Browsing "Pressure Ulcers"

Pressure Ulcers – Entry 3

Dear Diary,

We were doing so well with our pressure injury rates until last week! Staff have been assessing all residents on admission and readmission. We’ve worked hard on getting risk factors identified for pressure injuries and implementing care plan interventions. We have a good process down for reviewing residents at high risk for pressure injuries. LaNeka, one of our nurse managers, has taken the lead on pressure injuries throughout the building. Before the IDT meeting, she reviews the interventions and documentation. At the meeting, LaNeka discusses the residents at high risk or who have a current pressure injury. The team gives input and makes changes to the care plan during meeting. LaNeka works with other staff to get the information to the nursing assistants through their assignment sheets and daily huddles.

I thought things were going well. However, last week we had two new deep tissue injuries develop. Hattie, a long-term resident, had increased swelling in her lower legs and feet for a couple of days. During this time, she developed a deep tissue injury on her left outer ankle. It first looked like a bruise. Now that the edema has gone down, I’m sure it’s going to open. The nursing assistant, Shannon, who worked with Hattie the last couple of days, didn’t know her all that well. Her regular aide is on vacation. Shannon knew Hattie’s shoes were tight, but she didn’t think they’d cause an injury. Hattie’s leg and foot swelling is fairly new and likely due to heart failure. We had no strategies in place to prevent a pressure injury due to a change in condition like this.

I’m wondering how other organizations stay on top of new concerns?

The other deep tissue injury occurred when Bill, a resident on our Rosewood neighborhood, was picked up by a family member for a day outing. He was gone most of the day and when he got back he couldn’t stop talking about his family, especially a great niece he doesn’t get to see often. After the long day out, he wanted to sleep in the next morning. When he finally got up and had a shower, the nursing assistant helping him noticed a deep purple area on his coccyx. When she asked Bill about it, he said it was sore and he didn’t remember having it before. It’s definitely a deep tissue injury. It’s deep purple, warm to the touch, and feels “boggy.” We did a root cause analysis and discovered that when he was at the restaurant with his family he sat on a hard chair. They were at the restaurant quite a long time. His family then took him for a long car ride in the country. After the drive, they went to his daughter’s house, where he sat visiting until it was time to go. Bill said he didn’t lie down and rest like he usually does in the afternoon. Bill doesn’t go out too often, so we didn’t anticipate him developing a pressure area.

How do others teach families about pressure injuries and what to do to prevent them?

Signed, Donna

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Pressure Ulcers – Entry 2

Dear Diary:

A few weeks ago, we brought the nurses together on the transitional care unit (TCU) to talk about our process related to complete the Braden Scale for Predicting Pressure Ulcer Risk for our residents and next steps. Though these nurses are busy, they’re finding time to complete the Braden Scale for all residents. However, it isn’t clear to them who should follow up to make the necessary changes to the care plan once the assessments are complete. The TCU nurses had some great ideas for changing the process.

Recently, many of us listened to a Plan, Do, Study, Act (PDSA) webinar. We thought it would be a good idea to trial the new process on the TCU to get the bugs worked out before going facility-wide. It’s been two weeks and today our interdisciplinary team met to discuss how it’s going. There was a lot of feedback about this new process!

1. Include a list of evidence-based pressure ulcer prevention interventions for each risk factor on the back of the Braden Scale form that relates to the identified risks. Judy, our assistant director of nursing, agreed to put this together.

The nurses felt this step was double work. They thought it would be more helpful if we had a pressure ulcer care plan template including the list of interventions. Each time the Braden Scale is done, they can grab the pressure ulcer care plan template, or add to the one already in the health care record, and check off the appropriate interventions. Great idea for eliminating them having to do this twice!

2. The nurse completing the Braden Scale each week will check off which interventions to implement, ensure that any equipment needed and/or consults are in place, and update the care plan by the end of the shift. She’ll inform the health unit coordinator (HUC) of the changes.

The dietary and therapy departments aren’t available 24/7, so it isn’t always possible to get a consult completed by the end of every shift. So, the dietician will come up with a list of high protein, high calorie snacks and make those available in all of the kitchens. Staff will offer these snacks to high-risk residents twice a day until the dietary consult is done. We’re meeting with the therapy manager later this week to develop a plan for those consults.

3. The HUC will make changes to the NA assignment sheets and the nurse will make changes to the care plan by the end of the admission shift, or when a change of condition is recognized.

The assignment sheets are not always getting updated since a HUC isn’t available every day and shift. So, the nurse will need to be responsible for this step too, though she can delegate it if the HUC is available. We might be able to simplify this somehow through the electronic medical record. I need to set up a time to talk to our vendor about this.

The plan is to trial these changes on the TCU for two weeks and see if the team is better able to follow through on pressure ulcer risks identified on the Braden Scale. Once we get this process down, we’ll implement it in all of our neighborhoods. This has been a great exercise in using PDSA to test process changes! I wonder what other process changes nursing homes are putting into place to prevent pressure ulcers?

Signed, Donna

1 Comment

  • We had a problem that a nurse filled out braden but did not do any interventions with the information. We worked on a list of interventions for each area of the braden that the charge nurse needs to implement. Audts will be done to see if we follow through. I read the part where dietary stocked the kitchens with high pro high cal snacks, great idea!

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Pressure Ulcers – Entry 1

Dear Diary:

I was hoping we were finally making progress with one of our resident Hattie, but now she has developed a deep tissue injury to her right heel. Hearing about an acquired pressure ulcer is never good news. At our interdisciplinary team meeting, we completed a root cause analysis of this pressure ulcer and here’s what we discovered:

  • When Hattie returned from the hospital nine days ago, the nurse completed the Braden Scale on admission day, and then another one seven days later. By day seven, Hattie had the deep tissue injury on her heel.
  • The results of both of these risk assessments showed that Hattie was at moderate risk for developing a pressure ulcer.
  • Hattie’s highest areas of risk are from her very limited independent mobility, walking infrequently even with assistance, eating and drinking poorly, and potential for shearing.
  • Hattie’s care plan and the nursing assistant (NA) assignment sheet did not indicate any preventive measures related to her identified risk factors besides the standard “reposition every two hours”.
  • Prevention measures were not implemented in her care plan upon completion of the Braden Scale (such as a dietary consult, implementation of support surfaces, off loading of heels and so on).

We also discovered there is no process in place to act on risk factors identified in the Braden scale risk assessment. We decided that this is the root cause of this pressure ulcer/deep tissue injury, and probably other acquired pressure ulcers we have! We are not blaming anyone for this oversight, as it seems to be an overall systems problem. What should I do next?

Signed, Donna


  • We have a certified wound care nurse and team at our facility that really focuses on education and does wound rounds routinely.

  • With this being a systems/process issue it will take longer to correct. The IDT needs to determine where the breakdown(s) are occurring. Is it a lack of education? Is it a lack of communication regarding the expectations? Or something else? Once you determine what part of the system is broken, you can begin to put it back together and educate/communciate what the expectations are with regard to putting interventions in place. Through this deeper look at the process you may also find other areas that need to be looked at as well.

  • When there is systems breakdown there is potential harm to everyone. When we identify a systems problem we cite ourselfs and treat it with a plan of correction. 1.Identify and improve care for those affected. Put immediate interventions in place. 2. Perform a baseline audit including head to toe assessment on all residents to assure there is no skin breakdown that we are not aware off. Review all Braden assessments and quantify how many display risk that are not care planned. 3. Once the data is collected, we do root cause and protocol review and make improvements to our system . We educate staff so all are aware of the Quality improvement implementation. 4. Develop a system for monitoring ongoing success. 5. Identify a date for completion and monitor. This might be a QAPI sub committee. PDSA may be used in test solutions prior to systems roll out.

  • We have the same problem as noted in Hattie’s case. We do our braden’s in a timely manner but do not look at risk areas to implement preventive measures. Nursing staff does well at doing body audit and looking for red areas and working on preventive measures with this. Dietary does nutritional consult but may not be within the firstr 24 hours. We also put turning and repositoning every 2 hours on group sheets but usually no other preventive measures as in Hattie’s case.
    We need to identify risk factors within the first 24 hours and discuss as IDT.

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