Pressure Ulcer Questions and Answers

Q. I attended one of the statewide training sessions on Pressure Ulcer Prevention and Treatment. It was great information, but I'm not sure where to start?

A. It is always difficult to prioritize your program and get started. Try breaking your programs up into three categories:

  1. Admission Process
  2. Prevention Program
  3. Treatment Program.

Starting with your admission process first helps to ensure that new residents are being assessed for risk factors getting interventions put into place within the first 24 hours. When you have that system down, move to prevention, and then do treatment. Do not try and tackle them all at once or you and your staff will be very frustrated.

Q. At the basic level, what are some of the things we should ensure are being done at the time of admission?

A. At a minimum you want to ensure that a comprehensive risk assessment is being done. There should be an inspection of the skin and appropriate intervention(s) put into place within the first 24 hours of admission. It is very important that the following interventions are being implemented and communicated to the NAR: turning and repositioning support surfaces in the wheelchair and bed, incontinence care, and nutritional support. You can use the “Checklist of Skin Risk Factors & Interventions” (included in the Quality Resources Kit or downloadable from http://www.stratishealth.org to see if all risk factors and interventions are being started.

Q. When educating on pressure ulcer prevention and treatment, there is so much information, where do I start?

A. Try implementing your educational programs in the following order:

  1. Prevention of Pressure Ulcers (all staff)
  2. Assessment and Documentation of Pressure Ulcers (Licensed staff)
  3. Treatment Modalities for Pressure Ulcers (Licensed staff)
  4. Lower Extremity Ulcers, Assessing Etiology and Treatment Options (Licensed staff)
    You never want to start with treatment modalities before the assessment training—if a nurse doesn't know how to assess a wound, it will be very difficult to determine how to treat it. After each training session, assess to see if staff can apply the information at the bedside and follow up with bedside training. For example, after the classroom education on assessment and documentation of wounds, the next step would be to accompany staff at the bedside where they can apply the information just learned to measure/assess and document the wound properly. This is a good opportunity for bedside teaching, applying new information to practice, and reinforcement.

    Ensure that all staff receive pressure ulcer prevention and treatment education during orientation as well as periodically throughout the year.

Q. Do you have any suggestions for monitoring the pressure ulcer programs?

A. As with any program, once it is implemented, it must be monitored to ensure it is running effectively and being utilized. Monitoring programs should be an ongoing process or the chances of it failing are very high.

Utilize all staff for monitoring wounds. For example, licensed staff could monitor NARs during cares, NARs could check each other, and Staff Development can ensure monitoring is happening as well as identify educational needs along the way.

Here are some programs that have been successful:

  • Turning & Repositioning: Place a sticky note with a message to “return to______ (whoever is implementing the intervention) when found.” If the staff return it to you within the appropriate time for that resident give them positive reinforcement. If they don't get it back to you in time, with both the NAR and Licensed staff, look at where the process broke down for that resident and without blame , put into place steps to prevent it from happening again. You could also have Staff Development or Licensed Staff accompany and monitor the NAR as they do the “off-loading” or turning and repositioning. This is an opportunity to give immediate feedback and reinforcement to staff to assist them in improving their skills.

  • Monitoring Daily Cares: Ensuring NARs are inspecting the skin after pressure is redistributed, doing proper peri care, ROM, applying splints/devices appropriately, hand washing, and etc. Licensed staff can do this and/or involve Staff Development in so that they can identify/assess educational opportunities.

  • Monitoring that products are being utilized appropriately (i.e., wheelchair cushions, bed surfaces, medical devices, etc): Involve housekeeping to ensuring that the resident has the appropriate surfaces, devices, and etc. A list of the resident and the products they use could be available to housekeeping staff and when the resident room is cleaned, they could check to see if the correct products are where they should be.

  • Monitoring documentation once a month to see if skin inspection and risk assessments are being done at appropriate intervals.

  • Monitor that the care plan reflects the actual interventions being implemented

  • Monitor nurses doing dressing changes and wound assessments to ensure proper practice and to properly measure/assess the wound.

  • Monitor treatment records for implementation , so that orders are written appropriately and that treatment has not been started on a wound that has not yet been reported.

  • Monitor that topical treatments are being utilized appropriately

  • Monitor the ability of licensed staff to determine etiology of a wound (pressure verses lower extremity ulcers, etc.)

  • Monitor physician diagnosis, orders, and prognosis of area to ensure it is appropriate.

Q. What is tissue tolerance and how to we check it?

A. Tissue tolerance is the ability of the skin and its supporting structures to endure the effects of pressure without adverse effects. Every person's tissue tolerance is different, for example, some residents may tolerate an hour in the wheelchair without breakdown and others may not. To inspect the skin for tolerance, after and area is re-distributed or the pressure is relieved, the skin should be inspected for any skin discoloration (note darker skin tones my not show any change in color) and palpate it for any changes in temperature (warm or cold) or consistency (firm or boggy), if one of more of these signs exist, a stage I ulcer may have developed. Note that after pressure is relieved from any area of the body a hyperemia (redness) response will appear from the blood flow going back to that area (again note darker skin tones may not present with this). If this response doesn't resolve right away, check again within 45 minutes to hour. If it is still discolored, then it is a stage I ulcer. This process will allow you to determine if the turning intervals are adequate for the individual resident.

Q. Our facility has a hard time ensuring everyone is repositioned/turned every two hours, how are we going to do it hourly for our wheelchair bound residents?

A. First, it is important that staff understand why it is so important to move a resident more frequently while sitting, primarily to ensure circulation to that area to prevent skin breakdown. It is also important to note that a sitting position can be in the bed, recliner, or wheelchair—sitting is when the head is above 30 degrees. When a resident is in a sitting position, all their body weight goes to the buttock area, making it vulnerable to the effects of pressure. The turning program should be individualized per that resident's tissue tolerance. To ensure those appropriate residents are being turned and/or offloaded hourly break your facility down per unit and then per NAR assignment. Essentially, it would be the day shift NARs and the first part of evening shift NARs this will affect. By the end of evening shift and on the night shift most residents are lying in bed and back to every 2 hours. Look at each individual NAR assignment to see which residents need the hourly repositioning/offloading and then help organize/prioritize those assignments. It is strongly recommended that you sit down with your NARs and have them come up with the solutions, as they will be the ones who have to implement it. Whatever your solution is, monitor it to see if it is being implemented and if it is effective.

Q. What is “off-loading”?

A. Off-Loading is relieving the pressure to an area. During the CMS training for state surveyors, Dr. Courtney Lyder stated that “off-loading” is one full minute of pressure relief. Therefore, when a resident is in the wheelchair, you must stand them for one full minute. If the resident is unable to stand without the use of a lift, they will have to go back to bed, as the lift sling will continue to put pressure in that area. Also, if a resident is transferring from the wheelchair to the toilet, you would need to stand them for a full minute before putting them on the toilet to count that as off-loading.


September 28, 2005