction in PUs and in Falls

Now

* 10% had pressure ulcers
Beginning

NDNQI report is voluntary

* As of last quarter, 1.3% had pressure ulcers
Reference
Patton, R.M. (2013). Is diagnosis of pressure ulcer’s within an RN’s scope of practice?American Nurse Today, 5(1), 20.

Scope and standards of nursing: Assessment skills of nurses. Are nurses overstepping by categorizing and staging pressure ulcers?
ANA

*Hospitals are required to report stage II and stage III pressure ulcers
*Hospitals are not reimbursed for hospital acquired pressure ulcers (Stages II & III)
*Cost to hospital = $43K/patient

Reimbursement

* Back to Basics
* Q2Turns
* Learning Theories
- Behaviorism
- Cognitivism
- Design-based
Education

Reference
(2013) Retrieved from http://www.learning-theories.com

BEHAVIORISM
Both positive reinforcement and negative reinforcement increase the probability that the antecedent behavior will happen again

COGNITIVISM
The cognitivist paradigm essentially argues that the “black box” of the mind should be opened and understood. The learner is viewed as an information processor (like a computer).

DESIGN-BASED
A blend of empirical educational research with the theory-driven design of learning environments, DBR is an important methodology for understanding how, when, and why educational innovations work in practice
The need for approaches to the study of learning phenomena in the real world situations rather than the laboratory

* Good, thorough documentation is a must
* Done on admission and once every shift

Documentation

STAGE I CAN REVERT
* If you assess a stage I pressure ulcer you must reassess your patient in ½ hour after repositioning.
Recheck Your Patient

QUALITY OF CARE
HOW NURSES IMPACT CARE
*Decreased Falls *Decreased PUs
*Increased
*Customer Satisfaction
*BSN vs ASN nurses
*Evidence suggests that more education = better nurses
STAGE II AND STAGE III PUs
REPORTED TO STATE
-Some are hospital acquired and
some were just not documented

Acts on trends found in reports
NEW NURSES
- assessment skills are not as good as experienced nurses
-not looking under tubing
COLLABORATION
*Food Service
*Physical Therapy
*Wound care nurses now alert Amber of all PUs

* Nutrition
* Mobility
* Skin dry
* Possibility of sheer on skin
Newman’s System Model

ANNUAL COST APPROACH: $11 BILLION
* Conservative cost estimated between 5 billion and 8.5 billion
* Cost of each PU ranges from $500-$70,000
* Cost of healing a stage IV PU estimated between $30,000-$40,000

$$ SOME NUMBERS $$
WHY IS ASSESSING PUs IMPORTANT?
*Majority of patients with PUs are older than 65 years in US

*Medicare is the largest payer of PUs
MEDICARE
*Announced as of Oct. 2008- will no longer reimburse hospitals and nursing homes for preventable complications
*“pay for performance”
*CMS, JCAHO, NQF all endorse direct link between pressure ulcers and quality of care
* Occurrence in acute care hospitals is
more than 10% and may be as high as 38%

* In 2006 CMS found 322,946 PU occurring
as secondary diagnoses on hospital charts
-10 times more common than the next
prevalent which is Staphylococcus
aureus sepsis
* Suspected deep tissue injury- underlying tissue damage without current loss of overlying skin

* Unstageable- full thickness wound is covered with necrotic tissue obscuring deepest layer of involvement

* Will pay MS-DRG for stages III and IV PUs present on admission
MEDICARE REIMBURSEMENT
IMPORTANCE OF DOCUMENTATION
* If PU not documented within hours of admission-possible insurer with determine that the facility “owns” the ulcer

* All hospitalized Medicare patients charts reviewed for the quality, necessity, and appropriateness of health care provided

* Typical hospital has 35%-40% Medicare patients with some up to 60%
IMPORTANCE OF DOCUMENTATION
* Average ability of non-expert clinician to
correctly stage at PU is poor

- 23%-58% correct

* New tool NE1 WAT aided non-expert
clinician in improving accuracy on MS-DRG
eligible PUs

- 35% correct without tool

- 75% correct with tool

DOCUMENTATION
* Payment can be denied if the final Dx is not supported by documentation

* Initial skin assessment within 24 hours of admission

* Daily skin assessment

* Possibility of Risk stratification when determining preventability of PUs

- Avoidable: Developed PU that the facility did not do anything about

- Unavoidable: Developed PU even though the facility evaluated clinical
condition and implemented appropriate interventions

TYPICAL MEASURING TOOL
NE1 WAT
* Pictures and descriptions with ruled inner edges

* Picture is then taken to be included in MR


The National Database of Nursing Quality Indicators (NDNQI) was established by the ANA in 1998 to provide hospitals comparative data to use in quality improvement activities and to support the relationship between quality nurse staffing and patient outcomes. Data is collected at the unit level where nursing occurs, by the nurses who provide direct patient care. Some of the outcomes measured include:

* Frequency of C-sections
* Management of cardiac failure
* Catheter-associated urinary tract infections (CAUTIs)
* Central line-associated blood stream infections
* Fall rates and fall rates with injury
* Hospital acquired pressure ulcers (HAPUs)
* Restraint usage
* Ventilator-associated pneumonia
* Nurse job satisfaction

(ANA, 2012).

DIAGNOSIS-RELATED GROUPS
(DRGs)
* Assignment process determines amount of money the hospital with receive

* Use of an automated classification algorithm “Grouper Program”

* Upon discharge vital information from the MR is supplied to a fiscal intermediary

- Use of Grouper Program helps determine
the proper DRG assignment for the
patient

Several key conditions examined:

- Sex, age, principle dx, secondary dx,
surgical procedures performed during stay

- DRG consideration takes into account up
to 4 complications and/or comorbidities

- Final factor is discharge status of patient
DRGs
DRGs
* Patient being admitted for medical or surgical treatment of PU classified under one of three DRGs for skin grafts and ulcers

* DRG will not be assigned to the hospital acquired pressure ulcer group because it was not cause of admission

DRGs
Medicare Severity-Diagnosis Related Group
(MS-DRG)
* Additional payment for care of
more severe Pus that are present
on admission
* Not available for hospital-acquired
condition
* Important to correctly identify and
define PUs on admission as well as
prevent development during
patient stay

MS-DRG
1. Which of the following diagnostic tests is relevant for assessing the risk of developing a pressure ulcer for an older adult client who has no major health issues?

A. Serum albumin

B. WBC's

C. RBC's

D. Serum potassium
Answer: A. Serum albumin would provide information regarding the adequacy of protein intake. Inadequate protein poses a great risk for altered skin integrity and ineffective healing.

2. The nurse is caring for an elderly bedridden client. To prevent pressure ulcers, which intervention should the nurse include in the plan of care?

A. Turn and position the client at least once every 4 hours

B. Massage lotion into the bony prominences

C. Post a turning schedule at the patient's bedside

D. Slide the client, rather than lifting, when turning
Answer: C. Posting a turning schedule at the patient's bedside along with a signing sheet will ensure that the client gets turned.
3. Which of the following clients is least likely to develop skin breakdown?

A. A client incontinent of urine and feces

B. A client with chronic nutritional deficiencies

C. A client with decreased sensory perception

D. A client who is unable to move about and is confined to bed

4. The evening nurse reviews the documentation and notes that the day nurse charted a stage II pressure ulcer in the sacral area. What would the nurse expect to see when she assesses this patient?

A. Intact skin

B. Full-thickness skin loss

C. Exposed bone, tendon, or muscle

D. Partial-thickness skin loss of the dermis
Answer: D. Skin could be intact in a stage II pressure ulcer, but with a fluid filled blister and no exposed tendon, muscle, or bone. Full-thickness skin loss would be a stage III pressure ulcer.
5. The nurse is teaching about tissue repair and wound healing. Which statement by the client indicates effective teaching?

A. "I'll limit my intake of protein"

B. "I'll make sure the wound is covered tightly"

C. "My foot should feel cold"

D. "I'll eat plenty of fruits and vegetables"
6 Subscales
2 Factors
Influencing PUs
#18
Implement
protocol
Prevention is always the best approach. Use of the Braden Scale has been successful to markedly reduce incidence of hospital acquired PUs
REDUCES HAPUs
(Comfort, 2008).
(Tchato, Putnam & Raup, 2013)
Repositioning Q2H Reduces PUs!
(Peterson et al., 2013).
Frequency of turning and repositioning can be prognostic factors for development of PUs!
(Kaitani et al., 2010).
(Armour-Burton et al., 2013).
(Omolayo et al., 2013).
(Kelechi, Arndt, & Dove, 2013).
(Iranmanesh, Rafiei, & Sabzevari, 2012).
Most PUs are preventable with appropriate risk assessment and repositioning!
(Ousey & White, 2010).
Protein necessary to form new blood cells and new layers of skin
(Costa, 2013).
Prevention
Significant reduction of incontinence-related PUs when skin protectant with dimethicone 3% used!
(Beeckman et al., 2009).
(Brunner et al., 2012).


References
Answer: C. Options A, B, and D are phsyiological issues which are risk priorities.
Answer: D. Protein is needed for healing. The wound should be loosely covered and if the foot is cold than circulation is impeded.

www.youtube.com/watch?v=sdXIDpPmuw0
Deep Tissue Injury
Unstageable
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Purple or maroon localized area of discolored intact skin or blood-filled blister. Area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to nearby tissue.
ALSO
rjh.goingeast.ca/wp-content/SCI4/PressureUlcers.html
rjh.goingeast.ca/wp-content/SCI4/PressureUlcers.html
Full transcript