presented by: jennifer birt, ot reg(mb)csmc.ca/docs/archives/2013_archive/hnd/ws 13 best practices...

Presented By: Jennifer Birt, OT Reg(MB)Specialized Seating & Mobility

Clinical Specialist© 2013

1. Define and understand the concept of practical pressure management and categorizing individuals at different levels of risk from a practical perspective

2. Identify a minimum of 6 factors that commonly contribute to pressure ulcer development from a 24 hour perspective

3. Identify a minimum of 4 assessment techniques that can be utilized when evaluating these pressure factors

4. List a minimum of 4 recommendations guided by best practice to resolve these pressure factors

© Jennifer Birt 2013

Occipu t

Scapulae

Sacrum

Coccyx

Greater Trochanter

Ischial Tuberosity

Epicondyle

Spinous Processes

Malleolus & Heel

Elbow


General CPG’s

Winnipeg Regional Health Authority (WRHA) updated 2012

Registered Nurses of Ontario (RNAO) updated 2011 & 2007

National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel (NPUAP/EPUAP) 2009

Canadian Association of Wound Care (CAWC) updated 2006

SCI-Specific CPG’s

Rick Hansen Institute (RHI) 2013

Spinal Cord Injury Rehabilitation Evidence (SCIRE) updated 2009

New South Wales Agency for Clinical Innovation (NSW ACI) 2008

Paralyzed Veterans of America (PVA) 2000


What makes OT’s key clinicians in the role of practical pressure management?

Applying pressure management best practices into the functional context of

an individual’s daily life and environment

Holistic (24 hour) approach Adaptive approach

Activity analysis Assistive device & equipment specialists

Practical Problem solving P-E-O Model


Cognitive Issues


PURPOSE

To provide a clinical evaluation tool, based on best practice, that offers a systematic way of evaluating pressure management from a practical perspective

The PMAT provides a structural framework that investigates the causative factors that contribute to the functional aspects of pressure ulcer development from a 24 hour perspective


Working knowledge of clinical practice guidelines for pressure ulcer prevention & treatment

Working knowledge of pressure ulcer stages as well as additional signs & symptoms of pressure-related damage to skin

Ability to reliably landmark and palpate key bony areas that are most susceptible to pressure-related damage in a variety of positions

Working knowledge of proper support surface terminology and principles

Awareness of pressure-posture relationship

Understand team roles in addition to your own role


REFERRAL TO OCCUPATIONAL THERAPYDiagnosis: • Multiple Sclerosis

Associated medical

conditions:

• Spasticity• Incontinence

Pressure Issue identified:

• Skin breakdown on “buttocks”

Other issues flagged:

• Sliding in the wheelchair

• Postural deformities

Purpose of Referral:

• Needs a cushion • Needs a seating

assessment

Client ‘X’


FUNCTIONAL WOUND EVALUATION

• Visual inspection of skin over primary weight bearing surfaces

• Remove dressings whenever possible – involve nursing

• Side lying in “mocked” sitting position

• Rule of thumb when evaluating wounds:

• What do you see?• What do you feel?• What do you smell?

• Understand signs of pressure, shear, friction, & microclimate

• Digital photos


POSITIONING EVALUATION

• Palpation to correlate ulcer with each position

• Evaluate whether pressure ulcer is weight bearing, partial weight bearing, or fully offloaded for:

• All positions, on• All support surfaces• 24 hour perspective

• Mock up modified and/or additional positions with client as alternative solutions

• Understand PRESSURE- POSTURE relationship


POSTURAL SCREEN IN SITTING

• PRESSURE-POSTURE relationship

• What happens in the wheelchair is a good indication of what will happen on other sitting surfaces

• Influence of gravity• Bodies will go in 3 general

directions under the influence of gravity:

• Anterior• Posterior• Lateral


REPOSITIONING EVALUATION

• Evaluation of repositioning movements in:

• Bed• Wheelchair• Other sitting surfaces

• Goal is to determine whether:

• Client is capable of the movement

• Movement is effective• Palpate ulcer area during

movement to decide:• Effective offloading?• Shear, friction or trauma

during movement?


SUPPORT SURFACE EVLAUTION

• Visually inspect every support surface used over a 24 hour period

• Ensure equipment is:• Set up properly• In good condition

• Understand impact of support surface on:

• Stability• Microclimate• Shear & friction• Function

• Support surface performance may change when position changes

• Correlate ulcer location to support surface features


MOBILITY, FRICTION & SHEAR EVALUATION

• Watch transfer and repositioning movements and screen for signs of:

• Trauma• Shear & friction

• Palpate ulcer area during transfer and repositioning movements

• Mock up alternative methods of movement

• Confirm trauma, shear & friction are eliminated or minimized with alternative methods


COGNITIVE SCREEN

• Indirect evaluation gathered from Part 1 & 2 results

• Appropriate pressure management requires:

• Insight & awareness• Problem solving• Motivation• Ability to retain

information and apply new learning

• Sometimes people make BAD lifestyle choices and decisions


TOP 10 TIPS FOR PROVIDING PRACTICAL RECOMMENDATIONS

1 Initiate consult to physician for unresolved medical concerns

2 Initiate cross referrals as indicated & at transition points in care

3 Clarify & collaborate regarding bedrest vs. sitting orders

4 Prioritize repositioning schedules & support surface use based on bedrest vs. sitting orders

5 Prioritize what to do for the interim vs. long-term

6 Prioritize interventions for essential functional tasks: eating, sleeping, toileting & bathing

7 Think outside the box for practical solutions to these core tasks

8 Frame recommendations to create clear expectations & accountability

9 Provide clients with the opportunity to choose whether or not they will follow recommendations

10 Be clear on trade-offs & consequences if clients choose not to follow recommendations


RECOMMENDATIONS

1 Pressure ulcer should be offloaded 100% of the time to help determine capacity to heal

2 Recommend medical re-evaluation for:(a) Ruling out need for surgical intervention(b) Spasticity management

3 Recommend a period of bedrest for 4-6 weeks if appropriate therapeutic sleep surface and repositioning schedule can be implemented to allow for full offloading

4 Upgrade to a low air loss mattress

5 Alternate client’s position in bed between right and left side-lying; rotate 30 degrees over from supine and use a wedge to maintain this angle, and place pillows between knees and feet

6 Due to low tolerance in side-lying positions, initiate a turning schedule every hour to start and gradually build to 2 hours as tolerance increases


RECOMMENDATIONS

7 Check skin after each turn in bed to evaluate tissue tolerance over weight bearing areas – gradually increase turn intervals by 1 hour each week based on tissue response

8 Consult Home Care about increasing frequency of services to facilitate bed rest and turning schedule during the day

9 Use a slider sheet for repositioning in bed and remove after repositioning occurs

10 Use an alarm clock overnight to implement turning schedule and consult to Home Care to problem-solve day time turns

11 Evaluate client in side-lying with the head of the bed raised to 30 degrees as an alternative position to eat meals while on bed rest; place a wedge under knees in this position to minimize sliding and do not stay in this position any longer than 1 hour


RECOMMENDATIONS

12 Consult to nursing about alternative solutions for bladder management – catheter good or bad idea? Consult to Home Care about increasing frequency of brief changes

13 Eliminate use of soaker pads on sleep surface especially if briefs cannot be discontinued

14 Consult to nursing about bowel management for bed rest

15 Provide education to client’s husband about performing skin checks and proper methods for assisting with bed mobility & bed positioning

16 Consult to dietitian re: intake requirements; additional consult to Home Care to assist with meal provision during the day

17 If client demonstrates wound healing after 4-6 weeks and no further medical interventions are required, re-initiate seating consult and re-evaluate mobility & function on sitting surfaces


Ontario Neurotrauma Foundation (ONF): www.onf.org (can download Canadian Best Practice Guidelines for SCI Pressure Ulcer Prevention & Treatment)

Winnipeg Regional Health Authority (WRHA): www.wrha.mb.ca (‘for health professionals’ ‘evidence informed practice tools’ ‘wound care’ ‘pressure ulcer’

Registered Nurses of Ontario (RNAO): www.rnao.ca

International review. Pressure ulcer prevention: pressure, shear, friction and microclimate in context. A consensus document. London: Wounds International, 2010.

National Pressure Ulcer Advisory Panel (NPUAP): www.npuap.org

Spinal Cord Injury Rehabilitation Evidence (SCIRE): www.scireproject.com

New South Wales Agency for Clinical Innovation (Spinal seating online education program, module 8): www.aci.health.nsw.gov.au/networks/spinal-seating

Canadian Association of Wound Care (CAWC): www.cawc.net

Wound Care Canada (Official publication of CAWC): www.woundcarecanada.ca

Paralyzed Veterans of America (PVA): www.pva.org© Jennifer Birt 2013

http://www.onf.org/

http://www.wrha.mb.ca/

http://www.rnao.ca/

http://www.npuap.org/

http://www.scireproject.com/

http://www.aci.health.nsw.gov.au/networks/spinal-seating

http://www.cawc.net/

http://www.woundcarecanada.ca/

http://www.pva.org/

1. Define and understand the concept of practical pressure management and categorizing individuals at different levels of risk from a practical perspective

2. Identify a minimum of 6 factors that commonly contribute to pressure ulcer development from a 24 hour perspective

3. Identify a minimum of 4 assessment techniques that can be utilized when evaluating these pressure factors

4. List a minimum of 4 recommendations guided by best practice to resolve these pressure factors


PLEASE PLEASE

REMEMBER REMEMBER TO VISIT THE TO VISIT THE

EXHIBIT EXHIBIT HALL HALL

Jennifer Birt, OT Reg(MB)Specialized Seating and Mobility

Clinical Specialist(p) 204-787-4266(f) 204-787-8637

Email: [email protected]

presented by: jennifer birt, ot reg(mb)csmc.ca/docs/archives/2013_archive/hnd/ws 13 best practices...

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