healthy skin magazine - volume 3; issue 4

Improving Quality of Care Based on CMS Guidelines

Volume 3, Issue 4

CROSSWORD PUZZLE FOR CE CREDIT, PAGE 38!

Insight on Organization & Balance from Author

Julie Morgenstern

Jumpstart Wound Healing with COLLAGEN

CMSTargets Psychosocial Outcomes

Butterflies are Free:Exceptional End

of Life Care

7Great Stategies to Improve Care

Forms and Tools:

IInnttrroodduucciinngg EExxuuddeerrmm®® OOddoorrSShhiieelldd™™ --

tthhee ffiirrsstt ooddoorr--ccoonnttrrooll hhyyddrrooppoollyymmeerr

This patented new dressing uses naturally occurring

cyclodextrins, which are noncytotoxic molecules that

absorb odor and wound exudate. It is the only dressing

that combines the benefits of an advanced moisture man-

agement with powerful odor control.

MMoorree eeffffeeccttiivvee tthhaann cchhaarrccooaall

The Exuderm OdorShield dressing outperformed leading

charcoal-based dressings in laboratory odor absorption

tests.* While charcoal's odor-absorbing properties are

deactivated by the proteins in wound exudate,

Exuderm OdorShield's are actually enhanced. Other

advantages: Exuderm OdorShield is conformable,

absorbs more fluid than charcoal dressings and

requires no secondary dressing.

AAnn iimmpprroovveemmeenntt oonn yyeesstteerrddaayy''ss hhyyddrrooccoollllooiiddss

Exuderm OdorShield eliminates the major drawback of

traditional hydrocolloids: their distinctive odor upon

removal. It effectively absorbs exudate and provides a

protective, occlusive barrier that promotes wound healing.

Features include a tapered edge and low-friction backing

to help prevent rollup and extend wear time.

Ask your Medline representativefor more information onExuderm® OdorShieldTM dressings.

Most occlusive dressings do a good job of managing moisture,but unfortunately they can also contribute to wound odor.

Now there's a new option. . .

11--880000--MMEEDDLLIINNEE || wwwwww..mmeeddlliinnee..ccoommIInn CCaannaaddaa ccaallll 11--880000--339966--66999966

*Data on file.©2006 Medline Industries, Inc. Exuderm and Medlineare registered trademarks and OdorShield is a trademark of Medline Industries, Inc.

3Improving Quality of Care Based on CMS Guidelines

Page 6

4

Page 14

Page 68

SURVEY READINESS13 Ask Molly14 CMS and Psychosocial Outcomes22 Healthy Skin Interview28 The Wait Is Over: CDC Introduce New Guidelines for

Management of MDROs in Healthcare Settings46 How Good Are You at Assessing Risk? Sharpen Your Skills with

the Braden Scale50 Managing Dementia-Related Incontinence64 Documentation: Using the Best Words for You and Your Resident

TREATMENT20 Can a Cranberry a Day Keep UTIs Away?34 Chronic Wounds: Collagen Might Be the Answer55 Pressure Relief:A Concept of the Past56 Product Spotlight: Foam Dressings

SPECIAL FEATURES6 Butterflies are Free

32 Do It RIGHT! Joint Commission Releases Pressure Ulcer Prevention Video

42 Making Sense of Research Reports68 Oh,Your Aching Back79 What’s in a Name?82 Healthy Skin Word Search

FORMS & TOOLS84 Functional Incontinence86 Incontinence Quality Improvement/Quality Assurance and Assessment88 Policy & Procedure90 Guidelines for Use of Overnight Brief92 Use Our Web Tools94 Butterfly Watch95 End of Life Care Plan

CASE STUDY40 Use of Ionic Silver and Collagen to Reduce Bioburden and

Promote Healing for Improved Quality of Life in a Complex Patient

REGULAR FEATURES4 Letter from the Editor5 News Flash

38 CE Crossword Puzzle: Collagen Dressings in Chronic Wounds60 Hotline Hot Topic

CARING FOR YOURSELF72 PEP Talk from a Pro80 Top Ten Time Management Tips

ABOUT MEDLINEMedline, headquartered in Mundelein, IL, manufactures and distributes more than 100,000 products to hospitals,extended care facilities, surgery centers, home care dealers and agencies and other markets. Medline has more than700 dedicated sales representatives nationwide to support its broad product line and cost management services. For more information on Medline, visit our website, www.medline.com.

HEALTHY SKIN

EditorSue MacInnes, RD, LD

Clinical EditorMargaret Falconio-West, BSN, RN, APN/CNS, ET, CWOCN, DAPWCA

Clinical TeamCynthia A. Fleck, RN, BSN, ET/WOCN, CWS, DAPWCA, MBA, FCCWS

Janet L. Jones, RN, BSN, PHN, ET, CWOCN, DAPWCA

Barbara Leonard, MSN, RN, CWOCN, CWS

Joyce Norman, RN, BSN, CWOCN, DAPWCA

Elizabeth O’Connell-Gifford, RN, BSN, CWOCN, DAPWCA, MBA

Carol Paustian, RN, BSN, ET, CWOCN, DAPWCA

Amin Setoodeh, BSN, RN

Jackie Young, RN, BSN, ET, CWCN, DAPWCA

Wound Care Advisory BoardAnne Blackett, MS, RN, COCN, CWCN, CPHQ, CNS

Pat Emmons, RN, MSN, CNS, CWOCN

Beatrice Etzel, MSN, APRN, BC, CWOCN

Lynne Grant, CNS, MS, RN, CWOCN

Pam McFarland, RN, CWCN, OCN

Andrea McIntosh, RN, BSN, CWOCN, APN

C.C. Monge, RN, MS, DABFN, CWOCN

Susan Morello, RN, BSN, CWOCN

Susan Wood, PhD, RN, WOCN

Improving Quality of Care Based on CMS Guidelines

Contents

© 2006 Medline Industries, Inc. Healthy Skin is published by Medline Industries, Inc. One Medline Place, Mundelein, IL 600601-800-MEDLINE (633-5463)

4 HEALTHY SKIN

DDEAR READER,

To continue to bring you the hottest infor-mation that will have the greatest impact onyour job, we consistently reach out andinterview your colleagues and administrators.In preparation for this issue, we asked nursinghome DONs from all over the country, “Whatdo you worry about the most when the statecomes in for inspections?” Their top concernswere safety, pressure ulcers, compliancewith incontinence/toileting plans and falls. Tonursing home administrators we asked, “Whatconcerns do you have about the upcomingPay-for-Performance reimbursement?” Theiranswer … quality indicator ranking and theimpact of survey results to P4P.

Then, on December 12, 2006 Dr. Berwick, CEO of IHI (Institute for Health Improvement)announced that one of the new key platformsof IHI’s new 5 Million Lives campaign forhospitals was to prevent pressure ulcers.Aha! Pressure sores are on everyone’s list.Dr. Berwick underscored what you’ve knownall along – hospitals and nursing homes areboth stakeholders invested in improvingquality of care.

This edition of Healthy Skin is jam-packed with information on pressure sore prevention,assessment, treatment and ways to provideexceptional care. Let’s start with preven-tion. The Joint Commission (formerly referredto as JCAHO) recently released an educationalprogram on the prevention of pressure sores-see page 32 on how to “Do It RIGHT.” Youcan test your assessment skills using theBraden Scale and a simple case study. Andbe sure to read about treatment options,like collagen, that can jump start a chal-lenging wound and new technology infoam dressings.

We realize good skin care and preventioninclude other components such as resident-centered incontinence and toileting programs.Throughout Healthy Skin, you will findsuccess stories, tricks and helpful hintsto make your program work.

An example of exceptional care, you don’twant to miss “Butterflies are Free” a feature article that demonstrates the impact excep-tional care has on your staff, the residentand their family. Nina Willingham, adminis-trator of Life Care Centers of Sarasota,Florida, reminds us about what health careis all about and how to make a differencein people’s lives.

Finally, we close with something special justfor you. We decided to try something newin this edition, a section we call “Caring forYourself.” As a frontline provider, we knowhow much effort you put into caring foryour residents – and your families. But, weall need to take time for ourselves, refuel,energize and get organized so we can performat our best. We were so fortunate to be ableto interview Julie Morgenstern (you may haveread her column in O magazine or one ofher numerous books on time managementand organization). She has provided us withsome insightful tips to help find that balancein life and make the most of our time. Wehope you’ll enjoy it!

Best Regards,

Sue MacInnes

We all can agreethat we should dothings right…but it is our goal tomake it hard for the healthcareworker to do things wrong.

HEALTHY SKIN I Letter from the Editor


IHI Announces New CampaignThe Institute for Healthcare Improvement’s newest campaign, 5 Million Lives,

aims to dramatically reduce incidents of medical harm in U.S. hospitals by

challenging those hospitals to adopt up to 12 improvements in care in a

24-month period (ending December 9, 2008).

In addition to the six interventions introduced in the 100,000 Lives

Campaign, six new interventions were announced. They are:

• Prevent methicillin-resistant Staphylococcus Aureus (MRSA)

• Reduce harm from high-alert medications

• Reduce surgical complications

• Prevent pressure ulcers

• Deliver reliable, evidence-based care for congestive heart failure

• Get Boards on board

For more information on the new campaign, visit www.ihi.org.

CDC Releases New Guidelines on MDROs

The Centers for Disease Control and Prevention has released

its long-awaited updated guidelines on multidrug-resistant

organisms in healthcare settings. The guideline contains

specific recommendations designed to halt the progressive

increase in MDROs that began to be seen in the early

1990s. The guidelines contain two tiers of recommenda-

tions. The first tier includes general recommendations and

the second details intensified interventions for use in the

event that the first-tier recommendations are not effective.

Each tier consists of the same seven control measures:

administrative, MDRO education, judicious antimicrobial use,

surveillance, infection control precautions, environmental

and decolonization.

For more on this topic, please refer to “The Wait Is Over:

CDC Introduce New Guidelines for Management of

Multidrug-Resistant Organisms in

Healthcare Settings” in this issue of

Healthy Skin or visit www.cdc.gov.

CPSC Sets New Mattress Flammability Standards

The Consumer Product Safety

Commission has issued a flammability

standard for mattresses as part of the

Flammable Fabrics Act. All mattresses

manufactured, imported or renovated on

or after July 1, 2007 will need to conform

to the new standard.The goal of the new

requirements is to create mattresses that,

in the event of a fire, generate a smaller

size of fire with a slower growth rate,

which in turn would reduce the possibility

of flashover occurring.The Commission is

estimating that the new standard could

possibly eliminate 240–270 fire-related

deaths and 1,150–1,330 fire-related

injuries annually. For

more information on

the new standard, visit

www.cpsc.gov.

REGULAR FEATURES

6 HEALTHY SKIN

Butterfliesare

Free≤

By Nina Willingham, CNHA


SPECIAL FEATURES

≤When you come across an extraordinary story … youwant to share it with theworld. We have found such a story in a Florida nursinghome system that has createda special way to honor andcelebrate the lives of thoseresidents who are soon toleave our world. Their end-of-life quality program iscalled Butterflies are Free. The following is their story,in their words. You’ll learnhow the program at Life CareCenter of Sarasota started and how you can provide this exceptional care to your residents and their families.

The CatalystImagine our horror as we read a 2002 article in The New York Times quoting physicians from the AmericanMedical Association as saying that “nursing homes arethe worst place to die.” We were distressed to read sucha negative, broad, sweeping generalization about nursinghomes, especially when we believe that our nursinghome is an exception to the rule. We decided to provethem wrong.

Yet, when we examined our care and services, we quicklyrealized that what we provided for the dying residentwasn’t any different from what we provided for thenondying. So, on September 17, 2002, our continuousquality improvement (CQI) project was to develop aquality end-of-life program – Butterflies are Free. Thebutterfly signifies moving from one life to the next.

We Tapped Great ResourcesTo get started, we began tapping into every resource wecould find. The executive director attended an end-of-life seminar at the Florida Health Care Association’sannual conference. The director of nursing began meeting with our local hospice. The social worker beganlooking online for end-of-life resources. We found severalWeb sites as well as Dr. Elisabeth Kübler-Ross’ “stages of grieving” (denial, anger, bargaining, depression andacceptance) to be particularly helpful.

Two Web sites we found to be helpfulEnd-of-Life Nursing Education Consortium (ELNEC) www.aacn.nche.edu/elnec

California Coalition for Compassionate Care (CCCC) www.finalchoices.calhealth.org

We Took an In-depth Look at OurselvesUsing the CCCC’s “Assessing Your Facility’s Policy andPractice of End-of-Life,” we completed a facility self-assessment to determine how we felt about providinggood end-of-life practices. We identified strengths, weaknesses and opportunities for improvement andestablished baseline data with which we would measure

To learn more about Compass, contact your Medline representative or call 1-800-MEDLINE.www.medline.com

©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

Instead of wondering if your clinical team is in compliance with the updated

CMS Tags F309 and F314, take action with Medline’s Compass Program.

This comprehensive system of educational aids, best-practice protocols

and clinical tools takes the guesswork out of developing an effective skin

and wound care program in your facility.

The Compass Program was developed by Medline’s Wound Care Advisory

Board and Clinical Team to help your clinicians meet standards of practice,

improve care outcomes and be survey-ready all the time.

What’s in the box?• DON Instruction Manual (like a teacher’s guide)

• Survey Readiness Resource Books (put them on your treatment cart!)

• Self-study education programs (staff can earn CE credit)

• Wound care application videos (usage instructions for Medline’s

advanced wound care products)

• Wound measuring rulers (for consistent measuring)

• Continuous Pressure Ulcer Prevention booklets (to improve

communication and documentation)

DO YOU KNOW IF YOURFACILITY IS SURVEY-READY?

Butterflies


our progress. We reviewed the needs of our residents,their families and our associates to determine what serviceswere needed at the end of life. Some of the key issuesidentified were:

• Residents and families had major concerns about comfort.

• Families didn’t know what to expect from the dying process and were reluctant to accept their lovedones’ approaching deaths.

• Financial strain on residents and their families were posed by end-of-life programs already operating in the community.

• Our associates felt just as uncomfortable with the dying process as the families because of a lack of education and experience.

We assembled an interdisciplinary team to set our missionand our goals, including the executive director, director ofnursing, social services director, financial director, activitydirector and volunteer representatives from nursing,dietary and housekeeping. Three family members, representing various faiths, were also involved in the early planning stages.

Our Mission Statement and Goals Were SetMission: “To provide comfort through palliative care andindividualized attention for those residents who are at or near the end of their life.” We would accomplish this by “establishing an end-of-life program that maintains comfort and dignity for the resident, involving the family,residents, and staff in the plan of care at their personallevel of comfort. The end-of-life program should put no financial strain on the family.”

The Butterfly ProcessThe resident is identified for end-of-life care through theButterfly Watch process. For example, the resident couldbe identified through a change in two or more indicators,e.g., weight loss, pressure ulcers, falls, infections, mentalstatus, level of function or continence status. After com-pletion of a 14-day observation period (based on theabove criteria), a determination is made for a significantchange in status or admission into the program. If residentshave a sudden decline in condition, they can be admittedinto the program.

NotificationThe resident and family are notified of the program andeducation is provided on the program’s stages and whatto expect in the dying process. Hospice consult is alsooffered. The resident or legal decision maker providessigned consent to participate in the program.

Placing a butterfly by a resident's nameplate identifies theresident as one who is in the Butterflies are Free program.

10 HEALTHY SKIN

ButterfliesAssessmentSocial services completes the spiritual assessment, ensuringthat end-of-life wishes are known and opportunities forunresolved issues are available. Kübler-Ross’ five stagesof grieving are reviewed with families to help them copewith feelings of loss.

Care Plan DevelopmentAn end-of-life care plan is developed with the residentand family. The three stages of the program are againreviewed with the resident and family. (Just as each resident ages differently, residents die differently, and not every stage will apply equally to each resident.)Discussions are held regarding medications, lab testsand diet and consistency of food, as well as psychosocialand spiritual needs. The care plan will change and need to be updated as the resident progresses through thedying process.

A Focus Charting alert is placed in the resident’s chart sothat nurses will know to chart on the areas that are high-lighted. The highlighted items come from the care-planningprocess. A checklist is given to the nurse manager of theresident’s unit to ensure that we have not overlooked any opportunity to bring comfort to the resident.

Resident’s RoomThe resident’s name and stage in the program are listedon the daily bed management form. Residents arereviewed daily if changes are noted. A butterfly is placedabove or below the nameplate at the door of the resident’sroom to identify that the resident is in the program. A butterfly sticker is placed on the spine of the resident’schart to alert the nurses that the resident is in the program.A butterfly night-light and Butterfly Journal are placed onthe bedside table. An activity department representativewill interview the resident or the family to determine afavorite hobby or travel destination that the resident hasenjoyed. Every effort is made to decorate the resident’sroom so that he/she will remember the hobby, activity or favorite travel destination. If desired, a Butterfly Cartis wheeled into the resident’s room. The cart is a three-drawer heavy plastic cart on rollers that can be purchasedat any discount or office supply store. In the cart are itemsthe team believes will bring comfort to the resident andthe family.

Daily VisitsThe program’s chairperson is a housekeeper who makesButterfly rounds every day. She invites others to comealong and meet the residents. Residents are invited tocome and visit with other Butterfly residents, and oftenthey do sit and hold a hand. Other times they pray together.

Associates make several visits to the residents. Someassociates stop to pray, others read to the residents andyet others just stop by to ensure that the residents are

The ice cream shop is open every day and all residents can receivea free dish of their favorite ice cream. The staff reports that icecream is one of the most-requested comfort foods.

are Free


comfortable or to tell them that they are loved. Everyonewrites in the resident’s journal. Music is played, if desired,and lightly scented lotion is applied to the resident’shands and arms, if appropriate. Other attempts are alsomade to soothe and comfort the resident.

Family InvolvementFamilies are invited to participate in the resident’s care attheir own level of comfort. For example, if a family memberwants to participate in the pain-management program, training is given on how to monitor for signs and symptomsof anxiety and pain. When family members see thesesigns and symptoms, they will alert the nurse so thatmedication can be given.

Moving Through the ProcessAs the resident moves through the dying process, the careplan is constantly updated. Making changes to the textureof food is important, and comfort foods are added asdesired. (Cookies and ice cream is the number onerequested comfort food, and associates are quick to fillthose requests.) Routine medications are normally discon-tinued and pain medications are monitored for effectiveness.Labs and X-rays are discontinued unless they address an acute situation, relief of which might enhance the resident’s comfort.

• Dietary routinely checks with the family to see if snacks or soft drinks are needed.

• Spiritual comfort is provided per the resident’s preference.

• Every effort is made to have associates in the room with the resident at the time of death.

• Following the resident’s death, a book called Beyond This Day, with stories and devotionals geared towardhelping the family cope with the death of a loved one, is mailed to the family, along with a cedar keepsake box and the Butterfly Journal. A stuffed bear (similar to a Beanie Baby®) with a butterfly embroidered on its stomach is given to the family as a keepsake. When a family has small children, we often give each child a Butterfly Bear.

• Associates attend funeral services for the deceased resident and have been asked to speak at the funerals of several residents. Memorial services are also held at the facility.

To learn the step-by-step details of how you can set up a Butterflies are Free program in your facility, contact NinaWillingham at [email protected].

We have included a sampling of the Butterflies are Freeforms starting on Page 94.

Meeting the spiritual needs of the dying resident is very important.Here, an associate is reciting the Lord's Prayer with a resident.

Looking for more? Visit www.medline.com/butterflies to browse the complete program and its accompanying video.

flies are Free

12 HEALTHY SKIN

Nina Willingham is a Licensed and Certified Nursing Home Administrator (CNHA). She currently serves as the senior executive director ofLife Care Centers of Sarasota. Under her direction, LifeCare Centers of Sarasota was named to the 2003,2004 and 2006 editions of America’s Top NursingHomes; voted as Life Care Centers of America Facility ofthe Year in 2003; earned the JCAHO Ernest A. CodmanAward in 2004; earned the American Health CareAssociation Step I Quality Award in 2004 and receivedNursing Homes magazine’s 2005 Optima Award. Ninawas named Nursing Home Administrator of the Year in2006 by the Florida Health Care Association.

She is also currently a member of many professionalorganizations, including acting chair of the ProfessionalDevelopment Committee of the Florida Health CareAssociation, member of the Ethics Committee for theAmerican Health Care Association and Health ScienceAdvisory Committee of Sarasota County TechnicalInstitute, treasurer of the Florida Health Care Association,member of the Florida Health Care Association QualityCredentialing Committee and president of the EducationFoundation of the Florida Health Care AssociationService Corporation.

Make sure to go to www.medline.com/butterflies to learn more onthe Butterflies are Free program! Complete theform on the Web site to receive a copy of theprogram from Medline.


Q

Molly C. Morand, RN, BSN, BC is a certified gerontological nurse and former long term care surveyor. President of theMorand Group, LLC, a healthcare consulting firm, she provides consultation to long term care facilities, hospitals, providerorganizations, consumer organizations and suppliers throughout the United States on regulatory, compliance and qualityof life issues. Ms. Morand has provided expert witness testimony related to pressure ulcers, skin care and incontinencecare. She has been the guest of many associations and is frequently asked to share her expertise in long term care.She can be reached at 513-470-4894 or [email protected].

Askadvice from a former surveyorMolly

I have heard that surveyors have been issuing fines to nurses

for things like using veterinary product on skin. I hear one

nurse was fined $1,000. Is this true? Can individual nurses

be fined by CMS surveyors?

Amanda R., DON

Dallas, Texas

Dear Amanda,

CMS state surveyors do not issue fines or sanctions against

individual employees, including nurses. If a fine or sanction

is issued, it is issued to the facility, not to an individual. The

facility can receive a deficiency based upon the actions of an

employee. For example, if a nurse did not follow infection-

control standards when completing a dressing change, the

surveyors would issue the facility a deficiency. However, if

an individual employee’s conduct or deficient practice was

egregious, the surveyors could report, or require the facility

to report, the individual to any appropriate licensing agencies

and/or any appropriate law-enforcement agency, depending

on the deficiency.

In the example you have given where a nurse applied

a product intended for veterinary use, the deficiency was

likely issued for failing to follow standards of practice. The

use of a veterinary product intended by the manufacturer for

use on animals, not humans, would not meet standards of

practice if the product was used on a human.

The CMS Medical Director F-Tag (F501) contains the following:

“Current standards of practice refers to approaches to care,

procedures, techniques, treatments, etc., that are based on

research and/or expert consensus and that are contained in

current manuals, textbooks or publications, or that are

accepted, adopted or promulgated by recognized professional

organizations or national accrediting bodies.” Standards

of practice describe the responsibilities of healthcare profes-

sionals and are based on the values, priorities and practice

of a profession and describe the minimal standards of

performance against which actual performance can be

compared. Standards of practice also promote consistency

and quality and encourage a common, systematic approach

based on the most current scientific evidence.

Standards of practice for pressure ulcer treatment have

changed based on scientific research. In the 1980s, the use

of heat lamps was common in treating pressure ulcers.

However, scientific research demonstrated that moist wound

healing promotes faster wound healing and is less painful.

Therefore, the use of a heat lamp would not meet current

standards of practice.

Even if a nurse is following a physician’s order, the facility

could be cited for failing to follow a standard of practice.

Nurses are expected to question an order if the nurse knew

or should have known that the order did not meet standards

of practice or could cause harm to a resident. Ignorance is

not an excuse. Nurses are expected to remain up to date

with current standards of practice.

In order to ensure that they follow and stay up to date with

current standards of practice, nurses should subscribe to and

read industry and nursing periodicals, have a copy

of the nurse practice act for their state, have a copy of the

regulations that relate to their practice setting and have a

copy of the standards of practice for their practice setting (for

example, the National Gerontological Nursing Association

publishes standards of practice for gerontological nurses).

SURVEY READINESS

14 HEALTHY SKIN

CMS andPsychosocial

Outcomes

By Molly Morand, RN, BSN, BC

The Centers for Medicare and Medicaid Servicesrecently introduced the Psychosocial OutcomeSeverity Guide. As its name suggests, the guide aids surveyors

in determining the severity of psychosocial outcomes including, for example,those outcomes involving mood and behavior, dignity and pain.

For example, when evaluating incontinence care, surveyors will focus asmuch on privacy and dignity as they will on the actual procedure (handwashing and infection control, etc.).

This guide, which became effective on June 8, 2006, specifically targets psychosocial outcomes that result from noncompliance at a specific F-Tag (in the above example, F315). The guide can be used with any F-Tag becausepsychosocial outcomes can result from a facility’s noncompliance with anyregulatory requirement.

Unlike other releases from CMS, the guide is not a regulation. Rather, it is a tool used to determine the severity of a deficiency in any regulatory grouping (e.g., Quality of Care, Quality of Life) that resulted in a negative psychosocial outcome. The guide does not replace the current scope andseverity grid. It will be used in conjunction with the grid.

When applying the guide, the survey team will select the level of severity for the deficiency based on the highest level of physical or psychosocial outcome. For example, “a resident who was slapped by a staff member may experience only a minor physical outcome from the slap but suffer


SURVEY READINESS

16 HEALTHY SKIN

a greater psychosocial outcome.”1

Since the severity of the psychosocialoutcome of the resident beingslapped was higher than the physicaloutcome, the psychosocial outcomewould be used as the level of severity.

CMS Stresses Importance of Physical and PsychologicalOutcomesAlthough some residents mightexperience either a negative physicalor psychosocial outcome, othersmight experience both. With therelease of the Psychosocial OutcomeSeverity Guide, CMS is clearly stating that physical outcomes(such as a pressure ulcer) and psychosocial outcomes (such asembarrassment) are equally impor-tant in determining the severity of noncompliance, and both willbe considered before assigning a severity level.

Surveyors Will Look for ConnectionsIt is important to remember thatthe presence of a given affect (e.g.,behavioral manifestation of mooddemonstrated by the resident) does not necessarily indicate apsychosocial outcome directlyrelated to noncompliance. A resident’s reactions and responses(or lack thereof) can also be affectedby preexisting issues, such as illnesses, medication side effectsand other factors. Nursing homeresidents might experience sadness,anger, loss of self-esteem, etc. inreaction to normal life experiences,so the survey team must determine

whether the psychosocial outcomeis the result of noncompliance onthe part of the facility. Therefore, it is critical that facilities documentif a resident has always been anxious,for example. This documentationmight read, “Resident’s daughterreports that the resident has alwaysbeen anxious, that previousattempts at behavioral interventionand medication have been unsuc-cessful and that the resident is onlyhappy when she has something toworry about.”

Surveyors are interested in psychosocial outcomes caused bythe facility’s noncompliance withany regulation. This also includespsychosocial outcomes resultingfrom the facility’s failure to assessand develop an adequate care planto address a resident’s preexistingpsychosocial issues, which led tocontinuation or worsening of thecondition. For example, if a residentwas admitted with depression andthe facility failed to assess, developand implement an individualizedplan of care, the facility couldreceive a deficiency. However, aresident being depressed does notmean the facility caused thedepression or failed to providenecessary interventions. In order toapply the guide, the survey teammust have established a connectionbetween the noncompliance (atany regulation) and a negative psychosocial outcome as evidencedby observations, record reviewand/or interviews with residents,their representatives and/or staff.

“A residentwho was slappedby a staff member may experienceonly a minorphysical outcomefrom the slap butsuffer a greaterpsychosocial outcome.”

“


Psychosocial Documentation is Critical Surveyors will evaluate each resident’s psychosocial response tothe noncompliance. This will thenbe the basis for determining psy-chosocial severity of a deficiency.The surveyors will evaluate eachresident’s behavior and moodbefore and after the noncompliance.This evaluation could includeMinimum Data Set assessments,admission assessments, behaviorlogs, social service notes, activityprogress notes and activity partici-pation logs and physician progressnotes. The survey team will deter-mine severity based on the resident’sresponse in the following circumstances:

• If the resident can communicate a psychosocialreaction to the deficient practice, compare this response to the guide (e.g., the resident can say they are depressed or angry); or

• If the resident is unable to express her/himself verbally but shows a noticeable nonverbal response related to the deficiency.

The Reasonable Person Concept This is the most controversialcomponent of the guide. The concern is that surveyors will evaluate harm in part by whethera reasonable person (not necessarilythe resident) would be upset oroffended by what the facility did.

To apply the reasonable personconcept, the survey team willdetermine the severity of the psychosocial outcome or potentialoutcome the deficiency mighthave had on a reasonable personin the resident’s position. Forexample, if a nonverbal residentwas provided personal care withthe resident’s door open and theresident was visible to staff andvisitors in the hall, the surveyteam could apply the reasonableperson concept because eventhough the resident cannot statethat he was embarrassed or humiliated, a reasonable personwould be. The survey team canuse the reasonable person conceptwhen the resident’s psychosocialoutcome might not be readilydeterminable. For example, thereasonable person concept can be used when:

• “There is no discernable response or when circum-stances obstruct the direct evaluation of the resident’s psychosocial outcome. Such circumstancesmay include, but are not limited to, the resident’s death, subsequent injury,

cognitive impairments, physical impairments or insufficient documentation by the facility.” In this situation, the survey team may use the reasonable person concept to evaluate the severity of the deficient practice; or

• “The resident’s reaction to a deficient practice is markedlyincongruent with the level of reaction the reasonable person would have to the deficient practice. In this situation, the survey team may use the reasonable person concept to evaluatethe potential severity of the deficient practice.” 1 For example, if a verbal, alert, oriented resident was providedpersonal care with the resident’s door open and the resident was visible to staff and visitors in the hallway, and the resident said they did not mind, the survey team could still cite the facility because this is incongruent with a responsea reasonable person would have.

Surveyors will evaluate each resident’s psychosocial response to the noncompliance, and this will then be the basis for determiningpsychosocial severity of a deficiency.”

3

4

18 HEALTHY SKIN

In the Psychosocial Outcome Severity Guide, CMShas provided definitions for the following terms:

“Anger refers to an emotion caused by the frustratedattempts to attain a goal, or in response to hostile or disturbing actions such as insults, injuries or threats that do not come from a feared source.

Apathy refers to a marked indifference to the environment;lack of a response to a situation; lack of interest in orconcern for things that others find moving or exciting;absence or suppression of passion, emotion or excitement.

Anxiety refers to the apprehensive anticipation of futuredanger or misfortune accompanied by a feeling of distress, sadness or somatic symptoms of tension.Somatic symptoms of tension may include, but are notlimited to, restlessness, irritability, hypervigilance, anexaggerated startle response, increased muscle tone andteeth grinding. The focus of anticipated danger may beinternal or external.

Dehumanization refers to the deprivation of human qualities or attributes such as individuality, compassion or civility. Dehumanization is the outcome resulting fromhaving been treated as an inanimate object or as havingno emotions, feelings or sensations.

Depressed mood (which does not necessarily constitute clinical depression) is indicated by negative statements, self-deprecation, sad facial expressions, crying and tear-fulness, withdrawal from activities of interest and/orreduced social interactions. Some residents such as thosewith moderate or severe cognitive impairment may bemore likely to demonstrate nonverbal symptoms ofdepression.

Humiliation refers to a feeling of shame due to being embarrassed, disgraced or depreciated. Some individuals lose so much self-esteem through humiliation that they become depressed.”1

Examples from PsychosocialOutcome Severity Guide Examples of how the guide will be applied, and areas that may becited as psychosocial outcomes,are listed below. Please refer to the guide for a complete listing.

Severity Level 4 Considerations:Immediate Jeopardy to ResidentHealth or Safety

• Sustained and intense crying,moaning, screaming or combative behavior.

• Expressions (verbal and/or nonverbal) of severe, unrelenting, excruciating and unrelieved pain; pain has become all-consumingand overwhelms the resident.

• Ongoing, persistent expressionof dehumanization or humiliation in response to an identifiable situation, that persists regardless of whether the precipitating event(s) has ceased and has resulted in a potentially life-threatening consequence.

Severity Level 3 Considerations:Actual Harm That Is Not Immediate Jeopardy

• Persistent depressed mood that may be manifested by verbal and nonverbal symptoms such as:

- Social withdrawal; irritability; anxiety; hopelessness; tearful-ness; crying; moaning;

- Loss of interest or abilityto experience or feel pleasure nearly every day for much of the day;

Clarification ofterms

1

2


• Apathy and social disengagement, such as listlessness; slowness of response and thought (psychomotor retardation); lack of interest or concern, especially in matters of general importance and appeal, resulting from facility noncompliance.

Severity Level 2 Considerations: No Actual Harm with Potential forMore Than Minimal Harm that is Not Immediate Jeopardy

• Intermittent sadness, as reflected in facial expressionand/or demeanor, tearfulness,crying, or verbal/vocal agitation (e.g., repeated requests for help, moaning, and sighing).

• Complaints of boredom and/or reports that there is nothing to do, accompanied by expressions of periodic distress that do not result in maladaptive behaviors (e.g., verbal or physical aggression).

Severity Level 1 Considerations: No Actual Harm with Potential forMinimal Harm

Severity Level 1 is not an optionbecause any facility practice thatresults in a reduction of psychoso-cial well-being diminishes the resident’s quality of life. The deficiency is, therefore, at least a Severity Level 2 because it has the potential for more than minimal harm.”1

Putting the New PsychosocialGuide into PracticeFacilities have always put a lot offocus on residents’ physical health– preventing pressure ulcers, treat-ing incontinence, etc. However,with the release and implementa-tion of the Psychosocial OutcomeSeverity Guide, CMS is clearlysaying that a resident’s emotionaland psychosocial health is asimportant as his physical health.In order to meet these require-ments, avoid regulatory risk andimprove the resident’s quality oflife, facilities must place as muchemphasis on psychosocial care as they do physical care.

Facilities can do this in much thesame way that they focus on andimprove physical care:

• Implementing reward programs where staff are rewarded for providing appropriate behavioral interventions

• Including evaluation of psychosocial care in QA/QI audits and in discussions at QA/QI meetings

• Providing educational programson psychosocial care

• Providing role-play opportu-nities related to psychosocial interventions and

• Including questions regardingpsychosocial care in customersatisfaction surveys

Everyone is Part of the TeamCMS consistently refers to “the facility” throughout the guideline,indicating it is everyone in thefacility’s responsibility to meet aresident’s psychosocial needs. Thisis not just a social service issue.Just like meeting residents’ physicalneeds requires an interdisciplinaryeffort, so, too, does meeting resi-dents’ psychosocial needs. Meeting residents’ psychosocial needs andimproving quality of life for allresidents is not easy and will takeconsistent and diligent team effort– but the rewards are priceless!

For a complete copy of the Psychosocial Outcome SeverityGuide, visit:http://www.cms.hhs.gov

Reference1 Psychosocial Outcome Severity Guide.In: Guidance to Surveyors of Long TermCare Facilities. Department of Health andHuman Services and Centers for Medicareand Medicaid Services. 2006.

Molly C. Morand, RN, BSN, BC is a certified gerontological nurse and formerlong term care surveyor. President of theMorand Group, LLC, a healthcare consult-ing firm, she provides consultation to longterm care facilities, hospitals, providerorganizations, consumer organizations andsuppliers throughout the United States onregulatory, compliance and quality-of-lifeissues. Ms. Morand has provided expertwitness testimony related to pressureulcers, skin care and incontinence care.She has been the guest of many associationswhere she is asked to share her expertisein long term care. She can be reached at513-470-4894 or [email protected].

Is it just folk wisdom, or can this very tart berry actuallybe used to prevent urinary tract infections?

Early ResearchAs early as the turn of the century, research suggestedthat cranberries acidified urine, thus creating aninhospitable environment in the bladder for thebacteria that causes urinary tract infections. Morerecent research suggests that the cranberry couldhave bacteria-busting mechanisms other than loweringurine pH.

Contemporary ResearchModern research shows that cranberries containproanthocyanidins, which prevent the adhesion ofcertain bacteria, including E. coli, to the urinarytract wall. Bacteria that attach to the mucus liningof the urinary tract are more likely to contributeto infection, while unattached bacteria are simplyeliminated with urination.

Clinical Observations A small study involving sixteen children with spinabifida tracked the presence of white blood cells inthe urine (markers of infection) while they consumedtwo to three glasses of cranberry juice daily. Atthe onset of the study, most of the children hadmeasurable levels of both blood cell types in theurine. After two weeks of consuming the cranberryjuice, the levels dropped.

Studies show positive results, but, research aside,do physicians actually order cranberry juice for therapeutic prophylaxis? Upon reviewing 176 charts,it was found that 15 residents had doctors’ ordersfor one cranberry tab daily for the prevention of urinary tract infections.

Cranberry is available for purchase in a variety offorms. Beyond the traditional juice form, cranberrysupplements can be found as extracts, teas andcapsules or tablets.

More information on the cranberry’s health benefitscan be found at www.cranberryinstitute.org.

References

Avorn J, Monane M, Gurwitz JH,

et al. Reduction of bacteriuria and

pyuria after ingestion of cranberry

juice. Journal of the American

Medical Association. 1994.

Howell A, Foxman B. Fewer

infections may mean less antibiotic

therapy. Journal of the American

Medical Association. 2002.

Can a Cranberry a Day Keep

UTIs Away?

20 HEALTHY SKIN

TREATMENT

disposable briefsGet serious about skin care with

> Treated with Remedy Skin Repair Cream to nourish and protect skin

Medline’s Remedy Skin Repair Cream is applied to the entire length of the

Restore brief’s inner liner as part of the manufacturing process. This exclusive,

all-natural cream helps to prevent skin breakdown. It restores and maintains

skin’s natural moisture balance while delivering vital nutrients to the skin.

> Packed with features for great performance

Restore briefs have a super-absorbent “Ultra Care” core for maximum dryness,

plus antileak leg cuffs to protect clothing and bedding. Refastenable tape tabs

with new “grab anywhere” technology allow a secure fit and help reduce waste.

And a soft, clothlike outer cover helps prevent irritation and rashes.

Ask your Medline representative about Restore briefs today.

1-800-MEDLINE©2006 Medline Industries, Inc. One Medline Place, Mundelein,IL, 60060.www.medline.com

Restore briefs fit perfectly into

an incontinence care protocol

that complies with CMS F315.

Restore…the disposable brief that helps keep skin healthy and dry!

Healthy SkinInterview

Succe

ss Sto

ries

with Incontinence Care

Interview by Deb TengeRNC, MS, CWOCN

For this issue’s Healthy Skin interview, Deb Tenge spoke

with Pamela Quirk, APRN, BC, gerontological clinical nurse

specialist at the Soldiers’ Home in Holyoke, Massachusetts.

Established in 1952, the Soldiers’ Home provides both long

term and outpatient care services to eligible veterans who

reside in the state of Massachusetts.

22 HEALTHY SKIN

In 1999, the Soldiers’ Home created a bowel and bladder

team to investigate and develop an evidence-based bowel

and bladder policy and procedure. At the time, Soldiers’

Home’s incontinence budget was out of control.

Incontinence products were not being used consistently on

residents, which led to skin problems, leakage, odor and

ultimately complaints from the residents and their families.

That was then, this is now. Under Soldiers’ Home’s

revamped incontinence program, residents now experience

less leakage, fewer skin problems and a reduction in urinary

tract infections–and the facility can also boast about

cost savings.

While Soldiers’ Home, being a veterans facility, is not

required to follow CMS guidelines, Pamela Quirk says they

elect to do so. The issues they face regarding incontinence

are the same issues seen in other long term care facilities.

Why not see if the changes they made at their facility could

benefit yours?

Q – Deb Tenge: Can you provide some background

information about the facility?

A – Pamela Quirk: We are accredited by the Joint

Commission on Accreditation of Healthcare Organizations

and are inspected annually by the Veterans Administration.

Although we are not inspected by state surveyors, we do

follow CMS guidelines. Services are provided to veterans

who are in need of long term care and outpatient services

including optometry, ophthalmology, orthopedics, dental,

ENT, minor surgery, podiatry, urology, hematology,

nephrology and cardiology.

Q – DT: What is your total licensed census and what are

the current incontinence issues for your population?

A – PQ: The current census is 275 LTC beds. Included

in this census are an eight-bed acute unit and 18 comfort

care beds. The facility has a larger male population, with

only 16 females in residence. As far as incontinence is

concerned, there are more overflow incontinence issues,

due to our predominately male population. We also

encounter more benign prostatic hypertrophy and prostate

cancer compared to other long term care facilities.

Soldiers’ Home facility

Several members of the bowel and bladder team; Lori Manning,Michelle Beaudry, Jim Sadlowski and Judy Pickford.


SURVEY READINESS

24 HEALTHY SKIN

Problem• Incontinence budget out of control

• Inconsistent product usage on residents

• Complaints from residents and families

Solution• Education of staff

• Assessment and proper sizing

• List of residents, product used, size used

Results:• Cost savings

• Dramatic reduction in leakage

• Decreased incidence of skin problems–

from 4.4 percent in 2003 to 2 percent in 2006

• Leakage and odors

• Skin problems related to incontinence

• Fewer UTIs

• Improved staff compliance

• Spreadsheet calculates par levels for each unit so delivery is correct

• Monthly quality improvement checks encourage staff compliance

Judy Pickford makes sure that the right-sized product is used onthe right resident by checking the list.

Q – DT: When did you start your incontinence team, and

why was it started?

A – PQ: The bowel and bladder team officially began in

response to the facility change from a more institutional

organization to units we call veteran care centers. There

are four veteran care centers, each managed by a veteran

care coordinator. Each coordinator is a team leader for

one of our focus groups targeted at one of four areas:

skin, pain, falls, and bowel and bladder. I was assigned to

bowel and bladder, beginning a new enthusiasm for

incontinence care.

Q – DT: What were the initial issues you wanted to target?

Who was on your team?

A – PQ: Initially, the goal was to investigate and develop

an evidence-based bowel and bladder policy and procedure.

My group had representation from each unit with licensed

staff, CNAs, a social worker and a dietitian. We included

all work shifts. In the beginning, it was difficult to get

consistent representation from each of the shifts and units.

This continues to be an issue, especially on the 3-11 shift,

where there is a higher rate of staff turnover.

In 2005, we added the infection control nurse to comply

with F-Tag 315 changes with the goal of decreasing UTIs.

We also added the buyer, central supply clerk and storeroom

clerk to address distribution issues. Staff members were

chosen based on their interest in bowel and bladder

health and also their leadership abilities and experience

here at the facility.


Cathy Bergeron, Kathy Monahan, Pamela Quirk and HelgaSimpson discuss incontinence issues at a recent meeting

Q – DT: What problems were you looking to solve?

A – PQ: There was a variety of issues. We had complaints

from veterans and their families about wet clothes and

odors. The residents were not always wearing a consistent

product because by the weekend all the larges were gone

and the staff had to substitute something different. The

perception at the time was that a bigger brief would hold

more and control leakage better. Also, on the bed we often

had blue underpads stacked with reusable underpads in

several layers–all on top of a pressure reduction mattress,

so the effectiveness of the therapy was diminished. We had

skin issues due to incontinence that we felt could be

avoided. Also, the staff ’s efforts to manage incontinence

leakage often resulted in “brief stuffing” (placing additional

products within the brief ).

Q – DT: How did you get started?

A – PQ: We took advantage of clinical support from our

incontinence vendor in the form of a nurse specializing

in incontinence. The incontinence nurse began doing

education and rounds on all shifts to assist with develop-

ment of our policy and procedures. She in-serviced proper

measurement and product sizing so that the residents were

fitted with the right size garment. The nurse also checked

for proper brief application and use of appropriate products.

This hands-on help got us off to a great start.

The team made the decision to move to a more absorbent

brief, which resulted in a cost savings for the facility. By

using one brief that was more absorbent, the staff stopped

using extra products inside briefs and reduced the use of

blue underpads. Complaints have declined significantly.

Both residents and families are happier with the better-

performing product. This product also saves money for

the facility because it has refastenable tapes. These tapes

allow staff to check the resident and continue to use the

same brief if it is not soiled. Waste is reduced because tapes

no longer rip the plastic.

Q – DT: What other improvements were you able to make?

A – PQ: Our vendor’s incontinence nurse identified distri-

bution problems. Each unit had deliveries once a week–a

certain number of cases in each size. The storeroom was

jammed on delivery day, but staff was often scrambling by

the weekend. We might only have small sizes left because

the larger sizes were used earlier in the week. No wonder

there was leakage! This problem was alleviated when we

developed a spreadsheet that set product par levels for the

residents on each unit. The unit coordinator updates it

regularly with sizing information and saves it on a network

drive that can be accessed by the buyer and central supply

personnel. Now the correct numbers of each size of briefs

are delivered twice a week to the unit. This has been a

huge improvement!

Q – DT: Which issues took longer to solve?

A – PQ: Even after education and training, our staff often

used the wrong product, which drove up costs. This could

have been related to our distribution system – the “who

wears what item” information was not readily available to

the CNAs. We have since placed individual product iden-

tification lists on supply carts and in the bathrooms, along

with a size matrix and a troubleshooting guide. To truly

exact change, we have found that a monthly review is

critical. During these brief performance improvement

rounds, we check to make sure that the lists are current

and located in the cart and bathrooms. We also select five

residents at random to audit whether they are in the proper

product and proper size.

Continued on page 98

• Introducing Medline's new Green Tree line of toilet paper and hand towels made of 100% recycled material because we care.

• Medline is doing its share to help the environment, can we count on you to help?

• Ask your Medline Rep for more details about this program.

Call 1-800-MEDLINE

Did you know…• Each person uses approximately 700 pounds

of paper products per year?• Paper accounts for 40 percent of all waste?

Why recycle?By recycling one ton of paper, you save:• 17 trees

• 6,953 gallons of water

• 463 gallons of oil

More to think about• If every household in the United States replaced just one roll of

virgin fiber toilet paper (500 sheets) with 100 percent recycled paper, we could save 423,900 trees!

• Nearly half of the trees cut in North America go to papermaking.

• Recycled paper also needs less bleaching than virgin paper. Medline Green Tree products are produced without using chlorine compounds (PCF – process chlorine free), which are highly toxic.

• Producing recycled paper causes 74 percent less air pollution, 35 percent less water pollution and creates five times the number of jobs than producing paper from trees. It saves old-growth trees, forest ecosystems, native habitat and biodiversity.

• 687 pounds of air pollution

• 3.06 cubic yards of landfill space

• 4,077 kilowatt-hours of energy

By Alecia Cooper, RN, BS, MBA, CNOR

28 HEALTHY SKIN

They’re Finally Here!Following a lengthy five-year process, new guidelines

for management of multidrug-resistant organisms

(MDROs) were released by the CDC with specific

recommendations designed to halt the progressive

increase in incidence that began in the early ‘90s.

Healthcare facilities in this application are defined as

acute care hospitals, ambulatory care centers, homecare

services, infusion therapy and, of importance to you,

long term care facilities.

What You Need to KnowThe most common MDROs include MRSA, VISA, VRSA,

VRE and MDR-GNB and are defined, in general, as

bacteria that are resistant to one or more classes of

antimicrobial agents. They are also usually resistant to

all but one or two commercially available antimicrobial

agents. Because they are so difficult to fight and signif-

icantly impact colonization, infection, treatment, costs

and ultimately morbidity and mortality, measures have

been defined to control and stop their transmission.

Multidrug-resistant strains of M. tuberculosis are

not addressed in this document because of the

markedly different patterns of transmission and

spread of the pathogen and the very different control

interventions that are needed for prevention of

M. tuberculosis infection.

Two Tiers and Seven Control MeasuresThe first tier includes general recommendations for

all healthcare settings, while the second tier has

intensified interventions. These are recommended if

endemic rates do not decrease or if there is a first case

of an epidemiologically important MDRO identified in a

healthcare organization. Each tier consists of the same

seven control measures:

• Administrative

• MDRO education

• Judicious antimicrobial use

• Surveillance

• Infection control precautions

• Environmental

• Decolonization

First Tier:• Administrative engagement (including feedback

on facility and patient care unit trends in

MDRO infections)

• Education and training of personnel, including

MDRO transmission, trends and precautions,

measures and monitoring

• Judicious use of antimicrobial agents

• Monitoring of prevalence trends over time to

determine whether additional interventions

are needed

• Standard precautions for all patients—assess

patients for room placement, personal protective

equipment (PPE) and other environmental needs

• Contact precautions for patients known to be

infected or colonized— gowns and gloves required

(masks not routinely recommended—based upon

patient assessment)

Call to ActionMDRO control is one of the most serious problems

that we are facing in health care and now there is a

call to action! All healthcare delivery sites and systems

have a role to play in controlling MDROs. Now is the

time to work conscientiously to control MDROs.

You can:

• Assess the problem in your facility

• Develop a plan

• Assess the effectiveness of the plan

• Modify as needed

• Reassess


SURVEY READINESS

Second Tier:Indications for moving to second tier:

• First case or outbreak of an epidemiologically

important MDRO

• When endemic rates of a target MDRO are not

decreasing despite implementation of and correct

adherence to the first-tier measures

Example: At present, five residents in your long term

care facility have been diagnosed with MRSA. Tier 1 rec-

ommendations are successfully implemented. In three

months, you still have five residents with MRSA and an

additional resident is diagnosed with MRSA.

Choose from among these second tier measures and

add others as needed if not successful.

• Additional recommendations for intensifying:

— Administrative engagement/correction of

system failures

— Education and training of personnel/

adherence monitoring

— Judicious use of antimicrobial agents

— Monitoring of trends

• Active surveillance cultures from patients in

populations at risk at the time of admission to

high-risk areas and at periodic intervals as needed

to assess transmission.

— Contact Precautions until surveillance cultures

are known to be negative.

• Grouping and assigning specific staff to the care of

MDRO patients only

• Enhanced environmental measures

• Consult with experts on a case-by-case basis

regarding use of decolonization therapy for patients

or staff

• If transmission continues despite full implementation

of above, stop new admissions

To read the new CDC MDRO guidelines

in their entirety, go to www.cdc.gov.

Medline Keeps You InformedMedline is proud to keep you up to date! We’re offering

you a way to test your knowledge on appropriate

personal protective equipment (PPE) for standard

precautions. Simply visit www.medline.com and click on

the “Free Education: Standard Precautions & Personal

Protection” link. This will take you to a demonstration

on the different fluid levels and direct you to a compe-

tency quiz so you can gauge how you rate against others!

Right now, www.medlineuniversity.com is offering a

free course featuring the CDC’s Dr. John Jernigan and

his webinar titled "Management of Multidrug-Resistant

Organisms in Healthcare Settings.” The course includes

a rebroadcast of the live webinar and an accompanying

test. Successful completion of this course will earn you

one continuing education contact hour!

Once you have completed our free

offerings, why not enroll in other

Medline continuing education courses?

Enroll now and receive our Ami doll free

with the purchase of any three courses!

(The purchase price for three courses

is $19.95.)

Reference

Centers for Disease Control and Prevention. Management of

Multidrug-Resistant Organisms In Healthcare Settings, 2006.

Available at: www.cdc.gov. Accessed November 28, 2006.

Medline’s Ami doll

Medline’s Ami

demonstration

30 HEALTHY SKIN

Continuing education at your fingertips.

Medline University offers more than 50 self-study

nursing CE-credit courses including:

• Pressure Ulcer Assessment and Documentation

• Cleansing and Debriding Wounds

• Skin Anatomy

• Topical Dressing Selection

• Isolation Guidelines for MDROs

• Innovations in Hand Hygiene

• Developing a Successful Continence Program

• Standard Precautions Policy and Procedure

An affordable online continuing education resource

Enroll in continuing education courses you can

attend at any time, from anywhere you have

Web access!

Visit www.medlineuniversity.com to learn more.

MEDLINE UNIVERSITY

Joint Commission ReleasesPressure Ulcer Prevention Video

By Margaret Falconio-West BSN, RN, APN/CNS, ET, CWOCN, DAPWCA

Holly Majewski, MS, LD, RDN Registered Dietician

St. Mary’s Good Samaritan Hospital

Centralia, IL

Sue Kuberski, RN, BSN, CWOCN Certified Wound Ostomy

Continence Nurse

St. Mary’s Good Samaritan Hospital

Centralia, IL

Tom Sarina, MDMedical Director

Penn North Centers for

Advanced Wound Care

Warren, PA

32 HEALTHY SKIN

The Joint Commission on Accreditation for

Healthcare Organizations (JCAHO) is focused on

patient safety. Originally established in 1910 by

Ernest Codman, MD, and officially organized in

1951, the Joint Commission (as they are referred to

today) focuses on the “end result” of hospitaliza-

tion. Dr. Codman’s idea was to collect data and

improve care based on the information gleaned

from that data.

\Today, more than 15,000 healthcare organizations

are accredited by the Joint Commission and

proudly display the Gold Seal of Approval™. This

symbol tells the consumer that an organization

meets performance standards related to quality

and safety issues.

The bottom line for the Joint Commission is that

improved performance will likely lead to improved

patient care. A few of the Joint Commission’s proj-

ects include the Sentinel Event Policy and National

Patient Safety Goals. The Sentinel Event Policy and

the Sentinel Event Alert describe certain events

(such as unexpected death), investigate their causes

and suggest programs and procedures to prevent

the events. The National Patient Safety Goals are

announced annually and encourage healthcare

organizations to target patient-specific safety issues.

The National Patient Safety Goals for 2007 include:

Prevent health care-associated

pressure ulcers (decubitus ulcers)

Assess and periodically reassess each

resident’s risk for developing a pressure

ulcer (decubitus ulcer) and take action

to address any identified risks.

(Long Term Care)

The Joint Commission Resources (JCR), an affiliate

of the Joint Commission, develops and distributes

educational programs and materials related to

many issues within the Joint Commission. The JCR

recently produced an educational program and

video/DVD that is specific to the National Patient

Safety Goal 14 – prevent health care-associated

pressure ulcers.

This program, Do It Right, A Pressure Ulcer

Prevention Makeover, was developed and funded

in part by an unrestricted grant from Medline

Industries, Inc. The program takes the acronym

RIGHT and relates it to pressure ulcers.

For more information, please visit

www.jcrinc.com, click Education and

then click Videos/DVDs.

is for Risk.

The first step to preventing the development

of pressure ulcers is to identify those at risk

and to what degree the risk is present.

represents the Individual.

Each patient must be addressed; there is no

one program that will work for everyone.

is for Get Better.

Be sure to address the factors that affect

wound healing and do what can be done to

improve the patient’s overall health.

is for Hydration and Nutrition.

Consider that nutrition plays a key role in

the prevention of pressure-related ulcers.

reminds us to Teach the pearls of prevention.

Focus not only on the healthcare team—

teaching the patient and family about the

development of pressure ulcers is sure to help

with prevention.

Did you know…That one of the Institute for HealthcareImprovement’s six new interventions in the 5Million Lives Campaign is “prevent pressureulcers”? To learn more about this interventionand the others, visit www.ihi.org/campaign.


SPRECIAL FEATURES

14A

Goal 14

Chronic Wounds:Collagen Might Be the Answer

You are seeing a resident with a chronic wound. This wound has eludedyour treatment plan for years. It seemsto go through a cycle during which it

improves but does not close and usually deteriorates. Collagen could be

the answer, and here’s why.

By Debashish

Chakravatrhy,PhD

34 HEALTHY SKIN

Harmful enzymes that destroy collagen prevent

healing in chronic wounds. A collagen dressing can bind to several destructive enzymeslike a magnet to iron filings,

allowing the body’s own collagen to heal the

chronic wound.


TREATMENT

36 HEALTHY SKIN

If you are seeing achronic wound infront of you, it maybe possible that yourproblem wound is stuckin the inflammatory phase,where destructive enzymes(examples follow) that shouldhave long ago disappeared arestill present. Possibly destructiveenzymes could include:

• Elastase, which is secreted by neutrophils and is simply not useful at this stage in a wound’slife. Elastase destroys elastin.

• Matrix metalloproteases (MMPs). The MMPs are proteases that are associated with metal ions, and the worst of them are specific to collagenor fragments of collagen, meaning that they seek out collagen molecules and chemically break them down.

• Elastase destroys other enzymes too – those that could be useful to the wound, such as tissue inhibitors of matrix metalloproteinases (TIMPs).

TIMPs are described as “anti-MMPs” and must outnumber the MMPs (concep-tually speaking) for the wound to heal normally. In a chronic wound, the MMP to TIMP ratio is in favor of these collagen-destroying enzymes, MMPs.

How should you handle this problem?Bring fibroblasts to the wound thatwill produce fresh collagen and fillthe wound bed. A very effective method is to plant native collagendressings that will bind with the

MMPs, keeping the MMPs occupiedin the activity of breaking down thedressing material instead of the new(de novo) collagen made by thefibroblasts working hard in a chal-lenging environment. The enzymesare concentrated in the dressing,where collagen is plentiful, insteadof in the tissue, where the fibrob-lasts are putting out the body’s owncollagen at low concentrations.Denatured collagen, available insome wound care products today, is processed chemically to theextent that it has lost the sophisti-cated triple helix structure of the

Let’s take a look at the normal healing process

Normal wound healing involves three specific but overlap-ping steps or phases – inflammatory, proliferation and maturation.

After hemostasis, the control of bleeding, the groundwork is set for thewound to move into the first, or inflammatory, phase of healing. This typically lasts

two to three days and involves the macrophages and neutrophils cleaning the wounddebris and eliminating bacteria. These cells have a short life span and are usually able to

complete their mission in that time frame of two to three days.

The wound then progresses into the second phase, or proliferation. This phase involves fibroblasts appearing in the wound about three days after injury. Their main function is to manu-facture extracellular matrix (ECM) proteins, growth factors and angiogenic (new blood vessel) factors.This is part of the process called granulation. The ECM consists of collagen and elastin, amongother vital proteins. Collagen is secreted by the fibroblasts and is the most abundant protein inhumans, accounting for nearing 70 percent of all protein. It is one of the components that largelyfill the wound in normal healing. Elastin, another protein, provides strength and elasticity to theskin, though making up only about 3-4 percent of the skin’s protein. As this phase of healing

continues, cells migrate (epithelialization) and finally wound contraction occurs.

The final phase of wound healing, maturation, can take many more months and is the final strengthening phase. During maturation, collagen continues to

reorganize in the skin, gradually replacing the original scar tissuewith less-scarred, normal-appearing tissue.


collagen building block that is socharacteristic of skin collagen. Itseems that this triple helix structureof collagen is particularly attractiveto fibroblasts.

Fibroblasts also thrive in structuresin which they can spread out three-dimensionally (as they would inreal-life wound environment) andbe themselves. In other words, they like to do the things that theyshould be doing, like secreting collagen and other important materials of the extracellular matrix.So, using a collagen product with a noticeable three-dimensionalstructure allows the fibroblasts toact as normally as they possibly can.

Why native collagen-based dressingsinteract with the destructive elastaseenzyme to the extent that they seemto do is still under investigation.Binding of a dressing material toelastase obviously reduces the concentration of the elastase in the wound bed, which means that less of the wound bed’s elastin is

destroyed. But, perhaps moreimportantly, elastase is known toplay a role in creating the finaldestructive form of MMPs. Takingelastase out of play seriouslyreduces the potential of MMPsbeing freshly and efficiently createdin the wound bed. Elastase is alsoknown to destroy the beneficialTIMP enzymes that keep the MMPin check. A reduced elastase levelallows the TIMP concentration toreach a level that keeps MMP activity low in the wound bed.

What, then, happens to the dressingonce applied to the chronic wound?It is taken apart (in a chemicalsense) by the MMPs to which it was bound. The byproducts of thisbinding are collagen fragments,which are consumed by the fibrob-lasts. The fibroblasts will synthesizefresh collagen (or the body’s own de novo collagen) and secrete it outinto an environment relatively freeof MMPs, without whose removalthe newly synthesized collagenwould have been destroyed.

There is a good chance that thechronic but infection-free woundthat mystified you in refusing toheal, even when you tried every-thing else, including addressing all other associative factors, willnow proceed to healing.

38 HEALTHY SKIN

Understand how collagen dressings can help a chronic wound

Differentiate between the phases of wound healing

List two proteins that contribute to new tissuedevelopement

CE Crossword PuzzleCollagen Dressings in Chronic Wounds

Instructions:After you read the article “Chronic Wounds,” complete the crossword puzzle.

To receive your CE credit, you will need to go online to the Web sitewww.medline.com and click on the Healthy Skin magazine. Enter youranswers online. You will need to provide your name, home address andlicense number (especially for nurses with Florida licenses to comply with CE Broker).

Continuing education is valid through December 31, 2007. CE credit is provided through California Board of Registered Nursing and Florida Board of Nursing.

You can receive one CE contact hour by completing the crossword!

1

23

Objectives of Education:


REGULAR FEATURESAcross

3 The collagen in a collagen wound dressing ____ to the

destructive enzymes

5 Chronic wounds that are not infected often respond well to this

type of dressing

6 If MMPs are bad enzymes, then TIMPs are _____ enzymes

8 The extracellular _____ (ECM) consists of collagen and elastin

9 An enzyme that destroys elastin

13 Fibroblasts produce fresh collagen and fill the _____ bed

14 Proliferation is the second _____ of healing

15 MMPs seek out _____ and break it down into fragments

17 Inflammatory phase typically lasts two to three ______

18 Denatured collagen no longer has the triple ____ structure

20 Neutrophils help clean the wound but also secrete _______ which

can be detrimental in a chronic wound

21 Protein that provides strength and elasticity to skin

22 Must outnumber MMPs in order for wound to heal normally

24 Main function is to manufacture proteins, growth factors and

angiogenic factors

27 Type of collagen dressing that is effective in attracting MMPs

28 Epithelialization is when new _____ migrate over the surface of

the healing wound

29 Bad enzymes will migrate to the plentiful collagen in a

collagen ______

Down

1 How many phases in normal wound healing?

2 The first phase of healing

4 Collagen and elastin are both ______

7 The final phase of wound healing

10 Byproducts of MMPs’ destruction of collagen dressings are

collagen _____

11 Destructive _____ in the wound may prevent normal

wound healing

12 De novo

16 A wound that is not progressing

19 The most abundant protein in humans

23 Chronic wounds may be ____ in the inflammatory phase of healing

25 In the maturation phase, collagen continues to reorganize

as ___ tissue

26 Adding a collagen dressing to the wound ___ neutralizes

destructive enzymes by binding with them

Chronic Wound FAQs

How many people have chronic wounds?It is estimated that nearly 5 millionAmericans suffer from chronic wounds.1

What are the causes of chronic wounds?The majority of chronic, non-healingwounds can be linked to diabetes,immobilization, chronic edema and circulatory problems. Approximately 1.5million people with non-healing woundshave diabetes, and another 2.5 millionhave pressure ulcers. Chronic wounds can also result from traumatic injury,non-healing surgical incisions or otherdiseases affecting the skin.1

How can a chronic wound be identified?A wound is considered chronic if it has not improved significantly in four weeksor completed the healing process in eight weeks.1

Reference

1 Center for Wound Healing & Hyperbaric Medicine.

Frequently asked questions. Available at:

http://www.woundhealingcenter.org/faq.htm.

Accessed December 18, 2006.

CASE STUDYA pleasant 46 year old female was admitted to our service with a complex medicalhistory and several risk factors that affect her ability to heal. She was involved in amotor vehicle accident in 1985 and suffered from a SCI that resulted in decreasedsensation and function below T11. She is unable to participate in any of her personalcare at this time, making her dependent for all of her ADLs. She is incontinent of bothbowel and bladder, wearing disposable briefs for containment and has continued withher monthly menses. Past medical history is significant for a Stage IV pressure ulcer thatwas surgically corrected with a muscle flap procedure.

She presents with a problematic deformity of her entire perineal/perianal region and a Stage IV pressure ulcers measuring 20 cm x 15 cm. The ulcer bed is granular withapproximately 30% slough and eschar. There is undermining that measures 6.5 cm in the 9:00 to 11:00 range. Although she currently has a pressure ulcer, the Braden Scale is used to help identify others areas at risk for breakdown. Her score was 10, which isindicative of a “high risk” for the development of pressure ulcers. With these categoryscores, she needed intensive therapy in several areas, to not only prevent other ulcers,but to help this large wound progress.

Sensory Perception – 4 She really had no impairment with sensory perception and was able to participate indecision making.

Moisture – 1She was constantly moist with urine, stool, and through her menstrual cycle bloodydrainage. A skin care protocol was initiated. The pH balanced skin cleanser does notcontain harsh surfactants and instead utilizes a phospholipid that cleanses withoutstripping the skin of its natural acid protective barrier. Barrier creams containingdimethicone and several silicones were also utilized.

Activity – 1Due to the MVA and subsequent SCI with paralysis in 1985, she is wheelchair bound.Pressure redistribution is a key factor, not only with existing pressure ulcer, butprevention as well. She was evaluated and issued an appropriate support surface for both her bed and wheelchair.

Mobility – 1Considered completely immobile, she is unable to make any significant or even slightpressure changing position changes. Instituting a turning schedule while in bed helpedto address the needs of mobility and pressure redistribution. Teaching her position changeswhile in her wheelchair proved to improve her risk score, thus reducing her risk.

Nutrition – 2In July, her albumin level was 2.1 and nutrition was a big focus. By October, withnutritional education and better choices along with supplements, her level was 3.3 and into normal range of 3.6 by December 2005.

Friction and Shear – 1With slight contractures, immobility and muscle wasting, her friction and shear scorewas low, again placing her at high risk. Education about transferring allowed herindependence, but the knowledge she gained helped her communicate with others in her care.

ABSTRACTStatement of Problem: Provide optimalstandard of care based on best practiceto improve patient outcomes, byremoving necrotic tissue, addressinginfection, social and emotionalproblems and preventing patient fromfurther surgical intervention. Rationale:Co-morbidities such asSCI/neuromuscular problems,nutritional, social and emotional toname a few are things that cansignificantly change the outcomes of apatient. We present a young SCI patientwith paraplegia, S/P MVA in1985, withsurgical repair of a Stage IV pressureulcer in 1989. Admitted July 4, 2005with Stage IV, necrotic, foul smell,extensively infected pressure ulcercovering the entire sacral, righttrochanteric, perianal and vaginal vaultarea as well as bilateral foot ulcers. Her past history is unclear, unable todetermine prior treatment regimens prior to presenting to our setting.Methodology: Patient admitted withmalformed buttock, anus and vaginalvault making any treatment optiondifficult. It was necessary to addressinfection, reduce bioburden, andpromote healing. Patient with urinaryand fecal incontinence, as well asmonthly menses, added to problem with choosing an appropriate advancedwound care dressing. We willdemonstrate with this case theprogression towards healing by utilizingadvanced wound care products that arebioavailable to cleanse, debride, reducebioburden and maintain an optimalmoist environment. Results: Able toreduce ulcer size, promote granulationtissue, prevent infection, and improvenutritional status.

40 HEALTHY SKIN

Use of Ionic Silver* and Collagen+ to ReduceBioburden and Promote Healing for ImprovedQuality of Life in a Complex Patient

Study # LIT467

RESULTSEven though the double incontinence is a dailyissue, her menses a monthly issue, and thepotential for bacterial bioburden are present,her wounds are improving. This casedemonstrates that even under complicatedcircumstances with multi-factorial issuesaffecting her ability to heal; this wound wasmanaged and continues to improve the qualityof life for this young, unfortunate patient.

CONCLUSIONEven the most challenging wounds can beassessed, addressed, and treated with a littleingenuity and choosing the right treatmentregime. Dressings that serve several functions,such as the ionic silver hydrogel incombination with the collagen particles,provided the best healing environment for thisdifficult wound. We will continue to use thisproduct combination in our clinic as a viable option for all chronic wounds.

REFERENCESBaranoski S and Ayello E. Wound treatmentOptions (Chapter 9) in Baranoski and Ayello.Wound Care Essentials Practice Principles.Lippincott Williams & Wilkins. 2004Fleck C, Paustian C. The Use of SliverContaining Dressings: The New “Silver Bullet”in Wound Management?, Extended CareProduct News, July/August 2003, 22-25.Gibbins B. The Antimicrobial Benefits of Silverand the Relevance of Microlattice Technology.Ostomy wound Management. 2003: 49 (suppl): S4-S7.Olveda M and Trowsdale H. Meeting theChallenges for Wounds in Home Care with aSilver Amorphous Hydrogel and Collagen.Presented at the Clinical Symposium on Skinand Wound Care, Phoenix, AZ. 2004.

*Arglaes Powder from Medline Industries, Inc.Mundelein, IL Arglaes is a registered trademark ofGiltech, Ltd. +Medifil Particles from BioCore, KansasCity, KS.

Date Measurement (L xW) Undermining (9:00 – 11:00)7-11-05 20 x 15 6.5 cm8-31-05 10.5 x 6.2 4.8 cm10-26-05 10.5 x 4.9 3 cm12-28-05 8.8 x 4.4 3 cm3-1-06 8 x 2.5 3 cm3-22-06 8 x 2 3 cm

7-11-05 8-8-05

11-30-05 3-1-06

Sacral Wound Measurements, showing almost 95% decrease in the woundsoverall dimensions in approximately eight months

Over a period of eight months, this photographic series shows the progressof a complicated sacral wound. Overall, the wound decreased 95% andhelped improve the quality of life for this 46 year old paraplegic female.


CASE STUDY

She presents with a very large Stage IV pressure ulcer involving the entireperineal/perianal area extending to the buttocks. After careful assessment thedecision was made to aggressively treat this wound. A protocol was written thatwould not only provide an optimal moist wound healing environment, but alsoaddress debridement necessary and the bacterial bioburden. The treatment planincluded wound cleansing, debridement, and the use of ionic silver hydrogelwith bovine collagen particles. The ionic silver hydrogel and the collagen weremixed together and applied to the wound daily to every other day.

Mary Webb, RN, BSN, MA, CICSan Mateo Medical CenterSan Mateo, CA

Presented at The Symposium on Advanced Wound Care, San Antonio, TX, April 2006.

A sample of a new wound care product

and an accompanying case study of two

patients are dropped on your desk. As a

clinician, you often need to make clinical

decisions by evaluating scientific evidence

from published research and case studies.

Can a study of two individuals give you

enough evidence to make a decision?

Here’s a review to help you and your staff

in your clinical decision-making process.

Making Sense of

Research ReportsBy Carol PaustianBSN, RN, ET/CWOCN, DAPWCA

42 HEALTHY SKIN

How do we evaluate studies?The best studies are set up so the control and interven-

tion groups are receiving the same intervention with only

one variable.

Example: Group 1 gets wet-to-dry dressings; Group 2 gets

advanced wound care dressings.They must be treated with

the same standard of care with one exception–the inter-

vention. Both groups need to have the same cleansing,

antibiotics if indicated, compression, etc. It is improper to

have Group 1 get no wound cleansing with wet-to-dry

dressings while Group 2 is cleansed with wound cleanser

and dressed with a mixture of silver-containing powder and

collagen. Only one variable can be introduced at a time.

The gold standard for pharmaceutical studies is a Level 1

or randomized control trial (RCT). It is not typical to find a

well-constructed Level 1 study on devices such as wound

dressings.They must, however, demonstrate to the FDA that

the product is substantially equivalent in terms of safety and

effectiveness to an already legally marketed device. For

example, in the early 1980s, a revolutionary product for

wound care,Vigilon®, was brought to market and went

through the FDA process as a sheet hydrogel. More impor-

tantly, it became one of the standards for all other sheet

hydrogels to come to market. Once a product has developed

a history of safe use, the FDA may no longer require a new

product to undergo formal FDA review prior to marketing.

An example of this is the amorphous hydrogel category.

The FDA now requires a review process only if there is

another claim added to the product, such as antimicrobial

silver in the hydrogel.

What to do?Look at how clinical research studies are set up. Anyone,

including nurses, MDs and PhD researchers, can set up an

inaccurate or useless study. Does the intent of the study fall

in line with the information you are looking to acquire? Be

aware of the types of studies and know their advantages and

disadvantages. Research studies might look complicated, but

knowledge of the terminology and study setup will put you

in the best position for reading and understanding research.

The definitions here should get you off to a good start.

Case report (commonly called case study).This is a

clinician’s report of 1 or 2 patients and how they responded

to the intervention.

A case series is made of several (usually at least three)

case studies grouped together.

A control group will receive standard care without any

intervention. This is the “compare to” group.

Crossover refers to a part of the study where the groups

actually change unknowingly; the control group becomes

the study group and vice versa.

Double blind refers to a study where there are at least

two groups (control and interventional) in which neither the

subject nor the investigator knows which treatment is being

administered to which group.The purpose of a double-blind

study is to eliminate the risk of prejudice, which could distort

the results.

An intervention group (or study group) will receive

standard care in addition to the study intervention.

A placebo is an inactive substance often used in pharma-

ceutical studies. One group will receive the test medication

and the other will receive a non-medicated “drug” that looks

and possibly smells similar.

Randomization means that the study groups are decided

by a random method. A computer program usually does

this. It might appear to the non-statistician that there is no

logic to the order, but there is a method used to put the

groups together with the goal of their being similar in age,

sex and other co-factors.

Randomized controlled trials (RCTs) are recognized

for achieving as much control as possible of confounding

variables that might influence results. In wound care, it is

very difficult to obtain an accurate RCT. Patients have dis-

similar co-morbidities affecting circulation, nutrition and

immune function, or wounds might be at different phases of

healing. Clinicians need to consider other types of research

in the absence of RCTs. Many healthcare providers have

been trained to expect Level 1 RCTs. Realistically, it is very

difficult to do these for all interventions needing to be

studied. Large case series can be very powerful in predicting

outcomes. Small RCTs with low numbers can be combined

via meta-analysis (such as from the Cochrane Library in

England) to provide excellent predictive value.


SPECIAL FEATURES

44 HEALTHY SKIN

Statistical significance means that the difference in

outcome is most surely related to the fact that one group

received (or did not receive) the intervention.This usually

is demonstrated by a p value of <.05. In other words, it

is more than 95 percent probable that the effect of the

intervention was significant and can thus be labeled as

statistically significant. Not obtaining statistical significance

means that it is unclear that the outcome was really related

to the intervention.

N refers to the total number of patients or subjects in the

study. The study is more powerful with larger numbers,

especially if the treatment effect is likely to be small. So, the

studies with a larger N are probably going to be more

accurate and achieve significance.

Power analysis is the determination of sample size, a

pre-study calculation performed for the purpose of estimating

the sample size needed to adequately test the difference

between two or more therapies and establish if one is

superior to the other.

Hawthorne effect. When clinicians involved in a patient’s

care are aware of whether the patient is receiving the study

intervention or standard care, they tend to give more atten-

tion to the patient and spend more time assessing the part

of the body involved in the study. This can skew the results

of the study, usually making both the study and standard

care groups have altered outcomes.

Peer-reviewed study. This means that prior to publication

of a study, experienced, knowledgeable clinicians look over

the work to assess whether it is suitable and accurate for

publication.When a study is not peer reviewed, an author

could report misleading outcomes.

Clinical practice guidelines are a way to group together

all the published research reports and then assign a level

of evidence.These guidelines are not rule books.They are

more like cookbooks for thinking cooks.The guidelines

typically include all types of evidence, including posters, case

series and randomized controlled trials.

Current criteria for levels of evidenceLevel 1: Randomized controlled trial that demonstrates

statistically significant difference in at least

one outcome

Level 2: Randomized controlled trial that does not meet

Level 1 criteria

Level 3: Non-randomized trials with coexisting controls

selected by some systematic method

Level 4: Before-and-after study or case series of at least

10 patients with historical controls or controls

drawn from other studies

Level 5: Case series of at least 10 patients

without controls

Level 6: Case report of fewer than 10 patients

Carol Paustian, BSN, RN,

ET/CWOCN, DAPWCA is

a certified wound, ostomy and

continence nurse. She has

worked as a staff nurse, charge

nurse and CWOCN nurse con-

sultant in a variety of settings.

Carol is a member of the

Wound, Ostomy and Continence Nurses Society,

Association for the Advancement of Wound Care and a

diplomat in the American Professional Wound Care

Association. She has lectured extensively on the areas of

wound, ostomy and continence management and has

published in several peer-reviewed professional journals.

References

Bergstrom N, Bennet MA, Carlson CE, et al. Treatment of PressureUlcers: Clinical Guideline Number 15. AHCPR Publication No. 95-0652. Rockville, MD: Agency of Health Care Policy and Research,Public Health Service, U.S. Department of Health and HumanServices. December 1994.

Geronemus RG and Robins P. The effect of two new dressings onepidermal wound healing. J. Dermatol. Surg. Oncol.1982;8(10):850-852.

Mulrow C, Cook D (eds). Systematic reviews: Synthesis of bestevidence for health care decisions. Philadelphia, PA: AmericanCollege of Physicians; 1998.

R

46 HEALTHY SKIN

Risk assessment tools can help you identify those at risk of developing pressureulcers and improve their care. These risk assessments, such as the Braden Scalefor Predicting Pressure Sore Risk, are composed of subscales to help identifyareas of greatest risk. Patients are scored on the subscales, which includemobility, moisture, nutrition, friction/shear, sensory perception and activity.Understanding pressure ulcer risk factors will help you identify the risk beforea pressure ulcer develops and help you formulate a care plan that includes prevention interventions.

Test your skillsRead the following patient profile, then complete your assessment using theBraden Scale worksheet on the facing page. (Note: the answer sheet andrationale of this exercise are on page 48.)

Patient ProfileBefore arriving at your facility yesterday, Mabel had been living alone, caredfor by her daughter for the last 15 years. She depends on assistance with all herADLs. Up until now, Mabel has been alone at night and has not posed a safetyrisk to herself. With her Alzheimer’s progressing and “sundowner syndrome”increasing, Mabel is requiring more care and supervision, which is why shehas entered your facility.

Mabel is a breast cancer survivor, recently finishing her second round ofchemotherapy following a bilateral mastectomy. She walks slowly and deliber-ately with a walker. Once in bed, however, she has significant upper body weak-ness and is unable to reposition herself.

Mabel eats 100 percent of three meals per day, but requires significant prompt-ing and often hands-on assistance. She has been about five pounds under herideal body weight for the last 15 years. Her daughter has encouraged 32ounces of fluid throughout the day in addition to the fluid given with hermeals. Mabel is not on any fluid restriction. She drinks this additional fluidwith much prompting. Her skin is warm and dry and appears well hydrated,with minimal dry skin.

She takes a multiple vitamin with minerals, Darvocet N-100 PRN pain andLevoxyl 100 mcg per day. Her vital signs are within normal limits. She is alert,but confused as to the time, date and place. Mabel’s past memory recall isfair. While at home, her daughter toileted her in advance of need, therefore sheremained dry during the day. Mabel is incontinent of urine and stool at nightand wears a brief liner and mesh pants. If it wasn’t for the prompted voiding,Mabel would be incontinent of both urine and stool.

Her hematocrit is 44 percent, hemoglobin is16 g/dL, and albumin is 4.1 g/dL.

How Good Are You at Assessing Risk?

Sharpen your skills with the Braden Scale.


SURVEY READINESSComplete your evaluation of the sample resident using the form below,

then turn to page 48 to check your responses.

48 HEALTHY SKIN

Braden Scale for Predicting Pressure Sore Risk

Sensory Perception =2 Very limitedMoisture =1 Constantly moistActivity =3 Needs assistanceMobility =2 Very limitedNutrition =2 AdequateFriction and Shear =2 Potential problem

Total Braden Scale =12, Level of Risk = High Risk

Prevention:Mabel currently has no wound or skin issues. Physical therapy/occu-pational therapy should be consulted to evaluate her upperbody strength, endurance and ambulatory skills. She should bein a feeding program, which provides for maximal promptingand assistance, when necessary. A registered dietitian shouldevaluate Mabel for between-meal snacks or nutritional supple-ments to encourage weight gain. Mabel might be an ideal candidate for a bowel and bladder program, but she must bethoroughly evaluated. Due to her cognitive function, it could be determined that therapy will be of no benefit based on hermedical diagnosis. Enroll her in therapeutic activities, such ascards, crafts and music, depending upon her ability. She shouldbe placed on an appropriate support surface, such as a pressurereduction mattress replacement. When lying supine, elevateheels of bed with pillows (placed under calves).

In the next issue of Healthy Skin, we’ll look at the Norton Plus Scale.

CLIA Waived On Board QC No Refrigeration Small Sample

For consistent PT/INR results in less than 2 minutes usingone drop of fresh whole blood from a fingerstick.

www.hemosense.com

Why More Professionals are Choosing theINRatio PT/INR Monitoring System

• Make immediate warfarin dose changes• Allows for more frequent testing

Test StripsDo Not RequireRefrigeration

Small 1 DropFingerstickSample Size

2 Levels ofOn BoardQuality Control

Order Information:�P-T100004Z INRatio Monitor Pro KitP-T100139Z Test Strips 48/BoxP-T0200235 Blood Collection Tubes 50/pkP-T200046 PrinterTo order: www.medline.com1-800-MEDLINE (1-800-633-5463)

Remember when your grandmother used to tell you

It still is...?

Medline Compass programs provide clinical direction for:• Wound care and prevention

• Incontinence care

• Diabetes care

Having comprehensive programs in place when surveyors walk in the facility might be theounce of prevention you need. Compass can help you be survey-ready for CMS tags F309,F314 and F315. The Compass programs are practical, hands-on resources developed byMedline’s clinical staff to help your clinicians meet standards of practice, improve care outcomes and reduce regulatory risk.

Compass Survey Readiness Tag F309/F314 focuses on the care and prevention of pressureand non-pressure related wounds. It offers clarification of surveyor guidelines along withclinical tools and protocols.

Compass Survey Readiness Tag F315 is a comprehensive program for incontinence management, including assessment and treatment options, detailed clinical information and educational materials.

Compass Diabetes Resource for Long-Term Care—with 26 percent of nursing home residents battling diabetes and its complications, this Compass programprovides educational tools for residents, their families and caregivers.

1-800-MEDLINEwww.medline.com

©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc. Mundelein, IL 60060

50 HEALTHY SKIN

Managing Dementia-Related IncontinenceBy Amin Setoodeh, BSN, RN

Approximately 46 percent of all nursing home

residents and 50 percent of all residents in

assisted-living facilities have some form of

dementia. A resident with dementia typically

experiences a decline in cognitive abilities, loss

of memory, disorientation, poor judgment and

changes in personality. Prevalent among elderly

with dementia is the loss of bowel and bladder

control, resulting in incontinence.

Common causes of incontinence include inability

to recognize the urge to void, inability to hold

the urge until reaching the bathroom, not

being able to find the bathroom, medications,

urinary tract infections or constipation.

Incontinence can also develop when the

individual is in an unfamiliar environment or

when the individual is experiencing depression

or anxiety. It is imperative for the care provider

to develop a strategy to promote continence.


SURVEY READINESS

52 HEALTHY SKIN

What interventions should be considered?

The following should be considered when devel-

oping an efficient nursing care plan for individuals

experiencing incontinence and dementia:

• Conduct a complete physical examination to rule

out underlying conditions such as urinary tract

infection, vaginitis, constipation or prostate trouble.

• Identify the cause and type of incontinence.

• Identify the voiding pattern by noting frequency,

amount and time of leakage.

• Apply behavioral interventions such as promoted

voiding, scheduled toileting or bladder training

to promote normal bladder function.

• Use disposable absorbent products in conjunction

with other treatment options to promote dignity.

• Use protective creams and barriers to promote

good skin integrity and prevent skin breakdown.

• Provide family and caregiver education.

• Evaluate outcome and revise as needed.

How can incontinence episodes be reduced?

Management of incontinence for individuals with

dementia is a challenging task for healthcare

providers, but there are ways to reduce the

number of episodes of incontinence and improve

patient dignity.

• Consider existing medical conditions such as

stroke, diabetes or physical disabilities that

prevent the individuals from toileting

themselves properly.

• Review current medications and identify those

that could increase urine output or relax the

bladder, such as diuretics, sleeping pills and

anti-anxiety drugs.

• Eliminate bladder irritants such as cola, coffee

and alcohol from the resident’s diet.

• Promote proper hydration by encouraging the

individual to drink six to eight glasses of water

a day (unless contraindicated).

• Ensure the environment is safe by providing

proper lighting, a clear path to the bathroom,

walking aids and raised toilet seats, if necessary.

• Make sure the environment is familiar by posting

a picture of the bathroom on the bathroom

door, reminding the individual where the bath-

room is located or keeping the bathroom door

open at all times.

• Work with the family to select clothing the

resident can easily fasten and unfasten. For

example, try fabric fasteners instead of buttons.

• Protective underwear might be a better choice

than adult briefs since protective underwear more

closely resembles the resident’s own underpants.

• Ask or remind the individual to use the toilet at

regular intervals.

Promote communication and dignity

Incontinence often has a major psychological

impact on residents, resulting in anxiety for them

and a more complicated care process for clinicians.

Some individuals might feel depressed and have

difficulty expressing emotions or communicating

with others. Care providers need to ensure proper

communication while protecting individuals’ dignity.

Consider the following:

• Respect the need for privacy as much as possible.

• Remember that toileting accidents

are embarrassing.

• Encourage individuals to tell you when they

need to use the toilet.

• Pay attention to nonverbal cues, such as

restlessness or hiding behind furniture.

• Identify phrases for needing to use the toilet.

• Do not make individuals feel guilty by

providing negative feedback or scolding them. Reference1. Alzbrain.org. Assessment and Management ofUrinary or Fecal Incontinence.

Available at: www.alzbrain.org

Accessed November 21, 2006.

Managing Dementia-Related Incontinence continued

To learn more about Compass, contact your Medline representative or call 1-800-MEDLINE.www.medline.com

©2006 Medline Industries, Inc. Medline is a registered trade-mark of Medline Industries, Inc.

Instead of wondering if your clinical team is in compliance with the updated

CMS Tag F315, take action with Medline’s Compass program. This compre-

hensive system of educational aids, best-practice protocols and clinical tools

takes the guesswork out of developing an effective incontinence program in

your facility.

The Compass Program was developed by Medline’s clinical staff to help

your clinicians meet standards of practice, improve care outcomes and

be survey-ready at all times.

What’s in the box?• DON Instruction Manual (like a teacher’s guide)

• Survey Readiness Resource Books (put them on your treatment cart!)

• DVD education program (staff can earn CE credit)

• Forms for incontinence assessment (based on F315)

• Measuring tapes (to determine absorbent product size)

• Continuous Pressure Ulcer Prevention booklets (to improve

communication and documentation)

DO YOU KNOW IF YOUR FACILITY IS SURVEY-READY?

The soothingtouch of aloe in every wipe Thousands of healthcare facilities already know thesecret – Aloetouch® wipes are simply the best choice.

Why? Because there’s aloe in every wipe. The pH–balanced, hypoallergenic formula cleans, moisturizesand conditions skin…all at the same time!

Available in a fresh, gender-neutral scent or unscentedfor sensitive skin, the soft spunlace cloths are perfectfor any quick clean-up.

Aloetouch wipes from Medline – the right choice forhealthy skin.

1-800-MEDLINE www.medline.comTo learn more about Aloetouch Premoistened Wipes, contact your Medline representative or call 1-800-MEDLINE ©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

It’s been confusing.Support surface literature, product brochures and journal articles havethrown a lot of terms around. “Pressure relief” and “pressure reduction”have meant a lot of things but have been used most recently to representa difference between a therapeutic support surface and a preventive surface. Many clinicians have been waiting for more precise definitionsdescribing support surfaces.

Wait no longer! The National Pressure Ulcer Advisory Panel (NPUAP)released the final version of support surface terms and definitions inAugust of 2006 as part of their Support Surface Standards Initiative. Thisdocument breaks down the terms closely associated with pressure, skinand support surfaces. With so many myths and misconceptions out there,even these experts took several years to agree on terminology.

The most important thing for you to remember is that there is a newphrase to replace pressure reduction and pressure relief: pressure redistribution. We all know that the term pressure is defined as “the forceexerted over an area.” To reduce pressure, you can spread the pressureover a larger area or move the pressure completely to another part of thebody. In describing the way to spread pressure, the NPUAP introducessome terms that might be new to some: immersion (sinking into a surface) and envelopment (conformability of the surface to the body).

Other common terms such as shear, friction and mechanical load aredefined as well. In addition, there are sections that define the differenttypes of support surfaces, the components of surfaces and the featuresthey exhibit. The NPUAP gives clinicians a common language for discussion and description of pressure ulcer prevention and the support surfaces used.

The document also includes more than 60 references that you can turn to for more information. You can download a copy of Terms and Definitions Relatedto Support Surfaces at www.npuap.org.

A concept of the past.PRESSURE

Relief


TREATMENT

Jackie Young, RN, CWCN, DAPWCA Jackie Young is board-certified as a CWCN. She is a member of the Wound,Ostomy and Continence Nurses Society, the Association for the Advancementof Wound Care and serves as treasurer of the Southeast Region of the AmericanProfessional Wound Care Association. Jackie serves on the National PressureUlcer Advisory Panel (NPUAP) subcommittee for Support Surface StandardsInitiative (S3I) as a Corporate Advisory Council Member.

56 HEALTHY SKIN

FOAMDRESSINGS

PRODUCT SPOTLIGHT

Joyce Norman, BSN, RN, ET/CWOCN, DAPWCA


TREATMENT

Foam dressings are a mainstay in the practitioner’s

“wound care basket,” but they are frequently

misused or neglected as an option because of a

lack of understanding.We’re putting a “spotlight”

on foam dressings to clear up confusion and

provide strategies for appropriate use of foams.

Foam dressings are usually prepared from

polyurethane-based materials. Depending on the

manufacturing process and specific chemistry

chosen to prepare the polyurethane foam, the

following characteristics will vary:

• Hydrophilicity (the ability to absorb water

and not release it under pressure)

• Cell structure (with more openness in the

structure being related to quicker water

absorption)

• Conformability

• Dry and wet softness

In wound healing applications, the objective is to

create foam that can absorb exudate reasonably

fast and retain that fluid in the foam under a rea-

sonable degree of pressure.Think of it like a dry

kitchen sponge.When dry foam is placed in the

wet wound, it absorbs the fluid, just like the

kitchen sponge absorbs spills on a wet counter.

Understanding best practice use of foam dressings

requires a brief overview of the principles of

wound healing.

Foams have a valuable place in the wound careformulary because they increase dressing weartime on moderate to heavily draining woundsand extend the life of the primary dressing.

Wound Healing Principles

Is the wound healing?

If the answer is yes, then proceed with

best practice principles, including providing

an optimal moist wound environment.

If, however, the answer is no, consider

other factors that affect wound healing.

Address issues of moisture, nutrition,

mobility, pressure, friction and shear.

What is the etiology of the wound? Is

a biopsy necessary to rule out other

disease entities? Determine if the reason

for the delay is related to bioburden – is

there too much bacteria, is the wound

infected? Reevaluate the chosen topical

treatment – is the treatment or dressing

actually causing harm?

Optimal Moisture - Is the wound

wet or dry?

If the wound is wet or there is drainage,

it must be contained.Applying an

absorbing product or one that addresses

the drainage should be a focus. If the

wound bed is dry, a product that

donates moisture to the wound bed

might be necessary. Research has

demonstrated that wounds heal better,

faster, with less scarring and less pain

in a moist environment. Remember,

the overall goal is to provide an

optimal environment.

Tissue Condition - Is the wound

viable or necrotic?

If the wound is viable (living), measures

should be taken to maintain the living

tissue. If the wound bed is covered

with necrotic (dead) tissue, slough or

eschar, debridement is in order. Be sure

to assess whether debridement is con-

sistent with the overall goals for the

resident.There are several methods of

debriding a wound.The method used

should depend on what is best for

the resident.

Dead Space - Does the wound

have depth?

If the wound has depth or dead space,

loosely filling the wound cavity is neces-

sary to allow closure by secondary

intention, or “from the bottom up.”

If the wound is superficial or “flat,”

a cover dressing is usually acceptable.

Periwound Protection - What is

the condition of the periwound skin?

If the skin around the wound is compro-

mised, denuded or raw, the secondary

or anchoring dressing choice will be

affected. Consider products that are

non-adherent and will not stick to

fragile periwound skin. If the periwound

skin is not compromised, an adhesive

dressing can be considered.

Why the review? Each dressing type has

its place in wound care. Following the

principles of wound healing helps the

clinician know when and how to use

them to their full advantage.

How Can Foams Be Used?

Use for absorbing drainage

Foams, by design, are indicated for

wounds with moderate to heavy

drainage. Foams can be used as a

primary dressing directly on the wound

surface or as a secondary dressing to

provide extra absorption.

Foams come in many different shapes,

from squares to sacral shapes, with

58 HEALTHY SKIN

A foam without adhesive isa good choice for weepyvenous statis ulcers withfragile periwound skin.

adhesives and without. Some adhesives

totally coat the facing of the foam,

others have only adhesive borders.

Some foams are “naked” on both sides,

meaning there is no top or bottom.

These foams can be cut into strips

and inserted into tunnels or cut to

fill a cavity.

Use on wounds with depth

If a wound has depth, the cavity must

be filled.An ideal packing material for a

moderate to heavily draining wound

could be an alginate to fill the “dead

space” and provide absorbency.The

wound can then be covered with foam

as secondary dressing. Using traditional

gauze or an ABD pad as secondary

dressing might require a daily dressing

change because of drainage. Using foam

can give extended wear time for better

utilization of product, cost control and,

most importantly, better wound healing.

Use under compression

Many foams work under compression,

which seems contradictory. (Note:

Check with the manufacturer of the

foam before using under compression.)

An example of foam use under com-

pression is treatment of a venous stasis

ulcer.The foam absorbs the wound

drainage, allowing less frequent changes

of the compression dressing.

Foams Continue to Evolve

Many of the newer, more advanced

foams have a silicone facing on the side

that goes toward the wound. Resident

pain is reduced because there is no

trauma to the wound bed or to the

periwound skin.

One innovative silicone-faced foam also

includes new polymer technology within

the foam.As the exudate moves into

the foam, the fluid is drawn and locked

into polymer. Even under compression,

there is no exudate movement back

into the wound bed.

Another recent technological advance is

foam that contains silver to kill bacteria.

Because all wounds are considered

contaminated, an antimicrobial dressing

might be indicated.Antimicrobial foams

either feature silver coating on the

face of the foam or silver throughout

the foam.

Joyce Norman has vast clinical experience in many healthcare arenas, including acutecare and home care. She is a member of theWound, Ostomy and Continence NursesSociety and the Association of RehabilitationNurses Society. Joyce is also a member ofthe Association for the Advancement ofWound Care and a Diplomat in theAmerican Professional Wound CareAssociation. Joyce has practiced the fullscope of ET/WOC nursing since 1985 and has taught and lectured extensivelythroughout the country.


Remember that hydrocolloids only manageup to moderate drainage and are best on flat wounds.It is important to note that hydrocolloids should not be changed more than three times per week.Theseproducts are highly adhesive and require diligent careupon application and removal to avoid epidermal stripping.As an alternative, foams have many advantages:they don’t break down in the wound bed, they can holdconsiderably more drainage than hydrocolloids and they can be atraumatic to the surrounding tissue.

QuestionI have a resident who has a venous stasis ulcer on her

lower extremity with edema. Would an unna boot

be appropriate?

AnswerThis is a familiar question at the hotline as venous stasis

ulcers are common in long term care facilities and are

often quite challenging. A diagnosis of a venous stasis

ulcer means adequate arterial blood is getting to the leg

and foot, but the venous blood is not returning to the

heart. This fluid increases the pressure in the capillaries

and can cause an ulcer or prevent a scratch or small

injury to the leg from healing.

Why so challenging?Many clinicians focus on the wound itself, trying multiple

treatment modalities without success. This lack of improve-

ment is due to treating the result of the disease, not the

disease itself.

Research clearly shows us that we must treat the disease,

which is venous hypertension. Compression is the key to

healing venous stasis ulcers and is done with a compression

garment of some type.

If your resident has an Ankle-Brachial Index (ABI—see

page 62) of 0.8 or higher, then therapeutic compression

can be applied anywhere from 35 mm Hg to 45 mm Hg.

Note: It is of the utmost importance that you ensure

arterial perfusion is adequate before applying any form

of compression.

Compression optionsThere are many different types of compression garments

and systems to choose from. The two most common are:

Unna Boot (Paste Boot)

Delivers 35 to 45 mm Hg pressure on an ankle

circumference of 18 to 25 cm

An unna boot (paste boot) is a zinc – impregnated (with or

without calamine) gauze wrap. It is best used if the resident

is ambulatory because it becomes semi-rigid after applica-

tion. When the resident ambulates, their calf muscle pro-

duces counterpressure against the unna boot, which causes

venous blood to return to the heart. The compression,

although initially adequate, is not sustained and will

decrease to less than 10 mm Hg within 24 hours. Usually,

because this wrap can be messy, it is covered with a gauze

roll. If sustained compression is needed, a self-adherent

wrap (such as CoFlex® or Coban™) is often added.

To use:

• Apply the dressing, beginning with two anchor turns

just above the toes.

• Make sure the resident dorsiflexes the foot (think toes

to the nose).

• Continue wrapping from the toes in a spiral to just

below the gatch of the knee.

• To provide for therapeutic compression, apply a

self-adherent wrap on top of the rolled gauze.

60 HEALTHY SKIN

Hotline

Four-Layer Compression System

Delivers 35-45 mm Hg pressure on an ankle circumference

of 18-25 cm

A four-layer compression system, such as FourFlex or

Profore™, is a compression system and dressing all in

one. There are four layers or wraps that together provide

adequate sustained compression.

To use:

•The first layer, called cast padding, is used for padding

and absorbency. Begin wrapping all layers just above the

toes to just below the gatch of the knee. Start with two anchor

turns just above the toes and wrap in a spiral fashion.

•The second layer, also wrapped in a spiral fashion,

is a short stretch crepe that is used to smooth down the

first layer and provide added absorbency.

•The third layer is a long stretch bandage, applied

in a figure eight. The wrap is performed with a 50

percent stretch.

•The fourth layer is a self-adherent wrap. This layer

is applied in a spiral at a 50 percent overlap and 50

percent stretch.

The entire compression system should be changed

after 48 hours and then every five to seven days,

depending on the amount of drainage.

Hints for best practice •Use an appropriate dressing (such as silicone-faced

foam, antimicrobial dressings or an oil emulsion)

directly over the wound to allow the drainage to

pass into the dressing without the first layer sticking

to the wound.

•Remember that residents with venous hypertension

often have very dry, flaky skin (venous dermatitis).

Apply a topical emollient up to the wound margin,

from just above the toes to just below the gatch of

the knee, prior to applying the compression system.

•A topical silver dressing used in conjunction with

compression could aid healing. Venous ulcers are

frequently contaminated and topical silver products

are broad-spectrum antimicrobials.

After healing has taken placeOnce the wound is closed, it is important to get the patient

in a therapeutic support stocking or garment. Remember,

the disease is for life. The therapeutic support stocking or

garment will prevent further ulcerations from occurring.

Janet Jones is a board-certified wound, ostomyand continence nurse. Shehas extensive experience inlong term care and homecare and has developedwound prevention andtreatment programs formany national healthcaregroups. She’s also ready totake your call on Medline’sEducare Hotline!


REGULAR FEATURES

Do you have a wound or skin care question? Call the Educare Hotline! Medline’s toll-free hotlineis supervised by a board-certified enterostomaltherapy/wound, ostomy and continence nurse.

Just pick up the phone and call 1-888-701-SKIN (701-7456). We’re here to help!

62 HEALTHY SKIN

Ankle Brachial Index (ABI)An ABI is the bedside comparison of the blood flow pres-

sures in the lower leg and those in the upper arm. This

screens residents for significant arterial flow problems to the

extremities. An ABI will identify residents for whom com-

pression would not be appropriate. This test might not be

accurate for diabetics, whose vessels are often calcified, lead-

ing to a false positive.

Procedure

1. Place resident in supine position five to 15 minutes

before test.

2. Obtain brachial systolic pressure in each arm using a

blood pressure cuff and doppler.

3. Record the highest brachial systolic pressure.

4. Place a cuff around the affected ankle.

5. Apply acoustic gel over the dorsalis pedis or posterior

tibial pulse.

6. Lightly touch the doppler probe (at an approximately

45-degree angle) to the skin at either pulse location

very lightly. Listen for a pulse.

7. Inflate the cuff higher than the brachial

systolic pressure.

8. Slowly deflate the cuff, listening for the return of the

pulse. The point at which the arterial signal returns is

recorded as the systolic ankle pressure.

9. Repeat to obtain the ankle pressure over the other

pedal pulse on the affected extremity. Use the higher

of the two values.

To determine the ABI, divide the higher of the two ankle

pressures by the higher of the two brachial pressures. If only

one ankle pressure could be obtained, use it.

Ankle Pressure = ABI

Brachial Pressure

Interpretation of Ankle-Brachial Index

0.95 - 1.3 Normal range

0.80 - 0.95 Compression is considered safe at

this level

<0.8 - 0.5 Indicates mild to moderate arterial disease

<0.5 Severe arterial insufficiency

>1.3 Abnormally high range

or

=Dorsalis pedis pulse Posterior tibial pulse

Brachial pulse

ABI

NEW5 Second Results

0.6 µL Sample Size

Large Backlit DisplayMakes test resultseasier to see

Optimized features and value for the Post Acute Care Professional• 0.6 µL sample size

• Faster test time – only 5 seconds*

• Unique chemistry minimizes the effects of interfering agents, such as aspirin,vitamin C, uric acid and acetaminophen, providing reliable, glucose-specific results

• Designed to start when sufficient sample is detected – minimizes repeat testsand wasted strips

• Permits second drop if first sample is not adequate

• Accurate with hanging drop or touching application methods

• 450-test memory with time and date

Customized implementation to meet your organization’s needs• 24/7 Customer Care line

• Customized training

• Project management

*Compared to previous Optium™ Blood Glucose Test Strips.

For more information on Optium, contact yourMedline representative or call 1-800-MEDLINE(1-800-633-5463).

Medline Industries, Inc.One Medline Place, Mundelein, IL 60060www.medline.com

©2006 Abbott.

64 HEALTHY SKIN

Documentation:Using the Best Words for You and Your Resident

On November 12, 2004, the Guidelines forSurveyors in updated F-Tags 314 and 309 wasreleased.These tags are used in long term careand refer to various types of wounds. Specifically,Tag 314 addresses pressure ulcers and focuseson their prevention.

The guideline gives new meaning to terms that are hardly new to healthcare providers –avoidable and unavoidable. As clinicians,we’ve all encountered the resident who hasdeveloped a pressure ulcer even though excellent care was provided.

Consider a resident who is immobile, who mighthave severe contractures, decreased appetitewith severe weight loss, lab values below therange needed for wound healing and fecal andurinary incontinence.This resident could alsohave dementia, be taking several medications or maybe even have diabetes. Nobody wants tosee a pressure ulcer develop, but most clinicianswould agree that this resident is at high risk of developing a pressure ulcer despite excellentpreventive care.We would consider this a clinically unavoidable pressure ulcer.


SURVEY READINESS

The Guidelines for SurveyorsF-Tag 314 clearly defines whatthe terms avoidable andunavoidable mean to CMS:

Avoidable means that the resident developed a pressureulcer and that the facility didnot do one or more of the following to prevent it:

• Evaluate the resident’s clinical condition and pressure risk factors

• Define and implement interventions that are consistent with residentneeds, resident goals andrecognized standards of practice

• Monitor and evaluate the impact of the interventions

• Revise the interventions as appropriate

Unavoidable means that theresident developed a pressureulcer even though the facilitydid all of the following:

• Evaluated the resident’s clinical condition and pressure ulcer risk factors

• Defined and implementedinterventions that are consistent with resident needs, goals and recognized standards of practice

• Monitored and evaluated the impact of the interventions

• Revised the approaches as appropriate

As we can see, a pressure ulceris labeled avoidable if one ormore of tasks listed above wasnot performed. A pressureulcer is unavoidable if all ofthe tasks were performed andan ulcer still developed.

When assessing the risk for a pressure ulcer, look for guid-ance in a standard care plan.Care plans are necessary intaking care of our residents andevery nurse should know howto complete one.The problemis that many nurses assess andaddress the needs of the resident but do not necessarilyuse the care plan as guidance.Care plans should be updatedas needed – but often, whentime is short, paperwork suf-fers. However, care is oftenjudged using this paperwork –especially in a court of law.

A wonderful resource is theAmerican Medical DirectorsAssociation’s Clinical PracticeGuideline: Pressure Ulcers. The first edition was published in1996. It addresses recognition,diagnosis and treatment ofpressure ulcers.Three yearslater, the second (or compan-ion) document Clinical PracticeGuideline: Pressure Ulcer TherapyCompanion was released.Thecompanion guideline addsmonitoring as a focus.Thesedocuments are available forpurchase for AMDA members.For more information, go towww.amda.com.The guidelines

themselves provide valuableinformation for healthcareproviders treating residentswho have or are at risk ofdeveloping pressure ulcers.

Listed on the following pageare statements from the 1999companion guideline that canbe used in a number of ways.Physicians, nurse practitionersand physician assistants canuse them in progress noteswhen applicable.

These statements can also beused by nurses when talking tofamily members regarding the risk factors contributing to thedevelopment of pressure ulcers.Chart the discussion that tookplace, who was present and the family’s response to the conversation.

This reference can be clippedout and posted convenientlyfor your staff.

Karen Lou Kennedy-Evans was

the first Family Nurse Practitioner in

Fort Wayne, Indiana. She worked at

the Byron Health Center, a 500-bed

long term care facility in Fort Wayne,

Indiana, for 26 years. Her records in

the 1980s led her to the discovery of

a pattern to terminal pressure ulcers,

a type of ulcer that is now named

the Kennedy Terminal Ulcer. She

currently lives in Tucson,Arizona and

is the president of K.L. Kennedy, LLC.


Good, Strong DocumentationPhysician Reference Progress Notes for Residents with Pressure Ulcers

It is important to document on the progress note and to discuss with the resident and/or family the risk factorspredisposing the resident to pressure ulcers. Here are some additional suggestions from the AMDA Clinical PracticeGuideline: Pressure Ulcer Therapy Companion to add to the progress note and to that discussion.

Page numbers are from AMDA Pressure Ulcer Therapy Companion

1. Complete wound closure might not be a realistic goal... (page 7)

2. The wound may improve but complete healing is not expected... (page 7,Table 2)

3. Patient has a slowly progressive or irreversible underlying medical condition... (page 7,Table 2)

4. The patient is likely to get worse or to die and the wound may worsen or at least is unlikely to improve significantly...(page 7,Table 2)

5. Patient has an end-stage or terminal condition… (page 7,Table 2)

6. The wound represents an additional body systems failure in an individual who is progressing towards death… (page 7,Table 2)

7. Patient has been losing weight and or not eating well despite appropriate nutritional interventions...(page 7,Table 2)

8. A treatment plan emphasizing basic comfort measures such as minimizing pain and odor related to the wound during the dying process... (page 7,Table 2)

9. The presence of Stage 3 or 4 ulcers, especially in combination with significant active comorbidities and medical instability (for example, systemic infection), may indicate general instability, decline or a terminal episode. (page 8)

10. Advanced directives by patient or substitute decision maker to forego artificial nutrition and hydration may influence the feasibility of wound healing. (page 6)

11. Comfort measures only will affect the aggressiveness of overall care and the options selected to manage related complications. Basic wound care measures – such as protecting the wound from contamination and trying to absorb excessive exudate – should be considered as comfort measures compatible with palliative care plans. (page 7)

There are many reasons pressure ulcers develop, however, the conditions listed above may indicate an

unavoidable pressure ulcer unrelated to the F-Tag 314.

Adapted by Karen Lou Kennedy-Evans, RN, CS, FNP

References:

Clinical Practice Guideline: Pressure Ulcers American Medical Directors Association, Columbia, MD. 1996.

Clinical Practice Guidline: Pressure Ulcer Therapy Companion.American Medical Directors Association, Columbia, MD. 1999.

Did you know research shows

that long term care workers

miss more days of work due to

back injuries than truck drivers

or even construction workers?

Or that more than 10 percent of

nurses leave the profession each

year because of back injuries?1

If your facility doesn’t have a

“minimal lift” program or if

you’re interested in taking your

current program to the next

level, we suggest the following

must-reads: this article—a great

case study on what works and

why—and Safe Patient Handling

and Movement: A Practical

Guide for Health Care

Professionals. A tremendous

resource, this book provides

detailed information on

“best practices in safe patient

handling and movement, the

current evidence base, and the

scope of the problem. It also

addresses the challenges of safe

handling of special populations

such as the morbidly obese.”1

Oh,Your

Aching BackBy Julie Finley, BSN, RN

68 HEALTHY SKIN

WWhen You Do the MathMany facilities focus so much onresident safety that addressingemployee safety inevitably ends upat the bottom of the to-do list. KimKohls, an administrator, freely admitsthis was the case before she began alimited lift program at Countryside,an Aurora, Illinois, nursing home.When Kim heard in 2002 thatOSHA might be looking at backinjuries in her region, she recalledthat her insurance representative hadsuggested that back injury preventionwas an area ripe for improvement.At the time, her human resourcesdepartment handled the workers’compensation claims. Reviewing herfacility’s statistics for the first time leftKim astonished. Six of her staff hadbeen injured handling the same resi-dent! At one time she had as manyas three staff members on “lightduty.” Kim admits, “I was embar-rassed. Why had I not known thisbefore? Lifting residents was the mainsource of injury to my employees. Idecided to do something about it.”

Go to the Source: Program PlanningKim chose ten nursing assistants toinclude in a meeting during whichshe laid out all the statistics andinsurance data. “The CNAs wereshocked and a lively conversationensued. I just sat back and listened!”Kim asked if they would be willing toattack the problem and they wereeager to respond. Working togetherwith Kim on the project helped thestaff feel important and empowered.

Kim was impressed by the initiative,energy and enthusiasm of the CNAson her committee, who began theirwork by meeting twice a week for a

month. First, they brought in theinsurance representative to reviewthe cost of injuries to the facility.Another early session addressedequipment. “We had only two liftersat the time and they always hadbattery issues. The committee wantedto change that!”

A “show and tell” was organized totest equipment. The CNAs developedan equipment feedback form to helpevaluate the facility’s needs. The teamdeveloped a list of all the equipmentnecessary to convert to a limited liftplan. Kim was prepared to make acapital investment in additional liftingaids. Countryside invested $24,000in new equipment, including twice asmany sit-to-stand lifts as sling lifts.

Evaluate Your ResidentsOnce the equipment issue wasaddressed, the team knew they’dneed to assess the lift needs of eachresident. An initial review determinedthat approximately 30 percent ofresidents would need assistance.However, as the staff embraced theuse of equipment and a newlydeveloped resident assessment toolwas put in place, the team soonrealized that nearly 50 percent ofthe residents needed lift device assis-tance. By assessing each resident, theteam was able to determine equip-ment criteria for each wing. Kim says,“To this day, the team still does theassessment for each resident.”

Back It Up and Implement ItAfter evaluating costs, equipmentand residents, the team found thatdeveloping a formal policy andtraining both staff and residents on its importance helped ensuresuccess. Because the CNAs had

daily experience with lifting differentresidents in a variety of situations,they were the ideal staff to developthe facility’s resident handling policy.

Program Implementation: The EmployeesEveryone in the facility was notifiedthat the staff was going “lift free” ona certain date and a mandatory in-service was scheduled. The committeemembers were charged with trainingall of the direct care staff during thisfull one-day in-service. Kim notes,“Employees had to be educated too.There definitely was resistance. But ourcommittee members were enthusiasticabout how the program was for thegood of the employees.”

After training, a skills checklist went ineach employee file and the programwent into effect. The lifting committeewas given the power to suspend any-one who didn’t use the equipment,even if that person was a superior.Kim insists that the authority to suspendis critical to the program’s success.“Immediate three-day suspensionsgave teeth to the program. In threeyears, we have had nine peoplesuspended, but never once was therea repeat violation.”

In 2003, theAmerican Nurses

Association (ANA)launched their

“Handle with Care”ergonomics campaign

to promote safepatient handling.


SPECIAL FEATURES

70 HEALTHY SKIN

Program Implementation: The ResidentsThe work of the committee was readyto be put into practice. Informing thefamilies and the residents about thechange was important. “We wanted tolet the families know that the equipmentwas safe, that the staff would be fullytrained and that resident and employeesafety was a priority.”

Kim adds, “It is an exposed andvulnerable feeling to be swinging inthe breeze from a lift, so we wantedto make sure the residents werecomfortable. During a resident councilmeeting, we asked residents if theythought they were the most difficultto transfer and we then demonstratedthe equipment on those who volun-teered. Everyone could see how theequipment worked!”

Minimal Lift: A Win-Win for CountrysideThe year before the Countrysideprogram went into effect, workers’compensation claims totaled$152,000. The year after the programwas implemented, those costsdropped to just $1,200. After threeyears, there have been no significantlifting injuries.

The committee (now called theEmployee Safety Committee) continuesto meet monthly for QA/QI and toaddress concerns about injuries andemployee turnover. Other on-the-jobinjuries have virtually disappeared aswell because staff members at all levels

are more safety conscious. The cultureat Countryside has become one of“safety first.”

Beyond reducing costs and premiums,Kim is happy to report the completeelimination of light duty. “Light dutycan be a cancer in a facility—all theother full-time employees hate it whenthey are working so hard while some-one else is clipping fingernails!”

When Kim is asked what she wouldhave, in hindsight, done differently,she doesn’t hesitate to respond. “Ididn’t order enough slings! We nowhave more than enough on hand; wewash them regularly and date them.Anything frayed is thrown away.”

Countryside’s summary list of recommendations:• Plan on at least six weeks to

implement your program from start to finish.

• Set up a committee composed predominately of CNAs.

• Develop criteria for the kinds of equipment you need.

• Select a variety of equipment for consideration and recommendation.

• Notify residents’ families about the new program.

• Demonstrate the equipment to the residents.

• Train the trainers so they can then train the staff.

• Don’t be afraid to initiate suspensionif equipment is not used.

• Every year, retrain your staff as part of a skills fair.

Perhaps one of the greatest unpredicted benefits has been theadministration’s new appreciationfor their staff. “The CNAs are mybiggest employee group—that’s whereI can make the biggest impact,” Kimsaid. “Spending so much time withten CNAs on this project made me seewhat a great untapped resource I had!Some of these team members havesince been promoted to other posi-tions, such as admissions or restorativespecialist. Our minimal lift programhas eliminated light duty, improvedemployee morale and given all care-givers an everyday mindset of safetyfor themselves.”

Julie Finley, BSN,RN, has 26 yearsof nursing experi-ence dividedamong hospital,home, and physician officesettings. She has

functioned in both managerial and clinicalroles; her clinical experience is in criticaland home care. As a division director ata hospital, she was responsible for multipledivisions. She then transitioned into thepractice setting, hiring physicians andmanaging their practices.

Reference:

(1) Nelson A, ed. Safe Patient Handling andMovement: A Practical Guide for Health CareProfessionals. New York, NY: Springer

Publishing Company; 2006.

Suffering and Major Costs to Your Facility• In 2000, the incidence rate for back injuries involving days away from work was 181.6 per 10,000 for nursing home

workers (compared to 98.4 for truck drivers or 56.3 for construction workers).1

• In a 2001 study conducted by the ANA, 4,826 nurses cited “disabling back injury” as their second highest safety concern, just behind stress and overwork.1

Medline’s Safe ‘n Easy program teaches the seven key components of lifting and transfer. It provides comprehensive policy policy, procedure and assessment tools you can customize for your facility!

The program will teach your staff how to properly use equipment including Medline’s Electric Elevating Liftwhich can help even the smallest staff member lift up to 600 lbs safely and easily. It also wheels under thebeds and into the tightest spots. With its 24-volt batteries it has the power to keep going all day

Medline’s Safe ‘n Easy We’ve Got Your Back 1-800-MEDLINE www.medline.com

72 HEALTHY SKIN

D

PEP talk

Does your fast-paced, often erratic schedule have

you running on fumes? Do you laugh sarcastically

when someone suggests that you have to “find that

balance,” while wishing you really could? We hear

this consistently from long term care employees

nationwide and we want to help. So, we recently

talked to an expert in the field, Julie Morgenstern.

Does the name sound familiar? You might have

seen her on national news programs, Oprah and

other talk shows. The author of numerous time

management and organization best sellers,

Morgenstern has a formula that could really

make a difference in your life.

“When you’re working like this with an erratic

schedule and you are trying to balance work and

home life you really have to plan ahead to be

prepared for sudden shifts in your schedule.

The whole point of your time off should be to

recharge you as a human being. It shouldn’t be just

to do laundry, the chores, and what amounts to

basically another job – especially when you are

working this hard. You’ve got to find a way to

spend your time off that really recharges you. I

teach a formula called PEP. The concept is to balance

three different areas of your life. When you mix it

up, plan ahead and spend your time focusing on

these three areas it actually gives you energy,”

said Morgenstern.

from a pro


CARING FOR YOURSELF

“PEP” focuses on finding balance between Physical

Health, Escapes and People. Morgenstern’s latest

book Never Check E-Mail in the Morning outlines

this strategy. Following are excerpts from pages 25

through 32 of the book.

Physical Health

Lack of sleep and poor nutrition can be compensated

for with caffeine, sugar, power bars or the pure will

to concentrate; however, nothing is a substitute for

genuine physical health. Sleep, exercise, a proper

diet and regular checkups maintain your physical

body. This is a basic, essential priority, which

provides the well of energy from which you draw

strength to accomplish everything else you need

to do…making the commitment to your physical

health will have an immediately visible effect on

your productivity.

The message is that physical health is extremely

important! We should plan and make the time for

it! So many of us get wrapped up in taking care of

everyone else that we neglect our own needs. We

must:

• Plan to exercise

• Plan to go to the doctor

• Plan to eat well

Escapes

Certain activities renew us by providing relaxation,

refreshment or just sheer delight. Think about the

activities that instantly transport you to

a place of pure joy. It could be reading,

gardening, painting, dancing, listening

to music or pampering yourself by

taking a long bath or a long weekend.

This element of your personal life is

what defines you–what makes you

YOU. These activities – the no-brainers

of joy – are important to build into our

every day lives. Adding something

new and joyful to a crammed schedule

actually has the effect of stretching the

hours and days. You will suddenly feel

like you have more time on your hands

than ever, because you will be energized

as you look forward to your time off,

and renewed as you think back on

how pleasant the time was. So PLAN

time for those things that motivate and

recharge you.

• Plan to do nothing

• Plan to get pampered

• Plan to listen to music

• Plan a short vacation

People

With the busyness of everyone’s lives,

it’s very easy to take relationships for

granted – you count on the history, the

good times and the familial bonds to

hold them together. Yet relationships

thrive on more than good feelings and

memories – actually spending quality,

focused time with people lets them

know they are important to you.

Staying connected to the people you

care about isn’t only for them, though,

it’s for you.

There are people in your life who give

you a sense of value, love and connec-

tion. Whether they are family, friends

or people in your community, spending

time with them is essential to your

being. Keeping our relationships strong

feeds our spirits, grounds us, reinforces

our identities and brings out our best

selves. Rewarding relationships at

home can help us to tolerate tensions

at work more easily. Again, make a

plan to spend time with people that

really matter to you.

• Plan to have lunch with a friend

• Plan to have dinner with

your spouse

• Plan to read to your children

• Plan to really talk to your sister

How to get started:

Get a planner and write it

down TODAY.

Morgenstern suggests starting with

your largest blocks of free time when

you are not working. This could be

your weekends, evenings – wherever

the largest block of free time exists.

Literally start scheduling things way in

advance on your calendar. Front-load

Must Reads

Morgenstern’s books are must

reads that will help you get

control of your schedule and

your life. In addition to Never

Check E-Mail In The Morning,

we suggest you read her other

best-selling books Organizing

from the Inside Out and Time

Management from the

Inside Out.

74 HEALTHY SKIN

Oyour calendar with WHAT you’ll do and

WHEN you’ll do it – always remember-

ing to consider PEP.

Sudden opportunity list

With your erratic schedule, you need to

be ready for the unexpected.

Sometimes we find ourselves with an

extra 15 to 30 minutes. Make a short

list of things that really matter to you

that you can accomplish in that time.

Keep the list short. NO CHORES!

Morgenstern explains, “Then every

time you get a few minutes it’s a bonus

and you don’t lose half the time won-

dering what to do. Something that is

really wonderful and fabulous and not

doing the dishes.”

The list could include:

• Lunch with my spouse

• Go for a run

• Calling an old friend

Stuck at work

The flipside is to have backup plans

for those times that you are going to

have to go into work when you hadn’t

planned on it or for those times that

you are stuck at work when you

had planned to pick up your kids.

Morgenstern says to “do as much

preparation in advance so that when

these moments happen, you are just

able to execute.” Have several options

Organize Your BagMorgenstern has also tackled a problem you know well – organizing

your bag. A new partnership with world-renowned planners

Franklin Covey® has resulted in a new planner to help you

incorporate PEP as well as the perfect bag to help you grab and go.

Morgenstern shared these important tips about your organizing

your purse or bag.

The bag should be:

• Light when empty

• Roomy inside and flexible

Step 1.

Get rid of the junk – movie tickets, old hand cream, old shopping

lists and phone numbers with no names.

Step 2.

Divide contents into two piles

Permanent items – includes keys, wallet, glasses, cell phone,

pen and basic make up

Transient items – includes shopping lists, bills and possibly

a book

Step 3.

Obtain pouches for the permanent items. Those things stay

in the same place in your bag at all times.

Step 4.

Decide where your transient things should be placed in your

bag – and never put your permanent items there.

Step 5.

Begin a daily routine at the end of your day of unpacking the

items you don’t need in your bag.

Step 6.

Keep your bag by the door so you can grab and go.


76 HEALTHY SKIN

planned well in advance so that

you don’t always feel like you’re

begging at the last minute.

Keeping the balance

Remain focused on PEP throughout

your day. Remember to give your-

self a break – both mentally and

physically. “You may need, after a

hard day at work, a few minutes

to recharge yourself before you are

able to give back to your family.

So when you are home you are

100 percent present for your spouse

or your kids,” said Morgenstern.

Find ways to share the load

Many a long term care employee

has been accused by family or

friends of being a control freak.

That might be because there is no

transition time built in to switch

gears. Also try to remember that

you don’t have to be “in control” at

home the way you are at work.

“Are you running your household

and trying to be responsible for

everything at home? Is your home

set up in a way that people can

help you? You can organize your

space if you are a control freak, so

that it makes it difficult for someone

to help you. Look around your

house. Take away the obstacles to

somebody helping you. Label the

insides of cabinets to help your

husband and kids know where

things should go. Move the snacks

to a lower shelf so the kids can

help themselves,”

Morgenstern suggests.

You don’t have to be perfect

“When people get very busy they

tend to get very focused on the

small practical day-to-day stuff.

You have to put what is truly most

important first. And those are those

three things in PEP. It’s not whether

the laundry is done. It’s OK not to

be perfect. If you take care of your

physical health, your escapes

(recharge your spirit) and you take

care of the people that matter first,

you find that you suddenly have

time for the other stuff.

“It really gives you the energy to

get the other chores done. The

mistake most people make is that

they spend way too much time on

the ‘to do’ list before they get to the

things that matter. The trouble with

that is that the little stuff never

goes away. It is a never-ending list

and I don’t care how many ‘to dos’

you get done, there are always 700

more right behind them. You are

never done, so how do you know

when to stop? Now, on the other

hand, sitting one-on-one with your

spouse and spending an hour really

listening and finding out how their

day was – the return on investment

for that is huge.”

Excerpts from pages 25 through 32 from

Never Check E-Mail In The Morning

reprinted with permission from Julie

Morgenstern. ©2005 Fireside Publishers.

All rights reserved


JJulie Morgenstern is an internationally

renowned organizing and time

management expert, best-selling

author, corporate productivity

consultant and speaker. Her “Inside

Out” philosophy ensures customized

solutions for individuals and compa-

nies, that are innovative, practical,

and easy to maintain. Since 1989,

Julie and her staff have worked with

clients such as American Express,

Microsoft, FedEx, Bear Sterns,

GlaxoSmithKline, the Miami Heat,

NBC-Newsroom, NYC Mayor’s Office,

Sony Music, Medicare/Medicaid,

Viacom/MTV and Victoria’s Secret

As a speaker, media expert and

corporate spokesperson, Julie is

known for her engaging, articulate

style and warm sense of humor.

She is a columnist for O, The Oprah

Magazine, solving readers’ problems

by creating order in their life. Julie

has been a guest on many TV and

radio shows, including The Oprah

Winfrey Show, The Today Show,

Good Morning America, and National

Public Radio programming. She is

quoted and featured regularly in a

wide variety of publications and has

been seen in The New York Times,

Julie MorgensternAuthor, Speaker, Consultant

The Chicago Tribune, Woman’s Day,

Fitness Magazine, Cosmopolitan,

and Bottom Line Business.

Julie is the author of the New

York Times’ best-seller ORGANIZING

FROM THE INSIDE OUT and TIME

MANAGEMENT FROM THE INSIDE

OUT, both of which have been made

into popular one-hour PBS specials.

Julie and her teenage daughter Jessi

co-authored ORGANIZING FROM

THE INSIDE OUT FOR TEENS. Her

latest book, MAKING WORK, WORK,

is now available in paperback,

newly titled NEVER CHECK E-MAIL

IN THE MORNING.

78 HEALTHY SKIN

Julie Morgenstern Organizing System—Time Management Your WayJulie Morgenstern shows you how to design a balanced life based on

your unique personality and goals. The system’s unique page design

helps you master five basic time management skills to create meaningful

and fulfilling days: How to Estimate Tasks, Lighten Your Workload with

the 4 Ds, Group Similar Tasks, Create a Time Map, and Control the

Nibblers. Its sleek profile provides the best of mobile paper planning

without the bulk. Includes one wire-bound book featuring a full year

of calendars in a two-pages-per-month format and Julie Morgenstern’s

Skill Building Lessons, 12 monthly Planning Books in two-pages-per-day

format, a notebook, 20 Time Maps, a Pouch Pagefinder to hold the

Time Map and a Month Pagefinder.

Buckle Down Leather Wire-bound CoverSlip the Julie Morgenstern Organizer into this smooth leather cover with

buckle and you’re ready to conquer your day with panache. Coordinates

with the Grab & Go Bag to create a complete planning system. Features

vertical pockets for important papers and a horizontal pocket

for a notepad. Snap closure.

The Grab & Go BagThis stylish tote is fun, fast and ready to go anywhere you do – from

work to the soccer field to a shopping getaway. Its roomy interior fits

everything from business papers to workout wear. Features two side

pockets for water bottles, an umbrella or a cell phone. Large external

pocket is perfect for reading material.

The Switchables Four-piece Leather Accessory PackThis set of soft, full-grain leather pouches is designed to organize the

interior of your tote and make it easy to switch bags in an instant.

Includes a money pouch to hold credit cards and currency; a storage

pouch for makeup, personal, electronic, or other items; a business card

holder with two compartments, one for cards you give and another for

cards you get and an envelope to organize receipts and small paper

items. Available in red, black, and chocolate.

Franklincovey.comFor more information, or to purchase the products listed,please call 1-800-680-1812 or visit your local FranklinCovey store.


SPECIAL FEATURES

?What’s in a

Have you ever known people who seem to beborn into their profession – maybe it wastheir personality or even their name? Believe itor not, – these are the names of licensedphysicians.

ChiropractorsDr. BenderDr. Popwell

GastroenterologistsDr. ButtDr. Heine

DermatologistsDr. SpotDr. Whitehead

InternistsDr. B. Sick

Pain ManagementDr. OwDr. Pain

PodiatristsDr. KornDr. Smellsey

PsychiatristsDr. LooneyDr. MoodieDr. Strange

SurgeonsDr. ButcherDr. DoctorDr. Organ

UrologistsDr. WeinerDr. Streem

NAME

80 HEALTHY SKIN

Time StealersExperts say the first step in improving our

time management process is identifying

our biggest time stealers and working

to ELIMINATE or DELEGATE them.

Do any of the following get in your way?

Eliminate and Delegate PotentialTime Thiefs• Interruptions

• Meetings

• Lack of organization

• Procrastination

• Funny emails

I love them but they tear me away

from the important things.

The way we deal with others can also

have a big impact on our ability to get

things done. For instance, some of us

have trouble saying “no.” Some of us

don’t like to delegate so we wind up

doing everything ourselves.

#1. Time Waster—Failureto prioritize and planIt takes time, but people who do it

actually accomplish the most in a day.

This process includes doing a little

research before we jump into some-

thing. In the long run, a full under-

standing of the issues saves time—even

if it takes more time upfront.

Let’s Make a PlanNow that we know how important it is

to clearly define our objectives and cre-

ate a plan of action, we can get started

by evaluating how we currently use our

time. If you’re spending too much time

on nonessential tasks and doing big

projects at the last possible minute,

planning and prioritizing will really

help you get more done.

Remember Too Much on Your

Plate…Eliminate and Delegate!

TOPTime Management Tips

By Lynne Ellis

Time management. Sounds like an oxymoron doesn’t it? There is never really enough of it andaren’t we all too busy to manage it. How does anyone manage rushing to get the kids going,grab some coffee, wash the dishes, throw in a load of laundry, get dressed, out the door and tothe hospital by 6 a.m. Yikes—how could anyone be an OR nurse and still have a life? So howabout some time management tips to help get you going? After all, for busy women like you,time management is as critical as that first cup of coffee.

A rule of thumbis to delegateanything thatsomeone else

could do 80%as well as you

could do it.


TOP 10 TIPS1. Plan your day

2. Eliminate and Delegate as many time thiefs as possible

3. Break large tasks into smaller ones so they’re not so daunting

4. Use the 10-minute rule—spend just 10 minutes a day on

dreaded tasks (a suggestion from the Mayo Clinic)

5. Set aside a block of time each day for

paperwork and emails

6. Close your door and find other ways to eliminate distractions

7. When possible, say “no” to

extra tasks and interruptions

that don’t help you reach

your goals

8. Clear your workspace

of clutter—a messy desk

is not the sign of a

genius at work

9. Improve your concentration by

getting enough sleep and exercise

10. Take a break when you need one – this helps eliminate

stress and makes you more productive in the long run

Lynne Ellis is a freelance writer from Chicago, Illinois who has

written for Medline, Unted Airlines and American Airlines.

Be sure to ask yourself

if what you’redoing right

now is helpingyou achieveyour goals.

82 HEALTHY SKIN

SPECIAL FEATURES

Healthy Skin Word SearchFind 20 of the key words from this issue of Healthy Skin in the puzzle below! The words can be found up, down, backwards and diagonally in the puzzle and will occasionally share letters.Stumped? The solution is on pg. 98

Words to find:BRADEN SCALE

BUTTERFLIES

CASE STUDY

CHRONIC WOUND

CMS

COLLAGEN

CRANBERRY

DEMENTIA

DOCUMENTATION

FOAM

INCONTINENCE

MDRO

MINIMAL LIFT

OVERNIGHT BRIEF

PEP

PRESSURE ULCER

PSYCHOSOCIAL

RESEARCH

SOLDIERS HOME

UNNA BOOT


FORMS & TOOLS

FORMS I TOOLSThis section of Healthy Skin is all about making it easier for you to do yourjob. It contains practical information and ideas to help you provide the bestpossible care for your residents while following current guidelines and standards of practice.

The charts, forms and systems you'll find here are intended to be used. If you see something you like, feel free to tear it out and make it your own!

TABLE OF CONTENTS

Functional Incontinence 84

Incontinence Quality 86Improvement/Quality Assurance and Assessment

Policy & Procedure 88

Guidelines for Use 90of Overnight Brief

Try Our Web Tools 92

Butterfly Watch 94

End of Life Plan 95

84 HEALTHY SKIN

FUNCTIONAL INCONTINENCEResidents with functional incontinence have

properly functioning bladders, but are inconti-

nent for external reasons.These can include,

for example, restraints, vision problems and

residents who cannot transfer themselves.

Sometimes making residents safer is as simple

as making it easier for them to see the toilet.

A few suggestions:

• Install lights that go on automatically when

someone enters the bathroom. (Why? The

resident with dementia might not remember

where the lights are, and urge incontinent

residents don’t/won’t take the time to put

the lights on, which will put them at risk

for falls.)

• Create more of a contrast between the

toilet seat and the toilet.

• Install grab bars.

• Remove mirrors in bathrooms used by

residents with dementia (the resident might

think someone is in the room with them).

+White floors +White walls +White toilet +Poor depth perception

a fall=

By replacing white toilet seats withblack toilet seats in a white bathroom,the resident with poor eyesight cansee the toilet seat – like a bull’s-eye!

FORMS & TOOLS

Current CMS guidelines support the practice of keeping skin dry to prevent skin breakdown and pressure ulcers.

Your skin care protocol should include Ultrasorbs, a super-absorbent disposable underpad that actually wicks moisture away from residents’ skin.

Advantages of Ultrasorbs:• Keeps skin and bedding dry with absorbency of 3 standard underpads• Super strong, meaning less tearing and fewer linen changes• Cost-effective because you’ll use fewer underpads• Ideal for nighttime open-airing

Ultrasorbs underpads are available only from Medline; ask your representative for more information or call 1-800-MEDLINE.

©2006 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

“Ultrasorbs has saved us over 20% in product cost alone because of itsextraordinary absorbency and dryness.We went from using an average of 3–4 underpads to just one Ultrasorbs.We were also impressed with thestrength and the consistent quality.”

DON, Skilled Nursing Facility

Any Underpad Can Protect Your Bedding. Only UltrasorbsProtects Your Patients.

1-800-MEDLINE | www.medline.com

86 HEALTHY SKIN

Incontinence Quality Improvement/Quality Assurance and AssessmentRegular quality checks can have a big impact on compliance in regards to using the correct incontinence product on eachresident. Feel free to use this format when devising your quality improvement forms and program.

Instructions:1. QAA team assigns staff member to complete audit tool (i.e,. QAA nurse, staff nurse, wound nurse or clinical staff )2. QAA team will determine audit frames (i.e., quarterly, monthly or assign one unit per month)3. QAA team to determine time frame to review findings of audits and target issues from audit (i.e., resolution of issues

might be additional education to staff, determine distribution of products, determine if direct caregivers have access to resident sizes to ensure compliance)

Below is a form partially filled out. A blank form appears on the next page.

Quality Assurance and Assessment ProgramGolden Hills Nursing Facility

Incontinence Product Utilization

Unit: Date: Reviewer’s Signature:

QAA Targeted GoalTo maintain and ensure compliance with product selection related to resident’s specific type of incontinence

Products used within facility:

Briefs YES NO

Pull-ups YES NO

Liners YES NO

Other:

Color CodeGreenWhitePurpleBlueTan

Brief ProductsSmall

MediumRegularLarge

X-Large

Resident/Room#

Room 120 BResident: LK

Room 122 AResident: BH

Incontinent: Yes/No

YES

YES

Product Utilized

Brief-blue

Brief-blue

Correct Product: Yes/No

NO-Tan brief on

NO-Tan brief on

Feedback related toincorrect product

Staff indicates that onlytan briefs on cart.

Attending staff indicatedthat the larger sizes“hold more urine.”

Resolution

Review distribution schedulewith housekeeping and deter-mine if enough supplies havebeen ordered.

Staff educational sessioncompleted, related that largersizes cause more leakage relatedto poor fit, that each productsize of current brief have thesame absorbent factors.

10-11-2007 M. Davis RNLaurel

Follow-up/Conclusion notes:


FORMS & TOOLSQuality Assurance and Assessment Program

Incontinence Product Utilization

Unit: Date: Reviewer’s Signature:

QAA Targeted GoalTo maintain and ensure compliance with product selection related to resident’s specific type of incontinence

Products used within facility:

Briefs YES NO

Pull-ups YES NO

Liners YES NO

Other:

Color CodeGreenWhitePurpleBlueTan

Brief ProductsSmall

MediumRegularLarge

X-Large

Resident/Room# Incontinent: Yes/No

Product Utilized Correct Product: Yes/No

Feedback related toincorrect product

Resolution

Follow-up/Conclusion notes:

Facility Name

88 HEALTHY SKIN

I. Policy

Standard Precautions are to be followed by all employees

for all patients. They are designed to reduce the risk of

transmission of microorganisms from recognized sources of

infection in the hospital. Standard Precautions protect both

patients and employees and include:

• treating blood, all body fluids (secretions, excretions

[except sweat], non-intact skin and mucous

membranes) as infectious regardless of their source,

• hand washing before and after patient contact or

contact with infectious substances,

• using appropriate personal protective equipment

(PPE) when there is potential exposure to infectious

substances, and

• exercising general infection control practices.

All body substances (except sweat) are to be treated as

infectious regardless of their source. Recognition of potential

exposure risks is important. To reduce the likelihood of

exposure when dealing with potentially infectious substances,

it may be necessary to choose an alternative procedure,

technique or equipment.

II. Contact Precautions

Contact Precautions are intended to prevent transmission of

infectious agents, including epidemiologically important

microorganisms, which are transmitted by direct or indirect

contact with the patient or the patient’s environment. A

single-patient room is preferred for patients requiring

contact precautions. When caring for patients on Contact

Precautions the provider should wear a gown and gloves

for all interventions that may involve contact with the

patient or potentially contaminated areas within

the patient’s environment.

III. Use of Barriers

Hand washing

Hand washing is the single most important means of reducing

the risks of transmitting microorganisms from one person to

another or from one site to another on the same patient. Even

if gloves have been worn, hands may become contaminated

during glove removal. Wearing excessive jewelry (other than a

watch and plain rings) is not recommended during patient-

care activities. Antimicrobial soap, water and mechanical

friction are sufficient to remove most blood and body

substances. Hands must be washed before and after patient

contact or contact with items contaminated with blood or

body substances.

Personal Protective Equipment (PPE)

Appropriate PPE is to be worn when there is potential

for exposure to infectious substances. PPE is:

• gloves,

• protective face and eyewear, and

• gowns and other protective apparel, such as

shoe covers and hats.

Gloves

Gloves provide a protective barrier and prevent gross contamina-

tion of the hands when touching potentially infectious substances.

They reduce the likelihood that microorganisms present on the

hands of personnel will be transmitted to patients during invasive

or other patient-care procedures that involve touching a patient’s

mucous membranes and non-intact skin. Gloves must be changed

between patients.

Wear gloves:

• if there is potential for contact with blood, body

fluids, secretions, excretions (except sweat), items

that may be contaminated with any of these

substances, and

• if the healthcare worker’s hands are abraded or

dermatitis is present.

NOTE: Providers who have exudative lesions or

weeping dermatitis on their hands must not

provide direct patient care.

Change gloves:

• between each patient,

• between tasks and procedures on the same patient

after contact with material that may be

contaminated, and

• when holes or tears are noted.

Remove gloves:

• after each use,

• before touching non-contaminated items and

environmental surfaces, and

• before treating another patient.

Reuse of gloves:

• single-use gloves are not to be reused, and

• utility gloves may be decontaminated for reuse if

the integrity of the glove is not compromised.

An intermediate-level disinfectant, phenolic solution,

or 70 percent alcohol solution is suitable for

decontaminating utility gloves. Utility gloves must be

discarded if they are cracked, peeling, torn, punctured

or exhibit any signs of deterioration.Selection of gloves:

• gloves should be chosen to fit hand size,• flexibility and tactile sensitivity needed during the

procedure(s),• the need to follow sterile procedure (sterile vs. non-sterile),

Standard Precautions

POLICY & PROCEDURE


Standard Precautions

POLICY & PROCEDURE• potential for exposure to blood and body fluids during the

procedure(s) in terms of the amount and the length of timeexposed,

• exposure to other substances that break down glove material, such as disinfectants and solvents, and

• the amount of stress placed on the glove during the procedure.

Protective Face and Eyewear Masks, goggles or face shields must be worn to provide protection of the mucous membranes of the eyes, nose and mouth during procedures and patient-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions or excretions and to provide protection against thespread of infectious large-particle droplets. Removable side-shields are needed to adequately protect the eyes from bloodand body-fluid exposures when wearing prescription glasses.

Selecting masks:• check the mask box for the mask’s filtering efficiency,• make sure that the mask will filter to the level of protection

that is needed. NIOSH-approved respirators (N-95) shouldbe used when airborne precautions are required, and

• do not use adult masks on small children and infants.Wearing masks:

• adjust the mask so it fits snugly against the face, is securedalong the sides of the face and molded over the bridge ofthe nose. Air should not enter around the mask edges,

• keep beards groomed so that the mask fits closely to the face,

• change the mask between patients,• change the mask if it gets wet,• remove the mask as soon as treatment is over, and• do not leave the mask dangling around the neck.

Gowns and Protective Apparel Gowns and protective apparel are worn to provide barrier protec-tion and reduce opportunities for transmission of microorganisms.Uniforms and scrubs do not provide adequate protection fromblood and body-fluid exposure. Gowns and other appropriateprotective apparel must be worn when there is potential that anexposure (contact with contaminated surfaces such as bed linens,or splashing with blood or body fluids) will occur.Selecting gowns and protective apparel:

• protective garments should fit,• choose garments that prevent blood or other potentially

infectious materials from passing through or reaching the clothes or body, and

• select protective garments that are appropriate for the activity and amount of fluid anticipated (refer to AAMI PB70Level 1 – 4 Guidelines).

If the uniforms become soiled with blood or body fluids:• glove and remove clothing immediately,• wash contaminated skin with soap and water prior to

changing into hospital scrubs,• place soiled personal clothing in a plastic bag, seal

immediately and label for transport home. Once home, place hospital-furnished clothing in plastic linen bag to bereturned to the hospital for laundering, and

• at home, wash soiled personal clothing separately from other laundry using: 160ºF (71ºC) water and detergent or for water less than 160ºF (71ºC), use detergent and a bleach-containing product. Mechanical drying of the clothing is recommended.

IV. General Infection Control Practices Patient Placement In an ideal setting, each hospitalized patient would have a private room:• patients susceptible to infections due to decreased immune

responses such as severe leukopenia may benefit from placement in a private room,

• a private room may be necessary to prevent direct or indirect contact transmission when the source patient has poor hygienic habits, contaminates the environment, or cannot be expected to assist in maintaining infection control precautions to limit transmission of microorganismsto a roommate,

• patients that may shed large numbers of microorganisms, such as with actively infected or draining wounds, should not share rooms with patients who have fresh surgical wounds,

• patients known to be infected with target multidrug-resistant organisms should be placed on contact precautions and have a private room.

Transport of Infected PatientsLimiting the movement and transport of isolated patients within the hospital reduces the opportunities for transmissionof disease and microorganisms.

Patient-Care Equipment and Articles All patient-care equipment and articles that have become soiled or contaminated with infective material should be handled by employees wearing appropriate PPE. Any disposable item that has become soiled or contaminated with infectious material should be disposed of in the appropriate container. Reusable patient-care equipment and articles that have become grossly soiled or contaminated with infectious material should be covered and decontaminated or sterilized.

Linen and Laundry Linen that is soiled or contaminated with infective material should be handled by employees wearing appropriate PPE. Soiled or contaminated linen should be placed directly into impervious plastic linen bags. Soiled linen should be handledas little as possible. Double bagging of linen from isolation andnon-isolation rooms is not necessary unless the bag’s integrityhas been altered or the outer bag has become soiled with blood or body fluids.

Routine and Terminal Cleaning Routine and thorough cleaning and adequate disinfection of rooms, bedside equipment and shared patient equipment should be performed.

Regulated Medical Waste All waste should be handled by employees wearing appropriate PPE based on potential exposure risks.

Lab Specimens All collected specimens must be labeled and contained in a plastic biohazard lab specimen bag before leaving the collection area.

90 HEALTHY SKIN

FORMS & TOOLS

Guidelines for Use of Overnight BriefThe benefits of a good night’s sleep might outweigh the risk of not being checked and changed every two

hours. For residents who have trouble sleeping, the benefits of an overnight brief might include:

• Less daytime lethargy

• Less fall risk

• Less insomnia

• Increase in participation in activities

• Increase in weight gain

Goals• Resident-centered care

• Appropriate utilization of overnight (high-capacity) brief

• Maintain skin integrity

• Resident dignity

• Prevention of sleep deprivation

Other comments

Family/resident discussion

• If used, overnight briefs should be applied at 10 p.m. rounds

• If used other than at night, care plan should specify times brief used and justification for use

• Use of overnight brief should be listed on the care plan along with reason for use

• Examples of problems on the care plan could be “prevent sleep deprivation,” “improved sleep pattern,”

“maintain resident dignity,” “maintain skin integrity,” “prevention of behavioral episodes”

• Enclose a copy of this form with the care plan

Date

Adapted from Soldiers’ Home in Holyoke, Holyoke, MA One facility’s effort in individualized care for residents with incontinence, behaviors, and sleep disturbances.

Resident must meet two or more criteria to qualify for a overnight brief

Uses two or more diuretics or is on higher thanaverage dose (greater than 40mg BID)

Wet bed or wet clothes consistently after the two-hour check period

Diagnosis of diabetes, CHF or on tube feeding or intravenous fluids

Combative with hands-on care

Behavior issues such as wandering if awakened during the night

Document justification for brief use. Please describe. Be specific. List medications and dosage.

Level 1: Gown and Gloves• Housekeeping• Maintenance• Food Service• Daily care for patients with no serious illness

Because one of the biggest concerns with isolation protocols isusing the right combination of products at the right time, we'vetaken the liberty of showing the various levels below.

What, When, Where and Why...

Level 2: Gown, Gloves and Mask• Infected patient with airborne disease• Nurse cleaning the patient• Patients with antibiotic-resistant bacteria, hepatitis A,

scabies, impetigo or lice • Patients themselves moving away from isolation

should wear mask, as well as visitors• Patients who require droplet precautions

Level 3: Gown, Gloves, Mask and Eye Protection • Healthcare providers caring for patients with excessive fluids• Blood, body fluids, secretions (such as phlegm), excretions

(such as urine and feces), nonintact skin and mucous membrane

For more information, go to www.medline.com or call 1-800-MEDLINE

92 HEALTHY SKIN

Try Our Web Tools!

Here is a helpful list of Web sites recommended by our Wound CareAdvisory Board members:

www.medline.com/woundcare Medline advanced skin and wound care www.borun.medsch.ucla.edu The Anna and Harry Borun Center

Gerontological Research at UCLAwww.npuap.org National Pressure Ulcer Advisory Panelwww.apwca.com American Professional Wound

Care Associationwww.ahrq.gov Agency for Healthcare Research and Qualitywww.wocn.org Wound, Ostomy and Continence

Nurses Societywww.aawc1.com Association for the Advancement of

Wound Carewww.sawc.net Symposium on Advanced Wound Carewww.amda.com American Medical Directors Association

Don’t forget that if you have question about a particular product, the manufac-turer of the product might have helpful information on their Web site.


FORMS & TOOLS

Wound Care Product Selector Selecting an appropriate wound caredressing can be a challenge, particularlywhen your clinical staff or usual resourcesare not available. Medline has used theconvenience of the Internet to develop programming that can be accessed anywhere, anytime. Simply go online toreceive assistance in dressing selectionusing the Wound Care Product Selector at www.medline.com/woundcare. The program will ask questions about thewound, such as depth, drainage and periwound skin and suggest appropriatedressings that meet current standards of practice.

The Web site asks questions about thecondition of the wound.

Each question leads logically to the next,following a decision-making algorithm

designed by CWOCNs and other clinical experts.

With the information that is gathered, theprogram suggests dressing options that are

consistent with standards of practice forwounds with those characteristics.

1

2

3

4

5

BUTTERFLY WATCH

Residents are identified as potential Butterfly Watch by the management team.

The resident is reviewed during the “Resident at Risk” weekly meeting.

If a resident has 2 or more ‘indicators’ (as listed below), the resident may be

placed on a 14-day observation period and added to the Butterfly Watch.

Weight loss

Decubitus ulcer

Falls

Infections

Change in mental status

Change in level of function

Continence status

After completion of the 14 day observation, a determination will be made for a

“Significant Change” or admission to the “Butterfly’s Are Free” program.

The Admissions Office will be informed concerning the resident’s status. This

information will be added to the daily census report which is available to the

management team each morning.

94 HEALTHY SKIN

LIFECARECENTER

OFSARASOTA

END

OFLIFECAREPLAN

DATE

INITIATED

REVIE

W

DATE

PROBLEMS

AND

STRENGTHS

GOALS

APPROACHES

DISC

GOALANALYSIS

Isin

theEndof

Lifestage

relatedto

Residentwillnotundergo

unnecessary

medical

interventionsortransfers.

Residentscomfortwillbe

consideredwitheach

interventionto

ensure

he/sheremainsas

comfortable

aspossible.

(E.g.labs,weights,vital

signs,etc.)

ReviewAdvanceDirectives

Continueto

reviewresidentpreferences

Revieweffectivenessofcurrenttreatm

ent

plan

Provideoptionsandchoices

Attemptto

providesymptom

management

onsite

Elim

inate

unnecessary

treatm

ents

per

residentwishes

Reportanychangein

condition

Social

Services

Nursing

Willnotbehungry

or

thirsty.

Offerfoodsandfluidsasordered

Offercomfortfoodsandfluidsofchoiceif

dietary

restrictionislifted

Askfamily

forfavorite

foods

Family

tobringin

favorite

foodasallowed

andasable

Offernutritionandhydrationto

residents

toleranceanddesire

Nursing

Dietary

Isexpectedto

havean

increased

declin

ein

condition,which

isunavoidable

Willremain

pain

freeand

comfortable

aspossible

Willnotexhibitsignsor

symptomsofanxiety

Assesspain

qsandprn;offerpain

medications

Assesspain

more

frequentlyascondition

dictates

Medicate

asordered

Monitorfornon-verbalsignsandsymptoms

ofpainandreportchangesto

nurse

Monitoranti-anxiety

medication

effectiveness;changeorders

asneeded

Involveresidentin

pain

managementby

askingforfeedbackregardingthelevelo

f

pain,(asable)usinga1to

10scale

orvisual

analog

Involvefamily

inpain

managementthrough

observationofnon-verbalsignsofpain

suchasguarding,wincingormoaning

Notify

MDorARNPofpain

ordiscomfort

thatisnotalleviated

Providebedsideactivitiessuchas

therapeuticmassa

ge,aroma-therapy,music

ofchoice,visualimagery,anddocument

Nursing

All


FORMS & TOOLS

LIFECARECENTER

OFSARASOTA

END

OFLIFECAREPLAN

DATE

INITIATED

REVIE

W

DATE

PROBLEMS

AND

STRENGTHS

GOALS

APPROACHES

DISC

GOALANALYSIS

Isin

theEndof

Lifestage

relatedto

Residentwillnotundergo

unnecessary

medical

interventionsortransfers.

Residentscomfortwillbe

consideredwitheach

interventionto

ensure

he/sheremainsas

comfortable

aspossible.

(E.g.labs,weights,vital

signs,etc.)

ReviewAdvanceDirectives

Continueto

reviewresidentpreferences

Revieweffectivenessofcurrenttreatm

ent

plan

Provideoptionsandchoices

Attemptto

providesymptom

management

onsite

Elim

inate

unnecessary

treatm

ents

per

residentwishes

Reportanychangein

condition

Social

Services

Nursing

Willnotbehungry

or

thirsty.

Offerfoodsandfluidsasordered

Offercomfortfoodsandfluidsofchoiceif

dietary

restrictionislifted

Askfamily

forfavorite

foods

Family

tobringin

favorite

foodasallowed

andasable

Offernutritionandhydrationto

residents

toleranceanddesire

Nursing

Dietary

Isexpectedto

havean

increased

declin

ein

condition,which

isunavoidable

Willremain

pain

freeand

comfortable

aspossible

Willnotexhibitsignsor

symptomsofanxiety

Assesspain

qsandprn;offerpain

medications

Assesspain

more

frequentlyascondition

dictates

Medicate

asordered

Monitorfornon-verbalsignsandsymptoms

ofpainandreportchangesto

nurse

Monitoranti-anxiety

medication

effectiveness;changeorders

asneeded

Involveresidentin

pain

managementby

askingforfeedbackregardingthelevelo

f

pain,(asable)usinga1to

10scale

orvisual

analog

Involvefamily

inpain

managementthrough

observationofnon-verbalsignsofpain

suchasguarding,wincingormoaning

Notify

MDorARNPofpain

ordiscomfort

thatisnotalleviated

Providebedsideactivitiessuchas

therapeuticmassa

ge,aroma-therapy,music

ofchoice,visualimagery,anddocument

Nursing

All

96 HEALTHY SKIN

Evaluate

resident/family

needsandmake

necessary

referralsto

clergyorspiritual

supportpersonsasrequested.

Provideopportunityforprayerand

meditationsupportasindicated

Providebedsideactivitiesthatdistractthe

residentsuchas

________________________________

________________pertheresidents

preferenceandtolerance

Providehumortherapyforresidentand

family

Residentandfamily

bereavementconcerns

willbeaddressed

Contacthospiceifdesired

Provideprivate

timeforrelationshipswhile

minim

izingresidentandfamily

isolation

Chaplain

servicesprovidedasdesired

Nursing

Social

Services

Residentwillhavea

peacefuldeath

inthe

facility

inaccordancewith

expressedwishes.

Elicitorconfirm

residentorsurrogate

goals

andvaluesforlifeprolonginginterventions.

Nursing

Social

Services

RESIDENT___________________________________________________________

ROOM

NUMBER

________________________________

DATEOFADMISSIO

N__________________________________________________

PHYSICIAN

____________________________________


XXX

98 HEALTHY SKIN

Q – DT: What types of outcomes have you seen?A – PQ: We have witnessed cost containment by using theappropriate product. We’ve also seen less skin breakdown.Certainly resident and family complaints have gone down.Each care center now has a bladder scanner, which helpsto identify urinary retention. Veterans are administeredcranberry tablets for UTI prevention. We continue to lookfor a downward trend in the number of UTIs. Presently,numbers are not increasing.

Q – DT: How often does your bowel and bladder teammeet and what are your current targeted issues? A – PQ: Staff compliance is an ongoing issue. We needto provide constant reinforcement. Performing monthlyperformance improvement checks has really helped. Theteam also receives budget versus spending informationfrom the business office so if incontinence costs haveincreased, we can track down and solve the problem.Currently, the team is meeting monthly in order to gaincontrol of product compliance with the main issue beingthe misuse of the overnight (high-capacity) brief.

Q – DT: What are some of your concerns regarding theuse of your high-capacity brief?A – PQ: The overnight brief is extremely absorbent andcan hold very large voids, which is fantastic. But our staffwas misusing this brief, using them on all veterans insteadof targeting those who really needed them. Subsequently,costs went up. It became a compliance issue on all shifts.It might be partially due to poor performance on the partof a few staff members who did not want to change veteranswhen incontinent. The team has implemented a tool titledGuidelines for Use of Overnight/High Capacity Brief (seeForms & Tools page 90). It integrates the following com-ponents: the veteran’s diagnosis (e.g., diabetes, CHF, tubefeedings) and medication regimen (e.g., diuretics, behav-ioral issues, wandering during sleep). We identify thosewho qualify for use of the overnight brief. Then weinclude justification within the care plan with rationale,including prevention of sleep deprivation, maintenanceof skin integrity and preservation of veteran dignity.Currently, performance improvement data has shownmarked improvement, with 100 percent compliance inthe last two months.

Q – DT: Not all facilities have access to bladder scanners.How do you use them? A – PQ: We use our bladder scanner as part of the resident’sadmission assessment to test for overflow incontinence bymeasuring the post-void residual (PVR). We are lucky to

have a urology clinic within the outpatient portion of thefacility. The urologists frequently request our staff to checkfor PVR. We also can use the bladder scan if a veteran hasnot voided in eight hours. If the reading is greater than250ml, a straight catheter is used to relieve retention. Tomeet the needs of our population, administration supportedthe purchase of bladder scanners for all four care centers.

Q – DT: What areas do you see your committee workingon in the future?A – PQ: Toileting residents is still an area that can alwaysbe improved, particularly since our building design doesn’tinclude as many bathrooms as we’d like. It’s interesting tothink about how times have changed. Years ago our prima-rily male population could hang plastic urinals on theirwheelchairs no matter where they went. This resulted inmore self-toileting, but the filled urinals were everywhere!Currently, our staff focus is to know a resident’s individualvoiding pattern so that even if he is off the floor, we cantrack him down whether to help him with the bathroomor to check and change him.

The future for us holds even more resident-centered careas we embrace culture change and train our staff using theLEAP* program, which is resident driven. The bowel andbladder team will continue to meet regularly and tackleproblems as they come up.

*LEAP is a program designed by Mather LifeWays to educate, empower

and retain staff by using a resident-centered approach.

Healthy Skin Interview: Success Stories with Incontinence Care continued from page 25

Word Search Answers

This is one offer too good to passup. Now you can take any of morethan 50 CEU credit courses online.Choose any three and receive a FREE Ami Doll.

We Have toHand it toYOU...

Visit www.medlineuniversity.com to learn more.

FREE Ami Doll!With the purchase of any three

Medline University courses.

Only $19.95 for all three!

Limited-time offer. Three courses must

be fee-based courses.

MKT206318/LIT535/20M/MOR5

healthy skin magazine - volume 3; issue 4

Documents