> WOUND & SKIN CARE
Pressure ulcer alert! By Melodie Nelson, RN, and Ruth Harris, BSN, RN, ONC
A 70-YEAR-OLD WOMAN FALLS and fractures her hip, requiring an open reduction and internal fixation (ORIF). She weighs 110 lbs (50 kg) and has a history of type 2 diabetes mellitus. She has fragile skin, but no areas of skin breakdown are noted on admission. Her health history and physical assessment findings reveal several risk factors for pressure ulcers, primarily the decrease in her normal mobility. Her postoperative course is uneventful, and the patient is transferred to a rehabilitation facility. The nurses assess her on admission and note that she has nonblanchable erythema on both of her elbows and a category/Stage III pressure ulcer on her sacrum. Could these injuries have been prevented? This article discusses our hospital’s never event education project, which aimed to eliminate pressure ulcers and prevent other never events. Happily “never” after? The National Quality Forum (NQF) defines never events as “errors in medical care that are of concern to both the public and healthcare professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care organization.”1,2 In short, never events are usually preventable adverse events resulting in death or significant disability. The NQF lists 29 such events, including wrong-site surgery, patient suicide, 64 l Nursing2013 l November
medication errors, falls, and “any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care setting.”2 Pressure ulcer treatment costs 2.5 times more than preventive measures, with an average treatment cost of $43,180 per patient. More important, nearly 60,000 people die every year from complications of pressure ulcers.3 Pressure ulcers are categorized or staged according to severity. 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.4 (See Pressure ulcer classification.)
treatment options. The goal was to increase nurses’ knowledge about how pressure ulcers occur, the frequency of the occurrences, and the necessary steps to take once one’s identified. Let’s refer back to the 70-year-old patient recovering from ORIF. Her age, history of type 2 diabetes mellitus, and reduced mobility predisposed her for a hospital-acquired pressure ulcer following surgery.6 We don’t know how often a skin assessment was performed, if skin emollients were used to hydrate dry skin, if her skin was protected from exposure to excessive moisture with a barrier product, or if she was repositioned in a manner that relieved or redistributed pressure.7
Education goes a long way We conducted a systematic literature review to summarize evidence-based practice recommendations regarding prevention and treatment of pressure ulcers and guidelines for healthcare providers.5 This review served as the foundation for the never event education project. Educating the healthcare team on the post-op unit was a priority because staff education is the primary intervention for decreasing the incidence of pressure ulcers in post-op surgical patients.5 Education should include a skin product review, risk assessment tool, and unit protocols. The project involved a short but comprehensive slide presentation given to the nurses on the unit, concentrating on how a pressure ulcer develops, prevention techniques (including the six Ps of prevention, which we’ll discuss shortly), and
Prevent post-op problems We created and developed the six Ps of pressure ulcer prevention as a simple way to remember the care every patient in the post-op unit should receive. The purple pad is a paper-based pad that, compared with the typical cotton cloth pad, reduces the amount of moisture soaked into the bed. Purple cream is a barrier cream that reduces friction from clothes, sheets, and so on. Purple dots (an idea contributed by another nurse on the post-op unit) increase awareness of a patient’s pressure ulcer—where there’s a purple dot there’s a patient with a pressure ulcer. A purple sticker is placed on the patient’s medical record and wristband when that patient has a pressure ulcer. A pillow beneath the heels and propping a patient are strategies for redistributing the pressure on bony points on www.Nursing2013.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the body. This means the patient is repositioned using the 30-degree tilted side lying position instead of the 90-degree side lying or semirecumbent positions.7 The proper bed reminds nurses that all patients should have an air mattress instead of a traditional bed, which isn’t as efficient at redistributing pressure. Other literature-based interventions to prevent pressure ulcers include the following: • creation of a dedicated skin team • adherence to specific protocols such as repositioning a patient every 2 hours and assessing each patient’s skin on admission • performance monitoring with feedback • collaboration with other members of the healthcare team • identification of patients at high risk using the SKIN scale (s: sensory impairment, k: limited mobility, i:incontinent or excess moisture, n: inadequate nutrition) • more readily available skin care products, such as skin emollients.5,8 Our unit protocols include a very active skin care team and performance monitoring with monthly skin audits. During routine skin audits, all patients in the unit undergo a complete skin assessment, including assessing for erythema, as well as implementation of the six Ps of prevention. The skin team meets monthly to discuss findings. Education is reinforced by enterostomal therapy nurses. Besides the six Ps, our educational program recognizes the importance of assessing for preexisting conditions or risk factors that may lead to the rapid progression of altered skin integrity in debilitated, immobile patients. Patients may be transferred to our unit with nonblanchable erythema of a localized area of intact skin (Stage I), so nurses must initiate interventions www.Nursing2013.com
Pressure ulcer classification Stage I
Skin intact, nonblanchable erythema of a localized area usually over a bony prominence. In darker skin, skin may be a different color from the surrounding skin. Area may be painful, firm, soft, warmer/cooler than adjacent tissue.1,2
Stage II
Partial thickness loss of dermis; shallow, shiny, or dry open ulcer with red/pink wound bed, without slough/bruising. Can be intact open/ruptured serum-filled blister. Not skin tear, tape burn, incontinence-associated dermatitis, maceration, or excoriation.1
Stage III
Full-thickness tissue loss. Subcutaneous fat may be visible, but tendon and muscle not exposed. Slough may be present but doesn’t obscure the depth of tissue loss. Possible undermining and tunneling. Depth varies with location. Shallow if on the nose, ear, occiput, malleolus (no subcutaneous tissue).1
Stage IV
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough/eschar on some parts of wound bed. Often undermining/tunneling. Depth depends on location, similar to Stage III. Possible osteomyelitis due to ulcer extending into muscle/ supporting structures. Exposed bone/tendon may be present.1
Suspected deep tissue injury
Purple/maroon localized area of discolored intact skin or a blood-filled blister. Due to pressure and/or shear. Area may be preceded by tissue that is painful, mushy, boggy, warmer/ cooler, firmer than adjacent tissue. May evolve into a thin blister over a dark wound bed, possibly evolving further and becoming covered by thin eschar. Doesn’t always turn into pressure ulcer.1,3
Unstageable
Full-thickness tissue loss, base/wound bed covered with slough and/or eschar, which must be removed to determine the actual pressure ulcer stage.1
Reference 1. National Pressure Ulcer Advisory Panel. NPUAP pressure ulcer stages/categories. http://www.npuap.org/ resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories.
immediately to prevent further skin deterioration. An event of the past A brief test was administered to post-op staff members before and after the project presentation to determine the effectiveness of pressure ulcer education. The percentage of correct answers increased for every question. All staff members felt the presentation provided an informative update that would contribute to improvements in patient care.
There were as many as seven pressure ulcers during one monthly audit done in the 3-month period before the educational session. Three months after the educational session, no pressure ulcers were reported during the three monthly audits. This indicates that the pressure ulcer education and six Ps were adequate for reducing pressure ulcer prevalence. However, the monthly skin audits assess patients and pressure ulcers present only on that day. This audit doesn’t take (Continued on page 66)
November l Nursing2013 l 65
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
subtherapeutic levels. Following institution-specific policy is recommended. Here are some questions to ask when interpreting a vancomycin level: • Was the blood specimen obtained at the appropriate time (30 minutes before the fourth dose)? • Were any doses before the blood level missed or administered early or late? Nurses should be aware of the following when interpreting a vancomycin level: • Obtaining the blood specimen for the vancomycin level from the I.V. line used for vancomycin administration will give falsely elevated levels. • Missed doses may result in unintentionally low levels. • Variable administration times may result in misleading levels. Therapeutic drug monitoring of vancomycin is a complex process that involves an understanding of the usefulness of levels as well as careful interpretation by nurses, pharmacists, and prescribers. ■
REFERENCES 1. Vancomycin hydrochloride for injection [package insert]. Hospira, Lake Forest, IL; 2012. http://www.hospira.com/Images/EN-2972_32-91157_1.pdf. 2. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009; 66(1):82-98. 3. Vandecasteele SJ, De Vriese AS. Vancomycin dosing in patients on intermittent hemodialysis. Semin Dial. 2011;24(1):50-55. 4. Lodise TP, Lomaestro B, Graves J, Drusano GL. Larger vancomycin doses (at least four grams per day) are associated with an increased incidence of nephrotoxicity. Antimicrob Agents Chemother. 2008;52(4):1330-1336. 5. Launay-Vacher V, Izzedine H, Mercadal L, Deray G. Clinical review: use of vancomycin in haemodialysis patients. Crit Care. 2002;6(4):313-316.
Jamie M. Rosini is a clinical pharmacy specialist in emergency medicine and Nicole Srivastava is a clinical pharmacy specialist in infectious diseases at Christiana Care Health System in Newark, Del.
The authors have disclosed that they have no financial relationships related to this article.
DOI-10.1097/01.NURSE.0000435209.34142.0e
(Continued from page 65)
> WOUND & SKIN CARE into account pressure ulcers that were present previously. In order to adequately assess the effectiveness of education and prevention methods, we must change the way in which we assess and evaluate. We’re aggressively moving forward with our quality improvement initiative to ensure the continued reduction of pressure ulcers. ■
5. Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. J Wound Ostomy Continence Nurs. 2012;39(2):143-145.
REFERENCES 1. Kuhn H. Center for Medicaid and State Operation. 2008. http://downloads. cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD073108.pdf.
8. Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Jt Comm J Qual Patient Saf. 2011;37(6):245-252.
2. Agency for Healthcare Research and Quality. Never events. http://psnet. ahrq.gov/primer.aspx?primerID=3.
At the University of Pittsburgh Medical Center (UPMC) Shadyside ED in Pittsburgh, Pa., Melodie Nelson is an RN. At UPMC St. Margaret, Ruth Harris is an orthopedic nurse clinician.
3. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals: a toolkit for improving quality. 2011. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html. 4. National Pressure Ulcer Advisory Panel. NPUAP pressure ulcer stages/categories. http://www.npuap.org/resources/educational-and-clinical-resources/ npuap-pressure-ulcer-stagescategories. www.Nursing2013.com
6. Liu P. Diabetes mellitus as a risk factor for surgery-related pressure ulcers. J Wound Ostomy Continence Nurs. 2012;39(5):495-499. 7. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. 2009. http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf.
The content in this article has received appropriate institutional review board and/ or administrative approval for publication. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000435213.13057.5c
November l Nursing2013 l 67
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Pressure ulcer alert! By Melodie Nelson, RN, and Ruth Harris, BSN, RN, ONC
A 70-YEAR-OLD WOMAN FALLS and fractures her hip, requiring an open reduction and internal fixation (ORIF). She weighs 110 lbs (50 kg) and has a history of type 2 diabetes mellitus. She has fragile skin, but no areas of skin breakdown are noted on admission. Her health history and physical assessment findings reveal several risk factors for pressure ulcers, primarily the decrease in her normal mobility. Her postoperative course is uneventful, and the patient is transferred to a rehabilitation facility. The nurses assess her on admission and note that she has nonblanchable erythema on both of her elbows and a category/Stage III pressure ulcer on her sacrum. Could these injuries have been prevented? This article discusses our hospital’s never event education project, which aimed to eliminate pressure ulcers and prevent other never events. Happily “never” after? The National Quality Forum (NQF) defines never events as “errors in medical care that are of concern to both the public and healthcare professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures of the health care organization.”1,2 In short, never events are usually preventable adverse events resulting in death or significant disability. The NQF lists 29 such events, including wrong-site surgery, patient suicide, 64 l Nursing2013 l November
medication errors, falls, and “any stage 3, stage 4, or unstageable pressure ulcers acquired after admission/presentation to a health care setting.”2 Pressure ulcer treatment costs 2.5 times more than preventive measures, with an average treatment cost of $43,180 per patient. More important, nearly 60,000 people die every year from complications of pressure ulcers.3 Pressure ulcers are categorized or staged according to severity. 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.4 (See Pressure ulcer classification.)
treatment options. The goal was to increase nurses’ knowledge about how pressure ulcers occur, the frequency of the occurrences, and the necessary steps to take once one’s identified. Let’s refer back to the 70-year-old patient recovering from ORIF. Her age, history of type 2 diabetes mellitus, and reduced mobility predisposed her for a hospital-acquired pressure ulcer following surgery.6 We don’t know how often a skin assessment was performed, if skin emollients were used to hydrate dry skin, if her skin was protected from exposure to excessive moisture with a barrier product, or if she was repositioned in a manner that relieved or redistributed pressure.7
Education goes a long way We conducted a systematic literature review to summarize evidence-based practice recommendations regarding prevention and treatment of pressure ulcers and guidelines for healthcare providers.5 This review served as the foundation for the never event education project. Educating the healthcare team on the post-op unit was a priority because staff education is the primary intervention for decreasing the incidence of pressure ulcers in post-op surgical patients.5 Education should include a skin product review, risk assessment tool, and unit protocols. The project involved a short but comprehensive slide presentation given to the nurses on the unit, concentrating on how a pressure ulcer develops, prevention techniques (including the six Ps of prevention, which we’ll discuss shortly), and
Prevent post-op problems We created and developed the six Ps of pressure ulcer prevention as a simple way to remember the care every patient in the post-op unit should receive. The purple pad is a paper-based pad that, compared with the typical cotton cloth pad, reduces the amount of moisture soaked into the bed. Purple cream is a barrier cream that reduces friction from clothes, sheets, and so on. Purple dots (an idea contributed by another nurse on the post-op unit) increase awareness of a patient’s pressure ulcer—where there’s a purple dot there’s a patient with a pressure ulcer. A purple sticker is placed on the patient’s medical record and wristband when that patient has a pressure ulcer. A pillow beneath the heels and propping a patient are strategies for redistributing the pressure on bony points on www.Nursing2013.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
the body. This means the patient is repositioned using the 30-degree tilted side lying position instead of the 90-degree side lying or semirecumbent positions.7 The proper bed reminds nurses that all patients should have an air mattress instead of a traditional bed, which isn’t as efficient at redistributing pressure. Other literature-based interventions to prevent pressure ulcers include the following: • creation of a dedicated skin team • adherence to specific protocols such as repositioning a patient every 2 hours and assessing each patient’s skin on admission • performance monitoring with feedback • collaboration with other members of the healthcare team • identification of patients at high risk using the SKIN scale (s: sensory impairment, k: limited mobility, i:incontinent or excess moisture, n: inadequate nutrition) • more readily available skin care products, such as skin emollients.5,8 Our unit protocols include a very active skin care team and performance monitoring with monthly skin audits. During routine skin audits, all patients in the unit undergo a complete skin assessment, including assessing for erythema, as well as implementation of the six Ps of prevention. The skin team meets monthly to discuss findings. Education is reinforced by enterostomal therapy nurses. Besides the six Ps, our educational program recognizes the importance of assessing for preexisting conditions or risk factors that may lead to the rapid progression of altered skin integrity in debilitated, immobile patients. Patients may be transferred to our unit with nonblanchable erythema of a localized area of intact skin (Stage I), so nurses must initiate interventions www.Nursing2013.com
Pressure ulcer classification Stage I
Skin intact, nonblanchable erythema of a localized area usually over a bony prominence. In darker skin, skin may be a different color from the surrounding skin. Area may be painful, firm, soft, warmer/cooler than adjacent tissue.1,2
Stage II
Partial thickness loss of dermis; shallow, shiny, or dry open ulcer with red/pink wound bed, without slough/bruising. Can be intact open/ruptured serum-filled blister. Not skin tear, tape burn, incontinence-associated dermatitis, maceration, or excoriation.1
Stage III
Full-thickness tissue loss. Subcutaneous fat may be visible, but tendon and muscle not exposed. Slough may be present but doesn’t obscure the depth of tissue loss. Possible undermining and tunneling. Depth varies with location. Shallow if on the nose, ear, occiput, malleolus (no subcutaneous tissue).1
Stage IV
Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough/eschar on some parts of wound bed. Often undermining/tunneling. Depth depends on location, similar to Stage III. Possible osteomyelitis due to ulcer extending into muscle/ supporting structures. Exposed bone/tendon may be present.1
Suspected deep tissue injury
Purple/maroon localized area of discolored intact skin or a blood-filled blister. Due to pressure and/or shear. Area may be preceded by tissue that is painful, mushy, boggy, warmer/ cooler, firmer than adjacent tissue. May evolve into a thin blister over a dark wound bed, possibly evolving further and becoming covered by thin eschar. Doesn’t always turn into pressure ulcer.1,3
Unstageable
Full-thickness tissue loss, base/wound bed covered with slough and/or eschar, which must be removed to determine the actual pressure ulcer stage.1
Reference 1. National Pressure Ulcer Advisory Panel. NPUAP pressure ulcer stages/categories. http://www.npuap.org/ resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories.
immediately to prevent further skin deterioration. An event of the past A brief test was administered to post-op staff members before and after the project presentation to determine the effectiveness of pressure ulcer education. The percentage of correct answers increased for every question. All staff members felt the presentation provided an informative update that would contribute to improvements in patient care.
There were as many as seven pressure ulcers during one monthly audit done in the 3-month period before the educational session. Three months after the educational session, no pressure ulcers were reported during the three monthly audits. This indicates that the pressure ulcer education and six Ps were adequate for reducing pressure ulcer prevalence. However, the monthly skin audits assess patients and pressure ulcers present only on that day. This audit doesn’t take (Continued on page 66)
November l Nursing2013 l 65
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
subtherapeutic levels. Following institution-specific policy is recommended. Here are some questions to ask when interpreting a vancomycin level: • Was the blood specimen obtained at the appropriate time (30 minutes before the fourth dose)? • Were any doses before the blood level missed or administered early or late? Nurses should be aware of the following when interpreting a vancomycin level: • Obtaining the blood specimen for the vancomycin level from the I.V. line used for vancomycin administration will give falsely elevated levels. • Missed doses may result in unintentionally low levels. • Variable administration times may result in misleading levels. Therapeutic drug monitoring of vancomycin is a complex process that involves an understanding of the usefulness of levels as well as careful interpretation by nurses, pharmacists, and prescribers. ■
REFERENCES 1. Vancomycin hydrochloride for injection [package insert]. Hospira, Lake Forest, IL; 2012. http://www.hospira.com/Images/EN-2972_32-91157_1.pdf. 2. Rybak M, Lomaestro B, Rotschafer JC, et al. Therapeutic monitoring of vancomycin in adult patients: a consensus review of the American Society of Health-System Pharmacists, the Infectious Diseases Society of America, and the Society of Infectious Diseases Pharmacists. Am J Health Syst Pharm. 2009; 66(1):82-98. 3. Vandecasteele SJ, De Vriese AS. Vancomycin dosing in patients on intermittent hemodialysis. Semin Dial. 2011;24(1):50-55. 4. Lodise TP, Lomaestro B, Graves J, Drusano GL. Larger vancomycin doses (at least four grams per day) are associated with an increased incidence of nephrotoxicity. Antimicrob Agents Chemother. 2008;52(4):1330-1336. 5. Launay-Vacher V, Izzedine H, Mercadal L, Deray G. Clinical review: use of vancomycin in haemodialysis patients. Crit Care. 2002;6(4):313-316.
Jamie M. Rosini is a clinical pharmacy specialist in emergency medicine and Nicole Srivastava is a clinical pharmacy specialist in infectious diseases at Christiana Care Health System in Newark, Del.
The authors have disclosed that they have no financial relationships related to this article.
DOI-10.1097/01.NURSE.0000435209.34142.0e
(Continued from page 65)
> WOUND & SKIN CARE into account pressure ulcers that were present previously. In order to adequately assess the effectiveness of education and prevention methods, we must change the way in which we assess and evaluate. We’re aggressively moving forward with our quality improvement initiative to ensure the continued reduction of pressure ulcers. ■
5. Chaiken N. Reduction of sacral pressure ulcers in the intensive care unit using a silicone border foam dressing. J Wound Ostomy Continence Nurs. 2012;39(2):143-145.
REFERENCES 1. Kuhn H. Center for Medicaid and State Operation. 2008. http://downloads. cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD073108.pdf.
8. Soban LM, Hempel S, Munjas BA, Miles J, Rubenstein LV. Preventing pressure ulcers in hospitals: a systematic review of nurse-focused quality improvement interventions. Jt Comm J Qual Patient Saf. 2011;37(6):245-252.
2. Agency for Healthcare Research and Quality. Never events. http://psnet. ahrq.gov/primer.aspx?primerID=3.
At the University of Pittsburgh Medical Center (UPMC) Shadyside ED in Pittsburgh, Pa., Melodie Nelson is an RN. At UPMC St. Margaret, Ruth Harris is an orthopedic nurse clinician.
3. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals: a toolkit for improving quality. 2011. http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool1.html. 4. National Pressure Ulcer Advisory Panel. NPUAP pressure ulcer stages/categories. http://www.npuap.org/resources/educational-and-clinical-resources/ npuap-pressure-ulcer-stagescategories. www.Nursing2013.com
6. Liu P. Diabetes mellitus as a risk factor for surgery-related pressure ulcers. J Wound Ostomy Continence Nurs. 2012;39(5):495-499. 7. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: quick reference guide. 2009. http://www.npuap.org/wp-content/uploads/2012/03/Final_Quick_Prevention_for_web_2010.pdf.
The content in this article has received appropriate institutional review board and/ or administrative approval for publication. The authors have disclosed that they have no financial relationships related to this article. DOI-10.1097/01.NURSE.0000435213.13057.5c
November l Nursing2013 l 67
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
