RN Journal - Pressure Ulcers Management Part 1

by Wendy Trimboli, MA, BSN, RN, CIC, CPHQ, LNHA.
Administrator for Oceanview Nursing and Rehabilitation Center, LLC

Pressure Ulcers Etiology

In a small nursing and rehabilitation center serving 102 residents, we have developed an innovative management team who utilizes consistent standards to heal pressure ulcers. Pressure ulcers are a major complication associated with the loss of mobility, activity, increased moisture, poor nutrition, friction, shear, and altered sensory perception. They are caused by unrelieved compression of the blood vessels and tissues resulting in the lymphatic system not filtering waste products. This tension restricts blood circulation causing a lack of oxygen and nutrients over a certain time span resulting in tissue damage to the skin. The elderly resident in a skilled nursing facility is often admitted with or at high risk for pressure ulcers.

Wound Care Team

The skilled nursing facility has interdisciplinary team members. In 2007, the Nursing Director established regular teams for different aspects of care. The skin care team included an educator, a wound care physician, a registered dietitian, a licensed practical nurse, a physical therapist and a certified nursing assistant. This nursing home has established a proactive program to prevent residents without pressure ulcers from developing them, unless unavoidable due to the resident’s conditions. Oceanview promotes the healing of residents who have on admission or have developed pressure ulcers in-house by providing necessary treatment and services, preventing infection, managing pain and preventing new skin breaks.

Establishing Root Cause

This facility identified the root cause of nosocomial and non-healing pressure ulcers to be problematic in that resident’ risk factors were identified but not mitigated by the team. Prior to 2007, the team did not do rounds together, did not include unit staff and had no consistent physician assigned to assess progress on a weekly basis. This inconsistency leads to poor communication between team members. Resident physician orders went unchanged even when pressure ulcers worsened or did not heal due to lack of consistent information. Nurses did report acute symptoms such as vital signs results (i.e. temperature over 100), laboratory values (i.e. elevated white blood count) and acute wound abnormalities (i.e. pus drainage) to the attending not the wound care physician. Attending physicians reviewed four weeks of data, examined resident with monthlies, and occasionally were found inconsistent in documentation.

Finding Solutions

The plan of correction established by the Director of Nursing and Educator included developing a policy and procedure for skin care based on best community practices. The policy and procedure begins on admission assessing resident for skin breaks and areas at risk for pressure. Each day the nursing assistant validates skin integrity of their residents. The changes in the skin integrity are reported immediately to the unit nurse (the unit nurse informs the RN supervisor). The nursing assistant documents skin integrity findings on the certified nursing assistant accountability record each day. The registered nurse or unit nurse reports any changes to the physician on-call immediately.

Early Identification

For any new skin break an investigation (quality assurance audit is completed by the nursing supervisor) is initiated to determine causality (scratch, skin tear or pressure site). The unit nurse follows the chain of command and report findings. Audits are trended and reported into the Infection Control Committee (a sub-committee of performance improvement committee). The unit nurse informs the physician and obtains a treatment order on day of discovery. This investigation determines if the skin break was avoidable or unavoidable; and root cause of the condition or problem.

Follow Up

When a wound is present, weekly skin care team evaluations occur and the residents’ response to treatment is documented on a flow sheet. Interventions will show a team collaboration to reduce pressure, eliminate or lower risk factors and provide appropriate treatments according to residents’ conditions and circumstances. Interventions are carefully tailored for each individual through weekly rounds and care plan updates.

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Pressure Ulcers Management

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