The best way to treat wounds, of course, is to prevent them from developing in the first place. And while that is a noble goal and the focus of daily resident assessments, the truth is that wounds are a fact of life and can never be truly eradicated, clinical specialists agree.
“No matter what you do, there are always those times when your resident will develop a pressure ulcer,” says Sylvia Bennett, RN, nurse consultant at Save Medical. “Some people are just more susceptible to them.”
Bennett says she is not trying to discourage her peers from trying to eliminate wounds, but rather is trying to offer a realistic viewpoint on the issue. The long-term care environment — especially for residents who are bed-bound or have delicate skin — is a fertile area for wounds to occur. Even regular turning, lifting and tilting is not enough to head off the skin abrasions that lead to ulcers, she says.
Even so, that should only fortify facility staff’s determination to become familiar with all the nuances of wounds and do everything possible to ensure that every measure is being taken to keep residents wound-free. Beyond the obvious and routine check points, clinicians also need to consider nutrition, hydration, friction-causing elements such as clothing, co-morbidities such as diabetes or vascular status, and moisture levels on the skin, sheets and support surfaces.
“Be aware of the risks a patient has, based on medical condition, nutrition level, physical function and history of psychological well being,” says Diane Kubala, RN, clinical resource for ENSIGN Facility Services and president of the Arizona Chapter of the National Association of Director of Nursing Administrators. “Conduct an assessment at the time of admission, note any change of condition and implement interventions specific for the individual to prevent occurrence, including communication and education of family and caregivers.”
Sharon Strunk, director of nursing at Otterbein Retirement Living Communities in Cincinnati, recommends completing skin assessments daily with state-tested nursing assistants and twice weekly during bathing. All nurses should look for potential deep tissue injuries and check for signs of skin discoloration, redness with no blanching and skin warmth.
“Staff should be educated to these signs and should be capable of acting on them immediately,” she says.
Wound prevention responsibility goes beyond nurses to include just about all staff members in the facility as well as family members, says Henri Carlton, RN, director of nursing for Charlestown (MD) Retirement Community.
“Everyone should be involved in the discussions about how to identify even the most subtle changes in the resident’s pattern of daily activities,” Carlton says. “This includes programming staff, nursing staff, rehab therapists and dietary staff, including those who prepare resident meals.”
Food service staff can offer information about each resident’s likes and dislikes, while rehab therapists play a critical role in identifying cognitive impairments, Carlton says.
“Cognitive interventions are crucial to memory,” she says. “Speech therapy does more than identify dysphagia. Because dementia can create havoc in wound prevention, starting specific memory maintenance and enhancement programs can only help maintain the resident’s ability to remember the routines of eating, bathing, toileting and mobility.”
Familiarity with each resident’s nutritional intake, daily routines and physical condition is vital for identifying potential wounds. Yet staff needs to dig deeper than that, says Susan Cleveland, RN, chapter president, NADONA of Ohio.
“There needs to be a realization that your clients are individuals,” she says. “There may be similarities in the way skin trauma presents itself, but everybody is different. We know bony prominences are prone to breakdown, but if we truly know each client, we have a map right before our eyes that guides each assessment.”
Judith A. Morey, RN, senior consultant of wound and continence services for Pathway Health Services, endorses the collective prevention approach, calling it the “it takes a village” methodology.
“Everyone is responsible for prevention, from nursing to housekeeping,” she says. “For example, if a housekeeper notices that a resident has been in the same position for an extended period of time, it is her responsibility to request a position change from the staff.”
Beyond the obvious
There are many tried-and-true methods for uncovering potential wound starting points, but experts say there are also trouble spots that aren’t as obvious. For instance, the head area isn’t a common place for wounds, but it should be checked regularly.
“The head often gets missed because hair covers most of the scalp,” Bennett says. “Even the tip of the ear is vulnerable to wound development.”
Sherrie Dornberger, RN, executive director for NADONA, has first-hand experience with pressure ulcers on her head, which developed while she was in a comatose state. Ironically, it was due to the caregivers taking measures to help her, she says.
“I got a Stage 4, six-inch decubitus ulcer on the back of my head because a nurse thought she was doing me a favor by putting a small donut ring cushion behind my head,” Dornberger says. “But she never told anyone she did this, so no one knew to remove or reposition the donut, so it pushed into my head causing more problems than if nothing had been done. I also got pressure ulcers from the oxygen tubing under my nose, on the tips of my ears, between my knees and on my heels.”
Another consideration is clothing, Bennett says, such as behind the belt buckle or along the pant seam. Both present the potential for pressure and friction, which can cause skin shear.
“Once there is shear, it is followed by skin breakdown and once you have skin breakdown, you have lost your first line of defense,” she says.
Providers likely already have one of their best weapons against wound formation.
One of the most commonly referenced tools for identifying wound development is the Braden Scale for Predicting Pressure Sore Risk, which has six categories of identification: sensory perception, moisture, activity, mobility, nutrition, and friction and shear.
Sensory perception is especially effective in providing clues to where wounds might occur, says Margaret Falconio-West, senior vice president of clinical education for Medline.
“Sensory perception, or the ability to respond to pressure-related discomfort, is important because if patients feel discomfort, they can move or change positions,” she says. “If they are not able to sense the need to change positions, the staff will need to do that for them and place them on a specific turning schedule.”
The wound identification and management program at the Michael Malotz Skilled Nursing Pavilion in Yonkers, NY, is what Administrator Mark Pohar, RN, calls “very aggressive” and has been very successful as a result.
“We have an eight-bed ventilator unit and we have had several quarters where none of the patients have had pressure ulcers,” he says. “That is a great accomplishment of the staff.”
Pohar credits daily wound checks, getting residents out of bed regularly and an intensive education program on how to identify residents at a high risk for wounds.
“Basically, they are highly cognizant of what to look for and what to do if they see a potential wound,” he says.
As a veteran of long-term care for more than two decades, long-term care consultant Cathleen Bergeron has plenty of experience on wound care teams, most notably at Soldiers’ Home in Holyoke, MA. Over the years, she has seen techniques evolve and improve, with coordination of care serving as the most effective aspect of wound prevention.
“Wound care has gone from being reactionary to preventative,” she says. “It is no longer a top-down process; it has to be staff-driven. It also requires a lot of coordination with vendors, ensuring that they provide an ample supply of products.”
Direct Supply takes this role seriously and works closely with facility staff to provide the right breadth of products, says product engineer Justin Morgan.
“Clinicians have made it clear that wound management is a complex problem and that there is no one-size-fits-all solution,” he says. “This is why we offer a continuum of Panacea support surfaces to address a variety of needs, including multi-layer foam mattresses, foam mattresses with advanced technology, alternating pressure air mattresses, low air loss, air/foam combinations, and support surfaces with gel.”
As president of NADONA’s Massachusetts chapter, Bergeron also is working with a statewide coalition to institute wound prevention across the provider spectrum, from acute care to long-term care, home health and hospice.
“Because wounds often occur in the transfer arena, we have developed an interdisciplinary tool so that communications aren’t dropped,” Bergeron says. “Through coordination and cooperation, healthcare professionals can most effectively guard against wounds from developing in patients as they transition between environments.”
Head ’em off at the pass
When it comes to wound management, the best approach is prevention. Here are some proven strategies for identifying wounds before they have a chance to develop:
Conduct risk assessment evaluations, including medical history, nutritional history and lab results.
Utilize the Braden or Norton assessment scales to determine level of risk.
Conduct head-to-toe skin evaluations for baseline information that can be used to compare future assessments.
Identify co-morbidities such as diabetes, peripheral vascular disease and history of previous ulcers.
Assess residents upon admission, establishing a comprehensive plan of care.
Re-evaluate interventions and make changes where warranted.
Utilize proper pressure relieving devices, including bed, chair, cushions and foam wedges.
Educate the resident, family and all staff to specific signs related to potential wound development.
Focus on nutrition, specifically vitamin, protein and fluid intake.
Maintain regular levels of activity, ambulation and mobility.
Eliminate forces that cause skin friction and shear.
Remove moisture from perspiration, urine, feces and skin secretions.
Source: Julie Nitchie, Briggs Corp., 2013