Transcript Anderson Health Information Systems, Inc

Identifying and
Reporting changes
in skin condition
Presented by
Lizeth Flores, RHIT
Anderson Health Information Systems,
Inc
940 W. 17th Street, Suite B
Santa Ana, CA 92706
(714) 558-3887
[email protected]
Today’s Topics
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Pressure Ulcer risk factors
Checking for pressure ulcers
Pressure ulcer prevention
Facility protocols for skin assessments
Facility protocol for communicating
changes in skin integrity
What is a pressure ulcer?
• A pressure ulcer (a bedsore or pressure
sore) is skin breakdown caused by pressure
on bony prominences from being in one
position for too long.
What are pressure points?
• Bony parts of the body such as the
tailbone, hips, heels, elbows,
shoulders.
What can contribute pressure ulcers?
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Impaired/decreased mobility/functioning
Co-Morbid Conditions (e.g. ESRD, DM)
Drugs (Steroids)
Impaired blood flow from sitting or lying too long in
one place
Resident refusal of treatment/care
Cognitive Impairment
Urinary/Fecal incontinence
Wet clothing or a wet bed
Under-nutrition, malnutrition, dehydration – not getting
enough food or water
History of/healed ulcer
Use of physical restraints
OTHER RISK FACTORS……
• Tubing such as catheters that the resident
may lay on will cause unnecessary pressure
and friction that could lead to skin
breakdown
Are Pressure Ulcers the only type
of ulcers?
• NO –
• There are many types of ulcers that can
develop from disease process
• Example
• Stasis Ulcer
• Diabetic Ulcers
WHY IS IT IMPORTANT TO
MONITOR AND REPORT
CHANGES IN RESIDENT’S
SKIN CONDITION ?
It’s The Law
• The law states that each resident must
receive necessary care and services to attain
or maintain the highest practicable physical,
metal and psychosocial well-being in
accordance with the comprehensive
assessment and plan of care
F309 - §483.25 Quality of Care -2
• Expands Definition of Skin Ulcer/Wound
– Clinician expected to document the clinical basis*
which permit differentiating the ulcer type
ESPECIALLY if the ulcer has characteristics
consistent with a pressure ulcer but is determined
NOT to be one
I’m a CNA what can I do?
• CNAs are the first line of defense when it
comes to identifying skin breakdown
• You provide direct care to the residents daily
and will usually be first to notice changes in skin
color or integrity
When will I check the skin?
• During daily activities
• During showers, bed baths, bedside care
• Throughout the day as you carry out your
job duties
What do I need to look for?
These are the signs that there may be an
issue with the resident’s skin
• Changes in skin color / discoloration
• Changes in skin temperature – some
breakdown may not be readily visible on
darker skin tones so changes in skin
temperature, skin appearance may give you
the clues you need to identify a problem.
More signs of compromised skin
• Red areas on the skin that do not go away even after
the pressure is removed
• Cracked, blistered, scaly, broken skin
• An open sore involving skin surface or tissue under the
skin
• Yellowish stains on clothing, sheets, or chair (may be
tinged with blood)
• Painful or tender "pressure points" (back of head, ears,
back of shoulders, elbows, buttocks, hips, heels, and
any place a bony part rests on the bed surface.)
What to report…….
• All changes in skin condition must be reported
to ensure that the facility is in compliance with
regulatory requirements
Reposition vs Redistribution
• Repositioning plans should be outlined in the
plan of care consistent with the INDIVIDUAL
resident’s needs
• Pressure Redistribution
– Function or ability to redistribute a load over a
surface or contact area
– Specific devices and surfaces are addressed and
suggestions given for using and evaluating
effectiveness of such devices
DO YOU KNOW WHERE TO FIND
INFORMATION THAT WILL HELP
YOU CARRY OUT YOUR DUTIES
EFFECTIVELY?
You are a key player in pressure ulcer
prevention
– How do you know what pressure relieving devices
are being used for each resident?
 Special needs list (new form)
 Must be reviewed at the beginning of every shift
before waking rounds
– Where is this information located?
 In the front of each ADL flow sheet binder
– How is the information updated when there are
changes?
 DSD / DON will assign a staff member to update
the list
 No need to worry, every time you review the list
you can trust that the information is accurate and
reliable.
Walking Rounds
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What am I looking for during walking rounds?
Current Patient Status
Patient’s on B&B
Bed Linen requirements
a. Fitted sheet
d. Top Sheet
b. draw sheet
e. Blanket
c. 1 blue pad
Fluids, restricted or NPO
New Skin issues
Feeders
Falls, Injuries
How can I remember all of that?
• There will be a reference card on the
back of your name badge.
• What is the facility policy for turning and
repositioning?
 Turn and Reposition every 2 hours
• How do you know which way to turn the
resident?
Reference card behind staff name badge
• How do you document turning and
repositioning of residents?
 It is documented every shift on the ADL flow sheet
o What symbol do you use to document turning and
repositioning on the ADL flow sheet?
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“P”
Restraints and Devices
• How Often must you check and release
restraints or devices?
 Every 2 hours
o Where is this documented?
 In The ADL flow sheet
• During showers how do you document skin
assessment?
Using the “Shower Day Skin Inspection” form
o How often will we document skin checks
 Daily
Who will be responsible for
documenting skin ’s
• CNA’s providing showers will document on the “Shower
Day Skin Inspection Form”
• Non-shower days –
skin condition will be documented using the skin
assessment on the back of the skin inspection form
(new form)
 Remember to indicate any skin issues using
the body assessment diagram
What do you do with that information?
• Report it to the charge nurse
• Make sure the charge nurse initials the body
assessment (picture)
• Form must be signed by CNA and charge
nurse
Don’t take it for granted
• Just because a resident is on a pressure relieving
device does not mean they do not need to be
closely monitored and turned and repositioned
based on their specific needs
What else do I need to know?
• There are many other important aspects of
CNA duties and documentation that affect
resident assessment and care
• It is critical that you document what your
observations of the resident is during your shift
and not refer back to prior day’s charting
Documentation…….
• A decrease in resident’s intake of meals can indicate a
change in their condition, it does not necessarily mean
that they have pressure ulcers but the fact that they are
not consuming adequate nutritional amounts can be a
contributing factor to skin breakdown
• So remember….. It is extremely important that you
document % of meal intake accurately and timely.
•  This is the only way to know how much a
resident is eating
Documentation
• Low intake of fluids can result in dehydration
which can lead to skin breakdown.
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Remember…. Always offer fluids when at bedside /
chairside
• Always document accurately and timely
Who needs to know….
• If you identify a problem, who will you tell?
 The Charge Nurse
• How can you prove you reported the
changes?
 Using the skin inspection form “DAILY”
• Where can this information be found?
 In the Skin Check binder at the Nurses’ station
What is the nurse responsible for?
• The licensed nurse is responsible for assessment
of the resident, development of a
comprehensive plan of care and for carrying out
the care as specified in the care plan
Why am I being asked to check
the resident for pressure ulcers?
• You are part of the resident care team
and you play a very important part in
ensuring quality of care
• The nursing staff will use any
information you provide to ensure
patient’s receive the necessary care to
ensure their highest level of well being
Why is there such a focus
on pressure ulcers in
skilled nursing facilities?
• Prevention and treatment of pressure ulcers
is a focus in all healthcare settings and not
just nursing homes
• It is mandated by State and Federal
Regulations
Consequences
– Pressure ulcers can be very painful for the
resident
– Pressure ulcers can result in complications such
as infection and in severe cases loss of body
parts (amputation)
– Pressure ulcers can progress very rapidly if they
remain untreated
– Pressure ulcers sometimes result in death
• Pressure ulcers can lead to complaints and
investigation
• Pressure ulcers can lead to lawsuits and can
be very costly
If the facility has patients with
pressure ulcers does that mean
that the residents are no
properly care for?
NO
Even with very good patient care there can be
unavoidable ulcers
This is based on the overall condition of the
patient and diagnoses that can contribute to
poor skin integrity
Example
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Diabetes
Renal Failute
Dialysis
Poor circulation
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if the resident’s pressure ulcers
cannot be avoided, they should be
promptly identified and treatments
implemented to ensure they achieve
their highest level of well being.
You work hard…. Take credit for it
It takes a very special person to provide
quality caring services for residents in skilled
nursing facilities
That makes you very special people, your
participation in the overall monitoring of the
resident’s condition is critical to ensure they
are provided with the best care possible-
Discussion & Questions
Thanks for attending