healthy skin magazine - volume 4; issue 2

Improving Quality of Care Based on CMS Guidelines

Volume 4, Issue 2

“DR. MARLA”

How to bearSKIN

TEARS

10Top IssuesAffecting YourPracticeTake the survey today!

RESPECT:What does itmean to you?

battlesbreastcancer FREE CE!PAGE 18

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2 HEALTHY SKIN

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3Improving Quality of Care Based on CMS Guidelines

Page 23

Page 60

4

Page 78

Survey Readiness20 Untangling the Terms48 Wound Care Competency Day60 Love ThemTwoTimes

Treatment12 Understanding Skin Tears22 What’s That Noise?34 Seat Cushions40 Taking the Fear out of Male Catheterization45 If the Shoe Fits…53 Perineal Skin Care for the Incontinent Resident54 Case Study: Using Olivamine in a Skin Cream to Improve

Skin Quality in Diabetic Patients56 Easing the Pain

Special Features5 Top 10 Issues Affecting Your Clinical Practice Today Survey6 Two Important National Initiatives for Improving Quality of Care11 Advancing Excellence Campaign Goals26 The Perils of Ineffective Handwashing31 The Key to Hand Hygiene38 Incontinence64 Anurse inWOUNDerland74 Sharpening the Saw

Forms & Tools88 Guidelines forWound Photography89 Prevention of Skin Tears – In-Service Outline90 Bates-JensenWound Assessment Tool92 PUSHTool 3.094 Quick Guide to LabValues95 Foley Catheter Selection Guide

Regular Features4 Letter from the Editor8 News Flash16 CE-Credit Crossword Puzzle: Understanding Skin Tears51 Hotline Hot Topic58 Product Spotlight: Silicones

Caring for Yourself70 Respect78 “Dr. Marla” Battles Breast Cancer84 Best Day/Worst Day86 Recipe: Berries & Cream Pound Cake

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 Web site, www.medline.com.

HEALTHY SKIN

Editor

Sue MacInnes, RD, LD

Clinical Editor

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

Clinical Team

Cynthia A. Fleck, RN, ET/WOCN,CWS, DAPWCA, MBA, FCCWS

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

Joyce Norman, RN, CWOCN, DAPWCA

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

Carol Paustian, RN, ET, CWOCN,DAPWCA

Amin Setoodeh, RN

Deb Tenge, RNC, MS, CWOCN,Licensed Administrator

Jeannine Thompson, RN, CWOCN

Jackie Young, RN, ET, CWCN, DAPWCA

Wound Care Advisory Board

Mona Baharestani, PhD, ANP, CWOCN,FCCWS, FAPWCA

Ann Blackett, MS, RN, COCN, CWCN,CPHQ, CNS

Patricia Coutts, RN

Pat Emmons, RN, MSN, CNS, CWOCN

Cindy Felty, RN, CNP, MSN, CWS, FCCWS

Lynne Grant, CNS, MS, RN, CWOCN

Teresa Kellerman, MSN, ARNP, WOC/CNS

Bette Kussmann, RN, CWCN, COCN

Andrea McIntosh, RN, BSN, CWOCN, APN

Cathy Milne, MSN, APRN, CS, CWOCN, ANP

Laurie Sparks, RN, ET

Shelia Thomas, RN, CWOCN

Dot Weir, RN, CWCN, COCN, CWS

Lynne Whitney-Caglia, RN, MSN, CNS, CWOCN

Laurel Wiersema-Bryant, RN, BC, ANP

Linda Woodward, RN, OCN, CWOCN

Improving Quality of Care Based on CMS Guidelines

Contents

© 2007 Medline Industries, Inc. Healthy Skinis published by Medline Industries, Inc.One Medline Place, Mundelein, IL 600601-800-MEDLINE (633-5463)

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DEAR READER,

Recently, CMS released the final PPS rule forhospitals. This is a significant policy changethat will ultimately improve the quality ofcare by no longer paying for preventableconditions that are acquired in hospitals.These conditions include pressure sores,UTIs and falls.

What do you think will happen next? It’sonly a matter of time before reimbursementfor LTC and home health are also centeredaround patient outcomes and more cost-effective healthcare by putting the focus onprevention. Patient hand-off between health-care providers will be a major focus in thefuture. To that end, we intend to continueto bring you industry news and examplesof successful collaborations. We invite youto share your experiences – both goodand bad – so that others can learn andbenefit. Please feel free to contact me [email protected] with anythingyou would like to share.

Once again included in this edition are thekey initiatives in home health and long-termcare (see Page 6). Notice the icons at thebottom of this page. You will see these iconsthroughout the magazine whenever anarticle supports one of these quality goals.Then, on Page 11, follow the crosswalk ofnational initiatives. The Web site addressesof these organizations are provided so thatyou can explore the resources available toassist you in your practice.

If you would, please take a moment tocomplete the survey on the following pageand tell us your biggest challenges. Wewant to direct future content to address yourpressing concerns by first sharing the resultsin our next issue and then by tailoring futurearticles to give you those practical solutionsthat target your needs.

We know that your concerns on the jobalso include daily interactions with peersand motivating your staff. To that end,we’ve included an article titled “Respect” toremind us of how important it is to managethe interaction between our co-workers andprofessionals from other healthcare entities.

Finally, we are thrilled to feature an articleby Dr. Marla Shapiro, the well-knownCanadian physician, columnist, TV personalityand breast cancer survivor, to inspire us allto remember the importance of our familiesand friends. Her story is touching and hermessage a wake-up call to take care ofourselves and to balance our lives betweenour work, family and self.

Best regards,

Sue MacInnes, RD, LD

4 HEALTHY SKIN

We all can agreethat we should dothing right ... butit is our goal tomake it hard forthe healthcareworker to dothings wrong.

HEALTHY SKIN I Letter from the Editor

Content KeyWe’ve coded the articles and information in this magazine to indicate which National Qualityinitiatives they pertain to. Throughout the publication, when you see these icons you’ll knowimmediately that the subject matter on that page relates to one or more of the followingnational initiatives:• QIO – Utilization and Quality Control Peer Review Organization• Advancing Excellence in America’s Nursing Homes

We’ve tried to include content that clarifies the initiatives or give you ideas and tools for imple-menting their recommendations. For a summary of each of the above initiatives, see Page 6.


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Healthy Skin wants to hearwhat you, our readers, thinkare the top 10 most importantissues in your practice today!And for your time and effort,we will send you an Angelnurse doll. Go towww.medline.com/healthyskinto complete the survey.

Affecting Your ClinicalPractice Today

Simply go to the Internet and type in www.medline.com/healthyskinClick on Top 10 Issues Survey.

Rank your top 10 issues and concerns from one to 10.

Issues affecting your practice:

Survey Process

Reimbursement

Wound Care Product Selection

Aging Facilities

Liability Claims

Staffing

Resident and Family Satisfaction

Staff Development

Supply Management

Fall Prevention

Safety/Risk

Infection Prevention

Cost Control

Pressure Ulcer Prevention

Patient Handoff

Census

Incontinence

Pain Management

Additional issues:

When you have completed the survey, just click enterand your answers will be submitted for calculation.Deadline for submission is October 31, 2007. Checkout the results in the next issue of Healthy Skin.

We want to hear from you!

To take the survey and receiveyour Angel doll, go to

www.medline.com/healthyskin

12

3

Please select one that best describesyour area of practice:

Home Health

Nursing Home

Wound Clinic

Hospital

Hospice

Other


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6 HEALTHY SKIN

Two Important National Initiativesfor Improving Quality of Care

Achieving better outcomes starts with an understanding of current qualityof care initiatives. Here’s what you need to know about national projects andpolicies that are driving changes in nursing home and home health care.

Origin: The QIO Statement of Work (SOW) is based on Part B of Title XI of the Social Security Act. The QIO is currentlyoperating within its 8th Round SOW contract cycle, which started in August 2005 and will be in effectuntil July 2008.

Purpose: In the 8th Round SOW, QIOs are expected to provide assistance to providers that enable them to develop thecapacity for and to achieve the vision that every person receives the right care every time.

Goal: CMS has identified a set of Breakthrough Priorities for improvement. The purpose of these Breakthrough Prioritiesis partly to improve care, but more importantly to transform the expectations of participants in improvement bymaking very substantial improvement a fully credible ambition.

Quality Improvement Organization (QIO) Program’s 9th Scope of WorkThe Centers for Medicare and Medicaid Services’ Office of Clinical Standards will be seeking comments beginningSeptember 2007 on the Quality Improvement Organization (QIO) Program’s proposed 9th Scope of Work. The 9th Scope,which begins on August 1, 2008, will run through July 31, 2011.

Information about the 8th Scope of Work is provided at http://www.cms.hhs.gov/QualityimprovementOrgs/04_9thsow.asp.

Origin: A new coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursinghome residents and staff.

Purpose: A coalition consisting of the Centers for Medicare and Medicaid Services (CMS), organizations representing providers,consumers and government that developed a grassroots campaign to build on and complement the work of existingquality initiatives including Nursing Home Quality Initiative (NHQI), Quality First and the culture change movement.

Goal: To ensure that continuous quality improvement is comprehensive, sustainable and consumer-focused, the coalitionhas adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfactionsurveys into continuing quality improvements and increase staff retention to allow for better, more consistentcare for nursing home residents.

Participating providers will commit to focusing on at least three of the eight measurable goals, including at leastone clinical goal and one operational/process goal.

Advancing ExcellenceThe Advancing Excellence in America's Nursing Homes campaign kicked off in the fall of 2006 at a national NursingHome Quality Summit in Washington, D.C. 5,705 facilities nationwide have committed to work on at least three ofthe campaign's goals.

To download the Advancing Excellence tool kit, go to www.ahca.org/quality/ae.cfm

QIO UTILIZATION AND QUALITY CONTROL PEER REVIEW ORGANIZATION8TH ROUND STATEMENT OF WORK1

ADVANCING EXCELLENCE IN AMERICA’S NURSING HOMES2


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Trends in Goal SelectionEach nursing home participating in Advancing Excellence selects a minimum of three goals (outlinedabove). The goals – and the percentage of participating nursing homes that have selected them –are listed below.

Goal 1: 68.6% Goal 5: 2299..77%%Goal 2: 42.4% Goal 6: 65.2%Goal 3: 53.6% Goal 7: 39.6%Goal 4: 39.7% Goal 8: 33.5%

Stay tuned! First year results will be published in the January 2008 issue of Healthy Skin!

As of September 1, goals 1, 3 and 6 have the highest participation rates.

Clinical Goals:Goal 1: Reducing high-risk pressure ulcersGoal 2: Reducing the use of daily

physical restraintsGoal 3: Improving pain management for

longer-term nursing home residentsGoal 4: Improving pain management for

short-stay, post-acute nursing home residents

Operational/Process Goals:Goal 5: Establishing individual targets for

improving qualityGoal 6: Assessing resident and family

satisfaction with quality of careGoal 7: Increasing staff retentionGoal 8: Improving consistent assignment of

nursing home staff so that residents receive care from the same caregivers


Special Features

Task 1a: Nursing Home -Clinical Performance measures• High-risk pressure ulcers• Physical restraints• Management of pain in chronic

(long-stay) residents• Management of depressive symptoms

Organizational Change and Process Improvement Measures• Conduct annual employee

satisfaction surveys• Conduct annual resident

satisfaction surveys• Calculate annual CNA turnover rates

Task 1b: Home Health -Clinical Performance measures• Improvement in bathing• Improvement in transferring• Improvement in ambulation/locomotion• Improvement in management of

oral medications• Improvement in pain interfering

with activity• Improvement in status of surgical wounds• Improvement of dyspnea• Acute care hospitalization• Discharge to community• Improvement in urinary incontinence

QIO UTILIZATION AND QUALITY CONTROL PEER REVIEW ORGANIZATION 8TH ROUND STATEMENT OF WORK

ADVANCING EXCELLENCE IN AMERICA’S NURSING HOMES

TASK 1: ASSISTING PROVIDERS IN DEVELOPING THE CAPACITY FOR AND ACHIEVING EXCELLENCENATIONAL CAMPAIGN

CLINICAL AND OPERATIONAL/PROCESS GOALS

Check out the Web sites for these initiatives! 8th Statement of Work: www.cms.hhs.gov/qualityimprovementorgsAdvancing Excellence: www.nhqualitycampaign.orgAmerican Health Care Association: www.ahca.org

Progress reports will be posted on www.cms.hhs.govfor both campaigns beginningSeptember 2007


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CMS Releases Inpatient PPS Final Rule for 2008Will this impact resident-centered care?On August 1, 2007, the Centers for Medicare & Medicaid Services (CMS) released the inpatient prospective payment system(PPS) final rule for fiscal year (FY) 2008. The policies and payment rates included in this rule become effective October 1, 2007.

The rule adopts eight conditions, including three serious preventable events, for which CMS will not provide higher payments ifthe selected event occurs while a patient is under the care of the hospital. The changes will take effect for FY 2009 and willinclude:

• Object left in surgery• Air embolism• Blood incompatibility• Catheter-associated urinary tract infections

CMS will continue its three-year transition to cost-based relative weights, with two-thirds of the FY 2008 weight based on costs and one-third based on charges.

Consider your resident population and the continuum of care with regard to transfers both to and from acute-care settings. A display copy of the document is available at http://www.cms.hhs.gov.

CMS Issues Revised Guidance for F323 – Accidents & Supervision

The Centers for Medicare & Medicaid Services (CMS) has issued revised guidance for Accidents and Supervision (Tag F323) thatbecame effective on August 6, 2007. The revised guidance combines Tags F323 and F324 into one tag, F323.

According to the Survey & Certification Memorandum that accompanies the guidance, the interpretive guidelines clarify areas such asresident supervision, hazard identification and resident risk, falls, unsafe wandering/elopement, environmental assessment of hazardsand resident-to-resident altercations.

For complete information, please refer to the actual guidance and training materials, available at www.cms.hhs.gov.

Supervision:This section includes two behaviors for which a facility may provide supervision: Resident smoking and resident-to-resident altercations.

Hazard Identification and Resident Risk:Resident Vulnerabilities:

• Falls• Unsafe wandering or elopement• Physical plant hazards• Chemicals and toxins• Water temperature• Electrical safety• Lighting• Assistive devices/equipment hazards• Assistive devices for mobility

• Pressure ulcers• Vascular catheter-associated infections• Mediastinitis after coronary artery bypass graft• Falls

Deficiency CategorizationActual or potential harm/negative outcome for F323 may include, but is not limited to:

• Injuries sustained from falls and/or unsafe wandering/elopement;

• Resident-to-resident altercations;• Thermal burns from spills/immersion of hot water/liquids;• Falls due to environmental hazards;• Ingestion of chemical substances; and • Burns related to smoking materials.


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Update onHAIs from CDC:A new report from the Centers forDisease Control and Prevention(CDC) contains the following updatedestimates of healthcare-associatedinfections (HAIs):

• An estimated 1.7 million infections and 99,000 associateddeaths occur each year

• Equivalent to 1 death every 6 minutes

• Annually add $5 – $6.7 billionto U.S. healthcare costs

• Types of infections:— 32 percent of all

healthcare-associated infections are urinary tract infections

— 22 percent are surgical site infections

— 15 percent are pneumonia (lung infections)

— 14 percent are bloodstream infections

Hand hygiene is one way todecrease the spread of infection.Learn how to make hand hygiene asuccess in your facility by reading“The Perils of Ineffective Handwashing”and “The Key to Hand Hygiene” onpages 26 and 31.

Reference:The Centers for Disease Control andPrevention. Estimates of Healthcare-Associated Infections. Available at:www.cdc.gov/ncidod/dhqp/hai.html.Accessed August 23, 2007.

Held June 23 to 27, 2007 this year’s conference and exposition hadmore than 800 in attendance.

Kicking off the event was the keynote speaker, Andrea Higham,Director of Corporate Equity and the Johnson & Johnson CampaignFor Nursing’s Future, which highlighted “The Promise of Nursing.” Thissession was not only inspirational; it also set the tone of the conferenceand emphasized the bright future of nursing.

Molly Morand, President of the Morand Group, LLC was once again on hand to deliver her presentation titled “Just Say No to MandatoryIn-Services” to a packed audience.

“Compassion Fatigue – Preparing Professionals to be Resilient”explored the signs and coping measures for compassion fatigue andoffered strategies to assist in developing resiliency. This session waspresented by Barbara Rubel, MA, BCETS, CBS, CPBC, ExecutiveDirector of the Griefwork Center, Inc.

Medline Industries, Inc. introduced their revolutionary educationalpackaging (EP Packaging) for advanced wound care to all DONs(Directors of Nursing) who attended this meeting.

With more than 6,000 members, The National Association Directors of Nursing Administration in Long-Term Care, or NADONA/LTC, is thelargest educational organization committed exclusively to nursing andadministration professionals in the Long-Term Care and Assisted-Living professions.

Mark your calendars for June 21 to 25, 2008 when the 22nd AnnualNADONA/LTC National Conference will be held in Nashville,Tennessee at the Gaylord Opryland Hotel and Conference Center.

National Conference, Caesars Palace, Las Vegas, Nevada

Celebrating the 21st AnnualNADONA/LTC

www.cdc.gov

NADONA/LTC attendees share their

knowledge.


How 4 square inches of Puracol Pluschanged chronic wound care.

Forever.

This is Puracol Plus Micro-Scaffold as seen through anelectron microscope. Its open,cellular structure allows easyfibroblast migration.2 The highstrength of the MicroScaffold2

also assists in establishing afresh wound bed.

Each Puracol package, likeevery other Medline wound carepackage, is a 2-Minute Course™

in Advanced Wound Care.

Look closely. It’s not a bandage. It’s Puracol™ PlusMicroScaffold™, made entirely of pure native collagen.

Chronic wounds tend not to heal when unbalanced levelsof elastase and MMPs (inflammatory enzymes) destroythe body’s own collagen and growth factors.1

But apply Puracol Plus and help restore nature’s balance.

In vitro studies show that Puracol Plus has the abilityto reduce the levels of elastase and MMPs fromsurrounding fluid.2

1. Schultz GS, Mast BA. Molecular analysis of the environ-ment of healing and chronic wounds: Cytokines, proteases,and growth factors. Wounds. 1998;10 (6 Suppl): 1F-9F.2. Data on file.



Advancing ExcellenceCampaign Goals:A cross-reference outlining the clinicaland performance goals included in allfour National Initiatives in long-term care.

Did you know all of the National Initiatives are closely related?There are currently four national initiatives striving to improve the quality oflong-term care in America:

• American Health Care Association’s (AHCA) Quality First - www.ahca.org• Nursing Home Quality Initiative’s (NHQI) QIO Goals - www.cma.hhs.gov• Nursing Home Culture Change Movement - www.nccnhr.org• Advancing Excellence in America’s Nursing Homes - www.ahca.org

To learn more about each initiative, you are invited to visit each group’s Website, where they offer detailed information and educational tools.

Goal Quality NHQI Culture AdvancingFirst QIOs Change Excellence

Pressure Ulcers X X X

Physical Restraints X X X

Chronic Pain X X X

Post Acute Pain X X X

Setting Targets X X

Customer Satisfaction X X X X

Staff Turnover X X X X

Consistent Staffing X X

Special Features


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12 HEALTHY SKIN

Reprinted with permission from EPCN

Treatment




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16 HEALTHY SKIN



XXX

17 HEALTHY SKIN

OOUURR TTEEAAMM IISS BBEEHHIINNDD YYOOUU

As the primary supplier to more than 2,700 home health

care agencies nationwide, we know what you require

from a strong business partner. That is why Medline

HomeCare provides innovative solutions for supply

management, clinical support and ongoing training,

flexible financing and world-class medical products. It’s

like a whole team is supporting your staff during

every visit.

EEVVEERRYY SSTTEEPP OOFF TTHHEE WWAAYY

To learn more aboutMedline’s Total SupportProgram, call us at 1-800-678-7852 or e-mailus at [email protected]

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

©2007 Medline Industries, Inc.


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Crossword Puzzle

Understanding Skin Tears:the “Whys” and “Hows”

To receive one hour of

CE credit, enter your

answers online at

www.medlineuniversity.com

www.medlineuniversity.com1. Register (free) or log in2. Click Free Courses tab3. Locate the puzzle and click

Learn More, then Begin Course4. Certificates are available online

after puzzle completion


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Across2 Choose dressings that keep the wound

optimally moist without causing further

_____.

5 Between the epidermis and dermis is the

_____ membrane, a moving junction that

both separates and attaches the epidermis

and the dermis.

6 Keeping the patient well _____ can be the

difference between a bruise, a bump and a

skin tear.

7 Remember key measures such as cleaning,

moisturizing and nourishing the skin with

advanced skincare _____.

10 There are several _____ products that can

help alleviate the discomfort of skin tears.

11 As skin ages, the rete ridges or pegs begin

to _____ between the dermal-epidermal

junctions.

13 When injury occurs, there is an increase in

_____ absorbed by the skin.

15 Skin tears cause a resident to suffer _____.

16 Certain medications, such as _____, can

make the skin more prone to injury.

18 The use of protective sleeves or elastic

tubular support bandages can help to

_____ dressings in place.

19 The dermis has _____ projections.

20 It is estimated that at least 1.5 _____ skin

tears occur in institutionalized elderly each

year.

21 One dressing that can handle the initial

fluid is a _____ sheet.

Down1 The dermis and epidermis move as one in

_____ young skin.

3 Skin tears occur most commonly in the

_____ extremities.

4 It is _____ to look at dressing choices and

choose products that allow you to avoid

adhesives, decrease dressing changes and

maintain a moist wound healing environment.

6 Advancing age and a _____ of previous

skin tears put residents at risk for skin tears.

8 To protect the injury during dressing

change, indicate the _____ in which the

dressing should be removed.

9 The _____ has an irregular shape

resembling downward, finger-like projections

called rete ridges or pegs.

12 _____ skincare products that deliver

endermic nutrition and antioxidants can

assist in preventing skin tears.

14 _____ handling of skin tears in important.

16 Dermal-epidermal flattening is typically

seen by the _____ decade of life.

17 Hydration and the appropriate _____ are

the key objectives to healing and

preventing skin tears.

19 Skin tears of _____ origin make up one half

of the total skin tear population.

21 Patients and residents who are totally

dependent on others for activities of daily

living are at the _____ risk for skin tears.

22 Compromised nutrition, fluid volume deficit,

confusion, limitations in mobility, lack of

independence and ecchymotic skin are all

_____ for skin tears.


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20 HEALTHY SKIN

Prevalence or incidence?

Prevalence refers to the proportion of a population

(such as nursing home residents) who are affected with

a particular disease at a given time.

Incidence refers to the rate of occurrence of new cases

of a particular disease in the population being studied.1

Avoidable or unavoidable pressure ulcer?

Avoidable pressure ulcer refers to a facility’s failure to

do one or more of the following: evaluate the resident’s

clinical condition and pressure ulcer risk factors; define

and implement interventions that are consistent with

resident needs, resident goals and recognized standards

or practice; monitor and evaluate the impact of the inter-

ventions or revise the interventions as appropriate.

Unavoidable pressure ulcers occur despite the facility

evaluating the resident’s clinical condition and pressure

ulcer risk factors; defining and implementing interventions

consistent with resident needs, goals and recognized

standards of practice; monitoring and evaluating the impact

of the interventions and revised approaches as appropriate.2

Mattress overlay or mattress replacement?

Mattress overlays are pressure-reducing support sur-

faces placed on top of an existing mattress. They can be

filled with air, foam, gel, water or a combination thereof.

Mattress replacements, also pressure-reducing support

surfaces, are made of high-quality foam or other materi-

als and actually replace the inner-spring mattress directly

on the bed frame. They provide pressure relief that is not

possible with standard hospital mattresses.3

Friction or shear?

Friction refers to resistance to movement.

Shear refers to disruption of the connection between soft

tissue and bone.3

References1 Merriam-Webster’s Medical Dictionary. Available at: www.m-w.com. Accessed August 15, 2007.2 Centers for Medicare & Medicaid Services. CMS Manual System: Pub. 100-07 State Operations. Available at: www.cms.hhs.gov/transmittals/downloads/R4SOM.pdf . Accessed August 15, 2007.

3 Medline Industries, Inc. The Wound Care Handbook. 2007.

Can you explain the differences between these commonly confused terms?

Survey Readiness



What’s that noise?Your guide to assessinglung sounds

Know what’s normalLarge populations of geriatric patients have some type of a respiratorydiagnosis. Chronic obstructive pulmonary disease (COPD), emphysema,asthma and congestive heart failure (CHF) can all affect normal lungsounds. It is important to note what patients’ normal lung sounds are,especially since patients with limited mobility are prone to respiratoryinfections. Assessing patients’ lung sounds on a daily basis can helpyou know right away when something isn’t “normal.”

Assessment should include breath sounds, respiratory rate, heart rateand respiratory pattern. If the patient has a cough, note if it is dry orproductive. If the patient has a productive cough, note the color, textureand amount of sputum produced. Also check the patient’s oximetry fora baseline.

Hints for listeningAuscultation of lung sounds should be done in a quiet environmentwhenever possible. The patient should be sitting up in bed. If this is notan option, lung sounds may be assessed with the patient lying on theirside. Breath sounds are best heard when there is no interference fromclothing, so place the stethoscope on the patient’s bare skin.

Auscultation should be done on all lobes, moving from left to right for aminimum of two to four breaths. This enables comparison of the lobes toeach other and time to listen for abnormal or adventitious sounds.

Staff development coordinators frequently ask for in-service on lung sounds and how to document them.Rales, rhonchi and wheezes can be confusing and difficult to describe. Tear out this article to help youunderstand what you are hearing and what thesesounds mean for your patients’ health and care.

By Ellie Armstrong, LPN

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24 HEALTHY SKIN

Bronchial or vesicular?Normal lung sounds are described as bronchial or vesicu-lar. Bronchial sounds are what are heard over the largeairways. These sounds have been compared to the soundof air being blown through a tube. They are louder at theexpiratory phase. Bronchial sounds can be heard over thetracheal area, over the lung apices and between thescapulas.

Vesicular sounds are heard over the chest, away fromlarge airways. These sounds have been compared to thesound of wind blowing through the trees. Vesicular soundsare decreased in patients with COPD and over sites of pneumonia.

Absent or diminished?Abnormal breath sounds are classified as absent ordiminished. Absent breath sounds are just what the namesuggests – they are inaudible. Diminished breath soundshave softer-than-typical loudness. These sounds canreflect reduced airflow to a portion of the lungs, overinfla-tion of a segment of the lungs (such as with emphysema),air or fluid around the lungs and even increased thicknessof the chest wall. A decrease in the intensity of sounds ina given area can be the first sign of a disease process.

“Adventitious” another word for “abnormal”Rales, rhonchi and wheezes are the most common ofadventitious lung sounds. Pleural rubs and stridor are alsoclassified as adventitious, but are less commonly heard.

Rales, also called crackles, are caused by the explosiveopenings of small airways. They have been described asbeing similar to the crackling sound that wood makes as itburns. Crackles are most commonly heard during theinspiratory phase of breathing, although they can beheard during the expiratory phase also. Crackles areassociated with inflammation or infection of the smallbronchi, bronchioles and alveoli. Crackles that don’t clearwith coughing might indicate pulmonary edema or fluidtrapped in the alveoli due to CHF or ARDS.

Crackles can be categorized as fine or coarse. Fine crack-les are generally higher pitched, less intense and shorterin duration than coarse crackles. Fine crackles are usuallyheard in the late inspiratory phase. The sound of finecrackles can be simulated by rolling a strand of hairbetween fingers near the ear.

Coarse crackles are usually louder, lower in pitch andlonger in duration than fine crackles. The most commonconditions associated with coarse crackles are CHF andbronchitis. Coarse crackles have been described as similarto the sound opening a Velcro® fastener would make.

Rhonchi are continuous sounds, as they usually last morethan one quarter of a second. Rhonchi can be describedas a coarse rattling sound, somewhat like snoring, andare usually caused by secretions in the larger airways.They usually clear with coughing. These sounds can beheard in patients with chronic COPD and acute orsevere bronchitis.

Wheezes are high-pitched whistling sounds oftendescribed as musical. Bronchospasm, airway edema,secretions, endobronchial tumors and compression of theairway can cause this adventitious sound. It might also beheard in patients with CHF due to increased fluid in theperibronchial lymphatics, causing airway compression.

Know your residentThe lung sounds described above are the most commonlyheard lung sounds. Knowing your residents’ normal lungsounds and being able to assess changes will be avaluable tool for their care.

About the authorEllie Armstrong, LPN, regularly in-services healthcareprofessionals on the proper way to listen to, describe anddocument lung sounds in long-term care facilities. Shehas been an LPN for more than 26 years and currentlyserves as head of the clinical department at Enos HomeOxygen and Medical Supply, Inc.

October 7 – 10, 2007 Boston, MA, Hynes Convention Center

Make plans now to attend or exhibit at the AHCA/NCAL/MECF 58th Annual Convention and Exposition—where knowledge meets practice. Don’t miss your biggest opportunity to join your fellow quality care providers and leading long term care suppliers to learn, to plan, and to connect with over 3,500 professionals. • Learn how knowledge meets practice by networking with over

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knowledge meets practice through an array of products, services and demonstrations.

• Hear how knowledge meets practice through our stimulating general sessions and thought-provoking educational seminars.

So join us in Boston, for the premier long term care event of the year!

For more information, visit www.AHCAconvention.org,

www.NCALconvention.org or call 202-842-4444

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SAVE THE DATE!


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October 7 – 10, 2007 Boston, MA, Hynes Convention Center

Make plans now to attend or exhibit at the AHCA/NCAL/MECF 58th Annual Convention and Exposition—where knowledge meets practice. Don’t miss your biggest opportunity to join your fellow quality care providers and leading long term care suppliers to learn, to plan, and to connect with over 3,500 professionals. • Learn how knowledge meets practice by networking with over

3,500 of your peers in sharing ideas, challenges and successes.• Meet over 300 leading suppliers who will show you how

knowledge meets practice through an array of products, services and demonstrations.

• Hear how knowledge meets practice through our stimulating general sessions and thought-provoking educational seminars.

So join us in Boston, for the premier long term care event of the year!

For more information, visit www.AHCAconvention.org,

www.NCALconvention.org or call 202-842-4444

Co-Hosted by

SAVE THE DATE!


creo

By Scott A. Kale, MD, JD, MS

26 HEALTHY SKIN


staphylococcal

klebsiella

Bacteria, viruses and fungi are everywhere. They are on the walls, in the

beds and on the sinks. They are on the sheets, the gowns and the books.

Although I could go on with this travelogue of the residences of infectious

organisms, let’s talk about the one place we least want these creatures

lurking – our hands. These creatures are on the hands (and the clothing

and jewelry) of the doctors, the nurses, the clerks, the visitors. They are

ubiquitous and they are dangerous.

What’s the problem?An estimated 103,000 people die every year from healthcare-acquired

infections related to poor staff hygiene. This is a greater annual cause

of mortality than AIDS, breast cancer and automobile accidents

combined. Nearly 75 percent of patient rooms are contaminated with

a drug-resistant staphylococcal organism. Fewer than 50 percent of

physicians wash their hands between patients, let alone wash them

properly. Programs emphasizing hand hygiene have been largely ineffective

and beneficial doctor-nurse “debugging” behaviors remain elusive.

The increased use of alcohol-based hand rubs (the use of which is

standard practice in European hospitals) has improved the rate of hand-

washing compliance somewhat, but even these products must be used

intelligently (before each contact), in the proper volume (3ccs), for the

requisite period (18 seconds to 27 seconds, compared to one to two

minutes for soap) and over the necessary surfaces (hands and wrists).

One would think that medical school training and passing knowledge

of germ theory and simple handwashing strategies would conspire to

eliminate iatrogenic risks. One would be wrong.

Americans are not big handwashers in the first place (only 83 percent

wash their hands after using a restroom, for example, and more than

40 percent don’t wash after coughing or sneezing) or they wash incorrectly

(for fewer than 20 seconds) when they bother to wash at all.

Take a second to think about the average healthcare facility.


Special Features


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Influenza A

pseudomonasWhile they are not diligent or reliable

hand-washers, Americans are enthusi-

astic handshakers, and thereby cordially

pass on their shigella (diarrhea), kleb-

siella (wound infections), Haemophilus

(conjunctivitis), E. coli (urinary tract

infections), pseudomonas (infections),

bacteroides (infection), Influenza A

(pneumonia), Clostridium difficile

(colitis), assorted rhinoviruses (upper

respiratory infections/colds) and

staphylococcus (infection), among

other critters. Apparently, physicians

and nurses – being typical American

workers – have chalked up their own

set of dire statistics by disregarding

handwashing, as evidenced by the

outrageous iatrogenic death rates

in hospitals.

What’s the solution?So, what can we do? Certainly, the

problems associated with ineffective

hand hygiene are well recognized.

Even the Illinois General Assembly has

expressed concern, introducing a bill

in February 2007 that would require

schoolchildren to wash their hands

with antiseptic soap before eating.

Politicians, including President Bush,

Vice President Cheney, Al Gore and

Barack Obama carry hand sanitizers

with them at all times to help reduce

their risk of infection during glad-handing

season (which is now perpetual).

Scandinavian countries have been more

successful than the United States at

reducing deadly infections in healthcare

facilities because of a willingness of

their staffs to follow infection risk-

reduction protocols, obey mandated

cleaning of rooms and equipment,

wear disposable gowns and, of course,

wash their hands. American healthcare

administrators contend that enforcing

cleanliness rules is too expensive and

difficult. Apparently, it is easier and

perversely acceptable to allow one in

20 hospital patients to contract an

infection than it is to solve the infection

problem with its associated human and

financial losses.

There has been a visible public move-

ment toward self-protection. DVDs,

books and the Internet all tout aggres-

sive methods of keeping yourself – and

your loved ones – safe in healthcare

facilities. It would appear too few

people are taking advantage of them.

Perhaps we should enlist patients

and their families to help eradicate

infection risk. Residents can speak up

and tell their caregivers that they want

doctors to have clean hands before

touching them. We have actually creat-

ed a large blue button printed with

“Please wash your hands, my health

depends on it” that can be fastened to

patient gowns. Residents should also

be encouraged to speak these very

words to every caregiver with whom

they come into contact.

A large V.A. study demonstrated that

patient-initiated doctor handwashing

An estimated103,000people dieevery yearfrom HAIsrelated to poor staffhygiene.

28 HEALTHY SKIN


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rhino

Influenza A

viruses

on a surgical ward is highly effective

at reducing healthcare-acquired

infections. We have created an entire

kit (“The Advo Kit”) that is given to

each patient. It introduces these and

other proactive protective behaviors

for hospitalized people. Included in our

approach is the requirement that the

patient provide a “score” for their

caregivers. An individual score is

recorded for each doctor or nurse.

The score reflects the caregiver’s

hygiene skills, and the grades are

shared with the caregivers. The

prospect of being graded will change

behavior in the desirable direction.

It is my understanding that previous

methods have largely failed to change

the frequency and intensity of the

hand-washing behaviors of our staffs.

If it is true that more than 100,000

deaths each year is insufficient motiva-

tion to incite a change in hygiene

tactics and methods, then something

as simple as the proverbial “gold star”

or “ A+” issued to caregivers might be.

If administrative directives cannot

remediate washing performance,

perhaps simply honoring patient

requests will.

All we have to lose by trying a simple

method of behavior modification are

the germs.

About the authorScott A. Kale, MD, JD, MS, is in the privatepractice of internal medicine and rheumatol-ogy. He is an attending physician on the staffsof Rush University Medical Center and SaintJoseph hospitals. He is a Fellow of theInstitute of Medicine and the immediate pastchairman of the board of directors of the DePaul University College of Law’s healthcarepolicy division. He is also a non-practicing attorney with extensive experience in evaluating medical malpractice, including casesinvolving decubitus ulcers. His strong interestin medical risk reduction centers on usingawareness of past errors to design improvedsystems of medical care.

References:1. Widmer AF. Replace hand washing with use of awaterless alcohol hand rub? Clin. Infect. Dis.2000;31:136-143.2. Rotter M. Hand washing and hand disinfection[Chapter 87]. In: Mayhall CG, ed. Hospital epidemiol-ogy and infection control. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins, 1999.3. Chicago Tribune, Metro North section, Thursday,February 15, 2007, page 8. 4.Trick WE, Vernon MO, Hayes RA et al. Impact ofring wearing on hand contamination and compari-son of hand hygiene agents in a hospital. Clin. Infect.Dis. 2003 Jun 1;36(11):1383-90.



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Add comfort for complianceSterillium Comfort Gel’s incredible bactericidal effect doesn’t matter if the product isn’t being used! You’ll want to reach for Sterillium Comfort Gel again and again because it includes a balanced blend of moisturizing emollients that leverages technology shared with BODE Chemie by its parent company Beiersdorf AG, makers of well-known skincare products NIVEA® and Eucerin®. The result is a product proven to increase skin hydration by 14 percent in just two weeks.*

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The Key to Hand HygieneHave you tried alcohol-based hand gels?

Appropriate hand hygiene is the most importantaction that can be taken in the battle to preventcross transmission of nosocomial pathogens tosusceptible residents. Transmission of thesepathogens can lead to colonization, infectionand even death.1 Alcohol-based hand rubs arewidely considered to be the most appropriatetype of agent for every situation in which handsare not visibly soiled.2 However, several factorsneed to be considered when determining thebest possible protection for residents.

Efficacy and dosageBoth efficacy and dosage should be consideredto selecting an appropriate hand antiseptic.Hands of healthcare workers are mainly colonizedwith bacteria and yeasts.1 That is why a hand antiseptic should have the optimum efficacyagainst these pathogens. Alcohol-based gels with 85 percent ethyl alcohol fulfill the efficacyrequirements.4 Yet clinicians challenge manufac-turers to formulate with emollient technologydesigned to deliver good skin care and offsetconcerns they have with the dermal aspects of alcohol use.

Another factor is dosage. The efficacy of handantiseptics is often studied with aliquots of 3 or 5 mL, but the amounts used in clinical practice are largely unknown and it is unlikelythat they are as high as 5 mL. Recent unpublished

By Mary Beth Fry, BS, CIC

Special Features


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32 HEALTHY SKIN

evidence suggests that an aliquot as small as 2.4

mL might well be sufficient to cover both hands

with the preparation and also fulfill U.S. efficacy

requirements, especially if the preparation has

a high ethyl alcohol content. From a practical

point of view, and given the nature of the clinicians’

work environment – where time is short and

patient load is demanding – products that can

deliver required efficacy with minimal application

volume are desirable.

Dermal tolerance

Handwashing contributes to irritant contact

dermatitis on the hands of healthcare workers,

which can result in dry and rough skin, redness

and loss of integrity of the skin barrier. That

is why it is crucial to wash hands only when

absolutely necessary. In all other clinical situa-

tions, an alcohol-based hand antiseptic should

be applied to decontaminate hands. The hand

antiseptic should not be sticky and should ideally

improve the skin condition, e.g., by reducing

skin roughness or increasing skin hydration,4

which can increase the hand hygiene compliance

rate.5 If a preparation is unpleasant or uncom-

fortable to use, it will likely be rejected by health-

care workers. This can result in a low compliance

rate and, ultimately, cross transmission of noso-

comial pathogens. As a result, while implement-

ing a good hand hygiene program is intended to

have a positive impact on infection rates, product

selection decisions can lead to the opposite

effect if the products are perceived by staff to be

damaging to the skin and therefore go unused.

Easy access

In addition to being effective and gentle on

the skin, hand antiseptics must be easily and

conveniently available. Pocket bottles and wall

dispensers are two simple ways to achieve this.

A wall dispenser should be easy to use and

should be functional. In a recent study, only

77 percent of a certain type of wall dispenser

were found to be functional after 16 months.6

A malfunctioning or difficult-to-use wall dispenser

is likely to discourage healthcare workers to

perform hand antisepsis. Pocket bottles provided

to staff serve dual purposes. Their availability

leads to increased compliance and reduces the

amount of “contraband” product brought into

facilities without the necessary compatibility

testing typically required.

Key conclusions

Appropriate selection of a hand antiseptic –

including taking into account its dispensing

technology and packaging configuration – is key

in achieving optimum efficacy and comfortable

use of hand antiseptics. Meeting these goals will

likely have an impact on patient safety.

About the author

Mary Beth Fry, BS, CIC, is currently the infection

control coordinator at the University of Illinois Medical

Center, Chicago, Ill. She has more than 32 years of

experience as a clinical microbiologist and with all

aspects of infection control.

References1. Kampf G, Kramer A. Epidemiologic background of hand hygieneand evaluation of the most important agents for scrubs and rubs. Clinical Microbiology Reviews. 2004;17(4):863-893.2. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare set-tings. Recommendations of the healthcare infection control practicesadvisory committee and the HICPAC/SHEA/APIC/IDSA hand hygienetask force. Morbidity & Mortality Weekly Report. 2002;51:1-45.3. Kampf G, Rudolf M, Labadie J-C, Barrett SP. Spectrum of antimicro-bial activity and user acceptability of the hand disinfectant agent Sterillium Gel. Journal of Hospital Infection. 2002;52(2):141-147.4. Kampf G, Muscatiello M, Häntschel D, Rudolf M. Dermal toleranceand effect on skin hydration of a new ethanol-based hand gel. Journalof Hospital Infection. 2002;52(4):297-301.5. Kampf G. The six golden rules to improve compliance in hand hygiene. Journal of Hospital Infection. 2004;56(Suppl. 2) :S3-S5.6. Kohan C, Ligi C, Dumigan DG, Boyce JM. The importance of evalu-ating product dispensers when selecting alcohol-based handrubs.American Journal of Infection Control. 2002;30(6):373-375.


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34 HEALTHY SKIN

Seat Cushions:Padding YourPressure UlcerPrevention StrategyCynthia FleckMBA, BSN, RN, APN/CNS, ET/WOCN, CWS, DNC, DAPWCA, FCCWS

Diane L. HollandBS, PT, CWS, WCC, C. Ped.

Treatment



XXX

Frequently asked questionsWhy are they called “bedsores”

when pressure ulcers also occur

in seated individuals?

Approximately 68 percent of pressure

ulcers occur on the pelvis and are the

result of sitting upright.2 Clients who are

confined to a wheelchair for a significant

amount of time during the day are at

highest risk. Individuals with comorbidities

such as diabetes, renal and respiratory

failure, poor hydration and nutritional

concerns are also in danger of developing

a pressure ulcer. Even a client with good

sitting posture can experience skin

breakdown. Common locations where

pressure ulcers develop when confined

to a wheelchair are the sacral area (tail

bone) and ischial tuberosities (sitting

bones). Skin breakdown may also be

related to an individual’s body structure

and to the atrophy or loss of muscle

from nonuse.

Clients can sit in a wheelchair for more

than 16 hours a day; therefore, a combina-

tion of interventions must be implemented

and assessed when ordering a new

wheelchair cushion. The primary goal of

a wheelchair pressure redistribution device

is to evenly spread pressure over a larger

area. Pressure by itself does not cause

a pressure ulcer; peak pressures that

reduce circulation cause them. To help

prevent skin breakdown, a wheelchair

and wheelchair cushion must fit the client

in width, support the thighs and leave

two inches of space behind the knees. It

is important that the leg rest height is

correct so the client’s knees are not

positioned too high. Also, a client’s thighs

should be adequately supported. This will

distribute the pressure load and decrease

pressure on the ischial and sacral areas.

It is essential to look at issues such as

hypertonicity (high muscle tone) and

intervene to control and improve position-

ing. A client with limited range of motion

(ROM), such as decreased hip rotation,

will compensate with postural changes

in the torso. In this case physical therapy

or a referral to a positioning professional

may be needed for assessment and

wheelchair modification. Wheelchairs

with sling seat upholstery should be

discouraged when clients spend a

substantial amount of time in a wheelchair.

The sling causes internal rotation of the

femurs (legs), adduction (rolling inward)

of the lower extremity, a posterior pelvic

tilt (sliding down) and a kyphotic trunk

(slouched over) posture. Over a period of

time this can lead to decreased range of

motion, scoliosis and decreased function

and weakness in the abdominal and

spinal musculature.33,,44

What are the different types of

wheelchair cushions and which

one is the best?

There are many pressure redistributing

devices on the market that vary in cost

and quality. Most of the larger wheelchair

Pressure ulcers can occur when a client is lying down or in a

seated position. Wheelchairs and other seated surfaces, which

are sometimes an afterthought, could be the missing link in a

comprehensive care plan that mandates individualized care.

CMS Tag F314states, “Appropriatesupport surfaces ordevices should bechosen by matchinga device’s potentialtherapeutic benefitwith the resident’sspecific situation.”1

1

2


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36 HEALTHY SKIN

Why do some wheelchair cushions

need a piece of wood inserted

beneath them?

The upholstery in wheelchairs “slings” or

“sags” when you sit on it. A cushion will

also sag and cause poor positioning by

producing internal rotation and adduction

of the femurs, which causes torso insta-

bility. The wood or solid seat insert will

decrease the amount of sag in the wheel-

chair, improving the foundation and the

client’s posture. Some wheelchairs have

solid frames and do not fold; therefore, a

solid wood insert is not needed.

I didn’t realize the number of cushions

that are available and the various uses

for them. Is there any way to make it

less confusing?

Wheelchair cushions can be confusing

and wheelchair positioning and pressure

relief is a specialty in its own right.

Choice is important because a cushion

should last for an extended period of time.

Other factors that must be considered

when ordering a cushion include conti-

nence, transfers, amount of time per day

spent in the wheelchair, muscle tone and

mobility. Another issue to consider is client

compliance and choice. Educating the

client on the cushion and evaluating

which products improve position, offer

effective pressure reduction, optimize

function and offer versatility for transfers

and daily life are important steps. Your

facility’s rehabilitation department or a

wheelchair clinic in the community is a good

place to start. Look for a Rehabilitation

Engineering and Assistive Technology

Society of North America (RESNA)

certified clinician or technician. To become

certified they must study and pass a rigorous

exam in this specialty area. Once certified,

they are trained in wheelchair assessment

and proper wheelchair selection and often

utilize special computerized mats to assess

a client’s needs.8

What should we teach our clients when

they are restricted to a wheelchair?

This can be a very important piece of the

puzzle that healthcare professionals might

be missing. Sometimes we offer a client a

cushion or pressure redistributing device

but offer little to no follow up. Individuals

who use a wheelchair and/or a wheelchair

cushion need to be taught to move out of

the wheelchair and inspect the skin on

their buttocks. Reinforcement of proper

pressure relief techniques and weight-

shifting every 15 minutes is imperative.9

Cushions wear out, go flat and do not

perform optimally forever. We would not

dream of purchasing a new automobile

and never changing the oil, having a

tune-up or checking the tire pressure,

right? Yet, often this is what happens

after a cushion is purchased. This can

mean problems for the user and potential

pressure ulcers and other challenges.

What is “bottoming out” and why do

I need to check the cushion all of

the time?

It is important to check the cushion

every day to determine if it has bottomed

out. That may seem excessive but if the

client is not “floating” on the surface or

suspended, their tissue and bony areas

are not being protected. To test for bot-

toming out, simply don a glove and slide

your hand between the client and the

cushion. If it is difficult to do, you can

place your hand inside a pillowcase to

help it slide under the client more easily.

There should be about an inch of material

(air, gel, fluid, foam, etc.) between the

client and the bottom of the surface.

Have you ever stayed at a motel and

slept on a bed with the springs poking

you in the back all night? That is

bottoming out.

cushion manufacturers offer a range of

cushions that differ in pressure redistribu-

tion, support and functional needs. A proper

assessment and follow up is necessary

to determine changes in function that may

require modification to the wheelchair and

wheelchair cushion.

The majority of wheelchair cushions on

the market are made out of foam, layers

of multi-density foam, gel, a combination

of multi-density foam and gel, silicone

and varying densities of silicone material

and air. The air cushions are either

powered or non-powered. There are

also custom wheelchair cushions and

backs as well.

Published studies have compared several

types of cushions by judging their ability

to prevent skin redness or by measuring

interface pressure, which is the pressure

that occurs when a body comes in contact

with a surface or cushion. The over-

whelming result of this research indicates

that no single cushion is best for all

people.5 It depends on the client and

their particular needs.

I have seen egg crate and foam rings

used, are they suitable?

Foam or air “invalid” rings are not

appropriate for pressure reduction.6,7

The ring increases pressure around

the sacral region and decreases blood

flow, which may cause problems. The

ring can also cause deep tissue injury to

a high-risk client because the unnatural

shape does not conform to the anatomy

of the buttocks. Additionally, egg crate

cushions offer no pressure relief and

can bottom out, causing the client to

touch the bottom of the wheelchair and

not float on the surface. These products

should be avoided.

3

4 6

7

5


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suppliers who have Certified Rehabilitation

Technology Suppliers, or the credential

CRTS. These individuals have passed a

rigorous credentialing exam and have at

least two years of experience. They can

be found by visiting the National Registry

of Rehabilitation Technology Suppliers

(NRRTS) Web site at www.nrrts.org.

Another legitimate credential is the

Assistive Technology Supplier (ATS),

certified by RESNA.12

Clinicians who are Assistive Technology

Practitioner (ATP) certified provide

analysis of a client’s needs with regard

to all areas of seating, positioning and

assistive technology. These individuals

must possess a minimum of an associate’s

degree and three years’ experience in

his or her field, such as physical or

occupational therapy.

Cynthia A. Fleck,

MBA, BSN, RN,

APN/CNS, ET/WOCN,

CWS, DNC, DAPWCA,

FCCWS is a certified

wound specialist and

dermatology advanced

practice nurse, author,

speaker, Secretary/Treasurer of the American

Academy of Wound Management (AAWM),

Member of the Board of Directors of the

Association for the Advancement of Wound

Care (AAWC), Diplomat of the American

Professional Wound Care Association and

Vice President, Clinical Marketing for Medline

Industries, Inc., Advanced Skin and Wound

Care Division. Cynthia can be reached at

[email protected].

Diane L. Holland, BS,

PT, CWS, WCC, C. Ped

is a physical therapist

and Certified Wound

Care Specialist practicing

at Bellevue Hospital in

New York City. She was

formerly employed at

the Hospital for Joint Diseases, Diabetic Foot

Center, also in New York City. Diane can be

reached at [email protected].

The client’s skin should be checked for

persistent redness each time they are

moved. This will measure whether the

cushion is doing its job and whether

weight shifts or moving the client back

to bed should be done more frequently.

What are the surveyors looking for

and what does CMS state?

Key information regarding repositioning

and assessment of a client’s skin integrity,

especially in the immobile, is emphasized

in the CMS Guidance to Surveyors.11

Appropriate support surfaces should be

utilized wherever the client’s skin is in

contact with a surface area for a prolonged

period of time (beds, mattresses, chairs,

wheelchairs, etc.). The document further

describes the use of sheepskin-type

products, pillows and wedges and warns

that they should only be used for comfort

or reduction of friction, not pressure

redistribution. The use of donut-type

cushions is not recommended, nor are

wheelchairs with sling seats that may

not be optimal for prolonged sitting during

activities or meals.

The following recommendations are

quoted directly from the CMS Guidance

for Surveyors for Pressure Ulcers.11

— An at-risk resident who sits too long

on a static surface may be more

prone to get ischial ulceration.

— Slouching in a chair may predispose

an at-risk resident to pressure ulcers

of the spine, scapula, or elbow, (elbow

ulceration is often related to arm rests

or lap boards).

— Friction and shear are also important

factors in tissue ischemia, necrosis

and pressure ulcer formation.

Who can help?

Again, clinicians and providers with

expertise in seating and positioning

should be a part of the team. Look for

8

9

References1 Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System Pub. 100-07 State Operations Provider Certification. November 12, 2004.

2 Bryant RA, eds. Acute and Chronic Wounds: Nursing Management. 2nd ed. St. Louis, Mo: Mosby Yearbook, Inc.; 2000.

3 Schmeler M, Byning M. The Lecture Series on Application and Use of Wheelchair Technology Seating Biomechanics Lecture. WheelchairNet. Department of Rehabilitation Science and Technology. Oct.1999.

4 Carison MJ, Payette MJ, Vervena LP. Seating orthosis design for prevention of decubitus ulcers. Journal of Orthotists and Prosthetists. 1995;7(2):51-60.

5 Sprigle S. The match game. Team Rehab Report. May 1992:20-21.

6 Panel for the Prediction and Prevention of Pressure Ulcers in Adults: Pressure Ulcers in Adults: Prediction and Prevention. Clinical Practice Guidelines, No. 3. AHCPR Publication No. 92-0047. Rockville, Md: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. May 1992. Available at: http://www.ahrq.gov. Accessed August 21, 2007.

7 Ratliff C, Bryant D. Guideline for Prevention and Management of Pressure Ulcers. WOCN Clinical Practice Guideline Series, No. 2. Wound, Ostomy and Continence Nurses Society. Available at: http://www.wocn.org. Accessed August 21, 2007.

8 Fleck CA. Under pressure. Advance for Providers of Post Acute Care. November/December 2004:64-65.

9 Fleck CA. Pressure ulcers: risk, causes and prevention. ECPN. November 2005;105(9):32-40.

10 Fleck CA. The new cms pressure ulcer guidelines. ECPN. January/February 2005:36-42.

11Department of Health and Human Services. Centers for Medicare and Medicaid Services. CMS Manual System Pub. 100-07 State Operations Provider Certification. November 12, 2004.

12Rehabilitation Engineering and Assistive Technology Society of North America (RESNA). Available at: www.resna.org. Accessed August 21, 2007.


38 HEALTHY SKIN

INCONTINENCE:Reassuring residents

that they’re not alone.

Incontinence canleave your residentsfeeling embarrassedor alone – but itshouldn’t! In fact,it’s estimated that25 million Americanswill experiencetransient or chronicincontinence.1

Why not take amoment to reviewthe facts onincontinence?Perhaps doing sowill mean thatyou’ll have justthe right wordsto reassureyour residents!

What is urinary incontinence?Urinary incontinence refers to the inability to control the passageof urine. This can range from the occasional leakage of urine to acomplete inability to hold any urine. In fact, urinary incontinence canbe broken down into seven types:

• Stress incontinence: Occurs when sudden pressure is applied tothe bladder, causing urine to leak out. This can happen duringexercising, coughing, sneezing, laughing or lifting, for example.

• Urge incontinence: Describes the frequent, sudden urge to urinatewith little control over the bladder (also known as overactive bladder,spastic bladder or reflex incontinence).

• Overflow incontinence: Residents with overflow incontinencecannot completely empty their bladders. This leads to frequenturination or a constant dribbling of urine, or both.

• Functional incontinence: This is the most common type ofincontinence among elderly residents with arthritis, Parkinson’sdisease or Alzheimer’s disease. The limitations these residentshave with moving, thinking or communicating make them unableto effectively control their bladders.

• Mixed incontinence: Residents experiencing mixed incontinencehave two types of incontinence simultaneously, typically stressincontinence and urge incontinence. The causes of the two formsof incontinence are not necessarily related.

• Temporary incontinence: Can be caused by severe constipation,infections in the urinary tract or vagina or by certain medications,such as diuretics, narcotics, antihistamines, antidepressants orcalcium channel blockers.2

What causes incontinence?There are a number of reasons that incontinence develops – and,contrary to what many people think, it’s not a normal part of theaging process. Common causes of incontinence include:

• Weak bladder

• Weakened muscles around the bladder (common in women whohave given birth)

• A blocked urinary passageway

• Damage to the nerves responsible for controlling the bladder

• Diseases that limit movement, such as arthritis3

Reassuring the incontinent residentDespite how common incontinence is or what is causing it,residents who are experiencing incontinence might feelembarrassed or ashamed. Here are several tips for comforting themand maintaining their dignity.

• Remember that toileting accidents are embarrassing.

• Stay calm and reassure the resident that it is OK.

• Maintain a matter-of-fact approach, using phrases such as“Let me help you get out of these wet things.” 4

References1 Resnick NM. Improving treatment of urinary incontinence(commentary letter). JAMA. 1998:280(23):2034-35.

2 Mayo Clinic. Types of urinary incontinence. Available at:www.mayoclinic.org/urinary-incontinence/types.html. AccessedAugust 14, 2007.

3 U.S. Food and Drug Administration. Coping with bladderproblems. Available at: www.fda.gov/opacom/lowlit/bladprb.html.Accessed August 14, 2007.

4 Washington State Department of Social and Health Services.Caregivers’ handbook. Available at: www1.dshs.wa.gov/pdf/Publications/22-277.pdf. Accessed August 15, 2007.


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F


40 HEALTHY SKIN


FearMale Catheterization

Taking the

This is a true story that took place about 10 years ago. I was paged to see a patient in thehospital for a urethral catheter insertion. I introduced myself to him and he frantically told me,"You’re the third person trying to get this catheter in!" I learned a staff nurse and a resident hadalready tried and failed to insert a catheter into his distended bladder, and he was not lookingforward to my poking around. Half kidding, I told him I am an expert and I can insert thiscatheter in “one shot.” He took me up on my bet and, sure enough, I was able to insert hiscatheter in one try.

So, how did I do it?At that time I had been practicing urology nursing for more than a decade and had inserted alot of urinary catheters. Obviously, I learned a few tricks in the catheterization of males. I amalso the nurse called upon when everyone else gives up trying to place the catheter. Here aresome simple tips that all nurses can apply to their daily practice.

The first thing I do is introduce myself to the patient and inform him I am an “expert” incatheterization. Now, I know everyone isn't an expert, but it helps if the patient thinks you are.I learned early on that nobody wants to be your first patient. Whether you're an expert or anovice, this introduction goes a long way in relaxing an apprehensive patient. Remember, thesphincter is under voluntary control. If a nervous patient tightens up, catheterizations canbecome a cruel tug-of-war, with the patient’s sphincter often winning. Now that the patient isconvinced I know what I am doing, I explain the procedure to him. Most men like to be in con-trol and want involvement in this procedure, so why not get them involved?

out of


By Victor Senese, RN, CURN

Treatment


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42 HEALTHY SKIN

12

334455

When available, I instill 2 percent lidocaine jelly into the urethra. If this is not available or yourinstitution doesn't allow this practice, instill a water-soluble lubricant into the urethra. A catheter-tip syringe will work nicely for this. Use about 5 to 10 cc. The lubricant acts to dilate the urethraas well as lubricate the passage. Next, place the catheter into the urethral opening and instructthe patient to relax the muscles in his legs. The sphincter and leg muscles are both skeletalmuscles and relaxing the legs will help relax the sphincter. Advance the catheter with a steadypressure. Stop if you meet resistance.

Catheterization RecommendationsRecommendation #1: If you feel resistance, rest your arm against the patient's leg and askhim to relax. When you feel the leg muscle relax against your arm, push the catheter forwardand it will probably slide right in.

Recommendation #2: Be sure to insert the catheter up to the balloon’s “Y” port. Don'tassume that if you see urine the catheter is in. Examine a Foley catheter and you will noticethe drainage islets are in front of the balloon. If you assume the catheter is in because you see urine, you might inflate the balloon in his prostate! Profuse bleeding usually follows thiscareless act.

Recommendation #3:Assess your patient for balloon size. An elderly gentleman can easilypull a 5 cc balloon to his prostate. I usually prefer to use a 30 cc balloon catheter on all malesand inflate the balloon to 15 to 30 cc, depending on the patient's level of orientation.

Recommendation #4:Tape that tube! The last step is to secure the tube to the patient's legwith tape. This will prevent accidental trauma to the bladder, and is often the most overlookedstep in catheterization.

Recommendation #5:: A coudé catheter is often disregarded. It is designed with a slightcurve at the end to facilitate the passage around an enlarged prostate. If you encounter resist-ance just before the bladder, the prostate is probably enlarged and a coudé catheter will getyou by it easily.

Occasionally you will not be able to pass a catheter due to strictures or scars found within theurethra. This is when you need to call it quits and request your fellow urologist. If you follow myrecommendations you will probably be able to insert urinary catheters into most patients.

I still routinely see that patient from the hospital in our office. He has taken to calling me by thenickname "One Shot" and brags to anyone who will listen about that eventful day when I wasable to get a catheter into his bladder in one try!

About the authorVictor Senese has been a nurse for 25 years, is a past president of the Society of UrologicNurses and Associates and is currently employed as a urology nurse clinician in Oak Lawn, Ill.


SILVERtouch™ Foley CatheterLet us help you fight to eliminate catheter-associated urinary tract infections.

The clinical rationaleAccording to the CDC, catheter-associated urinary tractinfection (CAUTI) is the most common hospital-acquiredinfection. Each year, more than 1 million patients inU.S. extended- and acute-care facilities acquire such aninfection; the risk with short-term catheterization is 5percent per day. CAUTI is the second most commoncause of nosocomial bloodstream infection, and studiessuggest that patients with CAUTI have an increasedinstitutional death rate, unrelated to the developmentof urosepsis. Catheters coated with silver alloy/hydrogelhave recently been introduced into practice, and agrowing body of literature supports their use in a variety of clinical settings.1

UTIs account for 40 percent of hospital-acquired infections2

80 percent of nosocomial UTIs are catheter-associated (CAUTI)3, 4

Healthcare facilities have adopted prevention strategies to minimize the risk ofCAUTI. In addition to emphasizing good practice supported by CDC guidelines,coated catheters are routinely being utilized to improve patient outcomes.

� Silvertouch catheters contain silver; every Silvertouchcatheter is coated inside and out with ionic silver. Silver is well recognized as a broad-spectrum antimicrobial effective against gram-positive and gram-negative bacteria, including resistant strains such as MRSA and VRE.

� Silvertouch catheters are more comfortable due to a hydrophilic coating that hydrates quickly and maintains its lubricity for at least a week.

� Silvertouch catheters are latex-free and are 100 percentsilicone, so both caregivers and patients are kept safe.

References1. Rupp M et al. Effect of silver-coated urinary catheters. AJIC.

2004;32(8):445-50.2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nation-wide

nosocomial infection rate. A new need for vital statistics. Am J Epidemiol.1985;121:159-67.

3. Paradisi F, Corti G, Mangani V. Urosepsis in the critical care unit. Crit Care Clin. 1998;14:165-80.

4. Vincent JL, Bihari D, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe—The results of the EPIC study. JAMA. 1995;274:639-44.

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

©2007 Medline Industries, Inc. Mundelein, IL 60060Medline is a registered trademark of Medline Industries, Inc.Silvertouch is a trademark of Medline Industries, Inc.


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Medline University offers more than 50 self-studynursing CE-credit courses.

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If the shoe fits …Diabetic feetneed special

attention

Have you ever worn a pair of shoes only to findyour feet hurting because the shoes have causeda blister or other injury? What do you do when thishappens? Most of the time you probably do notconsider this a problem; you just put on anotherpair of shoes or a bandage strip. However, if youhave decreased sensation to your lower extremities,including your feet, this could be an emergency.Decreased sensation is called neuropathy and isthe leading cause of foot wounds inpeople with diabetes mellitus (DM).

By Joyce Norman, BSN, RN, CWOCN

Special Features


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46 HEALTHY SKIN

What causes neuropathy?The most common causes for loss ofsensation are neuropathies related todiabetes mellitus, but it can also berelated to alcoholic neuropathy, herpes,cancer and spinal cord lesions.Neuropathy is a change in sensationas a result of nerve damage that cancause an individual to have no feelingor an increase in pain. The client maydescribe symptoms such as burning,tingling and unusual pain. Traditionalpain medications are often not effec-tive, making other medications, treat-ments and modalities necessary.

Danger aheadManaging a patient with diminishedor no sensation can be dangerousand difficult. The patient may beunaware of items in or on theirfootwear and may continue to wearshoes that cause injuries, have for-eign objects in them or that simply do not fit correctly. Because of thelack of sensation caused by neuropa-thy, the patient does not feel thesource of the problem, continues towear improper footwear until thereare apparent signs of injury such asodor, drainage adhering to footwear,or a problem controlling their bloodsugar levels.

Injury can be avoidedThe problem with diabetes mellitus isthat these complications do not haveto occur. Literature indicates that asmany as 80 percent of ulcers couldbe preventable. In fact, they are usuallyrelated to poor management of thedisease over time. The disease hasan impact on many systems. Becauseof the damage to the small vessels,the eyes, kidneys, heart and peripheralsystem can be affected. As thecomplications worsen and an individualloses the ability to feel their feet,diligent monitoring is essential.

Someone with DM should have theirfeet examined at least once a year bya professional healthcare provider.The clinician needs to be trained in

how to determine changes in sensa-tion with the use of a monofilamentand other tools. When these subtlechanges start to occur, it is appropri-ate to obtain proper footwear. Thefootwear should fit well and help tomaintain proper alignment of the foot.

Beyond neuropathyAnother problem that occurs withpoorly controlled DM is neuromuscu-lar changes that affect the structureand form of the feet. The toes canstart to hammer and have otherdeformities, and the foot itself canchange in appearance and form,which affects the ability of the patientto wear regular shoes. Working with a doctor of podiatric medicine (DPM),orthotist or pedorthotist is importantbecause they can help to accommo-date footwear and align the foot sothat the changes in structure do notcause ulcers and damage. Whenorthotics and other accommodationsof the footwear are not enough, special shoes may be necessary.Depending on the degree of damageto the foot, the patient may be able topurchase them or they may need tobe custom-made.

Other features that can help protectthe feet are well-fitting footwear with adeep toe box in the shoe to decreaserubbing and reduce undue injury tothe foot. The footwear can be asandal-type or full shoe, with devicesbuilt in or attached to help keep pres-sure off of the affected area. When aclient has accommodative foot wear it is not the end of the condition.Footwear needs to be reexamined on a regular basis depending on the wear and amount of damage tothe foot. An individual with diabetesshould see their healthcare profes-sional at least annually.

CMS has recognized the importanceof proper footwear and provides cov-erage under Medicare for one to twoshoes per foot per year, insoles ororthotics for better foot alignment up

to three times per year, and podiatriccare every 61 days. These benefitshelp prevent further damage.

Inspection & protectionThe importance of inspecting andprotecting diabetic feet cannot be overemphasized.

It is important to be aware of the feet,the changes in the feet and what canbe done to protect the feet. Simpledaily inspection and protection canmake a huge difference.


48 HEALTHY SKIN

Could this helpyour facility?By Pat Rodecker, RN, WCC

Survey Readiness


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Nathan Littauer Hospital and NursingHome, located in Gloversville, N.Y.,recently joined with Community HealthCenter to promote consistent woundcare. We began by assembling ateam of experts who agreed to worktogether to make clinical wound care improvements.

At the team’s first meeting, a list of prod-ucts used in each setting was created tocross-reference and ensure consistencywhen patients transitioned from onesetting to another. The primary focusthen turned to education. The teaminsisted that improved wound careeducation would be necessary to pro-vide appropriate, effective care. To thisend, a wound care competency day was planned.

The wound care competency day wassplit into two sections. In the morning,a skincare representative was on handto educate the clinical nurse specialists(CNSs) on the proper use of skin-cleansing products. In the afternoon, a lecture on liability and wound carewas held.

Now that we have given you an idea ofhow the day was structured, we wouldlike to share what we feel made ourwound care competency day a success.Perhaps your own facility would benefitfrom a similar experience!

Skincare StationFirst was a review of Medline’s Soothe& Cool® No Rinse Hair/Body Wash. Wedetermined that certified nursing assis-tants (CNAs) wanted residents’ bathwater to have suds. Education wasprovided to the staff indicating that itwas not necessary to have suds. Aplan was then put in place to provideconsistent reminders to reinforce andassist with this practice change.

Medline’s Soothe & Cool moisturizingcream had recently been added to our

treatment regimen. We considered thisan appropriate setting to reinforce theimportance of using it daily to keep theresidents’ skin moist.

Calazime® Protectant Paste is used onsome of our residents and staff hadcommented that it was thick and hard to remove. To overcome this obstacle,the application of Calazime was demon-strated, stressing that a thin layer was all that was needed.

Another exercise included a demonstra-tion with hydrocolloid dressings. Somewere shown leaking and another wasshown rolled off the ulcer. CNAs wereasked which dressings they wouldreport to the nurse for changing.Samples of the various wound careproducts that we use in our facilitieswere included at this station withdemonstrations on how to apply andremove them. Finally, we reviewed flowsheets that are used for documentation.We ended by answering any specificquestions from the staff relating to eithera product or specific resident problem.

Heel Protection StationThe next station was heel protection.Heel pain is a common complaint;therefore we felt is an important subjectto address. Padded booties were shownto provide protection from shear; howev-er, they are not appropriate for pressurerelief. Heel relieving booties were shownto the staff and application was demon-strated to ensure proper placement ofthe heel. Staff was reminded to inspecttheir resident’s feet daily and reportconcerns to the nurse.

Dietary StationThe dietary station featured residentfood trays. Each person was asked tolook at the tray that was presented andthen compare it with the next three trays.They were then asked to assess whatpercentage of the meal was taken.Included in this display was a tray that

had spilled milk and food pushedaround on the plate but not eaten. Ourgoal was to see if the staff realized thisshould not be included in the percentagetaken. Dietary personnel included athorough explanation of the dietary program “every bite counts” (EBC).Certain foods are fortified and the staffwas instructed to encourage residentsto take these foods first (high calorieand high protein).

Play Detective StationThe last nursing station was fun. Weplaced a mannequin in a patient bed

Staff completed the following wound carecompetency questions:

Name four areas of the body that are at high risk for skin breakdown.

Name two reasons that patientswould be at high risk for skin breakdown.

Name four ways to relieve/preventpressure ulcers.

When would you report to a nursethat your patient needs a dressing change?

You are assisting a resident with lunch who typically eats only 25percent to 50 percent of their meal. Of the following foods, which three should you encouragethem to consume first to provide them with the most calories and protein:a.Coffee w/sugarb.Fortified puddingc. Tuna sandwichd.Canned peachese.Green beansf. 8 oz. whole milk

1

2

3

4

5


Got a question? Call 1-888-701-SKIN (7456)

QA

50 HEALTHY SKIN

to point out multiple potentials for skinbreakdown. Our mannequin was lyingon Foley tubing, wearing wet briefs, hadon heel booties that were not properlyplaced, wound drainage on the skin,lying on a bedpan with crumbs in thebed. If that was not enough, the O2 tubingwas not padded and the head of bedwas elevated to 90 degrees. The turnand position flow sheet at the bedsidewas not signed. The staff really enjoyedseeing how many things they couldfind wrong and comparing results withone another as to how well they did.Participants who recognized all of thepotentials for skin breakdown weregiven a small prize.

Physical therapy provided a visual displayof proper positioning in a wheelchair.This included back and feet positioning.They also stressed the need to repositionat-risk wheelchair residents every hour.

The votes are in: “Hands On” Is agreat way to learn and review!The day was well attended by nursinghome staff. The 11 p.m. to 7 a.m. nurs-ing home staff attended after their shiftwas over. The 7 a.m. to 3 p.m. staffcovered the floor for each other and the3 p.m. to 11 p.m. shifts attended whenthey arrived on duty. The hospital staffwho attended felt they learned a lot,although we did make a plan to improvetheir attendance at our next educationalworkshop. The workshop required aboutone-half hour for each person to gothrough all the stations. Setting up didnot take too long, either. Resourcesincluded a nurse at the three stations, a dietary staff person and someone from physical therapy to be available.The evaluations indicated that staff didincrease their ability to identify potentialpressure areas on the body and under-stand how to use the products we haveavailable in our facility. Responsesranged from “good” to “excellent” and the staff said it was worth attendingand would like more workshops like this.

About the author

Pat Rodecker, RN, WCC is the clinical coordinator at Nathan LittauerHospital and Nursing Home.

1234

5

6

Evaluation formIdentify pressure areas of the body.

Recognize potential causes of skin breakdown.

State how proper nutrition is important to the wound healing process.

Identify conditions and report the need for a dressing change to a nurse (CNA).

Identify wound ad/or dressing conditions that indicate the need for a dressing change (LPN/RN).

Discuss documentation requirements for wound assessment and care (LPN/RN).


Got a question? Call 1-888-701-SKIN (7456)

Janet JonesBSN, RN, PHN, CWOCN, DAPWCA

QA“I have a partial thickness wound related to incontinence but I can’t get

a hydrocolloid to stick in the area. Can you help?”

It is very difficult to get a physical dressing to stick when incontinence

is an issue. Repeated use of a physical dressing is usually ineffective

and often leads to additional skin damage such as shearing. The dressing

becomes wet and slides against the skin. Or breakdown from the skin

injury occurs because of prolonged contact with the now contaminated

dressing. However, it is certainly necessary to cover the injured skin,

protecting it from further assault by urine and stool.

Choose a barrier designed for wet skin(Second Generation Barrier Paste)A barrier paste designed for wet skin, sometimes called second generation

barrier, is an excellent option. Not all barriers are designed for this purpose–

look for ingredients such as zinc, karaya, calamine or menthol and indications

that read “for wet or weepy skin.” This type of barrier is a very durable paste

and will not wash off even with repeated episodes of incontinence, thus

creating a “physical dressing.” If turning and repositioning are appropriately

done, healing usually occurs without any difficulty.

Helpful hintsSome important tips when using a second generation barrier: 1. When applying the product it is important not to rub the product in;

spread the paste as a protective layer.

2. It is important when cleansing the area to merely clean off the urine or stool. If any barrier cream residue remains on the skin, merely applyanother thin layer of barrier cream on top.

3. Remember scrubbing can lead to further skin injury.

4. Cleanse and reapply once or twice a day.

5. Education is necessary so that the product is utilized correctly.

A second generation barrier cream is an excellent option when dealing with

superficial injury to the skin and continence issues are a problem.

See you on the Hotline!

DO YOU HAVE A WOUND OR SKIN CARE QUESTION?

Call the Educare Hotline! Medline’s

toll-free hotline is supervised by a

board-certified enterostomal therapy/

wound, ostomy and continence nurse.

Just pick up the phone and call

1-888-701-SKIN (7456).

We’re here to help!

About the AuthorJanet Jones, BSN, RN, PHN,

CWOCN, DAPWCA is a board-

certified wound, ostomy and

continence nurse. She has

extensive experience in long-term

and home care and has developed

wound prevention and treatment

programs for many national healthcare groups. She’s also

ready to take your call on Medline’s Educare Hotline!

>

>

>

>

>

“... spread the pasteas a protective layer.”


creo

for healthier skin: The innovative backsheet on

allows air to flow

through the pad while still acting as a

barrier to moisture.* The result is superior

skin dryness and comfort.

for lower cost: are so strong and

absorbent that they eliminate the need

for multiple pads. They can also reduce

the need for draw sheets, linens or

reusable underpads. This results in a

dramatically lower cost.

for easier care: can be used on both

standard beds and air-support

therapy beds.

ONEpad1 ONEpad1

ONEpad1

A I R - P E R M E A B L E P R E M I U M D R Y P A D

Advanced Technology

Soft, Non-Woven Topsheet– softer against skin for increased comfort

Advanced SuperCore®

Absorbent Sheet– thermo-bonded to provide better pad integrity and superior skin dryness

AquaShield Film– traps moisture, providing

better leakage protection

Innovative Backsheet– air permeability

means better skin comfort*MVTR of 3600 +- 1000 g/m2/24h

The power of ONE1

©2007 Medline Industries, Inc.Medline and Ultrasorbs are registered trademarks of Medline Industries, Inc.SuperCore is a registered trademark of McAirlaid’s Vliesstoffe GmbH & Co. www.medline.com1-800-MEDLINE


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Perineal Skin Care forthe Incontinent ResidentDecision tree for skin care based on the information from Minimum Data Set (MDS) 2.0 continence status.

Three simple steps for selecting the best skincare product:>> 1. Decide where the resident fits into the “continence” definition of MDS 2.0 Section H.1>> 2. Assess the resident’s current skin condition>> 3. Locate the closest description on the grid

4IncontinentHas inadequate

control.Bladder – multiple

daily episodes; Bowel – almost all

the time

0Continent

Includes use of indwelling urinary catheter or ostomy

device that does not leak stool

1Usually

ContinentBladder –

incontinent episodes once a

week or less; Bowel – less than weekly

2Occasionally Incontinent

Bladder – two or more times a week, but not daily; Bowel

– once a week

3Frequently IncontinentBladder – two

or more times a week, but not daily; Bowel – once a week

Moi

stur

ize/

Prot

ect

Moi

stur

ize/

Prot

ect

Remedy Nutrashield

Clea

nse

Skin Condition: Intact, Reddened or Chapped Skin

Clea

nse

Moi

stur

ize/

Prot

ect

Fung

alIn

fect

ion

Clea

nse

Remedy NutrashieldRemedy Nutrashield

Skin Condition: Dry, Ready-to-Tear Skin

Skin Condition: Macerated or Denuded Skin

Remedy Dimethicone Moisture Barrier or Remedy Skin Repair Cream

Remedy 4-in-1 Cleansers

Remedy Dimethicone Moisture Barrier or Remedy Skin Repair Cream

Remedy Nutrashield

Remedy Calazime Protectant Paste

Remedy Antifungal Cream or Powder

Remedy 4-in-1 Cleansers

Cleansing wipes or Remedy™ 4-in-1 Cleansers


for healthier skin: The innovative backsheet on

allows air to flow

through the pad while still acting as a

barrier to moisture.* The result is superior

skin dryness and comfort.

for lower cost: are so strong and

absorbent that they eliminate the need

for multiple pads. They can also reduce

the need for draw sheets, linens or

reusable underpads. This results in a

dramatically lower cost.

for easier care: can be used on both

standard beds and air-support

therapy beds.

ONEpad1 ONEpad1

ONEpad1

A I R - P E R M E A B L E P R E M I U M D R Y P A D

Advanced Technology

Soft, Non-Woven Topsheet– softer against skin for increased comfort

Advanced SuperCore®

Absorbent Sheet– thermo-bonded to provide better pad integrity and superior skin dryness

AquaShield Film– traps moisture, providing

better leakage protection

Innovative Backsheet– air permeability

means better skin comfort*MVTR of 3600 +- 1000 g/m2/24h

The power of ONE1

©2007 Medline Industries, Inc.Medline and Ultrasorbs are registered trademarks of Medline Industries, Inc.SuperCore is a registered trademark of McAirlaid’s Vliesstoffe GmbH & Co. www.medline.com1-800-MEDLINE


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54 HEALTHY SKIN

PROBLEMOur diabetic population presents with skinissues often resulting in skin injury andincreased costs. Autonomic neuropathy causesa decrease in the sweat and oil production,resulting in xerosis. Our goal was to decreasethese issues and costs of secondary injuriesand improve quality of life for our patients.

METHODOLOGYFifty patients were selected to participate in askincare product trial. Criteria for inclusionwas a diagnosis of diabetes, high risk for skinbreakdown and characteristics of xerosis,defined as abnormally dry skin with fine lines,scaling and fissures. Untreated xerosis may leadto itching and scratching, pain and cellulitis.Excluded were confused or non-verbalpatients. Skin cream containing Olivamine wasapplied daily to the patients’ legs and feet,after cleansing, for a period of four weeks. Skinwas evaluated weekly for integrity. Pain wasdocumented using a 0-10 pain scale. Patientswere queried regarding itchiness.

OUTCOMESOlivamine delivers amino acids, antioxidants(hydroxytyrosol), vitamins and methylsul-famethane to the skin. Transepidermal waterloss (TEWL) is preserved with dimethicone base,preventing damage from dehydration anddecreasing pruritis.

CONCLUSIONSA program of cleansing, moisturizing, andprotecting the skin with the Olivamine-containing product improved skin outcomesincluding skin integrity, prevention of break-down of fragile skin and decreased pain anditching for patients.

Case StudyUsing Olivamine* in a Skin Cream to Improve Skin Quality in Diabetic Patients

CMis 91-year-old female has had type 2 diabetes for more than 20 years. She presents withxerosis, fine lines, scaling and pain in her legs, which is increased at night (Figure 1a). Shedescribes the pain as “deep pain” and scores it as a number “8” on the scale of 0-10 . Sincedaily application of the Olivamine-containing product, she has had no xerosis, fine linesand scaling have decreased and her skin appears much healthier. She states that the painresolves completely for several hours after application of the product (Figure 1b).

PMis 63-year-old female has had type 2 diabetes for approximately five years. She also hastroublesome venous stasis disease and has an ongoing battle with severe xerosis, scalingand cracking of skin (Figure 2a). She has little sensation in her legs, so pain has not been a major problem. However, since she is using the Olivamine product daily, she states thatshe has “less of a pulling sensation” on her legs. Daily cleansing, moisturizing and protectingthe skin with the Olivamine-containing product has greatly improved the general conditionof her skin (Figure 2b).

RMis 46-year-old male has had type 2 diabetes for more than 10 years. He has had multipletoe amputations and additional foot surgeries due to osteomyelitis. He presents with arecent surgical incision from amputation of a metatarsal head and is presently under treat-ment with a podiatrist and WOCN. He has experienced xerosis, scaling and cracking of skinand itching (Figures 3a and 3b). He has noticed marked improvement of his symptomswith daily application of the Olivamine product (Figure 3c).

Figure 1a Figure 1b

Figure 2a Figure 2b

By Dawn R. Fortna, RN, CDF, CWOCNEphrata Community Hospital, Ephrata, Pa.



ConclusionAll participants in the study exhibited improvement of the initial xerosis, fine lines and scaling of skin while 84.6 percent of those who identified initial itching experienceddecreased itching following daily application of the Olivamine product.e participantsstated that they noticed immediate results and stated how good the skin felt with application of the product. Upon assessment, the skin integrity appeared to be muchimproved and no patient in the study had further skin breakdown or infection.Patients experiencing neuropathic pain, of which there were only 4 in the study, allexperienced pain reduction of at least 3-4 points on the 0-10 pain scale after applicationof the Olivamine product. e small number of participants with pain as a major concernis likely due to the number of patients with diabetes and their sensory neuropathy.Many of those with sensory neuropathy have either masked pain or are insensate. ereare obvious limitations to the effect of any product regarding pain in this study. eseresults demonstrate that a program of cleansing, moisturizing and protecting the skinwith the Olivamine-containing product improved skin outcomes including skin integrity,prevention of breakdown of fragile skin and decreased pain and itching for patients.e quality of life issues are evident by the number of participants who inquired aboutpurchasing the product as a result of their satisfaction with the product’s results.

Assessed Criteria Patients meeting Improved afterCriteria 4 weeks

XEROSIS 47 47 (100%)FINE LINES 50 50 (100%)SCALING OF SKIN 40 40 (100%)ITCHING 26 22 (84.6%)PAIN 4 4 (100%)

References1. Bale S, Harding K, Leaper DJ. An introduction

to wounds. London: Emap Healthcare, 2000.2. Fore J. A review of skin and the effects

of aging on skin structure and function.

Ostomy Wound Manage. 2006;52(9):24-35.3. Diabetes mellitus and wound healing.

Available at: www.diabetesforum.net.Accessed June 21, 2005.

4. Holland D, Fleck C. Skin assessment in patients with diabetes. ECPN. 100(4);30-36.

5. Preventing foot complications in patientswith diabetes. Available at: http://multimedia.mmm.com. Accessed August 22, 2007.

6. Remedy. Available at: www.medline.com/woundcare/products/remedy. Accessed August 22, 2007.

7. Scarborough-Roessler P. Keeping the footattached to the leg. Presentation. January 2003. Educators 2000 Plus.

8. Van Gills C, Stark L. Diabetes mellitusand the elderly: special considerations forfoot ulcer prevention and care. OstomyWound Manage. 2006;52(9):50-56.

*Remedy Skin Repair Cream with Olivamine fromMedline Industries, Inc. Mundelein, Ill. Remedy is a registered trademark of Medline Industries.

Figure 3a Figure 3b

Figure 3c

Treatment


In both the QIO’s Nursing Home Quality Initiative and Advancing Excellence inAmerica’s Nursing Homes, clinical performance measures and clinical goals includeimprovement in pain management.

Below are 15 pain management improvement strategies for your team to consider!

1. Design a facility admission tool that includes a question on whether the resident hasany pain.

2. Institute pain screening tools appropriate for cognitively impaired residents and create aeasy-to-carry pocket card.

3. Designate responsibility and accountability to specific staff positions for screening of pain atadmission and periodically thereafter as part of routine interaction with residents.

4. Promote pain as the “fifth vital sign” among all staff–screen for pain just as you wouldfor breathing.

5. Educate all nursing staff, including CNAs, about pain symptoms in the elderly.

6. Involve the patient and family and stress the importance of their working with staff to assureappropriate pain management.

7. Test staff members’ competencies in performing pain evaluation.

8. Use standardized evaluation tools, including pain-rating scales, to evaluate residents’complaints of pain.

9. Develop a procedure for incorporating information obtained during pain evaluation into theresident care plan.

10.Prescribe pain medications on a regular (versus PRN) basis for individuals with daily pain.

11.Educate all staff, including nurses and physicians, on good pain management and provideguidelines at each nurses’ desk.

12. Incorporate non-pharmacologic approaches to pain management. (e.g., relaxation, hot orcold packs, acupuncture, etc.).

13.Conduct regular in-services about pain management, focusing on myths of pain, the elderlyand pain medications.

14. Implement a procedure for contacting and communicating with clinicians (MD, MP or PA)about residents who continue to have pain after starting treatment.

15.Create a schedule for monitoring pain and response to pain management(e.g., after each dose of pain medication).

Reference: Nursing Home Improvement Collaborative: Pain Management Handbook. Available at:http://medqic.org/dcs/ContentServer?cid=1163010337357&pagename=Medqic%2FMQTools%2FToolTemplate&c=MQTools.Accessed August 16, 2007.

Improving painmanagement atyour facility

56


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The inside of an adult incontinent brief is a hostileenvironment for the skin. Assaulted by urine, fecalenzymes and bacteria, the skin of the incontinentresident needs all the help it can get. Traditionally,this has come in the form of petrolatum barriers,with or without zinc oxide or other ingredients.The paste or film spread over the skin would forma barrier between the skin and the moisture andchemicals trying to break it down.

Disadvantages of petrolatum barriers• Greasy/messy• Occlusive to the skin, perhaps preventing normal function of the skin

• Pastes that are opaque prevent viewing of the skin

• Pastes that are thick can be difficult to clean off• Petrolatum barriers can affect the effectiveness of absorbent incontinence products by clogging the facing

Silicone, the petrolatum alternativeSilicones have become prevalent in the past 15years as moisture barriers for incontinence. Theseinert polymers are strong compounds that are notbroken down by water or chemicals. The mostfamiliar is dimethicone, which is combined with analcohol that evaporates, leaving behind a thin, dryfilm that protects against moisture, maceration,urine and enzymes. This type of material is stillbreathable, allowing the skin to act normally.

Another advantage to silicone is that it feels smooth,less greasy and lasts longer than traditional petro-latum products, even when washed.

Three features of silicone barriers offer distinctadvantages over petrolatum barriers, particularlywhite pastes that include zinc oxide.

1.Very little dimethicone barrier is necessary to spread a thin film over the skin, so a tube will last a long time.

2.Because it is a cream rather than a paste, it glides smoothly over the skin, reducing the pain of spreading a thicker compound that will later have to be scrubbed to be removed. With improved focus on pain reduction in facilities, silicones will become more common.

3.Because most dimethicone barriers are clear once dry, the skin below the barrier can be viewed and monitored without having to be wiped off.

The Barrier Product for the 21st Century

PRODUCT SPOTLIGHT

58 HEALTHY SKIN


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The Barrier Product for the 21st Century

e don’t have to tell you how importantit is that the disposable brief you chose pro-vides a feeling of confidence and dignity.Nothing matters more. At the same timeyou’d hope for a solution that works onmore than one level. Just one touchand you knowComfort-Aire™disposable briefsare unique. Extra-soft side panels allowbetter airflow forenhanced comfort andimproved skin care. The comfy outer cover helps prevent irritation.

But that’s not all. Comfort-Aire’s enhanced, super-absorbent core keeps skin dry. And dry, healthy skinprovides both dignity and comfort. Isn’t that whatyou want most from a disposable brief ?

W

Comfort-Aire™ Disposable Briefs from Medline

Because Their Dignity Matters

©2007 Medline Industries, Inc. Medline is a registered trademark & Comfort-Aire is a trademark of Medline Industries, Inc.

www.medline.com

For more informationon Comfort-Aire, contact your Medlinerepresentative or call1-800-MEDLINE

Extra-wide,Skin Safe

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60 HEALTHY SKIN

2Love ThemTimes

Products designed for you and your residents

As a professional in the long-term care field, you perform a delicate balancingact every day you’re on the job – taking care of your residents whilecaring for yourself. Your ultimate goal, of course, is to deliver the bestpossible care to your residents–but when great products help make that easier,everybody wins!

In this edition of Healthy Skin, we’re excited to introduce you to two productswhose implementation can benefit all involved!



Exuderm® OdorShield™Resident dignity is a hot topic–and it’s a legal right of all nursing

home residents. The Nursing Home Reform Act, part of the

Omnibus Budget Reconciliation Act of 1987, established The

Residents’ Bill of Rights, among which are “the right to accom-

modation of medical, physical, psychological and social needs”

and “the right to be treated with dignity.”1

Wound malodor, in addition to being commonly associated with

chronic and infected wounds, can affect residents socially and

psychologically. In extreme incidences, it can even lead individuals

to withdraw from social contact, even with family and friends.2

Yes, a number of odor-absorbing hydrocolloid dressings are

available on the market, but Exuderm OdorShield is unique.

Unlike any other hydrocolloid, this patented, advanced

product is designed to absorb odors from matter that is

exuded from wounds. In fact, the odor-absorbing compo-

nent of Exuderm OdorShield–cyclodextrins–are even

used in consumer products such as Febreze® to control

odors. This represents a major improvement over traditional

charcoal-based, odor-absorbing dressings, which have a

limited capacity for odor control.

In addition to its odor-absorbing benefits, Exuderm OdorShield

has other features of equal benefit to residents and long-term

care professionals. Because it is translucent, it allows easy

visualization of the wound without removing the dressing. And

its smooth satin backing, tapered edge and low-residue formula

ensure that it is long-wearing.

But you don’t have to take our word for it – Exuderm OdorShield

was recently awarded the 2007 Medical Design Excellence

Award (MDEA) in the category “General Hospital Devices and

Therapeutic Products.” These awards recognize the achievements

of medical device companies responsible for creating innovative

products that improve healthcare delivery, increase effectiveness

of existing medical practices and ultimately provide enhanced

benefits to the patient.

Exuderm OdorShield was developed and is manufactured by

Avery Dennison Medical™. It is exclusively marketed in the

United States by Medline Industries, Inc.

Ultrasorbs® APIt’s no secret that incontinence can be embarrassing to residents.

And with an estimated 25 million Americans experiencing transient

or chronic incontinence, it’s incredibly common.3

Some incontinence management products do little to ease

embarrassment. Underpads can tear easily, leak or allow wetness

to remain in contact with resident skin, potentially leading to

irritation or complications to wounds in the sacral area.

Ultrasorbs AP from Medline are different. The innovative backsheet

on these underpads allows air to flow through the pad while still

acting as a barrier to moisture. The result? Superior skin dryness

and comfort. In addition, the thermo-bonded SuperCore®

wicks moisture away from the skin and locks fluid away,

increasing dignity and improving odor control and skin care.

According to the Wound, Ostomy, and Continence Nurses

Society (WOCN), these results are desirable–and recom-

mended. In their 2003 Guideline for Prevention and

Management of Pressure Ulcers, the WOCN recommended

selecting “underpads, diapers, or briefs that are absorbent to wick

effluent away from the skin.”4

This is great news for the resident, and there are benefits for staff

as well. Because Ultrasorbs AP are super strong, they’re resistant

to tearing. They’re also extra absorbent–in fact, one Ultrasorbs AP

has the absorbing power of three or more standard underpads.

Ultrasorbs AP are also versatile. Because they are completely

breathable, they can be used on both standard beds and air-

support therapy beds. They’re also suitable for absorbing ongoing

fluid loss or anywhere else skin dryness is desired.

To learn more about either of these products, contact

your Medline representative, visit www.medline.com or

call 1-800-MEDLINE.

References

1 AARP. The 1987 Nursing Home Reform Act fact sheet. Available at:

www.aarp.org/research/longtermcare/nursinghomes/aresearch-

import-687-FS84.html. Accessed August 16, 2007.

2 Van Toller S. Psychological consequences arising from the malodours

produced by skin ulcers. Proceedings of 2nd European Conference

on Advances in Wound Management.1993;70-71.

3 Resnick NM. Improving treatment of urinary incontinence

(commentary letter). JAMA. 1998:280(23):2034-35.

4 Wound, Ostomy, and Continence Nurses Society (WOCN).

Guideline for Prevention and Management of Pressure Ulcers.

Glenview, Ill.: Wound, Ostomy, and Continence Nurses Society

(WOCN); 2003.

Survey Readiness


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

• Medline is doing their share to help the environment. Can we count on you to help?

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

Green Tree is a trademark of Medline Industries, IncCall 1-800-MEDLINE



Cool tips

Aluminum• By recycling one aluminum can per

day, we can save enough energy tooperate a television set for three hours.

Automobiles• Three major items from our

automobiles cause problems in landfills: oil, tires and car batteries. Recycle motor oil with local oil and lube shops so that it can be used in commercial operations as fuel. If yourlocal recycling facility accepts tires, therubber can be used for playgrounds, flooring, asphalt or burned as fuel. Car batteries contain lead and sulfuricacid – but all elements can be reused in new batteries.

• Share a ride with coworker or friendand you’ll cut your emissions in half.

Electronics• Put your computer in sleep mode

when you are not using it.• Do not add electronic waste to

landfills. A computer monitor, forexample, might be 6 percent lead by weight.

Glass• Recycle glass – the energy saved from

one glass bottle will light a 100-watt light bulb for four hours.

Energy • Keep the temperature of your water

heater at home down to 120 degreesFahrenheit. It will be hot enough for everyday use but will keep energy usage lower.

• Invest in a programmable thermostat to make adjustments for you when you are not home or when you are sleeping at night.

• Unplug an underutilized freezer or refrigerator.

Paper• Think before you print a document –

do you really need a paper copy? If so, is there an economy print mode on your printer that will use less ink?

• Paperless billing – having statementssent to your email address and paying your bills online eliminates paper, stamps, envelopes, etc.

Trees• Plant a tree. If every American family

planted one tree, more than a billion pounds of greenhouse gases would be removed from the atmosphere every year.

Cool tips


64 HEALTHY SKIN

by Jeannine ThompsonBSN, RN, CWOCNClinical Education Specialist



Do you rememberthe story of Alice

in Wonderland?Alice wanted to find

the white rabbit. So,

without thinking, she

jumped into a deep hole.

Alice encountered many

challenges and detours

during her quest to find

the white rabbit.

Among Alice’s challenges:

1. A locked door and an unobtainable key.

2. Tweedle Dee and Tweedle Dum who were more concerned about themselves

than with listening to what Alice had to say.

3. Magical mushroom pieces without instructions.

4. The Mad Hatter and the March Hare’s tea party, where they celebrated

un-birthdays instead of birthdays, wasting Alice’s time.

5. A forest full of confusing signs.

6. Gardeners who had Alice help paint white roses red to cover-up

their mistakes.

7. The queen who blamed Alice for everything bad that had happened to her.

8. A court hearing where the witnesses were of no help to Alice.

Ultimately, Alice never did catch the white rabbit.

Anurse in WOUNDerland:The clinician’s Alice in WonderlandLike Alice, Anurse can jump into wound care without thinking. And, also like

Alice, Anurse may encounter many challenges and detours during her quest to

provide an optimal moist wound healing environment to promote the closure of

a pressure ulcer.

1. An unobtainable “key” dressing needed for healing.

2. Associates who care more about their own agendas than listening to what

Anurse has to say.

3. Wound care products that lack instructions for use.

4. Healthcare professionals who practice unconventional wound care instead

of care based on clinical research, which can cause Anurse to waste her time.

5. Literature that can be confusing.

6. Associates who want to cover up sub-optimal care.

7. State and federal surveyors who may not see the whole picture.

8. Associates who are of no help in court.

Ultimately, the pressure ulcer does not heal.

During Alice’s adventure, she meets a very wise Cheshire cat. Being lost, she

asks the cat which way she should go. “That depends upon where you want to go,”

responds the cat. Alice says, “It really doesn’t matter.” To which the cat replies,

“Then it really doesn’t matter which way you go.”

In pressure ulcer care, the “where do you want to go?’’ question

represents wound closure and how Anurse reaches that goal does

Special Features


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66 HEALTHY SKIN

Anurse can no longer waste her time with the Mad Hatter and March Hare and not reach

the goal in a reasonable amount of time. Becoming aware that the pressure ulcer has

not progressed at the time of discharge, end of the certification period, when the state

surveyors review the charts or when the lawyers appear at the facility is unacceptable.

How can you show healing?Validated assessment tools that use objective data to monitor pressure ulcer progression

can help determine if a specific treatment modality is appropriate.

Anurse knows the three phases of wound healing are inflammatory, proliferative and

maturation. Anurse also knows that the inflammatory phase typically begins on day

one and lasts for five days, the proliferative phase typically begins on day five and lasts

until day 25, and the maturation phase typically begins on day 25 and lasts up to18

months. In general, a clean pressure ulcer with adequate blood supply and innervation

should show evidence of stabilization or some healing within two to four weeks. However,

many pressure ulcer healing rates are like Alice’s white rabbit, who states “I’m late,

I’m late for a very important date,” thus making them chronic ulcers, which can linger

for weeks, months and even years.

Validated tools for monitoring pressure ulcer healing have existed since 1997. The

Pressure Ulcer Scale for Healing (PUSH), the Sussman Wound Healing Tool (SWHT)

and the Bates-Jensen Wound Assessment Tool (formerly known as the Pressure Sore

Status Tool (PSST)) can be Anurse’s pressure ulcer GPS. If Anurse uses a monitoring

tool on a routine basis, usually weekly, to assess the progression of the pressure ulcer,

she will know if the wound is progressing through the inflammatory phase as expected.

If the tool indicates slow to no progression, Anurse knows that she needs to notify the

doctor that a change to the plan of care might be necessary to promote healing and

move the wound out of the inflammatory phase.

As the assessment continues to be charted using a monitoring tool, Anurse can deter-

mine if the pressure ulcer is progressing through the proliferative phase. If the pressure

ulcer is not progressing, Anurse will contact the physician to change the plan of care to

promote collagen synthesis, formation of new blood vessels, formation of granulation

tissue and epithelialization.

If a pressure ulcer is not progressing and the clinician decides to continue the current

plan of care, the rationale for the decision should be documented.

PUSH Tool 3.0A useful tool for monitoring the change of a pressure ulcer over time is the PUSH tool,

developed by the National Pressure Ulcer Advisory Panel (NPUAP).

To use the PUSH Tool, the pressure ulcer is assessed and scored on the following

three elements:

1. Length x Width is measured and scored from 0 to 10

2. Exudate Amount is scored from 0 (none) to 3 (heavy)

3. Tissue Type is assessed and scored from 0 (closed) to 4 (necrotic tissue)

matter–physically, financially

and emotionally.Alice didn’t have a global position-

ing system to help her get from her

home to the rabbit, but Anurse

does. All Anurse has to do is use

the reliable and validated pressure

ulcer healing tools that have been

provided to her.

Using the GPS system model,

Anurse inputs the starting and

ending destinations and the best

way to get there in the plan of care.

If the wound does not progress as

planned, the GPS system alerts

Anurse immediately.

Anurse is already proficient in assess-

ment, planning and implementation,

but what about timely evaluation?

Pay for Performance (P4P) is here.

Poor healthcare practices will no

longer be paid for. Documentation

must indicate that Anurse’s treatment

modality is appropriate for the

pressure ulcer and that the pressure

ulcer is progressing positively.



XXX

Each element is assigned a number, which is then added together to obtain a total score.

That score is placed on the Pressure Ulcer Healing Graph. Changes in the score over

time provide an indication of the changing status of the ulcer. If the score decreases,

the wound is improving or healing. If the score increases, the wound is deteriorating.

Sussman Wound Healing Tool (SWHT)Developed by Sussman and Swanson in 1997, this two-part tool measures pressure

ulcer wound healing. The focus of the tool is to track a change in tissue status and

wound measurement, assess whether the wound is healing and track the impact of

physical therapy technologies for wound healing.

Part I of the tool assesses 10 variables that address wound tissue attributes. The attributes

are classified as “good for healing” or “not good for healing.” The scoring system is

simply marked with a “1” if the attribute is present and “0” if the attribute is absent.

Part II evaluates wound depth and location and measures the phases of wound healing.

To obtain a copy of the Sussman Wound Healing Tool, contact Aspen Publishers, Inc.

Bates-Jensen Wound Assessment ToolFormerly known as the Pressure Sore Status Tool (PSST)

This tool was developed by Barbara Bates-Jensen to enhance the communication

between healthcare clinicians regarding pressure ulcers. Thirteen assessment parameters

are measured on a scale of 1 to 5. Two additional parameters are measured with a

simple check system.

The tool will help Anurse track individual categories as well as an overall score. Once

the numbers are recorded and the scale is complete, a total is calculated using all

13 parameters and then placed on a linear chart. Data is collected on a routine basis,

usually weekly. The results are compared to previous assessments and treatment plans

can be adjusted accordingly.

In the movie version of her story, Alice states, “Well, I went along my merry way,

and I never stopped to reason. I should have known there’d be a price to pay,

some-day. Someday. I give myself very good advice, but I very seldom follow it.

Will I ever learn to do the things I should?”

Healthcare professionals have been publishing evidenced-based wound care research

for 40 years. If a nurse continues to practice old, ineffective treatments, she too may

find herself in trouble just like Alice.

With P4P, healthcare professionals are charged with improving patient outcomes with

efficient, effective, economical pressure ulcer care. To learn more about these wound

monitoring tools, please refer to pages 90 to 93 in the Forms & Tools section of

this magazine.

ReferencesAnna and Harry Borun Center for Gerontological Research. The Bates-Jensen Wound AssessmentTool Page. Available at:borun.medsch.ucla.edu/modules/Pressure_ulcer_prevention/pubwat.pdf. Accessed August 15, 2007.

National Pressure Ulcer Advisory Panel.The PUSH Tool page. Available at:http://www.npuap.org/PDF/push3.pdf. Accessed August 15, 2007.

Sussman C, Swanson G. Utility of thesussman wound healing tool in predict-ing wound healing outcomes in physical therapy. Advances in Wound Care.1997;10(5):74-77.

The End


68 HEALTHY SKIN

Medline and MyZiva open the door to OnlineEducational Opportunities...and a whole lot more

Medline, the number one provider of healthcare

supplies and equipment to the long-term care market,

and MyZiva, a leading online educational and

informational resource with more than 10,000

registered users, have joined forces to provide

enhanced educational oppor tunities to the entire

nursing home industry and a whole lot more!

As representatives of nursing homes from around the

nation can attest, MyZiva offers a broad spectrum

of education, information, tools and resources to

nursing home professionals and their staff, including

corporate compliance templates, easily retrievable

federal regulations, a searchable national nursing home

database and more.

MyZiva brings the clinical component of its educational

offerings to a new level through its relationship with

Medline. Together, they offer more than 150

courses on wound care, pressure ulcers, infection

control, incontinence, respiratory care and more.

Benefits to education subscribers include an array of

professional credits, including administrator CEs.

To learn more about the MyZiva/Medline educational

and informational initiatives, as well as its minimal

cost, visit www.medline.com/myziva or call

1-866-238-2845.


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Administrator Credit Abuse and Neglect (2) � Accidents and Falls (3) � Administration and Management (2) � Bariatrics (3)� Behavior Management (3) � Care Planning (2) � Corporate Compliance (3) � Deficiencies,Sanctions and Appeals (2) � Drug Therapy (2) � Elopement and Unsafe Wandering (2) � Emergencyand Disaster Preparedness (2) � Employee Health and Safety (2) � Ergonomics (3) � Food Service (2)� Hazard Communication (2) � HIPAA (2) � Hydration in the Long-Term Care Setting (2) � InfectionControl (4) � Medical Records (2) � Medicare (4) � Nutrition (2) � Pain Management (2) � Pressure Ulcersand Skin Care (2) � Public Relations and Marketing (2) � Quality Assurance (2) � Quality Indicators andQuality Measures (2) � Reporting Requirements (3) � Resident Assessment/MDS (3) � Restraints (2)� Risk Management (3) � Safety (2) � Sexual Harassment (2) � SNF Prospective Payment System(PPS) (2) � Survey Process (2) � Urinary Incontinence and Use of Urinary Catheters (2) � Wound Care (2)

Certified Activity Professional Credit Behavior Management (2) � HIPAA (2) � Therapeutic Recreation and Activities (2)

Certified Dietary Manager Credit Abuse and Neglect (2) � Emergency and Disaster Preparedness (2) � Employee Health and Safety (2)� Ergonomics (2) � Food Service (2) � Hydration in the Long-Term Care Setting (2) � Infection Control (2)� Nutrition (2) � OSHA (2) � Purchasing and Inventor y Control (1) � Quality Assurance (2) � RiskManagement (2) � Sexual Harassment (2)

Licensed Practical Nurse Credit Abuse and Neglect (2) � Accidents and Falls (3) � Administration and Management (2) � BehaviorManagement (3) � Care Planning (2) � Constipation and Fecal Impaction (2) � Corporate Compliance (3)� Drug Therapy (2) � Elopement and Unsafe Wandering (2) � Emergency and Disaster Preparedness (2)� Employee Health and Safety (2) � Ergonomics (3) � Hazard Communication (2) � HIPAA (2) �Hydration in the Long-Term Care Setting (2) � Infection Control (4) � Medical Records (2) � Medicare (4)� Nutrition (2) � Pain Management (2) � Pressure Ulcers and Skin Care (2) � Privacy and Confidentiality (2)� Quality Assurance (2) � Quality Indicators and Quality Measures (2) � Reporting Requirements (3)� Resident Assessment/MDS (3) � Restraints (2) � Risk Management (3) � SNF Prospective PaymentSystem (PPS) (2) � Survey Process (2) � Urinary Incontinence and Use of Urinary Catheters (2) �Wound Care (2)

Registered Dietetic Technician Credit Constipation and Fecal Impaction (2) � Food Service (2) � HIPAA (2) � Hydration in the Long-TermCare Setting (2) � Infection Control (4) � Nutrition (2) � Pressure Ulcers and Skin Care (2) � QualityAssurance (2) � Risk Management (2)

Registered Dietitian Credit Constipation and Fecal Impaction (2) � Food Service (2) � HIPAA (2) � Hydration in the Long-TermCare Setting (2) � Infection Control (4) � Nutrition (2) � Pressure Ulcers and Skin Care (2) � QualityAssurance (2) � Risk Management (2)

Registered Professional Nurse Credit Abuse and Neglect (2) � Accidents and Falls (3) � Administration and Management (2) � BehaviorManagement (3) � Care Planning (2) � Constipation and Fecal Impaction (2) � Corporate Compliance (3)� Drug Therapy (2) � Elopement and Unsafe Wandering (2) � Emergency and Disaster Preparedness (2)� Employee Health and Safety (2) � Ergonomics (3) � Hazard Communication (2) � HIPAA (2) �Hydration in the Long-Term Care Setting (2) � Infection Control (4) � Medical Records (2) � Medicare (4)� Nutrition (2) � Pain Management (2) � Pressure Ulcers and Skin Care (2) � Privacy and Confidentiality (2)� Quality Assurance (2) � Quality Indicators and Quality Measures (2) � Reporting Requirements (3)� Resident Assessment/MDS (3) � Restraints (2) � Risk Management (3) � SNF Prospective PaymentSystem (PPS) (2) � Survey Process (2) � Urinary Incontinence and Use of Urinary Catheters (2) �Wound Care (2)

Choose from any of the more than 150 online CEU-accredited courses...


R-E-S-P-E-C-T. This word is a familiarmantra vocalized years ago by ArethaFranklin and repeated by those of us inneed of just that – a little respect. Ashealthcare professionals, we practice dailyrespect for our patients and their givensituations. It is a normal part of our rolewithin that relationship. But have youever wondered if your professional peersfully appreciate the presence (or absence)of respect within professional relationships?Too frequently battle lines are drawnbetween acute, long-term care, homecare, hospice and physician’s office staff,



each of whom has at times voiced less than kind opinionsabout the care provided by their contemporaries. Sadly,this also takes place within one’s own nursing unit andbetween units of the same facility.

Nursing professionals have long prided themselves onexcellent patient care and, especially, on prevention ofpressure ulcers. Many of us were “raised” in a nursingculture where a pressure ulcer is the mark of less-than-adequate nursing care. Finger pointing and blaming forskin breakdown or wound development has becomecommon behavior, often because we cannot appreciateand respect the challenges encountered within otherenvironments and the severity of the patient’s condi-tion. We should honestly ask ourselves, “What careprovider does not strive for optimal outcomes for hisor her patients?”

Wound care specialists, encounter wound and skin issueson a daily basis. Many of these cases are considered tobe somewhat commonplace (skin tears, excoriation sec-ondary to incontinence, etc.). For many wound, ostomyand continence nurses (WOCN), certain scenarios and

cases are etched into our minds because of the signifi-cance of the details or the absurdity of the situation.

I received a call from a frantic nurse who had justreceived a 40-year-old male from an area long-term carefacility. She proceeded to tell me about the horrible neglectthat this man must have endured. She was certain thatthis facility should be reported to the state authorities.She was confident that this patient had multiple pressureulcers from poor nursing care.

Upon examination of the patient’s condition, I deter-mined that his tissue injuries were not pressure ulcers;location and quality of these lesions, as well as the

By Teresa Kellerman,RN, WOC, ARNP

Respect means to feel or show honoror esteem for someone or something;to consider the well-being of; or totreat someone or something withcourtesy. Showing respect is a basiclaw of life. The Sacred Tree

Caring for Yourself


72 HEALTHY SKIN

admitting circumstances regarding them provided valu-able information and explained the complexity of thisscenario. With the history provided by the patient’smother, it became apparent that this patient had necrotiz-ing fascitis, a condition that nursing has no control over.The patient, in fact, had been admitted from a surgeon’soffice for emergent surgery to address the rapidly pro-gressing necrosis. The response of this nurse, prior toadequate patient history and examination, assumed that the patient’s integumentary condition was directlyrelated to his level of nursing care.

This patient was a fragile, blind diabetic with renalfailure. He had a previous below-the-knee amputation,an extremely high white blood cell count, poorly controlledblood glucose levels secondary to his infection andseverely limited sensation. The nursing staff who hadpreviously taken care of him had in fact contacted thepatient’s primary care physician multiple times withinthe past week to report their growing concerns regardinghis condition. Without accurate information and withoutbenefit of doubt, clinicians might presume that apatient has suffered at the hands of a caregiver.

Effective communication When critical information is not shared between careproviders, we might fill in the blanks with inaccuratefacts, leading to faulty solutions or hostile rationaliza-tion. In the previous example, no documentation fromthe originating facility had accompanied the patient.Nothing beyond an order set for admission was pro-vided by the surgeon’s office. Multiple calls made to the extended-care facility resulted in the requested docu-mentation to gain more insight into the situation. An emotional circumstance was compounded with alabor-intensive effort to support the patient and to prepare him for surgery later that same evening.

Hand-offsCurrently, one of the the Joint Commission’s nationalpatient safety goals is improvement of hand-off commu-nication. Emphasis should be placed upon the hand-offof patient-specific information between caregivers or

the transition between care settings. This particular issueprovides an opportunity to practice the professionalprovision of much-needed care-related information. Itacknowledges respect for the care provided by the sendingand receiving facility and staff. National Patient SafetyGoal 2E is “to implement a standardized approach to‘hand off ’ communications including an opportunity toask and respond to questions. [Ambulatory, AssistedLiving, Behavioral Health Care, Critical AccessHospital, Disease-Specific Care, Home Care, Hospital,Lab, Long Term Care, Office-Based Surgery].”1

Improved communication and relationshipsForemost, we must practice respectful behaviors towardour nursing peers. We would expect and accept nothingless for ourselves, would we? As a profession, we mustassume that all caregivers practice within the samestandard of care until proven otherwise. If we observeotherwise, then communication becomes even morecritical. And, when we observe firsthand that a standardof care has not been met, we can report true andsupported cases of neglect.

Healthcare communities must develop a standardizedmeans of communication. Transfer forms need to bethorough and contact information should be provided inthe event that follow-up questions arise. You might con-sider forming a community task force to address con-cerns and build a positive, open relationship with yournursing colleagues.

Provision of appropriate information is crucial. Withregard to a patient’s integument and/or wound careneeds, the current treatment, skin and/or wound statusand related interventions for these issues should be theminimum data to accompany the patient. Current medications and lab values, medical history and previous treatments for skin/wound needs will supplement the aforementioned.

Respect for ourselves guides ourmorals; respect for others guidesour manners.

Laurence Sterne


Within the Midwest community where I practice, acoalition was formed to address pressure ulcer preventioninvolving acute, rehab, long-term, health department,home and hospice care entities. A noted need and subse-quent goal of this group was to improve communicationand care between services with regards to pressure ulcerissues. Open dialogue has occurred and recognition of theneed for further work has been established. But, as withany quality improvement initiative, identification ofthe problem must be done. All involved parties mustacknowledge and accept responsibility for the neededchange(s). Solutions must be discovered collaborativelywith the focus of best outcomes for patients whilemaintaining respectful interaction and behaviors.

ReferencesThe Joint Commission. The FAQs for The Joint Commission’s2007 National Patient Safety Goals page. Available at:www.jointcommission.org/patientsafety/nationalpatientsafetygoals.Accessed August 10, 2007.

Colleagueship is the bond betweenpeople who share a profession … it springs from a respect of each individual for each other and for themselves …

Julie Morath

About the authorTeresa Kellerman, MSN, ARNP, CNS,CWCN, COCN, OCN, is an oncology CNSand WOC nurse at St. Francis Health Centerin Topeka, Kan. She is a member of many professional organizations, including Wound,Ostomy and Continence Nurses Society(WOCN); Oncology Nursing Society (ONS)and the Greater Kansas City Clinical NurseSpecialist Group.

BURNT LIKE TOAST? Maybe you need more R-E-S-P-E-C-T in the workplace.

The warning signs of no R-E-S-P-E-C-T:• You feel fatigued in the morning when you get up

and have to face another day on the job.• You are no longer laughing or having fun at work.• You feel lethargic and empty on the job.• You have become uncharacteristically irritable.• You feel overwhelmed all the time. Even routine

tasks feel like enormous challenges to be overcome.• You have trouble concentrating.• You feel emotionally drained and "used up" at the

end of the workday.• Physical problems may include sleeplessness,

chronic fatigue or loss of appetite.

The causes• Lack of respect among co-workers or employees

and managers.• Lack of control over one's workload, schedule

and deadlines.• A feeling that one's ideas are not valued or listened to.• Absence of feedback, so employees cannot see or

appreciate the results of their efforts.• Conflict between employees, or between employees

and management.• Anxiety about job security, or the possible

consequences of failure at a job task or project.

The remedies• Let others know you are having difficulty and ask for

help. Be specific in your requests.• If you believe you are nearing the burnout stage,

seek professional guidance and support.• Cut back on responsibilities. If you feel the main

issue is overload of work, identify which tasks can be eliminated or delegated to others.

• Focus on what you can control. Distinguish between things in your personal and work life that you can control, and those you cannot.

• Take care of yourself with a balanced diet, rest and exercise.

• Don't take work home with you.• Pace yourself at work. Take mini-breaks.

Reference: Galt V. New study sheds light on preventingburnout. Globe and Mail. August 12, 2006.


74 HEALTHY SKIN


S H A R P E N I N G T H E S AW

"Why can't I get my employeesto do the things we ask themto do?"

In our work with departmental and unit level managers, one ofthe questions we get asked most often is, "Why can't I get myemployees to do the things we ask them to do?" Other versionsof this question are, "I am having trouble getting them to do (fillin the blank), what advice do you have for me?" or, "How canI instill a sense of personal accountability in my staff?"

Those of you that have worked with me in our LeadershipDevelopment Institutes know that I believe in simplicity andformulas. My motto is "Keep it simple, follow the formula!" Thisconcept guides my answers to managers who ask these questions.When answering, I tell managers there are essentially only fourreasons for nonperformance. The key is to determine which of thefour reasons apply in each case and then provide the remedy forthat reason.

Reason #1: The employee does not know they are supposed todo the job in a specific way. This is always the first question toask in any instance of nonperformance. I advise the managerto go to the employee and say, "Tell me what you are supposedto do in this situation." Note how closely their answer matchesyour mental vision of what is supposed to happen in thegiven situation.

Special Features

Most healthcare organizations, regardlessof size, location or profitability, all strugglewith the same issues. One common issue isgetting employees and physicians to dowhat they are supposed to do.



76 HEALTHY SKIN

In our work with management teams we often hear,"Everyone knows they are supposed to do this, it isjust common sense." I think you will be surprised howoften your vision differs from that of your staff. In fact,the common sense you think everyone has might notbe common at all. Correcting this miscommunicationwill fix many of your nonperformance challenges.

Reason #2: They know what they are supposed to do,but do not know how to do it. This is essentially anissue of training. In this circumstance, employees wantto perform, they just do not know how because theyhave not been trained properly. Once you are surethey know what they are supposed to do, the nextquestion to ask is, "Am I sure they have been trainedto do it the way I want them to do it?" We are alwayssurprised at the number of institutions that add instructional language to their policy and proceduresmanual and then assume that training has been doneregarding application or compliance with the new requirements. Managers must give their staff the toolsto be able to comply with the requirements of the job.

Remember that telling is not training. Just telling an employee they should "do it this way" is not sufficient. Effective training includes four elements:1. Explanation2.Demonstration3. Practice4. Reinforcement and feedback

If what you consider training does not include these four elements, the employee has not beentrained properly.

Reason #3: They know what they are supposed to do,but do not have the physical and/or mental capacityto perform it. In other words, no matter how muchtraining you give them, they are unable to do the job. This is often the most misdiagnosed reason fornonperformance. Experts estimate that up to 80 percent of the time supervisors are incorrect whenthey determine this is the reason for nonperformance.

Therefore, if you are positive the employee knowswhat they are supposed to do, and you are absolutely

sure they have received plenty of constructive trainingto do it, and they are still not doing it, ask "Does thisperson have the mental and/or physical capacity to do this job?"

The answer may be the employee does not have the capacity to do the job effectively with the amountof training you are willing to provide to them.Alternatively, you might have made a hiring mistakeand the person is not suited for the job you are askingthem to do.

Reason #4: They know what to do, how to do it andthey have the capacity to do it, but choose (for manyreasons) not to do it. This is willful noncompliance.The noncompliance may stem from these thought patterns:• My way is better• Your way will not work• I do not want to change• I am unable to do it because of institutional obstacles

• I do not want to do it• I will not be supported if I do it

The manager must determine why the employee is not performing and address the reason immediately.This response involves three components:1. Provide convincing information that the organization's way is better than the employee's way

2. Provide positive rewards for good performance3. Provide negative consequences for nonperformance

Knowing and using these four reasons for nonperfor-mance have helped me tremendously during my military career and in cofounding and leading twosuccessful businesses. Whenever I have been confrontedwith nonperformance I ask myself, "Which of the fourreasons is the cause?" If it is reason #1 or #2, I providetraining to fix the problem. If it is reason #3, it is bestto let the employee go as soon as possible. We do notdo the employee or the organization any favors bykeeping them in a job they are not capable of perform-ing. If it is reason #4, and I am unable to change the



employee’s behavior through positive rewards or negative consequences, again it is best to let thatemployee go as soon as possible.

Effective management of staff is not magic. It is taking specific actions to obtain the behaviors fromemployees that benefit the organization. It is thethings managers do that influence people's perform-ance. If managers do not do the right things at theright times, or in the right sequence, performance outcomes will not be satisfactory. Use these reasonsfor nonperformance to help you do the right things, in the right sequence, to obtain the performance you want.

Stephen W. HardenLifeWings PresidentLifeWings Partners LLC was founded by a former U.S. Navy Top Gun instructor and commercial airline pilot. The firm specializes in applying aviation-based teamworktraining and safety tools to help healthcare facilities save patients' lives and reduce costs. LifeWings has helped more than 70 facilities nationwide provide better care to their patients.

Reference:Harden SW. Sharpening the saw: a message from the president. The Pulse. June 2007.

www.saferpatients.com


“

78 HEALTHY SKIN

Dr. Marla”battles breast cancer

By Marla Shapiro, MD


creo

“I felt like my identity wasbeing stripped away.”


It was a routine mammogram, but when the X-ray was done, theradiologist asked for a magnified view of my right breast. She needed to geta better look at something.

I wasn't anxious. I knew that this was fairly routine. If the breast tissue isdense, the X-ray film can be difficult to interpret.

But when she came back, the news wasn't good. She tried to be reassuring,but her eyes were fixed on the floor as she suggested that I undergo a biopsy.

I could feel the fear rising. I knew I was in trouble. After all, I was a doctor too.

But on that day, Friday, Aug. 13, 2004, without warning, I switched roles andbecame a patient. It was foreign territory for me, and now, having spent 14months there, I have to admit the journey has not been easy. The biopsy led to surgery that ultimately confirmed I was suffering from invasivebreast cancer.

In many ways, where Dr. Marla ended and just Marla began was poorlydefined. My profession was inextricably woven into the very fabric of whoI was – someone taught to be a clear thinker and problem solver whosedecisions are based on evidence, even if it's just the best that science canoffer at the moment.

And when it comes to cancer, the evidence is staggering. According to theNational Breast Cancer Foundation, women in the United States developbreast cancer more than any other type of cancer, except skin cancer. Italso has the second highest rate of cancer death in females. An estimated200,000 women will be diagnosed with breast cancer this year and it willlead to the deaths of more than 40,000 of them.

However, this disease does not only affect women. The NBCF also notesthat approximately 1,700 men are diagnosed with breast cancer each year.It will kill roughly 450 of them.

As a doctor, you learn to respect those numbers and screen as effectivelyas you can, be it clinical examination, diagnostic tests or lifestyle counseling.As a patient, your life is changed forever. And mine has.

As well as the feelings everyone has when faced with a life-threateningdiagnosis, I had to deal with the fact that, thanks to my appearances bothon [Canadian morning news show] “Canada AM” and on [health and lifestyleprogram] “Balance,” my own show, I am a public figure.

Caring for Yourself


Just what this meant was drivenhome the day I went for my firstoncology appointment. As my husband, Bobby, and I stood at the reception desk in Toronto'sSunnybrook Hospital, we could seethat “Balance” was playing on thetelevision set in the waiting room.People behind us began to wonderout loud if "that woman standingthere" was Doctor Marla and if"she" had cancer.

I wanted to turn around and scream,"I may have cancer, but I'm not deaf."And yet I realized at the same timethat I'd have to say something aboutwhat I was going through. Keeping ita secret was the last thing I wanted.My goal was to deliver a message:Fight and hope. I wanted to supportmy family and friends with encourag-ing words.

So, when I wrote the first of my weeklycolumns for The Globe and Mail'shealth page almost exactly a yearago, I introduced myself to readerswith the news of my recent diagnosis.

I also explained that I did not wantthe disease to define me, but clearly ithas in many ways, some perceptibleand some not. I am not the samewoman who walked through the doorsof mammography that fateful day.

For one thing, the treatment meantthat I couldn't practice medicine. Idid not want to abandon this role I feltso comfortable with – I felt like myidentity was being stripped away. Butchemotherapy wipes out your white-blood-cell count and makes you a sit-ting duck for any infection; to keepworking in such a situation wouldhave been like doing the tango in a minefield.

I forced myself to keep up with“Canada AM” and my other mediacommitments. I needed to hold on to

a piece of me that was old and familiar. But most of my energy went into fight-ing the disease.

People ask if this fight has gone betterfor me because I'm an informedpatient. I really don't know. In so manyways, it has been easier because Iunderstand the language and theuncertainty. But in other ways, I knowtoo much and yet not enough. It isvery hard ever to feel reassured.

The treatment of breast cancer istailored to the individual and basedon where you are when you're diag-nosed. But even then, there are manyoptions and no black and white, noright answer. As I navigated throughthe maze of diagnosis and treatmentoptions, I realized that, despite myknowledge, I was totally unprepared.

It felt like I was running a race. Thereare so many decisions that have tobe made – and made quickly. Thevarious treatment options were out-lined, along with the potential benefitsand side effects, but ultimately I hadto make the choices that I hopedwere right for me.

And these choices hinged on the factthat my tests could not confirm

whether the areas where the cancerhad invaded my body were related toor independent of each other. As aresult, I was offered chemotherapy –although I could have refused that option.

After that, I had to decide betweenradiation and mastectomy, therapiesthat were considered equally effectiveeven if they are clearly so different.

So no one could tell me how to runthe race. It's something you have tofigure out yourself: what treatmentsare right for you, what your comfortlevel is, what risks you're willing totake. It's a race I had to run alone. Or so I thought.

When my husband and I told our twoolder children, daughters Jenna andAmanda, I minimized my concern.But when I was to start chemotherapy,I could not shield them from theobvious side effects I would have to endure.

We waited a while to tell nine-year-oldMatt, and thought we had done agood job of protecting him. But childrenare perceptive, and he soon sensedthat something was wrong. Whichfrightened him because our

80 HEALTHY SKIN

Marla – with her hair starting to grow back – and her family.



“silence suggested there was some-thing that he could not talk about.

Once told, he was obviously relieved,and being so young, he soon came upwith every conceivable question. Hefound it curious that I would lose myhair. (Actually, I did too.) He wanted toknow if cancer would just go away, likea cold does.When we told him it wassomething that had to be beaten, hewalked around for days, boxingimaginary demons in the air.

Also, suddenly I was home a lot. Mychildren have grown up in a busyhousehold with a mother who leavesearly and often comes home late.And while they knew that I was always"there for them," it wasn't always aphysical presence. Being there for carpools, events and homework oftenrequired a juggling act.

My newfound free time allowed me torediscover my kitchen. I started bakingand cooking so much that, after awhile, the kids complained they weregaining weight even as I was

gradually disappearing into the sideeffects of my treatment.

Thanksgiving last year came right aftermy first round of chemotherapy, and Iwas unbelievably sick. Nothing hadprepared me for how ill I would be. Ifelt like a toxic waste dump. I couldn'tmove, I couldn't eat.

Home from school for the weekend,the girls were confronted with just howill I had become. The fear in their eyeshit me like a ton of bricks. Clearly thiswasn't just about me. This was theirfight too.

As I tried to suppress my darkthoughts about not being around tosee them marry, have children and

move through life, I suddenly realizedthat they had the exact same fears.And while I felt I could force myself todeal with anything, I could barely copewith their pain and fear. Try as I might,I could not make it go away.

But as time went by, I found therewere things I could do.

The email and letters of support andconcern I received were overwhelming.I am eternally grateful to the womenwho came forward to share their stories.I did not have to be alone.

Then one day my husband asked mewhy, if one in nine of us has breastcancer, does Canada not have morebald women running around?

The answer is that we are here butoften silent.We carry on.We wear ourwigs.We move forward as best wecan, considering so little is said abouthow nothing in life prepares you todeal with a curve ball like this.

But when I was invited to go toVancouver to appear on “VickiGabereau,” I wondered about leavingthe wig at home. The truth was that Iwas wearing it only on “Canada AM.”In real life, I walked around bald. Igave speeches bald, went to dinnerbald. But I knew that this was different:national television without a wig.

I decided that this was who I was inreal life, and so I headed off to theWest Coast wearing just my littleblack hat to keep me warm.

Marla with Amanda, oneof her two daughters...

and with her son, Matt.

I realized that, despitemy knowledge, I wastotally unprepared.”


creo

As I sat in makeup and Vicki came into say hello, she stopped and, in hertypical way, said: "You look different,Mama." She smiled, I smiled and offwe went to do the interview.

She was frank and curious and askedtough questions. I was totally comfort-able in my own skin – and totallyunprepared for what happened next:Letters came from women sayingthey had taken off their wigs afterseeing the show.

I realized then that many people hadthought I was sailing through my fightwith cancer, that somehow I had theinside track. In reality, on many levels,it was exactly the opposite: I am nodifferent from anyone else in thesame situation.

It soon became apparent to me that Ihad a story to share – and it wasn'tas much about the medicine and sci-entific advances as it was about theimpact on my family, my life and allthe things we don't talk about.

When I spoke to CTV about making adocumentary, the network was pro-tective of me and said it was my deci-sion, but I felt strongly that I wanted todo this. A crew more or less moved inand followed me around. My familyand friends and physicians were open

and honest, and the result is calledRun Your Own Race.

Today, my chemotherapy is behindme. The surgeries I elected to haverather than radiation are over, and Ihave gone back to my office and acareer I love.

So how have I changed? In manyways, I am the same – juggling a zillionwork balls and loving the return. Butin so many other ways, I am different.The only word I can think of todescribe it is mindful. I am so muchmore mindful of the decisions I make,my family, my children and how Ichoose to live my life.

My children would say that my valueshave changed, and perhaps they arewiser than their mother, who hasfinally learned to match her emotionaland her time commitments.

There are those who insist that Ihave inspired them with my so-calledcourage, when, in fact, they haveinspired me with their stories. It doesn'ttake courage to fight when there is noother option. I am not alone. You arenot alone. Together, we all make a difference.

Based on an article originallyappearing in The Globe and Mail,October 2005.

About the authorFor years, well-known medical contributorDr. Marla Shapiro has waded through theconstant barrage of medical research andhas disseminated the most sensible med-ical information you need to make smarthealthcare decisions. She completedmedical school at McGill University andtrained at the University of Toronto for herMaster’s of Health Science in CommunityHealth and Epidemiology. She concludedher specialty training in CommunityMedicine receiving her Fellowship inCommunity Medicine from the RoyalCollege of Physicians and Surgeons ofCanada. She is an Associate Professor inthe Department of Family and CommunityMedicine at the University of Toronto andis in private practice.

In 1993 she joined City TV in Toronto,Ontario as the medical expert on thenationally syndicated show “Cityline.”Shortly thereafter she became the med-ical expert for “City Pulse” and CP24News. In 2000, she left City to becomethe health and medical contributor forCTV's “Canada AM.” In addition to herweekly appearances on “Canada AM,”she is seen on “Newsnet” and as themedical consultant on CTV’s “News withLloyd Robertson.”

2003 saw the exciting addition of“Balance: Television for Living Well.” Dr.Shapiro hosted this exciting daily healthand lifestyle show. It is seen across NorthAmerica and has sold internationally.

Dr. Shapiro is the recipient of the 2005Media Award from the North AmericanMenopause Society for her work inexpanding the understanding ofmenopause, and won the Society ofObstetricians and Gynaecologists ofCanada/Canadian Foundation forWomen's Health Award for Excellence inWomen's Health Journalism in 2006 forher documentary Run Your Own Race.

82 HEALTHY SKIN

Laughing with chocolatebreasts before her bilateral mastectomy.


A Must-ReadLife in the Balance is Dr. Marla Shapiro’sinspirational account of her battle with breastcancer from diagnosis to surgeries tochemotherapy and her agonizing decision to have both breasts removed. It is also thepersonal story of how her family handled thenews and came together to achieve newfoundbalance in their lives. This is a book for anyonewhose life has been touched by cancer orwho knows someone who has.

Order your copy at one of these online retailers:Amazon.ca Chapters.Indigo.caMcNallyRobinson.com


Tips for Early DetectionThe most important thing any woman can do to fightbreast cancer is to practice tips for early detection.Many women are not familiar with the territory, sohere are some early detection tips, signs and symp-toms from the National Breast Cancer Foundation,included as reminders.

Three recommended screening methods• Breast Self-Exam – Studies show that regular (monthly) breast self-exams, combined with an annual exam by a doctor, improve the chances of detecting cancer early.

• Breast Physical Exam (By a doctor) – This should be done on an annual basis and in conjunction with breast self-exams.

• Mammograms– The National Cancer Institute, the American Cancer Society and the American College of Radiology now recommend annual mammogramsfor women over 40.

Symptoms and signs• A new or persistent lump or a thickening in or near the breast or possibly in the underarm area

• A change in the size or shape of your breast• Discharge from either of the nipples that has not occurred before

• Changes in the color or feel of your breast, areola or nipples, which might consist of dimpling, puckering or a scaliness of the skin.

It’s critical to carry out regular breast self-examinations– this way, you will be able to detect any of thesesigns or symptoms. If you find something that you feel is abnormal, arrange an appointment to see your doctor.

Referencebreastcancer.org. Symptoms and diagnosis. Available at: http://www.breastcancer.org/symptoms/. Accessed August 21, 2007.


84 HEALTHY SKIN

“BEST dayEveryone has them, but often we do not take time to reflect and learn from whatever made the dayeither the best or the worst we’ve encountered. Many lessons could be learned from taking a fewminutes to sift through details and analyze data so that we can choose to either replicate oreliminate the factors that contributed to the success or demise of a given workday.

Below are some situational examples to stimulate your mind and help you start thinking aboutyour own best and worst days!

“When I interview people for nursingjobs, I’m very clear that this is not aplace of joy and happiness all thetime. Now that I’m older and I havesome experience, I feel it’s an honorto be there at the time of death. But ittakes a piece of you every time.Usually, I’m more happy after workthan sad. I sometimes miss the lightsand sirens, but I wouldn’t trade myworst day here for my best day at anyother job.”

“You never know what a day will bring.It’s strangely comforting to work in anursing home. There’s a rhythm toit…the housekeepers are cleaning thesame area when you arrive eachmorning, the cafeteria has chickenstrips again for lunch.”



WORST day

We want to hearfrom you!Please email stories about yourbest and worst days at workto [email protected] will share many of theresponses in future issuesof Healthy Skin!

”

“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our localhigh school had a shooting this past spring and the victim was brought to the hospital. The entireCommunications Department, save me, was out of the office at a seminar three hours away. Being apart-time writer, I had to step up and do interviews with national news agencies, over the phone withNPR, etc., which was a huge learning experience. And we were the heroes, because our staff savedthis kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the papertrashing the hospital for not covering his bills, etc. The good and the bad.That’s working in a hospital for me.”

“Hospitals are messy places wheregood and bad things happen, makingpublic relations a constant juggling act.Think about it…you have a young malemotorcycle accident victim arriving inthe trauma unit who is not likely tosurvive (bad) but the thought that hisorgans might just bring life to manyothers is the opportunity (good). Or thehospital is planning a major expansionof facilities to better serve its community(good) but an unfortunate incidenthappened to a patient who alsohappened to be a family memberof a local businessman with lotsof money (bad).”

Caring for Yourself


Midnight Blue

86 HEALTHY SKIN

&Berries CreamPound Cake

Grease and flour 10-inch tube pan. Preheat oven to 325º F

8 oz. cream cheese3 sticks margarine3 cups sugar1 tsp. vanilla extractPinch of salt6 eggs3 cups flour

1 large tub of whipped topping2 packages of strawberries (sliced),1 small package of each - blueberries,

raspberries and blackberries

Cream the first 5 ingredients together. Then add the 6 eggs(1 at a time) and 3 cups flour. Blend. Then spoon batterinto pan. Bake 1½ hours.

Once the cake is cooled, take a knife and slice the cake intotwo layers. Spread 1⁄3 of the whipped topping on the bottomlayer of cake. Top with a layer of strawberries and sprinkle withthe other berry options. Dab some additional whipped toppingon top of the berries and cap off with the top layer of the cake.Spread the remaining whipped topping on top of the cake. Addan additional layer of strawberries, then decorate with blueberries,raspberries and blackberries. Cool in the refrigerator and serve.

Caring for Yourself

FOLLOW THE LEADER Medline continues torevolutionize scrubwear

Custom embroidery is available on all items!

To learn more about the complete line of Medlinescrubs, contact your Medline salesrepresentative or call 1-800-MEDLINE.

• ComfortEase™: A poly-rich heavyweightfabric that offers durability, wick-dry comfortand a crisp look at a great price.

• AngelStat®: A 50/50 moderate-weight cotton/poly blend makes these scrubs soft yet durable.

• Encore: These soft, lightweight scrubsare both comfortable and economical.

Mariner Blue

Royal

Black Caribbean Blue

Eggplant Khaki

EvergreenWine Rich Purple

Ciel Blue

Seaspray

Jade Green

Colors shown are ComfortEase™ colors. Please con-tact you Medline rep for AngelStat® and Encore colors


creo


Forms & Tools

FORMS & 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

Guidelines for Wound 88Photography

Prevention of Skin Tears – 89In-Service Outline

Bates-Jensen Wound 90Assessment Tool

PUSH Tool 3.0 92

Quick Guide to Lab Values 94

Foley Catheter 95Selection Guide


88 HEALTHY SKIN

Forms & Tools

Guidelines for Wound Photography

General tips• Digital photos are always preferred.• Grid or disposable camera shots are not acceptable.

• Need three completed case studies with a beginning, middle and end photo.

Patient selection• Approach each resident as if their wounds will become a poster/case study.

• Get in the habit of using good photography techniques every time to improve your photo outcomes.

• Allow time to compose your shot and your patient.

PermissionBe sure to obtain a photo permit as required by youragency or facility.

FrequencyPhotos should be taken at admission, weekly thereafterand at wound closure. All efforts should be made to pro-tect patient privacy with regard to HIPAA compliance.

Preparing for your shootLighting Use natural light (no flash) whenever possible. Be care-ful that the sun does not wash out the subject or distortthe surface texture. If the light source is behind you,make sure your body does not create a shadow.

Background Your objective is to showcase the wound on a solidbackground. Drape the patient in a dark blue or blackcloth, which helps to absorb the flash and decrease thereflection off the patient’s skin. Avoid white because itwill cause many cameras to have trouble focusing.Shiny blue underpads that reflect the flash should also be avoided.

Composition• Avoid clutter in the background (i.e., printed clothing or towels).

• A ruler labeled with the date, length, width and depth of the wound(s) must be present in each photo.

• The resident must be positioned in the same manner for each set of photos so that progress can be seen.

• Take the photo from the same angle each time. It’s best to have the camera pointing perpendicularto the wound instead of down from the top.

• Taking all of the photos at the same time of the day will help with consistency in lighting.

• Camera movement is the most common cause of photo blurriness. Stand firm with your feet shoulder width apart and tuck your elbows tight to your sides to prevent any shaking.

• Take a minimum of four shots at each visit per wound site:> Location shot at four feet> Two-foot close-up – 90 percent person and 10 percent background

> Two-foot with zoom – highlight tissue texture, drainage

> Preview shots taken to ensure that pictures are clear and visible

Additional photos of wound care procedures that high-light dressing removal, amount and absorption ofdrainage, product performance, pre- and post-irrigationwounds and dressing application steps are all of interest and might be useful in a poster presentation.

Most of us are frugal when it comes to taking photos.Be liberal! The beauty of digital photography is that youcan delete what you do not like. It’s better to have a lotof photos and choose the best back at the computer.


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Forms & Tools

Prevention of Skin Tears – In-Service Outline

Effect of Aging on the SkinEpidermal cells thin and divide slowerDermis thins (overall appearance of skin is thinner)Less collagen production (more visual wrinkling)Elastin fiber wear (less elasticity to skin)Decrease sebum product, natural skin oils (skin is drier)Decrease sweat glands (skin is drier)Rete ridges flatten (makes skin more fragile)Decrease number of melanocytes (“aging spots”) whilesize of individual melanocytes increasesDecrease subcutaneous fat

Risk FactorsHistory of previous skin tearsCompromised nutritionFluid volume deficitConfusionMobility limitationsBruised skinMedications that cause thinning of skin

Prevention StrategiesLong sleevesGentle adhesivesPillowsCareful use of transfer equipmentProper nutrition (internal and topical)Appropriate hydration

Treatment OptionsNonadhesive oil emulsion gauzeHydrogel sheetTransparent filmSilicone faced dressingsWound closure strips

Young adult skin Old skin


90 HEALTHY SKIN


91Improving Quality of Care Based on CMS Guidelines“Reprinted with permission from Barbara Bates-Jensen


92 HEALTHY SKIN

Forms & Tools



Forms & Tools


94 HEALTHY SKIN

Quick Guide to Lab Values

Taking a look at your residents’ lab values can tell you a lot about why their wounds might not be healingproperly. For starters, lab values can indicate insuffi-cient nutrients, oxygen and cellular components. Theinformation below can help you evaluate lab valuesand identify health problems commonly associatedwith values above and below the normal ranges.*

Red blood cells (RBC)Normal values• Males: 4.7 to 6.1 M/µL• Females: 4.5 to 5.4 M/µL

RBCs contain hemoglobin, which allows the transportand exchange of oxygen and carbon dioxide to tissues.

Below normal range• Anemia• Lymphomas, leukemia• Cirrhosis• Dietary deficiency: iron, vitamin B12• Fluid overload• Hemorrhage• Normal pregnancy• Renal disease

Above normal range• Congenital heart disease• Severe chronic obstructive pulmonary disease (COPD)

• Severe dehydration: severe diarrhea or burns

White blood cells (WBC)Normal value• 5.0 to 10.0 K/mm3

WBCs fight infection and react against foreign bodiesor tissue. If the body makes poor or malformed cells,wound healing slows or halts and the wound might beleft in a state of chronic inflammation.

Below normal range• Autoimmune disease• Bone marrow failure• Dietary deficiency: iron, vitamin B12• Drug toxicity

Above normal range• Infection• Non-marrow cancers• Dehydration• Inflammation• Trauma, stress or hemorrhage• Tissue necrosis

Hemoglobin (Hb or Hgb)Normal values• Males: 14 to 18 g/dL• Females: 12 to 16 g/dL

Hemoglobin transports oxygen and carbon dioxide.

Below normal range• Anemia• Bone marrow failure• Cirrhosis• Dietary deficiency• Hematalogic cancers• Hemorrhage• Prosthetic valves

Above normal range• Congenital heart disease• Severe dehydration: severe diarrhea, burns• Severe COPD

Total proteinNormal value• 6 to 9 gm/dL

Protein is the building block of many body components,including muscle, skin, hair, internal organs and blood.

Below normal range• Burns• Inflammatory diseases• Malnutrition• Protein-losing processes• Overhydration

Above normal range• Dehydration

*List is not comprehensive.Reference: Medline Industries, Inc. The Wound CareHandbook. 2007

Forms & Tools


95

Forms & Tools

Foley Catheter Selection Guide

The longer a resident is kept on a catheter, the higher their risk of developing acatheter-associated urinary tract infection (CAUTI) climbs. In addition to CAUTI,these residents are also in danger of developing other complications, such as leakage, encrustation and blockage.

You can help reduce catheter complications and CAUTI by selecting the appropriatecatheter. Use your answers to the questions below to select the catheter that bestfits each resident’s needs.

Does patient have latex allergy or sensitivity?Yes • Latex-free Foley catheter

• 100 percent silicone Foley catheter

No • Latex-free Foley catheters• 100 percent silicone Foley catheters• Coated latex Foley catheter

Does patient have history of recurrent UTI?Yes • Latex-free Foley catheters

No • Latex-free Foley catheters• 100 percent silicone Foley catheters • Coated latex Foley catheters

Does patient have frequent blockage/encrustation?Yes • Latex-free Foley catheters

• 100 percent silicone Foley catheters

No • Latex-free Foley catheters• 100 percent silicone Foley catheters• Coated latex Foley catheters

Is it anticipated that the patient will have the catheter for more than ten days?

Yes • Latex-free Foley catheters• 100 percent silicone Foley catheters

No • Latex-free Foley catheters• 100 percent silicone Foley catheters• Coated latex Foley catheter


MEDLINE’S REVOLUTIONARY SHOW-AND-TELL PACKAGING

Each package isa 2-Minute Course™

in AdvancedWound Care

Ta ke a lookFor more information regarding our Educational Packaging contact your Medline representative,or call: 1-800-MEDLINE www.medline.com©2007 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.

MKT 207289/L IT 558/25M/J BK5


healthy skin magazine - volume 4; issue 2

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