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Pressure ulcers: Assessment, prevention, and compliance
PRESSURE ULCERS
CEU
by Angela Ducker, RN, BSN, MSN
H
ealth care officials recognize that pressure ulcers tax the health care system in human, treatment, litigation, and citation costs. They also recognize the magnitude of the problem during a
time when health care dollars are increasingly limited. In fact, a policy analyst at the Centers for Medicare and Medicaid Services, speaking to the American Association of Nurse Assessment Coordinators, indicated that almost 10% of nursing home residents—a staggering 17,000— suffer from at least one stage of a pressure sore at any given time. Not that the threat is confined to elders in nursing homes; the problem can show up practically anywhere, and case managers must play a leadership role in alleviating it. Physical and Fiscal Costs The skin is a vital organ that protects against infection, contamination, and temperature fluctuations and regulates fluids. When skin integrity is compromised, pressure ulcers can result, dam-
aging physical health, mental health, and quality of life in addition to creating a financial burden to the payor. Case managers know too well the disastrous consequences of pressure ulcers and the need for prevention at any effort and price. As we know, pressure ulcers also are called pressure sores, decubitis ulcers, or simply bedsores. Technically, they are localized areas of tissue necrosis that develop when soft tissue is compressed between bone and an external surface for an extended period. The body’s most susceptible areas include the ischials, sacrum, scapula, heels, and elbows. Pressure at these and other areas of the body actually collapses or crimps the capillary network, inhibit-
ing delivery of nutrients and oxygen to the cells. Severity of pressure ulcers ranges from mild to deep, and for certain populations, particular the elderly or disabled, pressure ulcers can develop very quickly. Pressure ulcers are the second most common reason for hospital readmissions, with treatment costs ranging from $20,000 to $70,000 per wound for serious breakdowns and $20,000 to $30,000 for less severe interventions. While pressure ulcers are responsible for great numbers of inpatient days, the problem is hardly limited to the hospital setting—even model centers for spinal cord injury (SCI) have a patient incidence of 40% for pressure ulcers. Of these, the recurrence rate is 35%. July/August 2002
TCM 61
CEU: PRESSURE ULCERS
Case Manager’s Role A case manager’s ability to help rein in the severity of this issue often seems limited. Direct preventive care is in others’ hands. Still, when an open sore halts medical progress, causes the patient grievous physical and mental suffering, and adds thousands of dollars in unforeseen costs, the responsibility falls on you, the case manager. To avoid this disheartening experience, skin integrity must be considered in virtually every care plan.
exposure to the physical factors leading to skin breakdown: • Pressure: Tissue is damaged by restricted blood flow, as when the skin is pressed between a bone and an external surface. • Friction and shearing: Skin rubbing against an external surface or another skin area causes abrasion, as from sliding down in bed. • Maceration: Excessive moisture, often from incontinence, weakens the skin.
The better you understand the risks, the better your plan and the more cooperation you will receive from others. Any good nursing manual provides a plan to prevent pressure ulcers. You can start, however, with a few basic questions: How much risk is involved? What are the specific risks? What preventive measures are needed? Will your plan be followed? Your role in framing such questions places you at the center of the health care team. Assessing Risk Because pressure ulcers occur where skin integrity is breached, you must understand the patient’s condition and
ON-LINE RESOURCES medicaledu.com/etiology.htm medicaledu.com/staging.htm text.nlm.nih.gov/ftrs/dbaccess/ulcc www.decubitus.org www.healthpages.org/ahp/library/hlthtop/ misc/bedsore.htm www.mayo.edu/geriatrics-rst/pu.html www.npuap.org
TCM 62
July/August 2002
General risk factors include age (elderly), gender (male), marital status (single or divorced), even educational levels (lower). Additional risk factors need to be reviewed. The incidence of pressure ulcers in the SCI population is as high as 40%. Specific risks for those with SCI of course are associated with the level of the injury. The impairment scale developed by the American Spinal Injury Association is a very helpful detailed neurologic classification system for assessing complete versus incomplete injuries, duration of
patient using a wheelchair may appear active, but if he or she cannot shift weight frequently, skin breakdown is likely. Skin can break down with as little pressure as it takes to place a postage stamp on an envelope. Accepted assessment tools, such as the Braden or Norton scales, most frequently are used in the clinical setting to quantify patient risk for skin breakdown. The Braden Scale measures six functional capabilities, including sensory perception, moisture, activity, mobility, nutrition, and friction and shear to assess patient risk. The Norton Scale considers five factors: physical and mental state, activity and mobility levels, and incontinence history. Patients should be assessed with one of these scales at the onset of a care plan and at periodic intervals thereafter. Vigilant monitoring and daily assessment are a critical part of everyday care. Above all when assessing risk, communicate! Talk with the patient, family, and caregivers to identify potential areas of concern. Perhaps the focus is a wheelchair or long hours in bed, incontinence, or lost sensation. The better you under-
We are responsible for acting as resources for our patients and their caregivers. Through this education, we reduce risk. injury, functional independence, attitude toward or lack of responsibility for skin care, smoking, alcohol consumption, and nutrition habits. Other individuals at high risk for skin integrity breakdown are patients exposed to moisture from incontinence and those who spend extended periods in wheelchairs or beds. We also must be aware of other conditions affecting the blood supply, such as diabetes and peripheral vascular disease. These risk factors become even more pronounced when mobility is limited. The risk to bedridden patients is obvious, but anyone with impaired mobility or sensation is vulnerable. A paraplegic
stand the risks, the better your plan and the more cooperation you will receive from others. Remember, neurologically impaired skin is associated with poor temperature regulation, rapid and measurable collagen breakdown, decreased collagen production, sensation loss, and too much or too little sweating. We are responsible for acting as resources for our patients and their caregivers. Through this education, we reduce risk. Planning for Prevention Each skin care plan is different, but all aim at keeping the skin clean and relieving pressure and friction at the appropriate points. Typical elements include turning or positioning schedules, using a 30-degree lateral position to reduce
CEU: PRESSURE ULCERS
pressure on the greater trochanters, seating and positioning equipment designed for the patient’s condition, a regular bowel program, cream or oil applications to skin, frequent inspection, and thorough cleansing.
SUGGESTED ASSESSMENT NEEDS AND QUESTIONS FOR CASE MANAGERS Identify which patients are at risk Educate those patients, families, and caregivers about pressure ulcer etiology
Special seating and sleeping surfaces should be considered early to prevent pressure ulcers rather than resort to expensive therapeutic treatment surfaces after they develop. In addition, consider a dietary consultation. Improper diet or hydration can lead to malnutrition, weight change, decreased healing, inactivity, poor circulation, and skin breakdown.
Intervene as follows: Develop a good skin care program Assign the same person to assess the skin daily for consistent observation Describe the condition and color of the skin—size, shape, color, drainage, odor of any lesion Remember that shape can indicate the cause—shearing forms irregular edges, and pressure creates small, round, red areas Use a handheld mirror during inspection Keep skin clean and dry Use a mild detergent and nonalcoholic moisturizing lotion for cleansing Maintain an ideal temperature to avoid sweating and overdrying of the skin Avoid clothing with synthetic fibers
The patient, family, and caregiver need to know what to look for, how to monitor symptoms, when to call a doctor, and how to maintain equipment. This up-front investment of time is indispensable.
Review moving and positioning considerations: Ensure enough people assist with the transfer Ensure assistive devices are available to complete move (ie, sheets, trapeze bars, transfer boards, dry lubricants or cornstarch)
Hospitals have developed protocols to intervene and treat pressure ulcers at every stage. These algorithms are specific to the wound and can be valuable for the caregivers in other environments. Three key rules to use with patients and caregivers common in hospitals are cleanse, inspect, and protect.
PROTECT, CLEANSE, INSPECT, TREAT
A recent study conducted by several health care experts from Yale University (Ostomy/Wound Management, April 2002, Vol. 4, Issue 4) explored the costs and outcomes of a pressure ulcer intervention program. The results of the two nursing-home study were very telling, with pressure ulcer incidence rates dropping 87% in one facility and 76% in the other after implementation of a comprehensive skin integrity program. The
Reduce pressure: prevention versus treatment Try mattress overlays or mattress replacement units Develop a turning schedule (eg, every 1-1/2 to 2 hours) Rule of 30—have patient lie laterally at 30 degrees and elevate the head of the bed 30 degrees Assess nutrition: Stress importance to maintain skin integrity Monitor for inadequate food intake and weight loss Increase protein and caloric intake (if not contraindicated) Ask patients about their preferences Assist with meal preparation Manage incontinence: Ask whether the patient has adequate bowel and bladder control Assess problems that may interfere with this control (eg, medications, confusion, infection, impaction) Ensure patient has needed supplies, skin barriers, etc.
researchers also found that a comprehensive program should cost no more than $750 a month per person, factoring in risk assessment and skin care labor, supplies, mattresses, chair support surfaces, nutrition, and CNA repositioning labor. Compared with the tens of thousands of dollars required for treatment, a prevention program obviously makes sense.
Consistency in the evaluation and the evaluator are critical. Get the patient involved in his or her own assessment and care. Observations of the ulcer’s size, color, shape, odor, and drainage must be documented and reported. If a nursing service is engaged, set clear expectations and demand follow-up reports on patient progress.
Ensuring Skin Care Compliance At the outset of any care plan, case managers should make allies of the patient, family, and caregivers. Educate them about the gravity of this health risk. Provide simple schedules and checklists.
The patient, family, and caregiver need to know what to look for, how to monitor symptoms, when to call a doctor, and how to maintain equipment. This up-front investment of time is indispensable. July/August 2002
TCM 63
CEU: PRESSURE ULCERS
FIGURE 1. FOUR STAGES OF PRESSURE ULCERS
Stage 1: Nonblanchable erythema on intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, and hardness also may be indicators. Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers. Taken from www.medicaledu.com/ staging.htm
In periodic contacts with patients and caregivers, include questions about skin issues: Have they noticed redness or irritation? Are cleansing and turning routines clear? Has a caregiver changed? Such questions emphasize your concern and can yield clues to compliance and situations requiring rapid intervention. Recently, an associate received a call from a patient requesting gauze squares. When asked about the need for this order, her patient said his heels were showing some redness. Our associate knew to intervene immediately with a call to the case manager, who was disTCM 64
July/August 2002
mayed to find that the “reddened” heels were open, draining, and foul-smelling. As a result, this patient was admitted to the hospital with a Stage 3 ulcer, which eventually degenerated to a Stage 4 wound that required surgery. Staging is another classification system to describe the severity of the wound. Figure 1 shows the four ulcer stages. While a Stage 1 (hyperemia) or 2 (ischemia) ulcer may heal over days or weeks if caught early, a Stage 3 (necrosis) or 4 (deep tissue destruction) ulcer, such as this patient’s, is extremely dangerous and may expose bone, muscle, tendon, or joint capsules to infection. While the individual who tuned into the real problem should be commended, if the immediate caregivers, patient, or family had prevented the pressure ulcer or assessed it earlier, $52,000 in medical costs, a lengthy hospital stay, and the patient’s pain and suffering could have been avoided. Although a sound skin care program will prevent most pressure ulcer problems, skin breakdown still may occur unexpectedly. Address pressure ulcers with aggressive treatment plans for recovery. Nutrition and hydration should be reviewed and adjusted as necessary. Interventions to relieve the pressure that led to the problem must be incorporated. Foam, gel, water, or air pads, wedges, special mattresses, even tilt-in-space wheelchairs for severely limited clients may be necessary to reduce pressure and allow the damaged area to heal. Where skin integrity is at stake, the case manager determines the effectiveness of the entire health care team. Who else but you, with your broad perspective, will ask the questions needed to assess risk, specify preventive measures, and provide vital education? Everyone on the care team must assist, but only your leadership can transform them into the “ounce of prevention” that makes the critical difference. The benefits of assessment, planning, and compliance are multiple, including decreased numbers of pressure ulcer wounds, identification of Stage 1 ulcers for early intervention, decreased hospi-
tal costs, and most important, improved patient quality of life. As case managers, it is our responsibility to report on outcomes—medical, financial, and quality of life issues—for our patients. With a relatively simple plan for prevention, we can report better outcomes in each of these three important areas. ❑ Bibliography Makelburst J. Pressure ulcers: what works. RN 1995;58:47-51. Popovich N. Treatment and prevention of pressure ulcers. New York: Home Health Care; 1998. p. 14-25. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. Pressure ulcer treatment. Publication E. Washington (DC): General Printing Office; 1994. Angela Ducker, RN, BSN, MSN, is a clinical educator and national sales manager (catastrophic care) for PMSI. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/126432 doi:10.1067/mcm.2002.126432
CEU: PRESSURE ULCERS
CEU APPLICATION This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research. To obtain your education credit, please do the following: 1. Read the “Pressure Ulcers: Assessment, Prevention, and Compliance” article. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the educational credit. 4. Mail this completed form with a check for $10 to: Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008 Questions: For which educational credit (1 hour) are you applying? CCM ID#___________ CRC ID#___________
CDMS ID#__________
1. Which of the following are risk factors for pressure ulcer formation? _____A. Moisture _____B. Immobility _____C. Both A and B _____D. Neither A or B 2. The body’s most susceptible areas of ulcer formation are? _____A. Sacrum _____B. Scapula _____C. Ischials _____D. All of the above 3. Identify the key components for patient assessment: _____A. Physical health _____B. Nutrition _____C. Pain _____D. Psychologic status _____E. All of the above 4. Pressure ulcers are described in four stages. _____A. True _____B. False 5. Components for a good skin care program consist of: _____A. Prevention _____B. Cleansing _____C. Waiting _____D. A and B _____E. A and C
Name ______________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________ State __________________ ZIP ________________________ Signature ___________________________________________________________________________________________________ An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Documentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. Credit available from July 1 to September 30.
July/August 2002
TCM 65
CEU
by Angela Ducker, RN, BSN, MSN
H
ealth care officials recognize that pressure ulcers tax the health care system in human, treatment, litigation, and citation costs. They also recognize the magnitude of the problem during a
time when health care dollars are increasingly limited. In fact, a policy analyst at the Centers for Medicare and Medicaid Services, speaking to the American Association of Nurse Assessment Coordinators, indicated that almost 10% of nursing home residents—a staggering 17,000— suffer from at least one stage of a pressure sore at any given time. Not that the threat is confined to elders in nursing homes; the problem can show up practically anywhere, and case managers must play a leadership role in alleviating it. Physical and Fiscal Costs The skin is a vital organ that protects against infection, contamination, and temperature fluctuations and regulates fluids. When skin integrity is compromised, pressure ulcers can result, dam-
aging physical health, mental health, and quality of life in addition to creating a financial burden to the payor. Case managers know too well the disastrous consequences of pressure ulcers and the need for prevention at any effort and price. As we know, pressure ulcers also are called pressure sores, decubitis ulcers, or simply bedsores. Technically, they are localized areas of tissue necrosis that develop when soft tissue is compressed between bone and an external surface for an extended period. The body’s most susceptible areas include the ischials, sacrum, scapula, heels, and elbows. Pressure at these and other areas of the body actually collapses or crimps the capillary network, inhibit-
ing delivery of nutrients and oxygen to the cells. Severity of pressure ulcers ranges from mild to deep, and for certain populations, particular the elderly or disabled, pressure ulcers can develop very quickly. Pressure ulcers are the second most common reason for hospital readmissions, with treatment costs ranging from $20,000 to $70,000 per wound for serious breakdowns and $20,000 to $30,000 for less severe interventions. While pressure ulcers are responsible for great numbers of inpatient days, the problem is hardly limited to the hospital setting—even model centers for spinal cord injury (SCI) have a patient incidence of 40% for pressure ulcers. Of these, the recurrence rate is 35%. July/August 2002
TCM 61
CEU: PRESSURE ULCERS
Case Manager’s Role A case manager’s ability to help rein in the severity of this issue often seems limited. Direct preventive care is in others’ hands. Still, when an open sore halts medical progress, causes the patient grievous physical and mental suffering, and adds thousands of dollars in unforeseen costs, the responsibility falls on you, the case manager. To avoid this disheartening experience, skin integrity must be considered in virtually every care plan.
exposure to the physical factors leading to skin breakdown: • Pressure: Tissue is damaged by restricted blood flow, as when the skin is pressed between a bone and an external surface. • Friction and shearing: Skin rubbing against an external surface or another skin area causes abrasion, as from sliding down in bed. • Maceration: Excessive moisture, often from incontinence, weakens the skin.
The better you understand the risks, the better your plan and the more cooperation you will receive from others. Any good nursing manual provides a plan to prevent pressure ulcers. You can start, however, with a few basic questions: How much risk is involved? What are the specific risks? What preventive measures are needed? Will your plan be followed? Your role in framing such questions places you at the center of the health care team. Assessing Risk Because pressure ulcers occur where skin integrity is breached, you must understand the patient’s condition and
ON-LINE RESOURCES medicaledu.com/etiology.htm medicaledu.com/staging.htm text.nlm.nih.gov/ftrs/dbaccess/ulcc www.decubitus.org www.healthpages.org/ahp/library/hlthtop/ misc/bedsore.htm www.mayo.edu/geriatrics-rst/pu.html www.npuap.org
TCM 62
July/August 2002
General risk factors include age (elderly), gender (male), marital status (single or divorced), even educational levels (lower). Additional risk factors need to be reviewed. The incidence of pressure ulcers in the SCI population is as high as 40%. Specific risks for those with SCI of course are associated with the level of the injury. The impairment scale developed by the American Spinal Injury Association is a very helpful detailed neurologic classification system for assessing complete versus incomplete injuries, duration of
patient using a wheelchair may appear active, but if he or she cannot shift weight frequently, skin breakdown is likely. Skin can break down with as little pressure as it takes to place a postage stamp on an envelope. Accepted assessment tools, such as the Braden or Norton scales, most frequently are used in the clinical setting to quantify patient risk for skin breakdown. The Braden Scale measures six functional capabilities, including sensory perception, moisture, activity, mobility, nutrition, and friction and shear to assess patient risk. The Norton Scale considers five factors: physical and mental state, activity and mobility levels, and incontinence history. Patients should be assessed with one of these scales at the onset of a care plan and at periodic intervals thereafter. Vigilant monitoring and daily assessment are a critical part of everyday care. Above all when assessing risk, communicate! Talk with the patient, family, and caregivers to identify potential areas of concern. Perhaps the focus is a wheelchair or long hours in bed, incontinence, or lost sensation. The better you under-
We are responsible for acting as resources for our patients and their caregivers. Through this education, we reduce risk. injury, functional independence, attitude toward or lack of responsibility for skin care, smoking, alcohol consumption, and nutrition habits. Other individuals at high risk for skin integrity breakdown are patients exposed to moisture from incontinence and those who spend extended periods in wheelchairs or beds. We also must be aware of other conditions affecting the blood supply, such as diabetes and peripheral vascular disease. These risk factors become even more pronounced when mobility is limited. The risk to bedridden patients is obvious, but anyone with impaired mobility or sensation is vulnerable. A paraplegic
stand the risks, the better your plan and the more cooperation you will receive from others. Remember, neurologically impaired skin is associated with poor temperature regulation, rapid and measurable collagen breakdown, decreased collagen production, sensation loss, and too much or too little sweating. We are responsible for acting as resources for our patients and their caregivers. Through this education, we reduce risk. Planning for Prevention Each skin care plan is different, but all aim at keeping the skin clean and relieving pressure and friction at the appropriate points. Typical elements include turning or positioning schedules, using a 30-degree lateral position to reduce
CEU: PRESSURE ULCERS
pressure on the greater trochanters, seating and positioning equipment designed for the patient’s condition, a regular bowel program, cream or oil applications to skin, frequent inspection, and thorough cleansing.
SUGGESTED ASSESSMENT NEEDS AND QUESTIONS FOR CASE MANAGERS Identify which patients are at risk Educate those patients, families, and caregivers about pressure ulcer etiology
Special seating and sleeping surfaces should be considered early to prevent pressure ulcers rather than resort to expensive therapeutic treatment surfaces after they develop. In addition, consider a dietary consultation. Improper diet or hydration can lead to malnutrition, weight change, decreased healing, inactivity, poor circulation, and skin breakdown.
Intervene as follows: Develop a good skin care program Assign the same person to assess the skin daily for consistent observation Describe the condition and color of the skin—size, shape, color, drainage, odor of any lesion Remember that shape can indicate the cause—shearing forms irregular edges, and pressure creates small, round, red areas Use a handheld mirror during inspection Keep skin clean and dry Use a mild detergent and nonalcoholic moisturizing lotion for cleansing Maintain an ideal temperature to avoid sweating and overdrying of the skin Avoid clothing with synthetic fibers
The patient, family, and caregiver need to know what to look for, how to monitor symptoms, when to call a doctor, and how to maintain equipment. This up-front investment of time is indispensable.
Review moving and positioning considerations: Ensure enough people assist with the transfer Ensure assistive devices are available to complete move (ie, sheets, trapeze bars, transfer boards, dry lubricants or cornstarch)
Hospitals have developed protocols to intervene and treat pressure ulcers at every stage. These algorithms are specific to the wound and can be valuable for the caregivers in other environments. Three key rules to use with patients and caregivers common in hospitals are cleanse, inspect, and protect.
PROTECT, CLEANSE, INSPECT, TREAT
A recent study conducted by several health care experts from Yale University (Ostomy/Wound Management, April 2002, Vol. 4, Issue 4) explored the costs and outcomes of a pressure ulcer intervention program. The results of the two nursing-home study were very telling, with pressure ulcer incidence rates dropping 87% in one facility and 76% in the other after implementation of a comprehensive skin integrity program. The
Reduce pressure: prevention versus treatment Try mattress overlays or mattress replacement units Develop a turning schedule (eg, every 1-1/2 to 2 hours) Rule of 30—have patient lie laterally at 30 degrees and elevate the head of the bed 30 degrees Assess nutrition: Stress importance to maintain skin integrity Monitor for inadequate food intake and weight loss Increase protein and caloric intake (if not contraindicated) Ask patients about their preferences Assist with meal preparation Manage incontinence: Ask whether the patient has adequate bowel and bladder control Assess problems that may interfere with this control (eg, medications, confusion, infection, impaction) Ensure patient has needed supplies, skin barriers, etc.
researchers also found that a comprehensive program should cost no more than $750 a month per person, factoring in risk assessment and skin care labor, supplies, mattresses, chair support surfaces, nutrition, and CNA repositioning labor. Compared with the tens of thousands of dollars required for treatment, a prevention program obviously makes sense.
Consistency in the evaluation and the evaluator are critical. Get the patient involved in his or her own assessment and care. Observations of the ulcer’s size, color, shape, odor, and drainage must be documented and reported. If a nursing service is engaged, set clear expectations and demand follow-up reports on patient progress.
Ensuring Skin Care Compliance At the outset of any care plan, case managers should make allies of the patient, family, and caregivers. Educate them about the gravity of this health risk. Provide simple schedules and checklists.
The patient, family, and caregiver need to know what to look for, how to monitor symptoms, when to call a doctor, and how to maintain equipment. This up-front investment of time is indispensable. July/August 2002
TCM 63
CEU: PRESSURE ULCERS
FIGURE 1. FOUR STAGES OF PRESSURE ULCERS
Stage 1: Nonblanchable erythema on intact skin, the heralding lesion of skin ulceration. In individuals with darker skin, discoloration of the skin, warmth, edema, induration, and hardness also may be indicators. Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage 3: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining adjacent tissue. Stage 4: Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage 4 pressure ulcers. Taken from www.medicaledu.com/ staging.htm
In periodic contacts with patients and caregivers, include questions about skin issues: Have they noticed redness or irritation? Are cleansing and turning routines clear? Has a caregiver changed? Such questions emphasize your concern and can yield clues to compliance and situations requiring rapid intervention. Recently, an associate received a call from a patient requesting gauze squares. When asked about the need for this order, her patient said his heels were showing some redness. Our associate knew to intervene immediately with a call to the case manager, who was disTCM 64
July/August 2002
mayed to find that the “reddened” heels were open, draining, and foul-smelling. As a result, this patient was admitted to the hospital with a Stage 3 ulcer, which eventually degenerated to a Stage 4 wound that required surgery. Staging is another classification system to describe the severity of the wound. Figure 1 shows the four ulcer stages. While a Stage 1 (hyperemia) or 2 (ischemia) ulcer may heal over days or weeks if caught early, a Stage 3 (necrosis) or 4 (deep tissue destruction) ulcer, such as this patient’s, is extremely dangerous and may expose bone, muscle, tendon, or joint capsules to infection. While the individual who tuned into the real problem should be commended, if the immediate caregivers, patient, or family had prevented the pressure ulcer or assessed it earlier, $52,000 in medical costs, a lengthy hospital stay, and the patient’s pain and suffering could have been avoided. Although a sound skin care program will prevent most pressure ulcer problems, skin breakdown still may occur unexpectedly. Address pressure ulcers with aggressive treatment plans for recovery. Nutrition and hydration should be reviewed and adjusted as necessary. Interventions to relieve the pressure that led to the problem must be incorporated. Foam, gel, water, or air pads, wedges, special mattresses, even tilt-in-space wheelchairs for severely limited clients may be necessary to reduce pressure and allow the damaged area to heal. Where skin integrity is at stake, the case manager determines the effectiveness of the entire health care team. Who else but you, with your broad perspective, will ask the questions needed to assess risk, specify preventive measures, and provide vital education? Everyone on the care team must assist, but only your leadership can transform them into the “ounce of prevention” that makes the critical difference. The benefits of assessment, planning, and compliance are multiple, including decreased numbers of pressure ulcer wounds, identification of Stage 1 ulcers for early intervention, decreased hospi-
tal costs, and most important, improved patient quality of life. As case managers, it is our responsibility to report on outcomes—medical, financial, and quality of life issues—for our patients. With a relatively simple plan for prevention, we can report better outcomes in each of these three important areas. ❑ Bibliography Makelburst J. Pressure ulcers: what works. RN 1995;58:47-51. Popovich N. Treatment and prevention of pressure ulcers. New York: Home Health Care; 1998. p. 14-25. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research. Pressure ulcer treatment. Publication E. Washington (DC): General Printing Office; 1994. Angela Ducker, RN, BSN, MSN, is a clinical educator and national sales manager (catastrophic care) for PMSI. Reprint orders: Mosby, Inc., 11830 Westline Industrial Dr., St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/126432 doi:10.1067/mcm.2002.126432
CEU: PRESSURE ULCERS
CEU APPLICATION This article has been approved for 1 hour of CCM, CRC, and CDMS education credit by The Foundation for Rehabilitation Education and Research. To obtain your education credit, please do the following: 1. Read the “Pressure Ulcers: Assessment, Prevention, and Compliance” article. 2. Make copies of this page for each person applying for credit. 3. Answer the following questions by selecting one statement. Four questions must be answered correctly to receive the educational credit. 4. Mail this completed form with a check for $10 to: Foundation for Rehabilitation Education and Research 1835 Rohlwing Rd., Ste. E, Rolling Meadows, IL 60008 Questions: For which educational credit (1 hour) are you applying? CCM ID#___________ CRC ID#___________
CDMS ID#__________
1. Which of the following are risk factors for pressure ulcer formation? _____A. Moisture _____B. Immobility _____C. Both A and B _____D. Neither A or B 2. The body’s most susceptible areas of ulcer formation are? _____A. Sacrum _____B. Scapula _____C. Ischials _____D. All of the above 3. Identify the key components for patient assessment: _____A. Physical health _____B. Nutrition _____C. Pain _____D. Psychologic status _____E. All of the above 4. Pressure ulcers are described in four stages. _____A. True _____B. False 5. Components for a good skin care program consist of: _____A. Prevention _____B. Cleansing _____C. Waiting _____D. A and B _____E. A and C
Name ______________________________________________________________________________________________________ Address ____________________________________________________________________________________________________ City ___________________________________________________ State __________________ ZIP ________________________ Signature ___________________________________________________________________________________________________ An individual application and $10 payment must accompany each request. Applicants who do not score 80% or higher may reapply with another application and additional $10 payment. No refunds will be issued for the $10 processing fee, regardless of the certification an applicant holds. Documentation of credit and an approval number will be mailed from the foundation in 3 to 4 weeks. Credit available from July 1 to September 30.
July/August 2002
TCM 65