Transcript Pressure Ulcers 101 b

Pressure Ulcers 101
or
Hospital Acquired Pressure Ulcers
What you need to know
Kristin Moeller, M.D.
Contra Costa Regional Medical Center
July 2009
Learning Objectives
• Learn the definition of a Hospital
Acquired Pressure Ulcer (HAPU)
• Learn the significance of HAPU
• Learn how to stage HAPU
• Learn who is at risk for HAPU
• Learn how to prevent HAPU
Pressure Ulcer
• Definition: Localized skin injury which
develops as a result of unrelieved pressure
• Frequently over a bony prominence
• Can be as a result of a medical device (Foley)
• Often is a result of shear or friction forces
combined with pressure
HAPU
(Hospital-acquired pressure ulcer)
• HAPU is the new buzz-word:
• Prevention of HAPU is key
• Preventing Stage 1 and 2 ulcers from
progression to Stage 3 or 4 is the next goal
HAPU
CMS (Medicare/Medicaid) will no longer
reimburse for treatment of Stage 3 or 4 pressure
ulcers acquired at our hospital
• Stage 3 and 4 ulcers are reportable events:
• If acquired at CCRMC or if present on admission
fill out SERS (Safety and Event Reporting System)
report on computer
• SERS information goes to Hospital Administration
and the State!
Who’s at risk?
• Everyone!
• Well, OK, not everyone but lots of our
patients.
• Risk factors: limited mobility, poor
nutrition, critical illness, chronic disease,
dehydration, incontinence, fever, infection,
poor sensation, obesity, age, medications,
and various other medical diagnoses
Whose job is it to prevent
Pressure Ulcers?
Everyone’s!
• Look at the skin, especially in high risk
patients
• Document what you see
• Ulcer, no ulcer/intact skin, color changes
• If Stage 3 or 4, document in H & P and fill out
SERS or bring to attention of the Charge Nurse
• If you can stage the ulcer, great; if not, talk
to an attending or the nurses to help you
Why????
• Good, complete patient care
• If no ulcer on admission, prevent one
• If there is an ulcer, heal it & prevent worsening
• Money $$$
• CMS is one of our main sources of
reimbursement – we are charged with caring for
some of the most vulnerable members of the
population
What do I have to do?
• We all need to Look and Document
• Document skin exam on H & P
• Check the skin regularly, especially in high risk
patients and document updated exams
• Request help from Attending Staff or Nursing
regarding staging and treatment
• If nursing brings an ulcer to your attention –
see it and document it a.s.a.p.
What if I identify a
Pressure Ulcer?
• Put it in your H & P (or Progress Note)
• Put it in your orders as an admit diagnosis, either as a
primary or secondary diagnosis
• Write orders for wound care
• Notify the Charge Nurse and fill out a SERS report
• Not sure? Ask a Staff member for help (Attending
M.D. or Charge Nurse)
Staging Basics
• Don’t be intimidated, the rules are easy
• ONLY Pressure Ulcers are stageable
• Other wounds (surgical, venous stasis,
neuropathic/diabetic ulcers) are not
• A wound never “regresses” in stage
• A Stage 2 is always a Stage 2
• As it heals, it becomes a “healing Stage
2 ulcer”
Stage 1 Pressure Ulcer
Non-blanching erythema over a pressure point;
area may be painful, firm, soft, warm or cool.
• Note: the skin is intact
Stage 2 Pressure Ulcer
Partial thickness disruption of the dermis with
shallow red/pink wound bed without slough;
no undermining or tunneling.
• Note: this includes blisters
Skin Tears
• Do not confuse a Stage 2 Pressure Ulcer
with a skin tear.
Stage 3 Pressure Ulcer
Full thickness tissue loss with disruption of
the dermis and into SubQ; may have slough,
tunneling,undermining. No muscle, tendon or
bone is exposed.
Stage 4 Pressure Ulcer
Any deeper disruption, which disrupts the
fascia and may or may not involve muscle,
bone, tendon or ligament.
• Note: does not necessarily go to bone but
be suspicious for osteomyelitis
Deep Tissue Injury I
Purple or maroon localized area of discolored
intact skin or blood-filled blister due to
damage to underlying soft tissue from
pressure.
Deep Tissue Injury II
The area may be preceded by tissue that
is painful, firm, boggy, warmer or cooler
as compared to adjacent tissue.
Evolution may be rapid exposing additional
layers of tissue even with treatment.
Unstageable I
Full thickness tissue injury in which the base
of the ulcer is covered by slough (yellow, tan,
gray, green, brown) or eschar (tan, brown,
black).
Unstageable II
* Special care must be taken with heel ulcers.
Do NOT unroof unless aided by an
experienced physician. They may be better
left intact.
Treatment I
• Keep wounds moist but not too moist.
• Debride any necrotic or excess fibrinous tissue
• Sharp, chemical or autolytic debridement.
• If you are getting near bone, tendon or ligament, STOP
until you have more experienced hands & eyes with
you.
• Unless the wound is a Stage 4 or causing sepsis, this can all
be done slowly and cautiously.
• Damp to dry dressing with Saline will get you through
the night.
• If you are the new primary team in the AM, look at the
identified wound a.s.a.p. and begin to formulate a treatment
plan.
Treatment II
• Initiate/reassess prevention strategies:
• Pressure reducing mattress
• Maximize mobility
• Maximize Nutrition
• Minimize devices
• Good skin hygiene
• Be sure to communicate with your patient
& caregiver in his/her native language
Empower your patient to partake in
his/her care
Wound Care Team
“Wound Wednesdays”
• Goal 1: Educate!
• Goal 2: Prevent Pressure Ulcers
• Goal 3: Prevent worsening of Pressure Ulcers
(avoid progression to Stage 3 or 4)
• Goal 4: Help guide treatment via
interdisciplinary team approach
• Goal 5: Planned Obsolescence!
Forms –
more paperwork!
• Yes, they are coming.
• Initial Documentation and order form
• Follow-up documentation form
• Q week or for any significant change of
status
Forms – Initial Documentation
Photo – op?
• All Pressure Ulcers must be documented
with photos
• Upon diagnosis and Q week on
Wednesdays
• Photos are uploaded in PACS (yup, with
the Xrays)
• Other wounds may be documented with
photos to document wound progression
In Brief
• Documentation is key
• Physician must be part of documentation
of HAPU
• Must be documented on admit H & P to
document that it was not caused at our
facility
• Prevention is key
• Ask for help as we are all learning this new
system