My name is Mary Beth Rebar. I'm a registered nurse in the Health Care Finance Administration, the Health Standards and Quality Bureau. Welcome to the broadcast on pressure ulcer and nutritional implications. In the past, we have often focused on the medical and nursing aspect of this care issue. Today, we will cover some of that, but we also will focus on the nutritional implications to pressure sore prevention and treatment. Federal requirements, as described in the Nursing and Home Reform legislation, outlines a comprehensive assessment, prevention, and intervention planned to ensure that the highest possible quality of life and quality of care is reached for the residents. This includes preventing declines in care areas like pressure sores. Today, for our broadcast, we have three main objectives. Our first one are to identify some best practices to prevent and promote the healing of pressure ulcers. The second is to identify factors which demonstrate when pressure ulcers are avoidable and unavoidable. And the third is to identify appropriate interventions to prevent development of and to promote the healing of pressure ulcers. Our agenda will follow in the order of your handout titled Guidelines for Prevention and Treatment of Pressure Ulcers in the Long-Term Care Setting. We will have two call-in question and answer sessions. Our first one will occur during the presentation of the care relating to the prevention of pressure ulcers. And our second one will occur at the conclusion of our presentations. We invite you to call in with your questions or to fax them into us. The call-in number is 1-800-953-2233. Or if you wish to fax your questions in, it's<PHONE_NUMBER>. Our panelists are experts in the area of pressure ulcers and nutrition. And we are honored to have them with us today. We have with us Dr. Charlotte Gallagher-Allred, Manager of Geriatrics and Long-Term Care for Ross Products, a division of Abbott Laboratories. Dr. Gallagher-Allred is also a researcher, author, and instructor. We also have Ms. Mary Ellen Post-Hauer, who is a registered dietitian and president of MEP Health Care Delivery Services. She is also an author, editor, and instructor. Mary Ellen is also the ADA representative to the National Pressure Auxer Advisory Panel. We also have Ms. Joanne McElbus, who is a clinical nurse specialist in wound care and is case manager in general and reconstructive surgery at Harbor Hospital Detroit Medical Center. In addition to being an author and instructor and researcher, she has co-authored pressure ulcers, guidelines for prevention, and nursing management. She's a panel member on the National Pressure Auxer Advisory Panel and the Agency for Healthcare Policy and Research and help with the development of the guideline for pressure ulcer treatment. Now beginning on my immediate left, Joanne, would you begin and each of you briefly describe your professional experiences in this area of pressure ulcers and their treatment and nutritional applications? I'll be happy to. Before I joined Harbor Hospital, I was a nursing instructor and taught nursing and became very interested in wound care at that time. I was hired then about 15, 16 years ago at Harbor Hospital as a wound care specialist and joined many others. And we formed a interdisciplinary pressure ulcer committee. And we did some research and published it and pretty soon wrote a textbook. And from there, we had many, many people request more information from us. And eventually I was fortunate enough to join the National Pressure Auxer Advisory Panel and the HCPR Pressure Auxer Panel, which have been peak experiences in my life. I'm sure it must be exciting to be in the groundwork of all this. Very exciting. Thank you. Mary Ellen? Well, I've had a lot of years of experience in working in long-term care. And so I have a keen interest in pressure ulcers. But one of my main areas of interest with the Dietetic Association has been working as a board member for developing clinical indicators for pressure ulcers and weight loss, which we then did field test throughout the states. And then we did publish in the American Dietetic Association Journal the results of those studies. And so that's been very interesting to see all of the feedback that we are receiving from dietitians and other practitioners who call in and want more information in this area. It's a very exciting area. Oh, sure. Again, to see how things are evolving. It's great. Charlotte? I, like Mary Ellen, have been involved in long-term care for many years. And in my job at Ross Laboratories, I'm working with several researchers to conduct an outcome study looking at prevention and treatment of pressure ulcers in long-term care chains. And we hope to identify those practices that do work, those practices that don't work, so that we can better develop the best practice guidelines for our long-term care facilities. Thank you. Great. We already have a lot of good expertise here and experience. It's wonderful. The guidelines, just for your own information, which you will be following in your handout, they were developed by our presenters. And they evolved. And the content is taken from the AHCPR guidelines. Charlotte, would you now begin our program and just talk to us about what a pressure ulcer is and how it impacts on the health care of the residents in the long-term care facility? I'd be glad to. Thank you very much. A pressure ulcer is a lesion that is caused by unrelieved pressure resulting in damage to underlying tissue, which usually occurs over a bony prominence. There are many other etiologies of ulcers, such as vascular ulcers. But we will not be covering those in today's broadcast. Pressure ulcers are very common in our long-term care facilities. The Agency for Health Care Policy and Research in 1994 identified that one in four of our nursing home residents has pressure ulcers. Went on to say that one in eight of patients in home care and one in 10 in hospitals typically develop pressure ulcers. Pressure ulcers can be prevented, and that is our goal. Residents at highest risk in our long-term care facilities for pressure ulcers have been identified by the Agency for Health Care Policy and Research in the document shown on this slide called Pressure Ulcers in Adults, Prediction and Prevention. They identify several high-risk patients, and I'd like to categorize those for you, particularly those that are malnourished. Patients who are malnourished are at highest risk for pressure ulcer development. Also, those patients who have diseases that are affected by diet are often at high risk. Diseases such as diabetes, renal failure, cardiovascular disease. Those residents who are bedridden or immobile, such as those with spinal cord injuries, fractures, comatose or semi-comatose residents are also at highest risk. The precise etiology of pressure ulcer formation is unclear, but several contributing factors include malnutrition, especially malnourished patients who have recently lost substantial amounts of weight. Residents who are malnourished, as indicated by low serum albumin levels, low total lymphocyte count, and sometimes low blood cholesterol levels. Patients who are subject to high pressure, high friction are also at highest risk. And those that are incontinent of both feces and urine, or one or the other, those that have infection, those that have moisture problems, or those that have body positioning problems find themselves at increased risk for pressure ulcers. And these are contributing factors. I believe Mary Ellen will be covering these issues more as she discusses guideline one. Some pressure ulcers may be unavoidable. And we'll discuss unavoidable pressure ulcers as we discuss guideline five. It's important to remember that pressure ulcers are very costly. They're financially very costly, and they take a toll on quality of life of residents. And they can be prevented much more cost effectively than they can be treated. It is estimated that the annual cost for treatment of pressure ulcers in nursing homes, home care, and hospitals in our country is $1.3 billion a year. Treatment of pressure ulcers is discussed in this slide, again by the Agency for Health Care Policy and Research, and included in your bibliography. Treatment of pressure ulcers will be discussed by Joanne and Mary Ellen in guidelines two, three, and four. There are several federal regulations that govern pressure ulcers. And I'd like to mention three of them to you. One is resident assessment. The intent of which is that each resident's needs and capabilities are properly assessed, identified, and care planned for by the facility. The second is pressure sores. The intent of which is that residents will not develop pressure sores while in our facility. And if they come to our facility with a pressure ulcer or they develop one while they're in our facility, that they will receive the treatment that is necessary to treat it properly and to prevent further development of pressure ulcers. And then the third one is nutrition. The intent of which is that the resident will be assessed for his or her nutritional needs, that they do not decline in terms of their nutritional status unless there is a clinical condition that makes this unavoidable, and that they will receive the appropriate therapeutic diet when there is a nutrition problem. I think we're ready for guideline one. Thank you, Charlotte. And I agree with you what you said, that the nursing home regulations support the care that we're going to talk about today with the residents. And it also encouraged health providers to be both proactive and innovative in the care that they give to the residents. Mary Ellen, would you begin then for us and describe for us how to identify residents who are at risk and then also how to assess for these risk factors? All right, thank you. First of all, any resident that is admitted to a long-term care facility does need to have an assessment. And as part of that assessment, we do need to look very specifically for areas that would be risk factors that could possibly set the resident up for potential pressure ulcers. And some of these that were previously mentioned, I'd just like to give a little more detail. Inactivity and in-mobility are very high risk factors for the potential development of pressure ulcers. And this is because the pressure when it is compressed and on those bony prominences and you're not getting any relief, then what's happening is the oxygen and nutrients that are going to those tissues is not arriving there. And in the end, we will have some tissue death and pressure ulcer formation. So this is critical for certain classifications of residents and in particular, those who are semi-comatose who cannot move on their own for quadriplegics and paraplegics that again, do not have the sense that they need to move or can actually move physically off those pressure points. So that sets them up for the potential for pressure ulcer development. Other areas that we evaluate are residents who have degenerative or neurological diseases such as dementia or a pain that they cannot identify on their own. Because many times again what happens is we have physical and chemical restraints that are designed to assist the residents but in fact what they're doing is they're leading to a decrease in immobility and inactivity and place them at risk for pressure ulcer development. Our geriatric residents have a lot of changes in their skin that just naturally occur and some of those changes include the fact that there is less elasticity. So the skin is very thin and fragile and skin tears are frequent happenings in nursing facilities. The other thing that happens is there is a decreased response. They don't realize when they're in pain, sometimes they don't realize the sensitivity of heat. Examples of that are if you spill a hot beverage and if it hits their hand they may not be as sensitive to that as a younger person would. So that again sets them up as a potential for risk factors for nutritional status and again for pressure ulcers. The confused resident and the demented resident, many times again the medications that they are given or the restraints that they are used to help them are in fact leading to their inactivity and immobility. And many times with our Alzheimer's patients for example, they're very resistive to care. They don't understand the need to move and the need to transfer. So actually when caregivers are approaching them they can be resistive and so they're not cooperating with relief of pressure off of areas that is needed because they don't understand that that needs to be done for them. Some other areas that we look for, we actually look to see residents who are at risk based on the fact of them being incontinent, either feces or of urine. This is an important risk factor because when you have the constant exposure to the bacteria and the toxins that are in the feces and urine that's setting them up for again be a risk factor for skin breakdown. Charlotte mentioned several other disease conditions that deserve a particular attention and those are residents who have suffered from recent strokes who have peripheral vascular disease, the diabetic patient because in the diabetic patient the continual hypoglycemia or the elevated blood sugar levels are contraindicated to tissue healing and this again is a concern. Other residents that are viewed very carefully are those that have chronic diseases such as renal disease or liver disease or sepsis. All of these disease conditions are placing them at risk for possible skin breakdown so they need to be assessed very carefully. We also pay attention to the type of treatments that we're using for the elderly resident and these may be treatments and combination with medications that we are offering residents. For example, some of the very medications that are given to the elderly resident that are designed to slow them down, to decrease their agitation are doing that but they may in fact be doing it to the extent where they are making them less active, less mobile and many times the other side effects we see nutrition wise are that their intakes decline. If they're too difficult to arouse at mealtime or to keep awake to complete a meal that's an effect on their nutritional intake. So that needs to be looked at very carefully. Other areas that are of concern are what are the side effects of some of the medications that are given to the residents for various reasons. For example, if we have side effects of nausea and vomiting and diarrhea, then we are compromising the nutritional intake of that resident, the nutritional intake and in particular the hydration intake. So we always need to be aware of what medications are being given and what might be the possible implications of those. Some of the treatments that residents also receive while they're in the long-term care facility such as the resident that needs to be on dialysis or the resident that's receiving chemotherapy or radiation. Again, the side effects frequently are the nausea, the vomiting and then we have the low oral intake and we have the weight loss and then we have the potential for skin breakdown. So all of these areas kind of go together when we are making assessments for the residents. So we need to look at medications in light of their, not only their chemical side effects but what side effects they're having on reducing the mobility and activity of a resident. One very important area that we look at of course in making our evaluation in the nutritional status is looking at not only what the current weight status is, the weight that that resident may have arrived at the facility but trying to get a historical pattern of weight loss and we're very key in very closely on unintentional weight loss, unplanned weight loss and using the parameters of the 5% in 30 days and 7.5% in three months and then a 6% weight loss in six months is considered to be very serious. So then we look at the weight loss coupled with the poor appetite and know that we are placing this resident definitely at risk for tissue breakdown and poor wound healing. Other areas that we look at along with nutrition and the actual weight is that we look at the diet that the resident is receiving. Many times the diet order places that heavy restrictions on a resident and what happens is then they pull back, they're not allowed to have their favorite foods so they're just not going to eat at all and when that happens then we begin the spiral of low intake, loss of body weight and eventual pressure ulcer development. So we all need to be very cognizant of the diet orders that are received and most of the time by talking with the physician, the other members of the healthcare team, there can become an agreement that just a few minor adjustments can be made and we can achieve the same end goal for that resident because if they're not going to eat the food, they're not going to get the benefit of the diet at all so they do need to be actually taking in the food. There are many other areas that are examined relating to the physical condition of the resident and also the nutritional intake. In long-term care facilities with the elderly resident, one of our major concerns is their ability to chew and swallow and for most of them that's been greatly diminished, many of them have dentures that no longer fit because they've lost weight or they don't have their dentures at all, they've lost them somewhere along the way. So then what we find is they cannot actually chew, tolerate, consume the diets that are being sent to them and this becomes an issue. In this case, we find that what they frequently avoid are the things that they can't chew that well and a lot of times those are the very items such as meat, meat alternatives that we would like for them to consume because of their protein and caloric value so that needs to be adjusted and many times texture modifications have to be made for the resident so that we can have an adequate intake. Another major problem in long-term care facilities is the problem of dysphagia or swallowing problems and dysphagia is related to the inability to farm a bolus or to actually swallow the food without the food being aspirated into the lungs and we have aspiration pneumonia which is another critical problem. So when we have signs and symptoms of dysphagia and there are certain ones that we look for, we look for coughing during eating, we look for actual choking, so we look for some physical signs that indicate to us that they are having some swallowing problems and need to have intervention by another healthcare team member. So in this case, if these signs and symptoms are untreated, again it's a pulling back of the intake of food and the weight loss is a concern. So those issues need to be addressed. Another issue that's quite common in nursing facilities is the loss of dexterity or the actual physical ability of a resident to feed themselves. And so again, if that's not caught, if that's not assessed, and if we don't have any ways to correct that concern, we're looking at poor oral intake. So that's definitely a concern. With all of the assessments that we're doing of various kinds, the real important thing to remember is this has got to be a multidisciplinary team approach. We all have to be working. All the various disciplines have to be looking at the resident. We all see them at different times of the day and we see different avenues that need to be addressed. So it is a multidisciplinary assessment. There are specific pressure ulcer tools, assessment documentation tools that are mentioned in the AHCPR guidelines and the Braden Scale and the Norton Scale are two of those that we would recommend for consideration by healthcare facilities. But the major thing is that the assessments are completed and they are documented in some formal way. I'd like to call your attention now to the next guideline which looks at residents at risk for pressure ulcers and addressing the fact of how often do we monitor the residents and how often do we reassess for critical care. One important area is that all the residents who have been determined to be at risk for pressure ulcers need to have a skin inspection daily. So they need actually to have the healthcare providers inspect those areas of the skin that are considered to be very critical. And just to mention a few of those, you wanna pay particular attention to the bony prominences, the areas that are going to be receiving extreme pressure when you're lying down or when you're sitting in a chair. Later on, there's going to be some illustration and a video that will demonstrate some of those. But just to give you some idea of what areas were particularly important, if you're lying down, we're looking at shoulder blades, the tips of the shoulders, the sacrum, we're looking at the intertrocanter of the thigh. It's important to consider the back of the head and the sides of the head, depending on where the person is lying. Ankles are important. Inner and outer ankles and the heels, all of these bony prominences that are receiving this extreme pressure need to be examined daily to see if there's any changes in these areas. And one of the things that the caregivers look for is they look for the redness of the skin where there has been that pressure, they look to see if there's a reddened area that when you actually touch the area the heat would radiate from that area. And if that does not go away within 30 minutes or a reasonable length of time, then that's definitely an area that needs to be spotted as an area of concern for that resident and pressure needs to be relieved off of those areas. So those are definitely some of the areas that we need to really look at on a daily basis because things do change daily. Also, the nutritional status of the resident needs to be monitored quite frequently. If we've made a determination that there's just a minimal risk for nutrition status, we look at that person at the very least every three months when we're doing our updates. But if we have made a determination that a person is at high risk for nutrition, then it would be appropriate to look at those risk factors every month and to actually see if there have been any changes so that we can avoid problems with malnutrition and weight loss before they actually are upon us. Weight is an excellent indicator of nutritional status, but I would like to caution everyone that what is very important is when these weights are taken. Weights need to be taken at the same time of the day, they need to be taken at the same day of the week or the same day of the month. So that's an important area that people aren't weighed today in the morning and then next week in the afternoon and we have these fluctuating weights that are giving us a false sense of what is really happening. Scales need to be calibrated. I find that very frequently in long-term care. We have these great fluctuations in weight and actually it can be traced back to a faulty scale. So those are just areas that need to be reviewed when you're doing weights for people. Laboratory values are also indicative of malnutrition and can give us some clues as to the nutritional status of the resident. Again, there's nothing that says that we have to have all of these lab values, but what I'm going to do is just give you a few of them that we do use and what some of the guidelines would be. For example, we look at serum albumin levels and if they run 3.4 grams per deciliter or below, then we are interested to look further to see if there is a possible problem with malnutrition. Transparen levels, again of 180 milligrams per deciliter or below, again a sensitive indicator of protein status. So we do want to pay attention to those levels. Many of the levels that we look at as far as lab values have to be looked at with caution because they are affected by the hydration status of the resident, they are affected by medications the residents take, and they are affected by all the other changes that are going on. So you do have to have the professional look at the total picture of the resident in making these determinations. And Charlotte had mentioned the cholesterol levels and we certainly do look at cholesterol levels and much of the research has shown us that cholesterol levels under 170 milligrams per deciliter combined with other risk factors are definitely causes to indicate possible malnutrition. So that's another area for lab values that we definitely look at. We definitely look at hemoglobins and hematocrites. And again, because we're talking about the oxygen-rich protein flow of the blood and bringing nutrients to those areas. And if we have hemoglobin levels that are below 12, if we have hematocrit levels below 33%, combined with other risk factors, then we want to pay special attention to the anemic possibilities with this resident and the nutritional status. Other things that we definitely look at is that we look at the electrolytes. We look at the BUN levels. And so we're looking again for evidence of hydration status and really calculating serum as malarities and so forth to make sure that we have not missed anything as it revolves around the nutritional status. Some records though that are very easy to look at, many times are the simple intake and outtake records of the resident. So looking at what is this person's output? Very concentrated urine, very small amount. We need to be concerned about the hydration issues. There's nothing any better or as the actual physical inspection of a resident. So we do want to actually take a look at the resident and look for those physical signs of malnutrition. So we're looking for the very pale skin. We're looking for evidence of muscle wasting and kiketcha. So making those judgments as to what might be the physical signs of malnutrition that we can address. So those are just some of the areas that, specific areas that we do review in doing an assessment and looking at them on a more frequent basis, always doing another assessment if anything is out of line with these particular areas. And like you said, looking at the whole picture and the trends for the resident, keeping it all in mind. Well, thank you, Mary Ellen. You're welcome. Now, Joanne and Mary Ellen together will tell us how a multidisciplinary team collaborates and actually looks at to plan and give care to prevent pressure ulcers and infection. Thanks, Joanne. Thank you. Well, that was an excellent summary of assessment. And I think that with that total assessment, one of the major responsibilities of the multidisciplinary team is to do education, pressure ulcer education. And that means educating the person at risk for pressure ulcer, the patient's family, and also all of the caregivers. We're going to begin this section of pressure ulcer prevention and treatment with a video on pressure ulcer prevention. And many facilities use this video for education in their facilities. And it does come with wall charts and a pre-test and a post-test and also an instructor's guide. So we hope you'll enjoy this. I'm always glad to be here. Joanne's skin is in great shape these days. He's happier and more comfortable that way. One skin problem that can really sneak up on patients is pressure ulcers. So Joanne's daughter is always on guard for them. She knows how awful they can be. The good news is we can prevent many pressure ulcers before they ever get started. In this program, you'll learn what causes pressure ulcers and some things you can do to help prevent them. Afterwards, you can review the information with the pressure ulcer fact sheet. So for now, just sit back and watch. But remember, all patients are different. So be sure to ask your nurse, physical therapist, or doctor if the information in this program is right for your situation. Pressure ulcer prevention. What caring people need to know. This is a pressure ulcer.  Pressure ulcers can happen to patients who tend to lie or sit in the same positions too long without moving. Here's what happens. In a chair or in bed, our body weight puts pressure on bony places, like the heels, tailbone, and buttocks. The pressure cuts off the blood supply to the skin and tissue. Without blood, the skin and tissue may start to die, causing a sore or pressure ulcer. That's why it's so important for patients to change positions often before a pressure ulcer can get started. You may hear pressure ulcers called by other names, like bed sores, pressure sores, or decubitus ulcers, but they're all talking about the same thing. Pressure ulcers can cost thousands of dollars to heal. Some even become life-threatening. At the very least, they're painful and upsetting to the patient. Watch. It only takes a few hours for a pressure ulcer to get started, usually as a red area on the skin that still hasn't faded within 30 minutes after pressure is removed. The skin may feel warm and firm to the touch, like an infected cut might feel. As the days go by, the skin may become blistered or broken. A sore area like this is called an ulcer. Without proper care, the pressure ulcer may get a lot worse. There may be foul-smelling drainage. Some ulcers tunnel under the skin, so the damage you see on the surface may be just the tip of the iceberg. Sometimes pressure ulcers go so deep, you may actually see the bone. Every year, more than 10% of patients get pressure ulcers. The danger is highest for people who don't move very well, like stroke victims, or people paralyzed because of injuries. Many elderly people have trouble turning themselves in bed, especially if they're weakened by illness or drowsy from medications. The risk is even higher for patients who don't eat well, or who can't control their bowel or bladder, or who tend to slide around or slump down in the bed or chair. Patients can be thin or overweight and still get pressure ulcers. Why don't active people like you and me get pressure ulcers? Well, we would, except we move all the time without even thinking about it, even while we're asleep.  But suppose I stayed like this all afternoon. I could have a pressure ulcer starting right here at this pressure point under the bone. The body has many pressure points. On this one at the hip, look at how close the point of the bone is to the skin. There's not much padding in between. That's why body weight can pinch blood vessels shut under a pressure point.  Soon, these tiny cells may start to die. But watch what happens if the patient moves in time. Fresh blood gets back in before a pressure ulcer starts. See, the skin's white because pressure forces the blood out. When I let go, the blood goes back. No pressure, no pressure ulcer. So how long can patients safely stay in one position? A rule of thumb is two hours. But be sure to ask your physical therapist, nurse, or doctor what's best for your situation. It depends on your patient's general health and ability to move and turn in bed. For example, this woman has strong skin, and she can move some on her own. She may be less likely to get pressure ulcers. She may be able to stay in the same position longer than two hours without skin damage. That's helpful during the night. But this man has frail skin. And he tends not to move much on his own. His caregivers may have to help him turn at least every two hours to keep pressure ulcers from starting. Now you know the most important rule for preventing pressure ulcers. Keep the patient turned. But it's not all we can do. To lower the risk even more, we can make sure patients eat well, have clean dry skin, and don't slide around or slump in bed. Watch. Why is good nutrition so important? The skin is the body's largest organ. To stay healthy, it needs a balanced diet, including protein, vitamin C, zinc, and lots of fluids. Clean, dry skin is stronger, too. Wet skin gets soft and swollen and weak. Even worse, urine and bowel movement can burn the skin, making it five times more likely to get a pressure ulcer. If the skin gets wet, clean it up and dry it right away. Did you know that sliding down like this can cause friction and dangerous, invisible damage? It's called shear. The force of shear can stretch and tear tissue and little blood vessels under the skin that can cause hidden damage you may not see on the surface until much later.  You slipped down in the bed. I don't want to watch TV. OK, you can sit up in the chair while I change your bed. Well, OK. Now let's build on what we've learned. For the next few minutes, I'll show you nine pressure ulcer prevention tips. Watch carefully and think about how you'll use these important tips with your patient. Here's the first tip. We know that friction and shear can start pressure ulcers. So keep the head of the bed low enough so the patient won't slide down. Here's another tip. While John's in a chair, there's a lot of weight pushing straight down on his bottom. Scoot back, Dad, and boost up. So encourage your patient to boost up like this every 15 minutes or so just to get the blood going again. And limit time in the chair to one hour. In bed, encourage simple movements like reaching for the telephone. Just a quick wiggle gives the skin a welcome moment of pressure relief in between regular position changes. Special air, water, and gel mattresses, and foam pads like this help reduce pressure over bony places on the body. Why is this pad special? It's thick and dense. Thin pads don't relieve pressure. Neither do sheepskins. Mechanical mattresses automatically shift pressure under the patient, but don't forget. Even with the most expensive pads and mattresses, we still have to turn patients. Besides, turning helps prevent pneumonia. Brush away crumbs and straighten out wrinkles since they can irritate the skin. Don't drag patients around in bed. See how that tugs the skin? Remember, friction and shearing force can start a pressure ulcer. Here's the right way with a turning sheet. That's better. Let's make sure you're not getting any pressure ulcers, dad. I'm going to check your skin for red areas. Remember, it's normal for skin to be red just after pressure is removed, as this model is showing. But within about 30 minutes, that red should have faded back to normal skin color. Any area of skin that stays red longer than 30 minutes or feels warm or firm to the touch is warning you that the patient may be staying in the same position too long. A pressure ulcer may be starting. Don't massage directly on the red area. And don't use a heat lamp or pad. These may hurt skin that's already damaged from pressure. Tell your nurse, physical therapist, or doctor about the red area. I'm worried about a red spot on her heel that's not clearing up. And keep pressure off. This color change may not show up as well on blacks and other dark skin people as it does on patients with fair skin. So watch for skin that feels warm or firm to the touch, or is blistered or broken. I'm going to check your skin for red areas now. Every day, such as at bath time, look for beginning pressure ulcers. Check all over the body, even the ears, scalp, and toes. Most pressure ulcers begin on pressure points, where the bone is close to the skin's surface, like the heels, the ankles, especially the outside, between the knees, on the hips, at the tailbone and buttocks. This is a common place for pressure ulcers. The elbows and the shoulder blades. Socks and elbow protectors can reduce friction. Pillows are a great way to take the weight off pressure points. Don't use protective rings like this to try to prevent pressure ulcers. They're called doughnuts, and while they may protect the skin here, this skin gets squeezed so much the blood may be forced out. This isn't the best way for John to lie on his side. It puts too much weight squarely on the pressure point at his hips. This is better, halfway between his back and his side. See how the pillow spread out his weight. You're in great shape, Dad. Good. Sometimes, in spite of our best efforts, patients still may get a pressure ulcer, but many really can be prevented. Could you explain what you've learned to a new caregiver, a friend, or a relative? Just remember, pressure is the key. If turning is skipped for even one night, a pressure ulcer could get started. So watch the clock and make regular position changes. Keep up good nutrition, and keep the skin clean and dry. All this may feel like a duty, but it's really an act of love. If you have any questions about the information in this program, or if you think your patient may be getting a pressure ulcer, be sure to talk to your nurse, physical therapist, or doctor. We think that short video was very packed full of information about pressure ulcer prevention, and we think that it's a useful thing for facilities to have. I'd like to emphasize some of the points in that film, and I'm going to go over a few major points. If I can have the first slide, please. It's important to cleanse the skin at the time that it's soiled and at routine intervals. The frequency of this has to be determined by the individual need, and it's very, very important when you're washing the skin to make sure that you don't rub too hard because we want to minimize friction and scrubbing. Hot water should not be used, just plain warm water. Oftentimes, you can avoid soap if the skin is dry. We need to make sure the skin is moisturized, and we use topical moisturizers to do that. Those can be in the form of lotion, or cream, or ointment. In a very dry environment, lotion is preferred because it has a high water content, but you do have to apply it frequently. You'll get the greatest benefit from moisturizing with lotion on a frequent basis. And as the film said, we do want to avoid massage over bony prominences, and the reason we want to do that is because massaging deep tissue may cause harm to the deep tissue, and people do vigorous massage, and massage, especially if the vessels are already engorged with blood, and you have a red spot over a bony prominence, there is some danger of rupturing that vessel and in causing damage to the deep tissue. So until there's scientific evidence that shows us that it's helpful and actually does prevent pressure ulcers, we're better off to avoid the harm, the possible harm that we might cause. So the recommendations in the guideline are to avoid massage, especially over bony prominences, and especially when the area is reddened. The next thing that we want to do is avoid exposure of the skin to chemical effects of things like incontinence, perspiration, and excessive moisture, and there are several ways to do that. We want, first of all, to use underpads, next please. If we can use underpads that are designed especially to absorb moisture and wick the moisture away from the skin, and this is an example in this slide of underpads that do not do that, these underpads are paper, and we call them blue pads, and they're paper and they stick to the skin, and the patient is actually lying in a puddle when they're lying on this, and it really is for a linen saver and not to protect the skin. So it's important to use the right kind of underpads. They can be either reusable or disposable, but they must actually wick the moisture away from the skin. The next thing that we want to do to protect the skin is to use some kind of a moisture barrier, and there are several different kinds of things that work. You can use a moisture barrier such as a copolymer skin sealant that leaves like a little plastic film on the skin. You can use something like Petrolatum, just plain petroleum jelly, or you can use a zinc oxide-based ointment. All of those are just samples of things that you can use. There are many, many incontinence products made that are useful for protecting the skin from excessive moisture and from chemical irritation. Our next area of concern in protecting the skin is avoiding injury from the effects of mechanical forces such as pressure and friction and shear, and the way that we do that is to be very careful when we're repositioning people, that we don't drag them across the sheets. People can get sheet burns and it's very useful, as you saw in the film, to have someone have a sheet underneath them that you can actually move to avoid the skin from rubbing across the sheet or to have two caregivers actually lift the person up and rather than dragging them. It's important to reposition them at regular intervals. It's important to use a pressure-reducing device, especially on immobile people, and we like to have them repositioned every two hours, especially if they're immobile. If you refer to your handout, you'll see that there is a picture of a 30-degree laterally inclined position, and that position is the position that they were demonstrating in the film that says it's halfway between the back and the side. We try to avoid the trochanter because that's the heaviest portion of the body in the pelvic girdle, and there's very little paddy go over the greater trochanter of the femur, and that is the area that causes the greatest amount of pressure. So if you put a person in a 90-degree angle, they're going to have direct downward pressure on that. If you position them in a 30-degree lateral position, they will be lying on the fleshy portion of their buttock, and both the sacrum and both trochanters will be free from pressure at the same time. Now next please, if you look at the next slide, you'll see that here's someone that's putting a foam positioning wedge behind the person to keep them at a 30-degree angle. In our facility, we actually had foam wedges cut to a 30-degree angle, and if you lean the person back against that without a sheet over it, it kind of grips the bed, and also the person can't wiggle out of it the way they can with pillows. You can use pillows also. Either one is satisfactory, but the positioning wedges do tend to maintain the position in a longer period. Next. The next thing that we're interested in is protecting pressure points from opposing body surfaces, such as the knees and the ankles. And you can see that you can use a pillow or a piece of foam between knees and between ankles to protect the pressure from rubbing together, because again, those are heavy portions of the body. Next. And you can see that we have a demonstration here of a pillow on the lower extremity. The pillow starts below the popliteal space and actually does not cut off the blood vessel behind the knee, but it does suspend the heel fully off the bed. Now, if you're at all worried about foot drop, you could use some kind of a footboard or a pillow at the end of the bed also. Next, please. The next thing that we're worried about is support surfaces, and it's very, very difficult to determine which kind of support surface to use. There are so many choices. Until we have scientific evidence that says that one is more suitable than any other at all times, it's really pretty much of a clinical judgment. And in order for us to determine whether or not we have adequate pressure relief, we do something that's called a hand check to see whether the person bottoms out on the support surface we've selected. Next. If you can see on this slide, the person, the caregiver, slides their hand with the palm up between the pressure-reducing surface and the mattress underneath. Next. And when they do that, they should have their palm, their fingers outstretched and their palm flat, palm up, and they should put the palm under the heaviest portion of the body. Now, there should be approximately one inch of uncompressed support surface between the caregiver's hand and the person's body. Now, if the body is actually lying on the hand, you know that you do not have adequate pressure reduction and you need to go with a pressure-reducing surface that has more depth. The next area that we want to talk about is actually sitting. And when the person is sitting in a chair, they have more pressure in a sitting position than they do when they're lying down because the pressures are so much greater in a sitting position. We need to protect the ischial tuberosities. Next slide, please. This person is sitting in a jeery chair, but you see that they have pillows behind them to balance them. The posturing and the balance are very, very important. It's important to maintain body alignment so that the hip and the knee are lined up. It's important not to put the feet up too high on a footstool or the wheelchairs, the pedals of a wheelchair because you throw all of the pressure onto the ischial tuberosity. It's important that immobile patients have chair cushions. And you can see in this slide, the person actually has very good posture and very good positioning and balance, and they do have an adequate chair cushion, but this is especially made wheelchair for long-time use. Next, if the person cannot have enough upper body strength to do something like a wheelchair push-up, which is demonstrated in this slide, this person can learn to relieve their pressure on an intermittent basis by pushing up. If people do not have the upper body strength to do that, they have to be taught to either shift side to side or forward but to back. And when they do that, if they can't do that, the caregivers actually need to reposition them while they're sitting or put them back to bed if they don't have time to do that. But they need to be repositioned while they're sitting on a routine basis. Next, we want to make sure that we maximize the rehabilitation potential for everyone who has that potential. We need to offer physical therapy. We want to increase functioning, and we can do that in many ways. One of the things that we can do is offer assistive devices, whether it's a bed patient or whether the patient has the possibilities of ambulating. Next, in this slide, you can see that the person has an overhead trapeze that they're hanging onto, and they do have the upper body strength to actually lift their body right off the bed so that they can pull themselves up in bed without creating friction across the buttocks. That gives them some independence to move by themselves. But if they can't do that, they need to be repositioned by caregivers. Next, side rails sometimes help for bed patients too. They can grab side rails and turn themselves independently. Here you see someone being evaluated for an assistive device to help them with ambulation. They could have a walker, or they might have a cane, progress to a cane, but this allows them to increase their independence. And that also increases their general well-being, their nutritional status, and their quality of life. So we really need to pay attention to maximizing their rehabilitation potential. Now, if pressure ulcers are actually found on the skin when the patient is examined and you do routine skin inspection, and if they're at risk, as Mary Ellen said, if they're at risk, they need to be inspected daily. And if on daily inspection, they have found areas that are threatened pressure ulcers. Next slide. Such as this. And this is an area right on the greater trochanter of the femur. And this person has this reddened area. And if they are not repositioned off of that, that area will develop further. Now, you have to be careful that you teach people not to reposition back on that reddened area before it's fully resolved. Because repetitive pressure on the same area at risk is really the way pressure ulcers are caused. Repetitive pressure on the same area of risk is just as great as continuous pressure. So we need to be very careful about putting something back on the same area. There sometimes are very few areas where you can position someone. And those residents are a very big challenge. Next slide. Sometimes heels are kind of sneaky. They are a very, very heavy portion of the body. And they have a very small surface area. And oftentimes, you'll have residents that will be wearing special socks or boots or protective devices. And it's very, very important that those be taken off and inspected every single day. Because you may find an unsuspected pressure ulcer when they're examined. Next slide. Again, this is the same kind of a hyperremic or reddened area that is very suspicious and probably looks like it may not resolve with pressure relief after a short period of time, but needs a much longer period of pressure relief. And this is from sitting too long. And this is over the ischial tuberosity. Now, if you have these kinds of pressure ulcers that are threatened, the entire plan of care needs to be intensified. And preventive strategies need to be built in at a more intense level. The entire plan must be re-evaluated. And now, Mary Ellen, I think, will talk about the nutritional component. Yes, as I mentioned, several areas that we're concerned about. And one of those being the unintentional weight loss. The weight loss of 5% in 30 days and 10% in 180 days. So when we have the weight loss and we have either potential for pressure ulcers or we have the actual pressure ulcers, and in particular, when we are dealing with the pressure ulcer itself, we look to provide adequate amount of calories and protein. There are some general guidelines that are used. And generally, the caloric needs can be met by offering 30 to 35 calories per kilogram of body weight daily. And it's very important that we look at how we are offering these calories. Because we want to make sure that we're offering adequate amounts of carbohydrate and fat so that the protein that we're offering can actually be used for the tissue healing process. So it's important that they get adequate amounts of carbohydrates in those calories. There are general ranges also for protein, and we generally recommend 1.2 to 1.5 grams of protein per kilogram of body weight. And again, an important issue with offering the protein is to offer adequate amounts of fluid. And we can't stress that enough that hydration is so critical. Because we're not going to achieve the nitrogen balance that we are striving for if we do not have adequate amount of fluids offered. In the area of fluid, we can generally meet fluid requirements with 1,500 milliliters per day. And especially when we have these very small frail elderly who need to have at least that minimum amount of fluid. Some other ways that we judge fluid allotments are by going with 30 ccs per kilogram of body weight or offering 1 milliliter per kilocalorie that we are offering throughout the day. So those are just some various methods that can be used for estimating fluid requirements. But I would always also caution that you pay particular attention to the individual resident. Because while they all, several people might have a stage three or four pressure area, they might have very different protein and caloric needs. Residents with very large draining wounds are losing protein, they're losing fluid, and they need to have higher fluid requirements. Or a resident who has nausea, vomiting, elevated temperature, or increased perspiration, all of the ways that they're losing fluids need to have that fluid replaced. So I can't stress enough that it needs to be an individual plan for each resident. Another area is looking at the particular vitamins and minerals that are very important and play a role in wound healing. And vitamin C is one of those that has an important function when collagen production. So again, we want to make sure that in our plan that we're offering adequate sources of vitamin C. And these can usually be met through the dietary sources. If we actually can confirm or we suspect from the intake records and from the observation of the resident that they're not taking in adequate calories, then the next recommendation would be to look to a vitamin mineral supplement. Because that would be one way to supplement the calories they're not consuming. But we do not recommend that you go over 10 times the recommended dietary allowances with any type of supplement that you would be offering a resident or recommending be offered. One of the other areas that we always caution is the use of zinc sulfate. Because that is one of the areas in vitamin mineral supplement that is frequently used. And we just caution that that's not used for too great a length of time or in too high dosages that we would have some interference with copper absorption. The best way to achieve this intake of calories is through the oral method. So that's the major way that we want to do it. We would like people to be able to consume the food on their own. If that's impossible, then we do have to consider alternate methods of hydration and nutrition. I'd like to share with you just a few ideas that perhaps you might want to use in your particular care setting. First of all, there's no set pattern. There's no set types of supplements that should be used. Again, it has to be individualized. You really need to use what's best for that particular client. Some of the things that we've been using in our settings are we always strive to have the maximum amount of calories in the meals rather than to have supplements between meals and never supplements with the meals. So we look for what we call power-packed foods. One idea that we're using is we serve a high-calorie cereal in the morning because breakfast is generally very well accepted by the elderly. And with this high-calorie cereal, we serve them half and half because that's what they like. They were brought up on half and half and forget the skim milk and the 2%. And that gives them the calories, and they do consume it. So that is one method that we use. Another idea that we have been using is our 2-Cal program that we offer this at Medication Pass. So it is offered when the medications are offered. And it is physician-ordered. And it is a 2-calorie per CC product. And we offer 60 CCs four times a day. And we've had excellent results with this particular method because it's a very little bit to drink, it tastes good, and it does supply the calories in the protein. Some other things that we have been doing is that we offer a hydration pass for all the residents because we know that drinking the water is difficult for some to achieve and not always what they want. So we do offer juice to all the residents, usually once, sometimes twice a day. So again, we can get those calories, that hydration. So those are just a few of the ideas of things that we have been using. One of the issues, though, I wanted you to look at was I would like for you to look at the nutrition assessment and support, appendix A. And we want to talk a little bit about what is the alternative when we have exhausted all areas and we cannot actually achieve our goal of enough calories and enough fluid for a particular resident. When that happens and it's coupled with the lab values that are unacceptable and the weight loss that is not acceptable, then there comes a time when you need to discuss with the family, the resident, and the caregiver and the physician, is this an appropriate time to offer a tube feeding? Again, this must be a caregiver decision. It's not the decision of the dietitian or any one person. So they need to be explained what the alternatives are. If the person has a functioning gut, we always recommend the tube feeding versus the total parental nutrition or a TPN, which would be strictly for those who have other disease complications. There are many ways that this can be accomplished if you do select and if the resident selects a tube feeding. We don't want to have this to be forever life long for many residents who are still alert. So many times a tube feeding that is run perhaps in the evening hours and the resident is free during the day to do other activities and to perhaps have a meal or have something to eat in between. But that would be enough, we would be providing them ample calories for the healing process. There are other ideas such as if we have someone on a tube feeding and then we're taking them off gradually, getting them back to oral supplementation and oral intake, we might cut the feeding strength, cut the dosage back. For example, they might eat a breakfast. If they don't eat 50% of the breakfast, they have an order that the tube feeding could then be administered. So we're trying to make sure that the gut is empty and they're hungry when it comes to meal time. So those are just several ways that once you have achieved your goals, you can gradually wean the person off of the tube feeding. So what you really need to do is to go through the algorithm and see at what point in time is it time to consider alternate ways or is it appropriate at all to consider these alternate methods. There are some people that if they are hospice residents, for example, or if they are desiring comfort measures only, if that's when documented in their plan of care, then of course, as providers, we must abide by those decisions and in that case, we would not be offering them tube feedings, TPNs, any type of aggressive source. But I think Charlotte's going to give you a little bit more information about the documentation issues and what needs to be discussed when those kinds of decisions are appropriate. What I'd like to share with you now is a video that we have on risk factors and the role of nutrition. Sort of a summary of what we've been discussing as far as nutrition and pressure ulcers and the risk factors. Studies have suggested as many as 50% of pressure ulcers can be prevented. But a number of other factors have been consistently shown to increase one's risk of developing these lesions. And nutritional interventions are important for managing the patient with a pressure ulcer. Capsule comments with Dr. Richard Allman, Director of the Center for Aging and Director of the Division of Gerontology and Geriatric Medicine at the University of Alabama at Birmingham and the Birmingham Veterans Affairs Medical Center. Interviewed by Dr. Sheila Campbell, Senior Clinical Research Associate for the Ross Products Division of Abbott Laboratories. The Ross Medical Nutritional System presents pressure ulcer management, risk factors, and the role of nutrition. Pressure ulcers increase patient morbidity and mortality. They also add to the cost of health care. Yet they can often be prevented. And if they do occur, a rational approach to care can halt progression and promote healing. Today we'll discuss pressure ulcer management, risk factors, and the role of nutrition. Dr. Allman, how common are pressure ulcers? Pressure ulcers are very common, particularly among bed and chairbound elderly. As many as 20% of individuals who are confined to bed or chair during the course of hospitalization will develop a pressure ulcer. And 15 to 20% of patients in the hospital do have such mobility and activity impairments. So why is there so much attention focused on this problem right now? Well it is a costly condition to treat. If it does occur, it is largely preventable. Studies have suggested as many as 50% of pressure ulcers can be prevented with appropriate interventions. And also the Agency for Healthcare Policy and Research has established a guideline panel to develop recommendations for the ways to properly prevent pressure ulcers as well as to treat them. So tell me about those factors that put people particularly at risk for pressure ulcers. Mobility impairment and limited activity levels are two factors that are thought to be the primary risk factors for the development of pressure ulcers. But there are a number of other factors that have been consistently shown to increase one's risk for the development of these lesions. This includes incontinence, nutritional impairment, and altered level of consciousness. And all of these factors go together to increase one's risk for the development of the lesions. You've done research that shows the relationship between malnutrition and pressure ulcer formation. Tell me about those findings. We found that a decreased body weight and a decreased tricep skin folder associated with increased risk of pressure ulcers. We also noted that those individuals with decreased lymphocyte counts had an increased incidence of pressure ulcers. Other investigators have reported that a decreased dietary intake is associated with an increased risk of the problem. So you've told me about a lot of predictors. Now, how can we use those predictors to help reduce the risk of pressure ulcers? Well, this first step in prevention of pressure ulcers is to use the predictors to help identify individuals at risk. Then you need to intervene by providing a program that will increase the vitality of the skin to increase its resistance to the external factors that lead to skin breakdown, including pressure, sharing forces, friction, and moisture. That would include proper positioning techniques, the use of a pressure reducing device, and frequent repositioning. For those people confined to a bed, you need to reposition the individual at least every two hours if they're at high risk for a pressure ulcer. For those persons who spend a great deal of time in chair, if they're unable to reposition themselves, they should be placed back in bed after an hour of sitting in chair. If they're able to do wheelchair or seat lifts, then they can lift themselves every 15 minutes. Then you also want to address a good nutritional program that will maintain a person's nutritional status or correct any nutritional deficiencies. So you've told me about steps for intervention that are fairly simple, relatively low cost when associated with the cost of therapy. In spite of those interventions, pressure ulcers might occur. What do you do then? Well, I think probably the first thing to keep in mind is if a pressure ulcer doesn't occur, then you need to continue all your preventive interventions that you've implemented. These individuals remain at risk for other pressure ulcers on other bony prominences. And so you want to make sure that you maintain all the things we talked about in terms of prevention. And for those wounds that are deep and are full thickness injury, you need to make sure that those wounds are cleansed and all necrotic tissue is removed in order to facilitate healing. And most frequently that requires some sort of surgical debridement. Then you probably need to use a moist wound healing approach to the pressure ulcer. For those deep lesions, generally that can be accomplished by using just gauze dressings that are kept continually moistened with saline. There are a variety of other types of occlusive dressings that now can be used to help superficial ulcers have a moist wound healing environment to facilitate epithelialization. Those include hydrocolloid dressings and various types of film dressings. But in individuals with really severe pressure ulcers, you may need to think about the use of specialized pressure reducing devices, some of the more costly specialized beds that are available, such as the air fluidized bed or the low air loss bed. And again, nutritional interventions are important for managing the patient. Generally, we know that good basic nutrition is important. But are there specific nutrients we should emphasize? Some studies have suggested that increased protein intake is particularly important for pressure ulcer outcome. One study showed that you were more likely to show improvement in your ulcer with higher protein intake than lower protein intake. And there have been a couple clinical trials now that have correlated a higher protein intake with pressure ulcer healing. Do we know levels? Do we know amounts of protein that we should give? Really, the data are not specific enough to allow us to make a definitive recommendation in that regard. There's a correlation. That is, the greater the protein intake, the greater the healing rate was observed. And so it seems to be some sort of a continuous relationship rather than there being a specific cutoff. But I think most people would agree that a gram per kilogram would be an appropriate level of protein intake. Well, what about other nutrients? Are there others that are important? Well, certainly a number of factors seem to be important in wound healing, such as zinc and vitamin C. But we don't have enough data in the pressure ulcer population to make specific recommendations about those. And I think what we need to try to focus on is to provide good nutritional support, both for prevention and the treatment of pressure ulcers when they do occur, and then we'll be doing what's best for the patient and we'll be optimizing patient outcomes. Thank you, Dr. Allman. Pressure ulcers are associated with negative outcomes and they increase the cost of care. Yet in many cases, they can be prevented with rational multidisciplinary approaches. By instituting measures to relieve pressure, provide skin care, and assure proper nutrition, clinicians can ease pain and reduce costs associated with pressure ulcers. Capsule comments on pressure ulcer management, risk factors, and the role of nutrition has been presented by the Ross Medical Nutritional System. We're going to focus on pressure ulcer treatment. And it's very important for everyone to understand that treatment, even though we're going to be talking about local wound care, pressure ulcer treatment also absolutely contains every bit that we've already discussed about pressure ulcer prevention. So, prevention never ends when you have a patient who's receiving treatment. The first thing that we're going to talk about is how to cleanse a pressure ulcer. Next, there are two things to consider when we're discussing cleansing. The first is which solution to use and the second is how do I deliver that solution to the wound? You can see that normal saline is being used here and normal saline is physiologic and is the solution of choice. In this slide, we're using a 250cc bottle, soft-sided bottle to squeeze. It's got a catheter tip on it that has a controlled amount of pressure. If I squeeze that full force, I will get about five pounds per square inch and I don't know if you can see in the slide the stream of saline coming out onto the wound better not. But that is an adequate amount to actually remove the debris in the wound and cleanse the ulcer. It's important that we decrease the bacterial colonization and we don't want to scrub the ulcer, but we do want to have a moderate amount of pressure. It's also important not to use topical antimicrobials to cleanse the ulcer. Next, vigorous cleansing and debris manner are what we generally do in order to decrease the bacterial load because the bacteria reside in the necrotic tissue. If we can get rid of the necrotic tissue, we can also decrease the number of bacteria. You can see in this slide that it looks as though someone has been using betadine or topical povidone iodine, which is not our method of choice and our HCPR guidelines ask us not to use topical antimicrobials to decrease the bacterial load and also the antimicrobials do not enter the living tissue, which is the area of concern where the bacteria would actually cause harm once they get into the bloodstream and in the living tissue. Next, when you have areas of necrotic tissue, they need to be debrided and there are various forms of debredement that can be used. Sharp surgical debredement, mechanical such as wet to dry, enzymatic debredement with chemicals or autolitic debredement, which is actually letting the body debride itself with the help of moist wound healing. The type of debredement really depends on the urgency required for the debredement. If you have cellulitis beyond the edge of the wound into the peri ulcer tissue, and this is an advancing rate, it will be necessary to do urgent sharp debredement because obviously that is infected and it's critical that we remove that necrotic tissue before the person becomes septic. If the person just has necrotic tissue in the wound bed that needs to be removed such as on this slide, any method of debredement will work. The length of time that it takes for debredement might vary, but if it's not an urgent thing to do and you just need to move the wound along, any method of debredement will work. Various types of debredement can be combined and you may want to assess whether the patient can tolerate something like sharp debredement and if they cannot, then you could go with one of the other methods. Now, every ulcer does not need to be debrided. Next, you can see in this slide, this is a heel ulcer that's covered with eschar. Now, if you palpate that eschar and it feels soft or squishy or there's drainage coming out from beneath the edges, that eschar needs to be removed. But if it is not and if it's dry and hard and it's sealed around on all the edges, it can act as a natural protective covering and the only thing that you need to do is relieve the pressure and it actually might auto-debride by itself so you would suspend that heel to remove the pressure and you would not have to debride that ulcer. Next, the next thing we're gonna talk about is dressing. What kind of a dressing do we use on the wound? Well, as long as the dressing supports moist wound healing, it really doesn't matter which type that you use. It's difficult to choose. There are so many products on the market today. It's very difficult and there are no control studies showing that one works better than another. So anything that supports moist wound healing, including moist saline gauze, is satisfactory in order to accomplish auto-debriedment and to keep the wound bed moist to promote granulation tissue and re-epithelialization. The choice of dressings might be based on the frequency of the dressing that needs to be changed or it might be based on the ease of putting the dressing on or it might be based on the expense. Now soil dressings can be removed with clean gloves and what we call a no-touch technique. And no-touch technique means that you grab the dressing on the outside only and remove it with your clean glove and dispose of it. You can use that same clean glove to apply the new dressing with no-touch technique as long as you're touching only the outside of the dressing and not the part that goes next to the wound. However, if the dressing is saturated through and there's drainage all over it and you're touching that, then you need to change your gloves before you apply the new dressing. The new dressings always may be applied with clean technique using the same clean gloves if it is not struck through, if it doesn't have any strike through on the dressing. The next thing I wanna discuss is the technique used to prevent infection of pressure ulcers. Next slide. Now clean oral sterile technique can be used to change the dressing based on your clinical judgment. But when you're debriding an ulcer, sharply debriding an ulcer with surgical instruments, you must use sterile instruments. Next slide. And you can see here that they have a sterile setup and sterile instruments and sterile gloves to debride that ulcer. Measures to use to prevent infection also include adequate hand washing before caring for ulcers. It's important to use universal precautions when caring for all patients with pressure ulcers. Now the same pair of clean gloves can be used to take care of a patient who has multiple ulcers as long as you're working from the cleanest ulcer to the dirtiest ulcer in a logical sequence. If there's one ulcer that's near the top of the body that's less contaminated, you can use the same gloves to care for that ulcer as you can for another ulcer on the body as long as the dirtiest ulcer is cared for last. Now sometimes that's confusing to people, but it's very important that between residents, between the care of individual people that the gloves be removed and your hands be washed and you wear a new pair of gloves. But you can use the same pair to care for all ulcers of the same patient. Now another thing that's important is how we diagnose infections. Some people use swab cultures to diagnose infection and that is not correct. Any pressure ulcer is highly contaminated and colonized. Everything in the world is growing on it and if you take a swab and just run it across there, you are going to get it growing everything and it is a misconception to diagnose infection based on the results of that swab culture. The organisms that cause infection actually reside in the live tissue, so you would have to go outside the ulcer or in the base of the ulcer in some live tissue and get an actual biopsy, either a tissue biopsy or from irrigation aspiration of the live tissue in order to diagnose the ulcer infection. The next guideline, guideline four, discusses systematically monitoring improvement or deterioration. Now the effects of treatment are often monitored by looking at staging and there are many misconceptions about staging and I'd like to try to clarify some of those. Next slide. Each pressure ulcer to stage defines a specified layer of body tissue. Here we have the epidermis, this is unbroken skin, non-blanchibularithema. Next. In here we have the dermis, which is the next layer of body tissue. And the dermis then is, the epidermis is removed and you have a denuded area and you have the dermis showing. Next.  A stage four pressure ulcer shows the muscle and or bone. Now on the right you can see that that person had an artificial hip repair and that is actually a hip screw that is showing instead of down to the bone it's down to the hip screw. But nevertheless that shows a stage four. Now pressure ulcer staging is used then as one assessment parameter to indicate the depth of the ulcer by noting the deepest visible layer of body tissue that's actually exposed. You cannot actually accurately stage an ulcer unless the bottom tissue is exposed. Next. There are some problems with staging, especially that we use a numeric staging system because we call them one, two, three and four and some would say that that implies progression because of the numeric system. But we don't believe that one, two, three and four is how ulcers progress in severity. It's not a severity index. And in fact they're non-homogeneous type wounds and a stage two might even have a different etiology. It might be a friction burn and yet a stage one ulcer of non-broken skin might signify something very deep and it's only the tip of the iceberg that you see. So it's very difficult to accurately stage something when you have a misnomer like that. And because it's numeric people tend to reverse it and say that's how ulcers heal. And that again is a misnomer because there isn't any such thing. Now ulcers that are covered with eschar next cannot be staged until the eschar is removed. And case in point, you see on the left an eschar covered ulcer and when it's removed you can see on the right that it's impossible to stage it until the eschar is off because you need to see the bottom of the wound bed before you can denote the stage. Now pressure ulcer healing is actually determined by the appearance of the ulcer tissue. So reverse staging should not be used to assess healing of pressure ulcers and that has become a very confusing point. Pressure ulcer staging has been used inappropriately in many ways and there aren't any data to show that it does progress from a one to a four nor regress from a four to a one. And if we do do that because each stage defines an area of body tissue in a layer to say that reverse staging would be a way to monitor healing is a misnomer because as that ulcer, as that hole fills in, it fills in with granulation tissue which is a different type of tissue. Those same layers actually are not replaced. You don't replace the muscle layer and the subcutaneous layer and the dermis layer, et cetera. So it's very important for us to realize that we are giving misinformation if we say there's such a thing as reverse staging. Another problem for many residents, the pressure ulcer stages often have been used as reimbursement criteria. For example, if a resident had a stage four pressure ulcer and had a therapy bed or pressure reducing mattress prescribed for them and the ulcer got better and someone said, well, it's now healed to a stage two and I just told you there wasn't any such thing. The Medicare Part B then would say the patient no longer qualifies for the pressure reducing device when it reaches a stage two. So the misnomer of reverse staging is threaded throughout reimbursement documents also. So then the resident is removed from the very therapy that he needs to heal the ulcer. So the whole thing is quite complicated. Now, we ask that ulcers not be restaged during a course of therapy to denote improvement. And the National Pressure Ulcer Advisory Panel currently is working on something called the push tool which is the pressure ulcer scale for healing. And this document was released at a national conference in Washington, D.C. in February and it is a research-based tool although it's not fully complete. And we can't share copies of it yet. It has undergone validity testing with two data sets but it is undergoing further validity testing and sensitivity to change over time. The idea is that it will give you a numeric score which will go up or down, which will show improvement or deterioration and it will be a practical tool and it will be very easy to use. And we hope to work with HECFA to be able to have this replaced reverse staging eventually. So I just want you to be familiar with that. So far, this push tool or pressure ulcer scale for healing, next slide, shows three areas of importance for healing. One is size and that would be length times width measured in centimeters. Next. And the next would be the amount of exudator drainage from a wound and here you can see a wound draining necrotic purulent material. Next. And here you see a wound just draining serosanguanness drainage. But the amount of drainage has been shown to be an important factor. Next. And the predominant type of tissue. As the ulcer progresses from eschar, an eschar or necrotic covered wound as you see here to a wound covered with granulation tissue as you see in the next slide. Next. See the shiny bumpy granulation tissue? This is a great improvement. Now this isn't the same ulcer I showed you, these are just two examples. But this is exactly what we want the ulcer to do is progress and the ulcer would be improvement. Now all of this will be worked into a common score. The size, the amount of exudate, and the appearance or predominant tissue type which would be used to show improvement or deterioration. Now the next phase of the push tool is actively in process. And as I said the goal is to develop a very practical tool that clinicians and surveyors and payers all could use very quickly and very easily. And this then would replace the practice of reverse staging. Now the next thing that we wanna talk about is the time required for healing. A clean, well vascularized ulcer should show evidence of healing within two to four weeks after receiving all of the best practice guidelines that we've just given you. If someone has received care, they've received adequate pressure reduction, good positioning change, adequate nutrition, and adequate local care. And then the ulcer is well vascularized within two to four weeks. If there is no improvement in the ulcer itself, then the entire plan of care needs to be reevaluated. The facility has to reevaluate everything, the objectives, and think of alternative interventions. Next slide. What we would like to see happen is starting on the left, you can see a necrotic covered ulcer. And in the center you can see that there's less necrosis and some granulation tissue. And on the right you can see that the ulcer is almost healed. This is the progress that we would like to see. And we hope that these best practice guidelines will help everyone accomplish that. So that's the end of my treatment section. Thank you, Jillian. Now Charlotte will talk to us about documentation, how this impacts on the care given to residents. Thank you, Mary Beth. Guideline five addresses documentation in the medical record. Documentation must be sufficient to track outcome and implementation of the care. And documentation, as we've said all afternoon today, must be interdisciplinary and multidisciplinary. And that the information should be documented in a timely manner to assure that care is appropriately planned and provided. This may mean that documentation is done daily for many of our residents with actual pressure ulcers and weekly or monthly for others, certainly on a timely basis. Joanne has just very nicely reviewed for you the pressure ulcer treatment guidelines and what goes in to a documented plan of care are really those things that we've talked about all afternoon, regular assessment and reassessment, regular repositioning, pressure reducing support surfaces, adequate nutritional care that was very well covered by Mary Ellen, incontinence management, local wound care, monitoring of outcomes and improvement of outcomes. And then as Joanne said, if all of these things are happening, yet the wound is not healing or more wounds are forming, then we need to reevaluate our plan of care and obviously do something differently. If all of our best practices are followed, sometimes pressure ulcers are unavoidable. Pressure ulcers may be very difficult to prevent if the resident is terminally ill, if they are comatose, if they are semi-comatose or if they have requested that all life support measures be withdrawn. It is critically important that the nursing home interdisciplinary team with the patient, first of all, and family as well, document what the goal of therapy is. If it is curative treatment then all necessary treatment for healing of those wounds should be done. If the goal is palliative care, comfort care, many other treatments just as aggressive as curative care to promote lack of development of further pressure ulcers, management of pain, promotion of quality of life should be our goals and should be as aggressively pursued as is curative therapy. Most importantly, the care that we give our resident must be compatible with the resident as well as the family's wishes and must be within the realm of what that nursing home personnel can provide. Thank you, Charlotte. We are now gonna have our phone in session. We have a few minutes for some questions and again, our number is 1-800-953-2233. Or if you wanna fax in questions, our area code is<PHONE_NUMBER>. And while we're waiting for our first question, Charlotte, how does the nursing facility reconcile this need for additional protein and nutritional requirements and what the resident may or may not want in their family, all those different issues? I think it's very important that we realize that what we're talking about here when we talk about malnutrition and weight loss is really a downward spiral that if we can do something about it, we really must. Malnutrition is typically defined as a loss of subcutaneous fat and when we lose subcutaneous fat, we lose that cushion that's necessary to help the patient not experience much pressure. When we lose fat, we also lose protein and tissues. As soon as we lose protein and tissues, then we compromise the integrity of that skin and when integrity is compromised, it's a perfect place for infection to occur. Once infection occurs, our appetite decreases greatly. With a decreased appetite, it's very difficult to get patients, residents to eat. Interestingly, one of the things that they like best if their appetite is poor, are high carbohydrate and usually high fat containing foods, which is wonderful as Mary Ellen has just told us because they're often cool, such as sherbet shakes or milkshakes or puddings or eggnogs. I love half and half on cereal and butter added to vegetables that taste good. Fruit juices with added syrup to them. Cold things, so that protein that is taken can be utilized for wound healing. Now my experience is with protein that the easiest way to get high protein containing foods into them is through eggs and through dairy products, but egg salad sandwiches, maybe on toast. Chicken salad, ham salad, usually not beef is my experience, but things that don't have much smell to them because they do tend to smell that wound that doesn't smell good if it hasn't infected. And as you pointed out, it's so important with the assessment and the things the resident likes. I mean, they love the sweets, so putting the eggs and the milkshake and then adding the calories and all those kinds of things and all the things they couldn't have for the 20 years before that. Now they can have, which is great. Let's see, we're still waiting for some questions. So if anyone wants to call in or fax in a question, please do. In the meantime, we always have some more questions we can talk about. Mary Ellen, in the event that a resident does receive enteral feeding to help nutritional status and help with the pressure, sore healing, et cetera, how can you manage the situation where the resident doesn't become dependent on the tube and the tube feeding and then they lose the ability to swallow and chew? That's a good point. And what we do is we request that more frequent evaluations by the speech language pathologists who will come in and screen the residents and work with the residents and try to get them back on perhaps a puree diet if they're having swallowing problems and working up then to a regular diet. And we can accomplish this by doing some of those methods such as cutting down the amount of tube feeding or just running the tube feeding in the evening so that they are hungrier during the day to eat. But we definitely don't just take them off without doing it gradually so that they always do have that backup of the caloric needs that they have. But definitely it's a prime concern that we don't let them have the tube feeding for too long a time that as you say, their muscles begin to weaken and then they lose all interest in chewing and swallowing. So we try to keep that up as much as we can. Yeah, some of your suggestions sound real good. Thank you. We now have a question from Seattle, I believe. Hi, can you hear me? Yes. This is Janet Woldeport. We have several questions, but one question was that must the daily assessment be done by a professional or can the nursing assistant staff accomplish this? You would like to answer that. I think the nursing assistant can accomplish it. I think they have to be taught to do it, but I think in many facilities, your nursing assistants are your first line at the bedside and they certainly should be taught to do full skin assessments. And I think maybe if they find an area of concern, they need to bring that to the attention of the registered nurse, but they certainly can do an initial assessment and collect the information. I would like to see the dietitian be more of a physical assessment staff person. And I think that that can happen. And I think quite frequently you will see if you go in and visit perhaps the little lady that looks like her face is nice and full and she looks very plump, but if you pull those covers back and do a skin assessment, you will find these very wasted arms, legs, and pressure points. So it's... So again, the whole team. Probably everybody in the facility needs to be aware and needs to do a some assessment. Everybody. I think you can get together a whole team and teach everybody to do this and the residents will benefit from that. Is another question, Mary Ellen. How can you actually determine nutritional status? If you're just watching the resident and you're not doing a lot of lab studies, but keep a handle on that. One of the ways that we try to keep a handle on it is, as I mentioned, by doing some type of physical assessment, by just really going in and looking to see what their skin looks like, is are they very pale around the eyelids, for example? Are they showing any signs that perhaps they might be anemic? Are they fatigued, tired? Are they having any recent falls which might indicate low blood pressure, which might indicate some type of anemia going on with them? Critically important that the dietitian and any of the healthcare professionals really actually are in the dining rooms or in the room when a resident eats to see how much they eat and what they are eating because that's vital to link that with what weight loss they might be having. But using those weights, if they're accurately done, is an excellent way along with all of these other parameters of intake and physical assessment. Yeah, that sounds good. Like you say, keeping an eye on the resident and the whole picture again and what they look like and the changes that you say. Can I ask a question? Sure. Okay, I have a question for the dietitians. I would like to know in patients who have enteral feedings and we worry about the head of the bed being elevated to less than 30 degrees, now we understand that we have to put the head of the bed up to about 45 degrees when we're tube feeding and then we can put it back down. But I think there's some controversy or some misinformation about the difference between where the tube is placed and whether or not it's still necessary to elevate the head. I guess I'd like to ask the difference between a G-tube and a J-tube and whether or not it's necessary to keep the head elevated during a J-tube feeding that's continuous. In general, a J-genostomy tube feeding ought to be safer than a gastrostomy tube for aspiration. I wouldn't want any of our listeners, however, to think that a J-genostomy tube feeding will prevent aspiration. The chances are reduced, but J-genostomy is not a treatment to eliminate the chance of aspiration. When you can change a patient from continuous drip with a J-genostomy feeding to an intermittent feeding, particularly feeding at night when the patient can be at a 30 degree angle, maybe a little bit longer, I think that's a modification that one might make and allow the patient to eat as much as possible early during the day.  But if you can intermittently feed patients. Yeah, I think that there are many people who don't believe that there is any chance of aspiration with the J-genostomy feeding. That's a misnomer. That's right. Thank you. So again, you have to watch the positioning and when you're feeding the resonance, et cetera. And the other goal of intermittent feedings too is that the fact that you do enhance their quality of life because you free them to be able to go to activities, have your position changes, change of location and scenery, does a lot for their mental status. Okay, thank you. We now have a call from Boston. Hi, this is Boston. Several of the Massachusetts survey has said it served electrical stimulation being offered at several long-term care facilities. And this is being administered by the physical therapy departments. Do you have any research on the findings or the outcomes as of yet and does it actually work? Thank you. There are four or five randomized control studies showing the benefits of electrical stimulation. However, most of those were done in research settings and the reason the guidelines recommended that they be considered after other good care did not offer any progress is because we kind of softened that with consider only because there were not a lot of clinicians out there who had actually done it. So while physical therapists are doing it, as long as they're skilled in doing it, yes, there is some evidence. There is some evidence that the electrical stimulation does work. It's been done mostly by researchers and there needs to be, I think, much more instruction to the physical therapists on how to do it clinically. And that'd be nice if we had some large-scale studies. Is that something new coming down the pike? Thank you, Julianne. Okay, we have a call from Baltimore. Yeah, the panel recommended, or didn't recommend actually mentioned two scales that are used in risk assessment, the Norton and the Braden scale. Does the panel recommend one scale over the other if a long-term care facility is thinking about doing some sort of risk assessment, program or plan, or should the long-term care facility use both scales and determining pressure ulcer risk? Thank you. Could the audience hear the question? Okay, the question was about the risk assessment scales. The HCPR guidelines recommended the use of either the Norton or the Braden scale for determining the risk for pressure ulcer development. And both of them have predictive validity. I think the Braden scale has been the one that's been tested more in the long-term care facility. So I think that the Braden scale, which is currently undergoing more testing, and Doreen Norton, who developed the Norton scale and all other scales are derived from that scale, is in Great Britain and she's retired. So there's not further work on going on the Norton scale now. So probably the Braden scale would be the assessment scale of choice, but you certainly wouldn't do both of them unless you were doing a research study. You wouldn't be doing both of them. Certainly one would be adequate. And I believe the Braden scale does include nutrition as one of its components. That's correct. Oh yeah, and that's a critical component now. Okay, thank you. We're gonna need to wrap up now. And as we close, I'd like to ask Mary Ellen and Joanne and Charlotte just to give us one final thought for the day that you want us to keep with us and take away from this broadcast. Well, I think it's really quite heartening to see the multidisciplinary teams develop in all settings. And I guess an important point from my perspective is the misnomer of the reverse staging and that we let everybody know that we're working on it and we're trying to fix it. And HICFA realizes that it's wrong, that they really have to follow the rules and regs and tell something replaces it, but that it is being worked on and stay tuned. Right, and that's correct. And all the HICFA says at this point is to use the MDSS, the instructions are given, but other documentation, et cetera, care, do like you said. Thank you. Okay, Mary Ellen. And from my viewpoint, I just also am very much for the multidisciplinary team and that we're working together as a team. And in particular that the registered dietician be part of that team and be very proactive. And that when we plan our care that we really key in on the resident and the individuality of the resident. And bring that family together, bring the resident's choices together because we can accomplish a lot more if we constantly go in and change what we're doing and adjust it to meet that resident's needs. Then we'll come a lot closer to achieving our goals. So resident center definitely is the keyword. Right, and individualized, thank you. Okay, Charlotte. And I would just emphasize that malnutrition is associated with poor wound healing. And that good nutritional status is associated with shorter wound healing and as well a reduction in ulcer size within a very short period of time. I guess my final parting comment would be that nutritional management not only contributes to reduced cost of care but also decreased pain and suffering definitely for our residents. And the quality of life and quality of care like you all brought out. You know what, I wanna thank all of you for being here. It's wonderful having the expertise that you bring. I think we've done an excellent job where you have with covering the subject in its entirety. And we wanna thank you too for being with us today and for your participation. If you have any further questions, you can send them into HICFA at my email address and that will be m-r-i-b-a-r at HICFA.gov. And I will get those questions to our panelists. And in partnership with you, with providers and others, we're all working together for the same goal and that is to provide the best quality of care and quality of life to our residents and especially in this area of pressure, ulcer prevention and care. Thank you. DTVS. Telephone systems. Teleconferencing. Teleproduction. DTVS. The Center of HICFA's Communications Network.