Lundgren Handouts Skin Integrity Risk Assessment and Care Planning

2/6/15
Prevention of Pressure Ulcers:

Risk Assessment & Care Planning
Jeri Lundgren, RN, BSN, PHN, CWS, CWCN
VP, Clinical Consulting
Joerns
PEOPLE PASSION PERFORMANCE Confidential & Proprietary
Regulatory
F314:
Based on the comprehensive assessment of a resident, the facility
must ensure that --
A resident who enters the facility without pressure sores does not
develop pressure sores unless the individuals clinical condition
demonstrates that they were unavoidable; and
A resident having pressure sores receives necessary treatment and
services to promote healing, prevent infection and prevent new sores
from developing.
Regulatory and Litigation
The care setting must PROVE

that the wound was..
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Regulatory & Litigation
Can the care setting prove:

Assessed for risk factors
Interventions correlate to individual risk factors
Implemented the plan of care
Evaluated the plan of care
Updated the plan of care with changes
**NOT AS SIMPLE AS HAVING THE PHYSICIAN WRITE IT WAS

UNAVOIDABLE!!
Pressure Ulcer Definition
Pressure Ulcers:
A pressure ulcer is localized injury to the skin and/or
underlying tissue usually over a bony prominence, as a
result of pressure, or pressure in combination with shear
and/or friction7.
Prevention
Assessing for Risk of

Skin Breakdown
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Risk & Skin Assessment

Comprehensive Risk Assessment in LTC
Upon Admission
Weekly for the first four weeks after admission
Change of condition
Quarterly and annually with the MDS
Skin Inspection in LTC

Upon Admission Imperative they capture wounds within the
first 24 hours
Daily with cares by the nursing assistant
Weekly by the licensed staff
Upon a PLANNED Discharge

Comprehensive Risk Assessment in Acute Care
Upon Admission
Daily
Upon discharge
Skin Inspection in Acute Care

Upon Admission
Daily
Upon discharge

Comprehensive Risk Assessment in Home Care
Upon Admission
With each licensed nurse visit
Skin Inspection in Home Care
Upon Admission
With each licensed nurse visit
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Risk Assessment Tools

Validated Risk Assessments
Use a recognized risk assessment tool such as the
Braden Scale or Norton
Use the tool consistently
Regardless of the overall score of the risk assessment,
assess each individual risk factor
No risk assessment tool is a comprehensive

risk assessment
Braden
Sensory Perception
Moisture
Activity
Mobility
Nutrition
Shear and Friction
Doesnt capture
Diagnosis
Medications
Resident Choice, etc
Overall goal is to identify the INDIVIDUAL risk

factors and implement correlating interventions
that modify, stabilize or eliminate the risk factors
Problem Goal Interven/ons: Responsible

Poten.al for Skin will Provide a pressure person(s)
altera.on in skin remain redistribu.on maDress Nursing
integrity secondary intact Provide a wheelchair
to: cushion
Immobility due to Elevate heels with bilateral
right sided heel liF boots
hemiplegia Turn and reposi.oning q2
hours
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Braden Scale
Note on the Braden Scale the lower the score

the higher the risk
15-18 At Risk
13-14 Moderate Risk
10-12 High Risk
9 or lower Severe Risk
Before utilizing the Braden please get permission at
www.bradenscale.com
PEOPLE PASSION PERFORMANCE Footer

Confidential &IProprietary
nfo Here 13
Breaking Down the Braden
Impaired Sensory Perception

Inability to feel pressure or pain to the skin/tissues
CVA, paraplegia, quadriplegia, etc.
Cognitive impairment
Neuropathy
Braden Scale - Activity
Activity:
Decreased activity level leading to staying in one
position for a long period of time
Chairfast
Bedbound
Choosing not to get out of the bed or chair
Chooses not to change positions
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Braden Scale - Mobility
Mobility
Due to being unable to move or having limited
movement leads to staying in one position for long
period of time:
Diagnosis: CVA, MS, Paraplegia, Quadraplegia, end stage
Alzheimers/Dementia, etc.
Fractures and/or casts
Cognitive impairment
Pain
Restraints or medical equipment
Choosing not to be mobile
Contractures
Breaking Down the Braden
The interventions are basically the same for:

Immobility,
Impaired sensory perception, and
Decreased activity
All lead to inactivity/movement
Goal of interventions is to decrease or remove the
pressure to promote circulation to the skin and
tissues
Immobility, decreased activity and/or

impaired sensory perception interventions
Restorative & Mobility Programs

Referral to Therapy and Restorative Nursing
Amputation/Prosthesis Care
Communication
Eating
Mobility
ROM and PROM
Self care training/ADLs
Toileting
Splint/brace
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Restorative Nursing Program-MDS
Requirements
Technique, training or skill practice was performed for a
total of at least 15 minutes per 24 hours
The 15 minutes can be broken up (i.e. remove & clean
splint and skin, inspect skin and perform ROM for a total
of 5 minutes 3x/day)
Restorative nursing does not include groups with more
than four residents per supervising helper or caregiver.


Restorative Nursing Program-MDS
Requirements
The care plan & medical record must document
measurable objective and interventions
The medical record must reflect periodic evaluation by a
licensed nurse.
Nursing assistants/aides must be trained in the techniques
that promote resident involvement in the activity
A registered nurse or licensed practical (vocational) nurse
must supervise the activities in a restorative nursing
program.

Assistive devices to promote mobility:
Grab Bars for repositioning & egress
Bed at correct egress height
Utilize electric bed to assist to a standing position
Lifts (ceiling, sit to stand, transfer, walking)
Lateral transfer devices
Repositioning slings
Walking devices (cane, walker, etc)
Rocking chairs
Assistive devices
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Pressure Redistribution: The ability of a support

surface to evenly distribute load over the contact area
of the human body.
Pressure redistribution replaces prior terminology of
pressure reduction and pressure relief support surfaces
The goal of the support surface is to
Evenly distribute pressure over the surface
Envelop and immerse into the support surface
Control microclimate

Support surfaces for the bed:

Preventative (foam, foam/air)
Low Air-loss/Alternating air
Air fluidized
Fluid Immersion Simulation
Document on care plan type and date implemented
Not a substitute for turning schedules
Heels may be especially vulnerable even on low air loss
beds

Elevation of heels OFF of the surface

YES
Pillow prop
Wedges
Heel lift boots
Always provide heel elevation bilaterally
Feel to ensure the heel has no pressure YES
NO NO
YES
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All wheelchairs should have a cushion

Air and gel is more aggressive than foam products7
A sitting position = head elevation of 30 degrees or higher
All sitting surfaces should be evaluated for pressure
redistribution

Recommend a Therapy screen for wheelchair

cushion
When positioning in a chair consider:
Postural alignment
Weight distribution
Sitting balance
Stability
Pressure redistribution

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Develop an INDIVIDUALIZED turning &

repositioning schedule
Current Standard:
Turn and reposition at least every 2 hours while lying
Reposition at least hourly in a sitting position (if the
resident can reposition themselves in wheelchair
encourage them to do so every 15 minutes)
When possible avoid positioning on existing pressure
ulcer

F314 Guidance in LTC, Tissue Tolerance:

Tissue tolerance is the ability of the skin and its supporting
structures to endure the effects of pressure with out
adverse effects
A skin inspection should be done, which should include an
evaluation of the skin integrity and tissue tolerance, after
pressure to that area, has been reduced or redistributed
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Establish an Individualized repositioning

schedule based on:
Individual tolerance
Preferences (i.e., wanting uninterrupted sleep, comfort)
Characteristics of the pressure-redistribution support
surface
Utilize repositioning & positioning devices as
appropriate
Remember to protect your back and safely handling the
resident when repositioning!!!
PEOPLE PASSION PERFORMANCE Confidential & Proprietary 31

F314: Momentary pressure relief followed by a return

to the same position is usually NOT beneficial (micro-
shifts of 5 to 10 degrees or a 10-15 second lift).
Off-loading is considered 1 full minute of pressure
RELIEF
Good compromise if choosing not to reposition

Restraints
Release restraints at designated intervals
More importantly try to eliminate restraints
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Pain management
Pre-medicate the individual 20 -30 minutes prior to
repositioning, treatment or cares as appropriate
Scheduled pain medication
If palliative care is the primary goal; comfort may
supersede prevention causing the individual to have a
single position of comfort.
Utilize appropriate support surfaces in the bed and
wheelchair to provide comfort as well as improve
pressure redistribution

Pain management
Do not place Individuals directly on a wound when ever
possible or limit the time on the area
Pad and protect bony prominences (note: sheepskin,
heel and elbow protectors provide comfort, and reduce
shear & friction, but do NOT provide pressure reduction)
Do not massage over bony prominences

Pain Management, Continued:

Provide soothing music
Distraction
Conversation
Relaxation techniques
Position changes
Meditation
Guided imagery
Transcutaneous electrical stimulation (TENS)
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Braden Scale: Moisture
Moisture can irritate and breakdown the skin
Incontinence of bladder
Incontinence of bowel
Excessive perspiration
Moisture within skin folds
Moisture
Interventions to protect the skin from moisture

Individualized B & B Program
Peri-care after each episode of incontinence
Appropriate, dignified absorptive incontinent products
Apply a protective skin barrier to peri-area or wound
edges (ensure skin is clean before application &
appropriate with the absorptive product)
Foley catheter and/or fecal tubes/pouches as
appropriate (in LTC for stage III or IV only)
Moisture
Interventions to protect the skin from moisture

4x4s, pillow cases or dry cloths in between skin folds
Inter Dry Ag sheets if prone to intertrigo infections
Antifungal powder or ointment for active intertrigo
infections
Bathe with MILD soap, rinse and gently dry
Keep linen dry & wrinkle free
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Moisture
If there is already an elimination problem on

the care plan that addresses the interventions:
List incontinence of bowel and/or bladder as a risk
factor under skin integrity, however,
State under interventions:
See elimination problem
Braden Scale: Nutrition
Nutritionally at Risk
Serum Albumin below 3.5g/dl
Pre-Albumin 17 or below (more definitive than an albumin
level)
Significant unintended weight loss
Very low or very high body mass index
Inability to feed self
Poor appetite
Difficulty swallowing
Tube fed
Admitted with or history of dehydration
Nutrition
Interventions for Nutritional deficits

Dietary consult to determine interventions
Provide protein intake of 1.25-1.5 gm/kg/body weight
daily7
30-35 kcalories/kg of body weight/day7
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Nutrition

Dietary consult to determine interventions
Provide a simple multivitamin5
Unless a resident has a specific vitamin or mineral deficiency,
supplementation with additional vitamins (i.e., Vit. C) or
minerals (i.e., zinc) may not be indicated5
Zinc no more than 40mg/day for no more than 2-3 weeks5.
Higher dosages or long term use of zinc can decrease copper
status and lead to anemia5
Appetite stimulants as appropriate
Nutrition
Providing food per individual preferences
Provide adequate hydration
Accurate Intake, output and weights
Nutrition
If nutrition is already addressed on the care

plan:
List nutritionally at risk as a risk factor under skin
integrity, however,
State under interventions:
See nutritional problem
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Braden Scale Friction & Shear
At risk for friction and shear

Needs assistance with mobility
Tremors or spasticity
Slides down in the:
Bed
Wheelchair/sitting surface
Agitation
Friction and Shear
Interventions for Friction and Shear

Lift -- do not drag -- individuals
Utilize lifting devices & slings
Ceiling liFs
Transfer liFs
Sit to stand liFs
Walking liFs
Lateral transfer devices
Specialty slings
Reposi.oning slings
Limb liFer slings
Friction and Shear
Interventions for Friction and Shear

Elbow or heel pads
Protective clothing
Protective dressings or skin sealants
Raise the foot of the bed before elevating
Wedge wheelchair cushions (therapy referral)
Pillows
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Comprehensive Skin Integrity Risk Assessment
In addition to the Braden Scale, review

H&P
Diagnosis
Physician/NP notes
Consultations (podiatry, wound clinic, etc.)
Medications
Labs (albumin and pre-albumin)
Blood sugars
MDS/CAAs (if complete)
Interview resident & family, etc.

nfo Here 49
Other Risk Factors not on the Braden
Overall diagnoses that can lead to skin

breakdown:
Anything that impairs blood supply or oxygenation to the
skin (cardiovascular or respiratory disease)
Immunosuppression
History of pressure ulcers and skin breakdown indicate
type of skin breakdown, location and stage (pressure ulcer)
if known
End stage diseases (renal, liver, heart, cancer)
Overall diagnoses that can lead to skin

breakdown:
Diabetes blood sugars consistently above 140 or A1c
greater than 7
Anything that renders the individual immobile
Anything that can affect his/her nutritional status (inability to
feed themselves)
Anything that affects his/her cognition
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Medications or Treatments, such as:

Steroid therapy
Medications that decrease cognitive status
Renal dialysis
Head of bed elevation the majority of the day
Medical Devices (tubes, casts, braces, shoes, positioning
devices)
Other Risk Factors

Fragile skin or dry cracked skin
Choosing not to follow interventions be specific as to
what they are not following
Pain
Smoking
PEOPLE PASSION PERFORMANCE Confidential & Proprietary 53
Overall Prevention Interventions
Monitor skin this should be listed on all plans

of care
Inspect skin daily by caregivers
Inspect bony prominences look & feel
After pressure has been reduced/redistributed
Under medical devices (cast, tubes, orthoses,
braces, etc).
Weekly head to toe skin inspection by a licensed nurse
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Overall Prevention Interventions
If the resident has a wound it should be

assessed/documented by a licensed nurse at
least every 7 days

nfo Here 55
Interventions
Medications or Treatments
Evaluate steroid use and dosage
Adjust medications as appropriate to improve cognitive status
Notify dialysis of skin concerns and interventions
Keep head of bed at the lowest level possible & ensure
appropriate support surface
Pad medical devices and ensure proper fit
Interventions
Smoking
Risk discussion
Smoking cessation plan if resident agrees
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Interventions
Consultation
Provide adequate Psychosocial support/Psychology referral
Obtain a Podiatrist, Dermatologist, Vascular Physician and/or
Wound Care Consultation as appropriate
Involve primary physician and/or appropriate physician
support
Interventions
Diabetes
Monitoring & management of diabetes as ordered
Dietary consultation
Exercise program/therapy
Diabetic foot care
Can state see diabetes problem
Interventions
Dry or Fragile Skin

Apply non irritating lotion at least daily
Protective clothing
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Lower extremity disease

Arterial insufficiency
Venous insufficiency
Peripheral neuropathy
Diabetic ulcers

nfo Here 61
Interventions
Lower Extremity Disease

Etiology identification is imperative!!!!
Ankle Brachial Index (ABI)
Vascular/Physician consultation for diagnosis and plan
Goal is to identify the disease process to prevent or minimize
skin breakdown
Lower Extremity Disease

Appropriate, well fitting foot wear at all times
Inspection of feet
Appropriate nail and foot care
No warm foot soaks
Keep clean and dry
Exercise
Venous Insufficiency
Leg elevation
Compression therapy

nfo Here 63
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Interventions
Dermatitis and other skin concerns

Dermatology Consultation
Appropriate treatment for etiology of skin concern
Interventions
Individual choice
Be specific as to what the individual is choosing not to do
or allow
List interventions and alternatives tried on the plan of
care (do not delete)
Document date and location of risk/benefit discussion on
care plan
Re-evaluate at care planning intervals
Care Plan
Care Plan Tips

Ensure care plan has appropriate goals
Only list the type of ulcer and location of it on the care
plan (i.e., Pressure ulcer to right trochanter)
Once the pressure ulcer heals, ensure it gets listed on
the care plan (i.e., history of pressure ulcer to right
trochanter)
Physician diagnosis and prognosis are appropriate
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Communication
Nursing Assistant assignment sheets should

include:
Turning & Repositioning schedule
Type of Bed & Wheelchair surface
Bowel & Bladder program and products
Type of heel lift
Restorative cares
Supplements to be given
Skin protection devices/lotion
Lifting/transferring instructions & equipment/devices
Dressing(s) and the location, to notify the nurse if missing,
loose or soiled
Inspect skin daily
Notify nurse of any skin concerns
Case Study
Ima Swee/e
75yo female
Suered from a stroke aec.ng her right side.
Progressed to the point where she can use a walker,
independently for short distances.
Suers from depression and does not like to leave her
room.
Is intermiDently incon.nent and requires pad changes
qshiF. However, she does not inform sta/family when
she has been incon.nent.
Case Study
Ima Sweetie
Prefers to spend most of her day laying in her bed on right
side, despite attempts to reposition q2 hrs.
States she has diminished sensation on her entire right
side
She occasionally slides down in her chair at the evening
meal
Eats about half of each meal served, and occasionally will
take dietary supplements
She has fragile skin & states she has had many skin tears
on her hands and arms
Her right hand is starting to contract
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Resources
Available Resources and Web Sites:

www.wocn.org (Wound, Ostomy & Continence Nurse Society)
www.ahrq.gov (Agency for Health Care Research and Quality)
www.abwmcertified.org (American Board of Wound
Management)
www.npuap.org (National Pressure Ulcer Advisory Panel)
www.woundsource.com (Great source to find wound care
products)
www.wcei.net (Wound care Education Institute)
References
1. Bergstrom, N., Horn, S.D., Rapp, M.P., Stern, A., Barrett, R., Watkiss, M. (2013).
Turning for ulcer reduction: a Multisite randomized clinical trial in nursing homes.
The American Geriatrics Society 61:1705-1713
2. Defloor, T., D. De Bacquer, M.H.F. Grypdonck. (2005). The effect of various
combinations of turning and pressure reducing devices on the incidence of
pressure ulcers. International Journal of Nursing Studies 42(1):37-46
3. Eyers, I., Young, E., Luff, R., Arber, S. (2012) Striking the balance: night care
versus the facilitation of good sleep. British Journal of Nursing 21(5). 303-307
4. Kamel, N., Gammack, J. (2006) Insomnia and the elderly: cause, approach, and
treatment. American Journal of Medicine 119, 463-469
5. National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory
Panel. Prevention and treatment of pressure ulcers: Clinical practice guideline.
Washington DC: National Pressure Ulcer Advisory Panel; 2009
6. Sanford, J.T., Townsend-Roccichelli, J., VandeWaa, E. (2010) Managing sleep
disorders in the elderly. The Nurse Practitioner: The American Journal of Primary
Care Vol 35:5
References
7. Wound Ostomy and Continence Nurses Society. (2010). Guideline for Prevention
and Management of Pressure Ulcers. Mount Laurel, NJ: Wound, Ostomy, and
Continence Nurses Society
8. Wound Ostomy and Continence Nurses Society. (2008). Guideline for
Management of Wounds in Patients with Lower-Extremity Arterial Disease. Mount
Laurel, NJ: Wound, Ostomy, and Continence Nurses Society
9. Wound Ostomy and Continence Nurses Society. (2012). Guideline for
Management of Wounds in Patients with Lower-Extremity Neuropathic Disease.
Glenview, IL: Wound, Ostomy, and Continence Nurses Society
10. Wound Ostomy and Continence Nurses Society. (2011). Guideline of Wounds in
Patients with Lower-Extremity Venous Disease. Glenview, IL: Wound, Ostomy, and
Continence Nurses Society
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QUESTIONS
Thanks for your participation!!!

Jeri Lundgren, RN, BSN, PHN, CWS, CWCN
Vice President, Clinical Consulting
jeri.lundgren@joerns.com
Cell: 612-805-9703
25

Lundgren Handouts Skin Integrity Risk Assessment and Care Planning

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2/6/15

Prevention of Pressure Ulcers:

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Regulatory and Litigation

The care setting must PROVE

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Regulatory & Litigation

Can the care setting prove:

**NOT AS SIMPLE AS HAVING THE PHYSICIAN WRITE IT WAS

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Pressure Ulcer Definition

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Assessing for Risk of

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Risk & Skin Assessment

Skin Inspection in LTC

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Risk & Skin Assessment

Skin Inspection in Acute Care

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Risk & Skin Assessment

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Risk Assessment Tools

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Risk Assessment Tools

No risk assessment tool is a comprehensive

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Risk Assessment Tools

Overall goal is to identify the INDIVIDUAL risk

Problem Goal Interven/ons: Responsible

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Note on the Braden Scale the lower the score

PEOPLE PASSION PERFORMANCE Footer

Breaking Down the Braden

Impaired Sensory Perception

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Braden Scale - Activity

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Braden Scale - Mobility

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Breaking Down the Braden

The interventions are basically the same for:

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

Restorative & Mobility Programs

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

Restorative & Mobility Programs

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

Restorative & Mobility Programs

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

Pressure Redistribution: The ability of a support

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

Support surfaces for the bed:

PEOPLE PASSION PERFORMANCE Confidential & Proprietary

Immobility, decreased activity and/or

Elevation of heels OFF of the surface