LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone Toll-free: 866.814.0192 or 305.436.5030
Fax Toll-free: 866.818.0373 or 305.436.0086
E-mail Address: orders {at] LEEDerGroup [dot] com

F Tag 314 309 Quality of Care Part 4 Interventions Pressure Ulcers

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  • INTERVENTIONS KYDEX PRO Multi PodusLEEDerGroup.com: KYDEX Pro Multi Podus boot with ambulation pad Prevent Mitigate Heel Ulcers
    The comprehensive assessment should provide the basis for defining approaches to address residents at risk of developing or already having a pressure ulcer. A determination that a resident is at high risk to develop a pressure ulcer has significant implications for preventive and treatment strategies, but does not by itself indicate that development of a pressure ulcer was unavoidable. Effective prevention and treatment are based upon consistently providing routine and individualized interventions.
    In the context of the resident’s choices, clinical condition, and physician input, the resident’s plan of care should establish relevant goals and approaches to stabilize or improve co-morbidities, such as attempts to minimize clinically significant blood sugar fluctuations and other interventions aimed at limiting the effects of risk factors associated with pressure ulcers. Alternatively, facility staff and practitioners should document clinically valid reasons why such interventions were not appropriate or feasible.
    Repeated hospitalizations or emergency room visits within a 6-month period may indicate overall decline or instability.
  • Resident Choice
    In order for a resident to exercise his or her right appropriately to make informed choices about care and treatment or to refuse treatment, the facility and the resident (or the resident’s legal representative) must discuss the resident’s condition, treatment options, expected outcomes, and consequences of refusing treatment. The facility is expected to address the resident’s concerns and offer relevant alternatives, if the resident has refused specific treatments. (See Resident Rights at 42 CFR 483.10(b)(3) and (4), F154 and F155.)
  • Advance Directive
    A resident at the end of life, in terminal stages of an illness or having multiple system failures may have written directions for his or her treatment goals (or a decision has been made by the resident’s surrogate or representative, in accordance with state law).
    If a resident has a valid Advance Directive, the facility’s care must reflect a resident’s wishes as expressed in the Directive, in accordance with state law. However, the presence of an Advance Directive does not absolve the facility from giving supportive and other pertinent care that is not prohibited by the Advance Directive. If the facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes, and has implemented appropriate efforts to try to stabilize the resident’s condition (or indicated why the condition cannot or should not be stabilized) and to provide care to prevent or treat the pressure ulcer (including pertinent, routine, lesser aggressive approaches, such as, cleaning, turning, repositioning), then the 9development, continuation, or progression of a pressure ulcer may be consistent with regulatory requirements.
    NOTE: The presence of a “Do Not Resuscitate” (DNR) order is not sufficient to indicate the resident is declining other appropriate treatment and services. It only indicates that the resident should not be resuscitated if respirations
    and/or cardiac function cease. Based upon the assessment and the resident’s clinical condition, choices and identified needs, basic or routine care should include interventions to:
    a) Redistribute pressure (such as repositioning, protecting heels, etc);
    b) Minimize exposure to moisture and keepskin clean, especially of fecal contamination; c) Provide appropriate, pressure distributing, support surfaces;
    d) Provide non-irritating surfaces; and
    e) Maintain or improve nutrition and hydration status, where feasible. Adverse drug reactions related to the resident’s drug regimen may worsen risk factors for development of pressure ulcers or for non-healing pressure ulcers (for example, by causing lethargy or anorexia or creating/increasing confusion) and should be identified and addressed. These interventions should be incorporated into the plan of care and revised as the condition of the resident indicates.
  • Repositioning
    Repositioning is a common, effective intervention for an individual with a pressure ulcer or who is at risk of developing one.29, 30 Assessment of a resident’s skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. Such plans should be addressed in the comprehensive plan of care consistent with the resident’s need and goals. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. The care plan for a resident at risk of friction or shearing during repositioning may require the use of lifting devices for repositioning. Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing.
    Surveyors should consider the following repositioning issues:
    • A resident who can change positions independently may need supportive devices to facilitate position changes. The resident also may need instruction about why repositioning is important and how to do it, encouragement to change positions regularly, and monitoring of frequency of repositioning.
    • The care plan for a resident who is reclining and is dependent on staff for repositioning should address position changes to maintain the resident’s skin integrity. This may include repositioning at least every 2 hours or more frequently depending upon the resident’s condition and tolerance of the tissue load (pressure). Depending on the individualized assessment, more frequent repositioning may be warranted for individuals who are at higher risk for pressure ulcer development or who show evidence (e.g., Stage I pressure ulcers) that repositioning at 2-hour intervals is inadequate. With rare exception (e.g., both sacral and ischial pressure ulcers are present) the resident should not beplaced directly on the greater trochanter for more than momentary placement.
    Elevating the head of the bed or the back of a reclining chair to or above a 30 degree angle creates pressure comparable to that exerted while sitting, and requires the same considerations regarding repositioning as those for a dependent resident who is seated.• Many clinicians recommend a position change “off loading” hourly for dependent residents who are sitting or who are in a bed or a reclining chair with the head of the bed or back of the chair raised 30 degrees or more.31 Based upon an assessment including evidence of tissue tolerance while sitting (checking for Stage I ulcers as noted above), the resident may not tolerate sitting in a chair in the same position for1 hour at a time and may require a more frequent position change.
    • Postural alignment, weight distribution, sitting balance and stability, and pressure redistribution should all be considered when positioning a resident in a chair.32 A teachable resident should be taught to shift his/her weight approximately every 15 minutes while sitting in a chair.
    • Wheelchairs are often used for transporting residents, but they may severely limit repositioning options and increase the risk of pressure ulcer development. Therefore, wheelchairs with sling seats may not be optimal for prolonged sitting during activities or meals, etc. However, available modifications to the seating can provide a more stable surface and provide better pressure reduction.
    • There isn’t evidence that momentary pressure relief followed by return to the same position (that is a “microshift” of five or 10 degrees or a 10-15 second lift from a seated position) is beneficial. This approach does not allow sufficient
    capillary refill and tissue perfusion for a resident at risk of developing pressure ulcers. Ongoing monitoring of the resident’s skin integrity and tissue tolerance is critical to prevent development or deterioration of pressure ulcers.
  • Support Surfaces and Pressure Redistribution Pressure redistribution refers to the function or ability to distribute a load over a surface or contact area. Redistribution results in shifting pressure from one area to another and requires attention to all affected areas. Pressure redistribution has incorporated the concepts of both pressure reduction (reduction of interface pressure, not necessarily below capillary closure pressure) and pressure relief (reduction of interface pressure below capillary closure pressure). Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation; for example, multiple ulcers, limited turning surfaces,
    ability to maintain position. The effectiveness of pressure redistribution devices (e.g., 4-inch convoluted foam pads, gels, air fluidized mattresses, and low loss air mattresses) is based on their potential to address the individual resident’s risk, the resident’s response to the product, and the characteristics and condition of the product. For example, an overinflated overlay product, or one that “bottoms out” (completely compressing the overlay, when, for example, the caregiver can feel less than one inch between the resident and support material) is unlikely to effectively reduce the pressure risk. These products are more likely to reduce pressure effectively if they are used in accord with the manufacturer’s instructions. The effectiveness of each product used needs to be evaluated on an ongoing basis. Surveyors should consider the following pressure redistribution issues:
    • Static pressure redistribution devices (e.g., solid foam, convoluted foam, gel mattress) may be indicated when a resident is at risk for pressure ulcer development or delayed healing. A specialized pressure redistribution cushion or
    surface, for example, might be used to extend the time a resident is sitting in a chair; however, the cushion does not eliminate the necessity for periodic repositioning.
    • Dynamic pressure reduction surfaces may be helpful when: 1) The resident cannot assume a variety of positions without bearing weight on a pressure ulcer, 2) The resident completely compresses a static device that has retained its original integrity, or 3) The pressure ulcer is not healing as expected, and it is determined that pressure may be contributing to the delay in healing.
    • Because the heels and elbows have relatively little surface area, it is difficult to redistribute pressure on these two surfaces. LEEDerGroup.com: KYDEX Pro Multi Podus boot with ambulation pad Prevent Mitigate Heel Ulcers
    Therefore, it is important to pay particular attention to reducing the pressure on these areas for the resident at risk in accord with resident’s overall goals and condition. Pillows used to support the entire lower leg may effectively raise the heel from contact with the bed, but use of the pillows needs to take into account the resident’s other conditions. The use of donut-type cushions is not recommended by the clinicians.
    • A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from skinto-skin contact. Some products serve mainly to provide comfort and reduce friction and shearing forces, e.g., sheepskin, heel and elbow protectors. Although these products are not effective at redistributing pressure, they (in addition to pillows, foam wedges, or other measures) may be employed to prevent bony prominences from rubbing together.