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Long-Term Care Survey Alert

Skin Care:

Stave Off Decubiti With 3 Smart Moves

Published on Tue Jan 10, 2012

Beware this type of incontinence pad, advises nurse expert.

In a lively presentation at the recent LeadingAge annual meeting, Karen Russell, RN, observed that "people always seem to be willing to react when a wound is there and be very willing to get involved in the treatment plan of care. But that whole prevention piece" doesn't seem to be something "that they can grab onto easily," she cautioned.

Russell discussed several preventive approaches, including the following:

1. Evaluate how you manage a potential Stage 1 pressure ulcer. You have to get "the message out to everyone involved that a red area is a safety issue," stressed Russell, who is with the Pennsylvania Restraint Reduction Initiative. Russell credits her colleague and co-presenter, Ruth Bish, RN, for asking "what would happen if nursing home staff responded to a reddened area the way they do when someone falls on the floor."

"Think about what happens when somebody falls in your facility," Russell said in her presentation. "We all run and get vital signs, we do the assessment, we contact the physician, we call the family, we document our assessment ... [and] fill out an incident report. Most of us are doing post-fall investigations. We document on that fall for 72 hours."

Yet nursing facilities "don't for the most part look at a reddened area on the skin as a safety issue, but it is," Russell tells Eli. "I think CNAs often report this, but charge nurses and unit supervisors may not always respond like they should by seeing if the area blanched and implementing pressure relief for a certain period of time."

Tip: "Facilities that have someone designated to do head-to-toe skin assessments based on the [resident's] risk have a much lower incidence and prevalence of pressure ulcers," Russell tells Eli.

2. Eliminate these incontinence pads. Russell cautioned conferees about cloth quilted incontinence pads, which she reports seeing in about 90 to 95 percent of the facilities that she consults with in Pennsylvania.

Problem: "The quilted pads separate after they are laundered and get wrinkly and provide much more potential for pressure than a flat disposable blue plastic pad," says Russell.

"Quilted pads were made for use with cloth adult diapers," Russell adds. And "since we are rarely using cloth products anymore, what is the need for the quilted pads? If the disposable products fit the way they are meant to, then there is rarely leakage and the need for bed changes," she points out.

"The reason we hear people cling to the cloth incontinence pads is that they use them for a lift pad, but they weren't meant to be a lift pad," adds Russell. "Some residents pretty much take up the width of those pads, so there's very little for staff to really hold onto," she explains. Therefore, "it's difficult for [staff] not to create shearing and friction injuries when they drag the person up in bed." But "if you use a draw sheet, you can roll it in from each side and lift the person rather than dragging him/her," Russell continues. "An incontinence pad used as a draw sheet may be OK for a 90-pound frail woman but a lot of residents aren't 90 pounds."

"We have advocated for using draw sheets again, which have gone by the wayside," adds Russell.

Success: One facility that Bish worked with removed the cloth quilted incontinence pads and saw its pressure ulcer rates drop from 14 percent to 7 percent within a month, Russell says. "Then two very vocal family members and one resident complained to the director of nursing and the facility began to use them again."

As a result, the pressure ulcer percentage climbed back up, Russell relayed in her talk. But "one of the cheerleaders for this project in the facility went to back to the director of nursing" and convinced her to remove the pads, she said. The facility's pressure ulcer percentage "decreased significantly and they run typically at 2 to 3 percent now but always less than 5 percent -- and that was the first change that they made in their facility."

Don't overdo it: "Even with the disposable pads that have plastic backing, people may think one pad is good but 50 are better," Russell cautions. "And what's meant to be placed under the patient's buttocks ends up under his/her upper back or even shoulders, which can make for a very warm bed. Then the person perspires," which can cause skin breakdown, she warns.

3. Offer an educational tool. Russell suggested facilities compile a small brochure for residents and families who are new to the facility. The brochure would explain "some basics about skin as people age" and let residents know to inform staff if they feel "burning sensations ... numbness or tingling, especially in [their] lower extremities" -- for example, if their "heels start to burn," Russell said.

"I realize if you are like most long-term care facilities, you have a number of people with dementia who would not remember to do that," Russell told conferees. "But don't give up on it. It doesn't mean it doesn't have some worth. You may have some short-term people who ... are higher risk" and you want them to report discomfort or an odd sensation in an area, she said.

Editor's note: For additional coverage of the LeadingAge presentation by Russell and Bish, see Eli's MDS Alert, Vol. 10, Nos. 1 and 2. If you aren't already a subscriber, call 1-800-508-2582.

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