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«Best Practice for the Prevention and Treatment of Pressure Ulcers Created by the Occupational Therapists in Vancouver Coastal Health and Providence ...»

-- [ Page 1 ] --

Occupational Therapy Skin Care

Guideline

Best Practice for the Prevention and

Treatment of Pressure Ulcers

Created by the Occupational Therapists in

Vancouver Coastal Health and Providence Health Care

April 2008

OCCUPATIONAL THERAPY SKIN CARE GUIDELINE FOR VCH/PHC

BEST PRACTICE FOR THE PREVENTION AND TREATMENT OF PRESSURE ULCERS

ACKNOWLEDGEMENTS

This guideline has benefited from the contributions of many occupational therapists.

We would like to acknowledge the following contributors:

Occupational therapists in Vancouver Coastal Health and Providence Health Care who participated in the Huddles and trialled the guidelines.

Members of the Core Committee:

Elaine Au Jeanette Boily Linda Boronowski Jo Clark Dawn Daechsel Guylaine Desharnais Sandy Leznoff Jenny Finnegan

Members of the Equipment Group:

Jeanette Boily Guylaine Desharnais Peter Haughton George Kokuryo Cheryl Sheffield Joanne Yip

Members of the Documentation Group:

Elaine Au Samantha Carter Jenny Finnegan Teresa Green Sandy Leznoff April 2008 2 of 53

OCCUPATIONAL THERAPY SKIN CARE GUIDELINE FOR VCH/PHC

BEST PRACTICE FOR THE PREVENTION AND TREATMENT OF PRESSURE ULCERS

TABLE OF CONTENTS

Acknowledgements

Table of Contents

1.0 Purpose and Scope

2.0 Levels of Evidence

3.0 Schematic of Best Practice for the Prevention and Treatment of Pressure Ulcers........... 6

4.0 Best Practice Recommendations for Occupational Therapy

4.1 Professional Practice

4.1.1 VCH/PHC Recommended Courses

4.1.2 Recommended External Courses

4.2 Risk Assessment

4.2.1 Braden Scale

4.2.2 Risk Factors

4.2.3 Skin Assessment

4.3 Record Assessment

4.4 Develop a Care Plan

4.5 Occupational Therapy Intervention

4.5.1 Positioning Schedule

4.5.2 Repositioning Transfers

4.5.3 Support Surfaces

4.5.4 Pain

4.5.5 Moisture

4.5.6 Nutrition

4.5.7 Communication

4.5.8 Education

4.6 Reassessment

Appendix 1 – Glossary of Terms

Appendix 1A – Pressure Ulcer Definition and Stages

Appendix 1B – Interdisciplinary Decision Grid for Topical Treatment of Wounds (Excluding Burns and Malignant Wounds)

Appendix 1C – Physical Concepts Related to Support Surfaces

Appendix 1D – Categories of Support Surfaces

Appendix 1E – Features of Support Surfaces

Appendix 2 – Grading Levels of Evidence

Appendix 3 – Braden Pressure Ulcer Risk Assessment

Appendix 4 – Skin Care Risk Assessment Form Guidelines and Template

Appendix 4A – Occupational Therapy Skin Care Risk Assessment Form Template......... 33 Appendix 5 – Care Planning Considerations

Appendix 6 – Mattress and Overlay Support Surfaces Decision Tree for Persons at Risk or With Existing Wound(s)

Appendix 7 – Heel Protection Decision Tree

Appendix 8A – Seating Decision Tree (Low Risk)

Appendix 8B – Seating Decision Tree (Moderate Risk)

Appendix 8C – Seating Decision Tree (High Risk)

Appendix 9 – Practice Guideline References

Appendix 10 – Search Strategies

Appendix 11 – Bibliography

–  –  –

1.0 PURPOSE AND SCOPE The development of a pressure ulcer significantly impacts the individual’s ability to participate in activities of daily living (ADL). The occupational therapist’s expertise can be used to identify causative factor(s) to skin breakdown, and to make recommendation(s) that protect the skin or promote wound healing while promoting participation in meaningful occupation.

The Occupational Therapy Skin Care Guideline was developed over several years (2005-2007) with

the intention of:

• Supporting occupational therapy practice through the continuum of care including acute;

rehabilitation, residential and community services;

• Providing evidence-based recommendations to direct occupational therapy practice;

• Providing tools and resources to facilitate clinical reasoning;

• Integrating recommendations into broader inter-professional practice.

An inter-professional team provides best practice for the prevention and treatment of pressure ulcers.

As such, some aspects of the Occupational Therapy Skin Care Guideline may be completed by other disciplines depending on the individual practice environment. The interventions discussed focus on the occupational therapy contribution. The guideline includes a schematic summarizing the flow of care followed by evidenced-based recommendations applied to occupational therapy practice across the continuum of care. Furthermore, explanations of terms and concepts used throughout the Occupational Therapy Skin Care Guideline are included in Appendix 1 – Glossary of Terms.

In order to bring equal emphasis to the prevention of skin breakdown, it was elected to refer to a skin care guideline rather than a wound care guideline.





Please note: the Occupational Therapy Skin Care Guideline is not intended for venous leg ulcers, burns or arterial wounds.

2.0 LEVELS OF EVIDENCE

The Occupational Therapy Skin Care Guideline has been developed using:

• Existing nursing guidelines (see Appendix 9 – Practice Guideline References);

• Research evidence (see Appendix 10 – Search Strategies and Appendix 11 – Bibliography);

• Consensus from occupational therapists within Vancouver Coastal Health (VCH) and Providence Health Care (PHC) with expertise in pressure ulcer prevention and treatment where gaps in the current research evidence exist.

The table on the next page reflects the strength of evidence for specific recommendations within the Registered Nurses Association of Ontario (RNAO) guidelines. These are used to provide a summary of available evidence. In order to improve the readability and flow of this document, levels of evidence for individual recommendations in the Occupational Therapy Skin Care Guideline are not listed.

Additional information is included in Appendix 2 – Grading Levels of Evidence.

–  –  –

TABLE 1: LEVELS OF EVIDENCE FOR INTERDISCIPLINARY PRACTICE RECOMMENDATIONS

Source: Keast, DH et al. (2006). Best Practice Recommendations for the prevention and treatment of pressure ulcers:

Update 2006. Wound Care Canada, 4 (1), pp 31-43. Copied and used with permission publisher.

Registered Nurses Association of Ontario (RNAO). (2005). Risk assessment and prevention of pressure ulcers. Toronto ON.

http://www.rnao.org/Page.asp?PageID=924&ContentID=816

–  –  –

3.0 SCHEMATIC OF BEST PRACTICE FOR THE PREVENTION AND

TREATMENT OF PRESSURE ULCERS

The Schematic of Best Practice for the Prevention and Treatment of Pressure Ulcers included on the next page is designed to provide an overview of the process for assessment and intervention for occupational therapists. It emphasizes inter-professional responsibilities for risk assessment and skin assessment, and focuses on occupational therapy’s contributions to the inter-professional care plan.

The headings in the schematic are used throughout the Occupational Therapy Skin Care Guideline to provide more in-depth information.

–  –  –

DIAGRAM 1: SCHEMATIC OF BEST PRACTICE FOR THE PREVENTION AND TREATMENT OF PRESSURE ULCERS

Holistic assessment, management and intervention are the responsibility of the inter-professional team

–  –  –

4.0 BEST PRACTICE RECOMMENDATIONS FOR OCCUPATIONAL

THERAPY The best practice guidelines in this section follow the flow of practice shown in Diagram 1: Schematic of Best Practice for the Prevention and Treatment of Pressure Ulcers on the previous page. Tools and resources are included in the handbook under the headings shown in Diagram 1 and are intended to better enable occupational therapists to incorporate the recommendations into their own practice.

The role of the occupational therapist will differ depending on the clinical practice setting. Each practice area should develop a clear understanding of interdisciplinary roles for skin assessment, management and intervention.

–  –  –

4.1 PROFESSIONAL PRACTICE Occupational therapists are responsible for ensuring that they are knowledgeable of the Occupational Therapy Skin Care Guideline and evaluating its application in clinical practice. They should consider the strength of new evidence before incorporating it into practice.

Knowledge of the following areas should be included:

• Etiology and risk factors predisposing to pressure ulcer development;

• Use of risk assessment tools, such as the Braden Scale for Predicting Pressure Sore Risk.

Categories of the risk assessment should also be utilized to identify specific risks and ensure effective care planning;

• Skin assessment;

• Staging of pressure ulcers;

• Selection and/or use of support surfaces and other equipment;

• Development and implementation of an individualized skin care plan;

• Demonstration of positioning/transferring techniques to decrease risk of tissue breakdown;

• Instruction on accurate documentation of pertinent data;

• Roles and responsibilities of team members in relation to pressure ulcer risk assessment and prevention.

4.1.1 VCH/PHC Recommended Courses

The following are VCH/PHC courses recommended for occupational therapists:

–  –  –

4.2 RISK ASSESSMENT Occupational therapists should perform or access information from the initial risk assessment in the person’s first episode of care. They should also perform a risk assessment on entry to a health care setting, and repeat on a regularly scheduled basis or when there is a significant change in the individual’s condition.

–  –  –

Risk assessment tools such as the Braden Scale are useful as an aid to structure assessment and documentation. The literature stresses the importance of using risk assessment tools and scales as an adjunct to, but not a replacement for, clinical judgment.

4.2.1 Braden Scale The Braden Scale predicts the risk of pressure sores, but does not predict whether or not a client will develop a pressure sore. Research using the Braden Scale for Predicting Pressure Sore Risk has demonstrated reliability and validity in multiple clinical settings. Predictive validity of cut-off scores

varies across different populations:

• 16 for acute care settings • 18 for nursing home residents • 19 for home health patients When the frequency of monitoring is low, the risk will likely increase.

However, as with most screening tools, the Braden Scale cannot stand alone in predicting pressure ulcers in individual patients. Regular skin assessment for early signs of injury is an essential adjunct to risk assessment. See Appendix 3 – Braden Pressure Ulcer Risk Assessment for the Braden Scale tool and guidelines.

–  –  –

4.2.2 Risk Factors Particular attention should be paid to vulnerable areas, especially over bony prominences. When skin breakdown is present, identify cause(s) – for example, bed versus chair acquired wound.

Clients who are restricted to bed and/or chair, or those experiencing surgical intervention, should be assessed for skin breakdown due to pressure, friction and shear in all positions and during lifting, turning and repositioning.

Assessment of mobility should include all aspects of independent movement including walking, ability to reposition (for example in bed or a chair), or transfer (for example from bed to chair).

–  –  –

4.3 RECORD ASSESSMENT Occupational therapists should record and document the assessment of risk, noting all relevant factors. All data should be documented at the time of assessment and reassessment. Please refer to Appendix 4 – Skin Care Risk Assessment Form Guidelines and Template.

4.4 DEVELOP A CARE PLAN An individualized plan of care is based on assessment data, identified risk factors and the client’s goals. The plan is developed in collaboration with the client, significant others and health care professionals.

The goals of treatment may change (through the continuum of prevention, treatment and palliation) based on ongoing assessment. A list of care planning considerations is provided in Appendix 5 – Care Planning Considerations.

4.5 OCCUPATIONAL THERAPY INTERVENTION

Any intervention must take into consideration the identified risk(s) and causative factor(s) of the skin breakdown. The following are possible options to consider and should not be viewed as an exhaustive list. Referrals should be made to interdisciplinary team members as appropriate.

Interventions must be evaluated for their effectiveness in preventing and treating pressure ulcers through such mechanisms as ongoing client monitoring and identifying client/equipment variables that may lead to best skin care outcomes. Quality assurance and audits may also be used to evaluate effectiveness of interventions.

4.5.1 Positioning Schedule Occupational therapists should consider all support surfaces throughout the 24-hour period, causative factors and environmental limitations. They should participate in creating a 24-hour schedule for persons vulnerable to skin breakdown or with existing pressure ulcers.

When developing the schedule, changes consistent with activities of daily living (ADL) routines and lifestyle choices should be considered, as well as the acceptability and needs of the person and care provider.



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