Chronic Pain in Long Term Care Residents

Chronic pain is a major issue in our elderly population and is frequently under managed in Long Term Care facilities and thereby decreasing the resident’s Quality of Life (QOL). When chronic pain is not managed properly, other medical problems can worsen and the risks of immobility, falling, dehydration and malnutrition increase.

Health care providers must have resources and knowledge to assess and treat pain and therefore meet residents’ needs as every resident has the right to be pain-free.

Research has identified the presence of chronic pain to be as high as 50% to 80 % in elderly people, with the majority experiencing pain on a daily basis. It is twice as common in women and the problem increases with age. Dementia, sensory impairment, and stoicism are frequently the consequences of poor pain management. Anxiety, insomnia, decreased functional ability and activity as well as social withdrawal and increased behavioral problems may also be signs of chronic pain.

Nurses must have a good understanding of pain and be able to identify those signs especially when the resident is unable to communicate. Having completed a  good pain assessment, an individualized plan of care must be developed, ensuring more optimal pain management.

Pain is an unpleasant emotional and sensory experience and is highly individualized.It can be  localized, such as a backache, or after an injury or surgery or it may be widespread. Conditions that can cause widespread pain in the body are arthritis and fibromyalgia.

Acute Pain may occur after injury or surgery and as a result of illness and should be resolved after treatment, within a short period of time. However, symptoms of pain may remain active in the nervous system for years and become chronic. Any unresolved pain may lead to Chronic Pain. This pain may wax and wane or be constant  and can take a severe physical and emotional toll on the resident.

The emotional toll can then worsen the pain. Anxiety, depression, stress, anger and fatigue may decrease the body’s production of natural painkillers called Endorphins and may increase the substances that amplify sensations of pain known as Prostaglandins. This can cause a vicious cycle of pain. The body’s most basic defenses can become compromised and there is considerable evidence that the immune system can be suppressed by unrelenting pain.

There are many different types of pain; sharp or dull, constant or intermittent. Nociceptive pain occurs when specific receptors are stimulated. The receptors are somatic and visceral. The receptors sense chemicals released from damaged cells, vibration, stretching or temperature. Somatic pain is felt in the skin, muscles, bones or joints.It is usually sharp and localized. Chronic somatic pain includes arthritis, fibromyalgia, and tension headaches.

Visceral pain is felt in the organs of major body cavities. The receptors sense inflammation, Ischemia and stretching within the organ. It presents as deep aching pain and occurs with irritable bowel syndrome (IBS), interstitial cystitis and vulvodynia, which can occur in women after menopause.

Neuropathic pain is caused by the nerves themselves. There are two types, sympathetic and neuropathic.  Sympathetic pain is caused by the sympathetic nervous system and occurs after injury to an extremity. It can be severe and intense and renders the person incapable of moving the injured extremity. Neuropathic pain can cause tingling, aching or numbness.It's the type of pain that occurs with Shingles, Sciatica, Peripheral (diabetic) Neuropathy and Multiple Sclerosis .

Psychogenic pain is associated with mental health issues. There is no physical cause of this pain identified, but none the less it feels very real to the affected patient. Traditional methods of treatment are ineffective but treating the underlying mental health problems may be beneficial. Some conditions which may cause psychogenic pain are Anxiety Disorder, Somatoform Disorder and Depressive Disorder.

Idiopathic pain cannot be traced to any known cause however it is very real. People susceptible to this type of pain usually have been diagnosed with some painful condition such as Temporomandibular joint disorder or Fibromyalgia. These patients are often diagnosed with Chronic Idiopathic Pain Syndrome. (CIPS).

All residents admitted to the Long Term Care facility should have an initial pain assessment. This should include  accurate historical and clinical information and a direct appropriate examination observing the resident’s facial expression for grimacing or frowning and for lack of mobility and guarding.  Resident’s behavioral symptoms, such as agitation, resisting care or restlessness may all  be  indicative of pain. Direct verbal communication with the resident is very important. “Do you have pain?” This question should be asked frequently and reassurance that help is available should be given readily to the patient.  

The most important factor is the resident’s own perception of pain. Again, this can be  determined through verbalization or by the use of scales. The numerical scale with severity listed from zero to ten, or the face scale showing faces smiling to frowning or grimacing. It is also relevant  to learn of any previous beneficial pain management strategies. The goal for pain relief and/or tolerance must be individualized, realistic and a timeframe set for reevaluation. Complications and side effects of treatments, and medications must be observed, reported and documented immediately.

The treatment of chronic pain is varied and requires a multidisciplinary approach. Even if it cannot be cured, the impact can be greatly reduced.

No single treatment is appropriate for everyone and there can be much trial and error before a beneficial course of treatment is reached. The goal for those suffering from chronic pain should be a reduced focus on pain and improvement  in QOL.

It is frequently recommended a non-pharmacological approach be first attempted.  Simple remedies and cognitive and behavioral therapies are often suggested.  These may be used in combination with pain medications. Ice usually used for acute pain reduces swelling and due to its numbing effect, can provide relief from chronic pain. A combination of rest, ice, compression and elevation (RICE) may provide relief based on the location of the pain.

Heat increases the blood flow and provides relaxation to muscles and joints. Heat is very helpful in treating arthritis. Hot packs can relax tight muscles caused by muscle spasm and tension. Massage may be superficial or deep and can relax muscles. The type of massage depends on the resident’s tolerance.

TENS is transcutaneous electrical stimulation. This is performed by placing electrodes on the skin over the painful area, these create a small

current  that feels like pins and needles.

Relaxation techniques like guided imaginary can be done by listening to an audio recording. Relaxation provides distraction and helps muscles to relax, thereby reducing pain.

Complementary approaches to chronic pain include chiropractic care, hypnosis, specialized diets, energy medicine, yoga, herbal remedies, and acupuncture. Aromatherapy and homeopathy are sometimes beneficial.Their effectiveness has not been verified by scientific research but are becoming more acceptable. Their goal is to relieve the pain adequately to prevent being the focus of everyday life.

Counseling may also be beneficial. Stress often increases muscle tension. Providing pain psychology education helps lessen worry and provide a more positive outlook. The resident may feel more in control with the appropriate information.

Breathing exercises and Physical therapy (PT) treatments are other approaches to pain relief. Distraction can be a powerful mind over matter technique for pain relief.The brain can only focus on so much at one time. The pain does not go away but the resident’s awareness of it can be decreased. Involving the patient in activities, such as music therapy, reminiscing or storytelling  may also provide a similar outcome. PT may also recommend a variety of balancing and strengthening exercises to improve the patient’s tolerance and endurance. Exercise increase the ability to ambulate safely, increase circulation and prevent falls.

Ultrasound is a treatment modality that provides high or low-frequency sound waves. As well as providing relaxation, the warming effect of the sound waves cause dilation of the blood vessels (vasodilation) which increases circulation to the area that assists in healing.

Iontophoresis is a form of electrical stimulation provided by PT that can push medication through the skin to the affected muscles, ligaments, and/or tendons. This is usually used for anti-inflammatory purposes. However, a variety of medication can be used for different conditions.

In addition to the above-stated remedies, analgesic pain relievers are usually needed and frequently  advance to stronger pain medication for relief of chronic pain. Acetaminophen can relieve mild pain. NSAIDS(non-steroidal anti-inflammatory drugs) such as ibuprofen and aspirin can be very effective in reducing swelling that often contributes to pain. All have side effects involving the liver, stomach, kidneys, heart, and blood pressure.

Stronger pain killers such as, codeine and tramadol, have more side effects, such as drowsiness and constipation and can also be addictive. Regular use can cause chronic daily headaches.  Opioids are narcotics that include codeine and morphine. They cause sedation that can be life threatening when used inappropriately and are also addictive.

Corticosteroids are a class of steroids such as prednisone and cortisone that  reduce swelling  and therefore decrease pain. Antidepressants: Tricyclic antidepressants increase the body’s production of seratonin, which reduce the number of pain signals reaching the brain.Examples are Amitriptyline and Imipramine.

Anticonvulsants are used to treat pain caused by neurological disorders These drugs inhibit certain nerve transmissions and are beneficial in treating neuropathy and migraines. Gabapentin is frequently prescribed to curtail neuropathic pain.

Topical analgesics are creams and patches which disrupt the pain cycles and gives the sensory nerves another distraction such as cold and tingling.

Capsaicin (made from chili peppers) is available in cream and patches and is frequently prescribed for local application.

It is very important to monitor the benefits and sideeffects of all prescribed medications. Reporting and documenting any changes is mandatory. Pain is now considered the fourth vital sign and the resident has a right to have it monitored and treated appropriately.

(I must give credit to Coursera for much of the information I have provided  in this blog. Last year I took courses on Preventing Chronic Pain and on Vital Signs which were incredibly informative.)

Urinary Incontinence

I would be remiss if I did not discuss urinary incontinence as a major issue in long-term care (LTC)  facilities.   Urinary incontinence (UI) is the inability to control urination. It affects people of all ages but women are twice as likely as men to develop incontinence. According to the literature, at least one in ten people over age sixty-five have a problem with UI. Many people deny the presence of this problem due to the associated social stigma. It is embarrassing and uncomfortable but it can usually be improved. However, Urinary Incontinence is referred to as overactive bladder (OAB) Continuous incontinence occurs when a fistula develops between the bladder and vagina and may require surgical intervention.

There are four types of UI.

Urge Incontinence occurs when there is a sudden urge to void with the inability to control urination. This condition is also referred to as overactive bladder and occurs with the involuntary contraction of the bladder muscle (detrusor instability). Urge  incontinence can also be caused by neurological conditions such as multiple sclerosis and Parkinson's disease. UI is not a disease but a symptom and can be caused by everyday habits, physical problems, and medical conditions.  Low hormone levels after menopause and urinary tract infections are also contributing factors. It most often affects older women.

Stress Incontinence occurs when the sphincter opens under sudden pressure such as coughing, sneezing, heavy lifting or laughing. It is more common in women who’ve had prolonged or difficult labors, are obese or have pelvic floor weakness or prolapse. A combination of urge and stress factors are referred to as mixed incontinence.

Overflow incontinence when the bladder is constantly full and leakage occurs.

Functional incontinence occurs with physical disabilities, external obstacles and problems with thinking or communicating that will prevent a person from getting to the bathroom before voiding occurs.

Transient or temporary incontinence can occur as a result of a urinary tract infection or side effects from some medications. Treatment of the condition or change of the causative drug enables the incontinence to subside.

There are numerous causes for UI. These include alcohol, caffeine, (in drinks like tea and coffee) overhydration, bladder irritation caused by carbonated beverages, highly spiced foods, acidic foods such as tomatoes and citrus fruit. Cardiac and antihypertensive medications, diuretics, muscle relaxants and sedatives all can contribute to bladder control problems

Constipation may also be a cause, as the rectum and bladder share many of the same nerve supply. When there is a hard compacted stool in the rectum, the nerves can become overactive which can result in UI. Aging of the bladder muscle leads to decrease in bladder capacity to store urine and can increase OAB symptoms

Toileting in advance of need (TIAN) was one of the older methods to avoid or decrease incontinent episodes.  Residents were put on a bladder observation program for seventy-two hours after admission.Times and amounts of urination were observed and documented. Based on that information residents were toileted in advance of need, usually before and after meals and at two to three-hour intervals. This decreased incontinent episodes preserved residents’ dignity, protected the skin from prolonged moisture and was certainly labor saving.

It may be beneficial for the resident to have a urological consultation as other medications and treatments may be prescribed. Many medications may be prescribed to control OAB.

Anticholinergics can block the action of acetylcholine that triggers abnormal bladder contractions associated with OAB.These bladder contractions can make the resident feel the need to urinate even though the bladder is not full.

Ditropan xl, Oxidative and Vesicare are the medications I have seen more frequently prescribed.The extended release medication is taken once daily and had fewer side effects than other anticholinergics which are taken multiple times daily. Vesicare has been effective in treating urgency, frequency, and leakage. Most common side effects are dry mouth and constipation.

Mirabegron is a drug which relaxes the bladder muscle allowing increase in bladder capacity and may also increase the amount of urination at one time, which helps to empty the bladder more completely.

Tricyclic Antidepressants also help in controlling OAB. These medications allow the bladder muscles to relax while causing the smooth muscle at the bladder neck to contract. The drug Imipramine is often prescribed for mixed incontinence. It should be taken at HS (hour of sleep) as it causes drowsiness.

Antidiuretic  Hormone(ADH) is a drug which reduces the amount of urine produced. This can help with incontinence that occurs from a full bladder.

Low-dose topical estrogen in the form of vaginal cream may help rejuvenate deteriorating tissues in the vagina and urinary tract and may improve some incontinent symptoms.

The physician may also prescribe Physical Therapy treatments to improve OAB. These treatments may include electrical stimulation to the pelvic floor. Biofeedback, kegel and relaxation exercises and exercises to improve abdominal and core muscle control may be beneficial.

Bladder training (learning to hold on for longer) should be taught and encouraged.

Men may also suffer from UI. Over fifty per cent of men after prostate surgery experience some degree of UI. This can range from “dribbles” after voiding to full loss of bladder control. Kegel exercises may be beneficial but should be done at least ninety times daily. These exercises can be done anywhere anytime and takes only a few minutes. It is important to remind the resident to do them

The results of all prescribed medications and treatments should be observed and documented.

Care of Other types of Wounds

Last month I discussed pressure ulcers so I will continue with the description of other types of wounds common to the Long Term Care facility (LTC).  Wounds are classified based on cause and location. Ulcers can be venous, arterial and diabetic/neuropathic. Fungal dermatitis is common in obese residents and can become ulcerative if left untreated. Various surgical wounds and stomas can also be cause for concern.

     

Ulcers are usually caused by circulatory insufficiency, both arterial and venous. In arterial insufficiency, blood supply to the lower extremities is greatly diminished. These ulcers usually occur in the distal areas of the lower extremity including the toes, top of the foot and the outside edges of the foot. However, they may also occur in the heel and ankle.

Residents with a history of atherosclerosis, peripheral vascular disease (PVD), heart attack or stroke are very susceptible to arterial insufficiency ulcers. The wound bed is usually dry, pale, deep based and painful. The pale color is due to lack of oxygen. The surrounding skin is dry, shiny, pale and without hair. Pedal pulses are frequently non palpable.

Venous ulcers usually occur in the lower and back portion of the leg. They are caused by circulatory insufficiency. When the one-way valves in the veins do not function properly, there is an accumulation of the breakdown products of hemoglobin due to the venous stasis. The wound bed is usually superficial, red in color and moist. The edges are irregular and the surrounding skin shows induration and edema. Drainage can be variable based on the amount of edema and the presence of infection. Dilated varicose veins may also be present. Symptoms of venous ulcers can be relieved with elevation, but not eliminated.

Diabetic/Neuropathic Ulcers: Longstanding diabetes mellitus, especially if poorly controlled, has severe consequences for the lower extremities which often result in ulcer formation.There are changes to the microvasculature and accompanying nerve damage (neuropathy). They often occur in the sole of the foot in areas of constant repetitive pressure and because of the neuropathy, they are often painless. The wound bed can be covered with fibrotic tissue called callus. The ulcer can be deep and can penetrate the bone resulting in osteomyelitis (bone infection) adding to the prolongation of the healing process.    

When a resident is admitted to the LTC facility with an existing wound, obtaining a good medical history is of the utmost importance. Details of how the wound started, how long it has been present, treatments used and the resident’s response to the intervention should be obtained and documented. If non compliance with care has been an issue, the cause should be identified if possible. As information is gathered, nurses should never be judgemental about the patient’s actions or inactions.

Wound healing can occur by two possible mechanisms. Scar tissue formation and regeneration. The depth of the wound will determine which mechanism will occur. Wounds also heal by primary and secondary intention. Those healed by primary intention are surgically closed.  With secondary intention wounds are left open and heal by granulation, contracture and epithelialization. It takes much longer for a deep wound to heal than a superficial one.

Wound cleansing is very important as it removes non-adherent debris from the wound bed. This prevents infection and promotes healing. Follow the physician’s orders for products to use but normal saline at room temperature can be very effective. During cleansing the surrounding tissue should be protected from trauma.

Wound treatments should be performed at a time of the day when the resident is least fatigued (get the treatment done before the resident goes to therapy). Pain assessment should also be done prior to dressing change and pain medication should be administered at least 20 minutes prior to commencing the treatment.

Debridement is very important and there are many methods to this procedure. Necrotic tissue can adhere to the wound bed causing delay in the healing process. This is more common when the moisture level of the wound decreases (It is important to keep the resident well hydrated). Debridement is necessary to allow healing to continue. The type of debridement is determined by the amount of necrotic tissue present, the location of the wound and the general condition of  the resident.

Autolytic debridement occurs when the body’s own physiological process removes the necrotic tissue. To enable this to occur, it is important to utilize the proper dressing. Hydrogel dressings are most often used. Amorphous hydrogels are effective in digesting the necrotic tissue. Hydrocolloids are also beneficial in their ability to absorb drainage while keeping the wound bed moist.

Enzymatic debridement involves the application of concentrated, commercially prepared enzymes to the necrotic tissue. These do not harm healthy tissue.

Mechanical debridement is achieved by applying wet to dry gauze dressings to the wound, usually with normal saline. Studies have shown that healthy viable tissue can be removed as well as the necrotic tissue. Whirlpool therapy can also be used for this type of debridement.

Chemical debridement involves the use of chemical agents. Dakin’s solution in a 0.25% strength is most often prescribed. I have also seen Iodine in use but appears to have a drying effect on the wound bed. Surgical debridement is rarely an option for LTC residents as due to their compromised state, they are  not  good candidates for such invasive procedures.

Wound dressings can be divided into two categories: those placed inside the wound and those placed as a cover over the wound. Dressings protect the wound from the environment, provide a barrier to prevent infection, maintain moisture to the wound bed, curtail fluid from areas of tunneling and absorb drainage. Dressings that add moisture to the wound bed are referred to as hydrating and those that remove excess exudate from the surface of the wound are absorptive.

Hydrocolloid dressings are an occlusive dressing that prevents secondary infections. They are used for wounds with a large amount of drainage. After absorption they become gel. They are comfortable but must be secured with another dressing.

Hydrogel dressings are usually applied to superficial wounds with limited drainage. They have a hydrating quality which promotes healing.

Foam dressings protect wounds at risk to further damage from shear and can be used with topical treatments. Foam provides thermal insulation, conforms to body shape and leaves no residue in the wound.

Silver Impregnated dressings are a treatment option for infected or heavily colonized wounds. They have an antimicrobial effect and have shown to reduce bacterial count in wounds. They do not adversely affect healthy tissue.

Calcium Alginate dressings are very highly absorptive. They are a good choice for bleeding wounds as the aid in hemostasis.

Composite dressings are a combination of more than one substance and fulfill many helpful functions in wound care. They have an effective barrier against bacteria and have an absorbent layer.They are comfortable and available in many shapes and sizes.

Gauze dressings are rarely used at present. They have poor absorptive qualities and are less effective in coping with drainage. They also have to be changed frequently.

Some dressings incorporate collagen which is an important protein involved in wound healing. They are absorptive while keeping the wound bed moist and are easily removed.

Failure of a wound to heal may be due to systemic issues, such as, ischemia, infection and continuation of the causative factors. These must be addressed first to achieve optimum wound healing.

Whatever type of dressing is prescribed, it is vitally important that the wound care nurse follows the manufacturer’s instructions explicitly. An evaluation of the products in use and the progression of the wound should be completed at each dressing change. Clinical signs of improvement should appear between two to four weeks.

  

Documentation of wounds should be frequent and concise. Only approved abbreviations should be used and all dates and times should be accurate, and the name of the clinician providing the care should be included.

(Last year I took a took a wonderful informative course on wound care provided by NetCE. I learned so much from it. It was a three part course, was reasonably priced and awarded 20 CEUs. I would recommend it to any nurse who is involved in wound care).

Wound Care in Long Term Care Facilities

There is a high incidence of wounds in the Long Term Care (LTC) setting and according to the literature over 6.5 million people are affected by chronic wounds and an estimated $25 billion is spent annually in the United States for treatment. Therefore prevention of wounds is of the utmost importance.

There are various types of ulcers: Pressure ulcers,

Venous ulcers, Arterial ulcers and Diabetic/Neuropathic ulcers. LTC residents may also acquire a fungal dermatitis. This is a superficial skin infection, which, if left untreated can progress into ulceration or bacterial cellulitis Wounds may also be the result of operative procedures that has delayed healing.

Skin tears result from shearing or friction that causes  separation of the skin layers. These occur most frequently in the upper extremities and can mostly be prevented with careful handling and the use of protective sleeves.

In this blog I will concentrate on pressure ulcers and their staging, treatment and prevention. Pressure ulcers are lesions resulting from unrelieved pressure which causes damage to underlying tissue. These most commonly occur over bony prominences such as in the hips, buttocks, back, ankles, heels and elbows.

In bygone days pressure ulcers were considered to be the result of poor nursing care. A billboard on a Florida highway had the following advertisement “If you have concerns about a loved one’s care in a nursing home call 1 800 bed sore”. Greater knowledge and better equipment have removed most of that burden from nurses.

Several factors other than pressure contribute to ulcers  including friction, moisture, sensory loss, immobility and underlying medical conditions. If there is a severe loss of mobility, it may be appropriate to involve the physical therapy department. Seemingly healthy and ambulatory residents may be at risk for pressure ulcers and other wounds. It is very important to schedule frequent “skin check” when doing rounds.

Moisture weakens the resilience of the epidermis resulting in maceration, which results in softening and resultant breakdown of the skin. Residents’ should receive care after each incontinent episode. Friction can be avoided by providing skincare that is gentle with no aggressive rubbing or scrubbing. A resident’s position should be changed by careful lifting not dragging.

The ASPECTS of pressure ulcer prevention.

I found these in some literature many years ago and memorized them for future use.

A: Assessment of the risk for pressure ulcers. We need to consider underlying medical conditions such as diabetes, obesity, arterial disease, anemia, hypoxemia and a previous history of pressure ulcers. Review the paitent’s medication profile. Use a validated risk scale like

Braden or Norton. Be sure to check skin turgor.

S: Skin assessment should be done daily on compromised residents. Integrity, turgor, temperature, color and moisture status should be assessed and documented.

P: Patient concerns and pain: Keep the resident informed of progress and remind them of the goals set for prevention. Ask the resident if they are in pain and the location of the pain. Use a validated, cognitive appropriate pain scale. Provide pain medication prior to a dressing change.

E: Eating and drinking: evaluate eating, drinking, swallowing and  weight. Have the dietician assess the resident for nutritional needs and adequate hydration.

C: Continence and moisture management: Assess for urinary and fecal incontinence. Clean and protect the skin with barrier creams after each episode. Moisturize dry skin.

T: teach the resident, family and caregivers the importance of prevention and observation.

S: Support surfaces, repositioning and turning the resident. There are many pressure relieving and redistributing products, such as foam, memory foam, low air loss and alternating pressure mattresses available for at-risk residents but they only work if they are used. Turning and repositioning limbs must be done at individualized time-intervals based on need. Both bed and chair bound residents should be repositioned at least every 2 hours.

Stages of Pressure Ulcers:

Stage 1 ulcers are areas of non blanchable erythema.These can be difficult to identify in people with dark pigmentation. The resident may complain of pain but the skin is intact.

Stage 2 ulcers are artificial skin breaks in the dermis layer only or may appear as a clear blister.

Stage 3 is a full thickness skin break involving the subcutaneous tissue. It may have undermining or slough present but you can always visualize the depth of tissue lost.

Stage 4 ulcer goes all the way through muscle until there is bone showing. Slough or eschar may be present in parts of the wound bed and tunneling and undermining may also be present. Tunnelling is channeling that may pass through subcutaneous tissue and muscle and may result in dead space and abscess formation.

Undermining is tissue destruction underlying the intact skin along the wound margins indicating the wound margins have separated from the wound.

Unstageable ulcers are so called because there is so  much necrotic tissue (eschar) present that the base of the wound cannot be visualized.  

SDTI (Suspected Deep Tissue Injury) may present on the  the surface as a purple discolored firm warm area. It is pressure related and is injury  to the subcutaneous tissue under intact skin. It can present as a deep bruise but can quickly become a stage 3 or 4 ulcer even with the best care.

Pressure ulcers do not heal in a reverse sequence. The body does not replace lost tissue, so as the ulcer heals, it would be referred to as a healing stage 4 or healing stage 3 ulcer.

Nurses should be aware of the changes that occur in aging skin which makes it more susceptible to injury. These changes also slow healing. The area between the epidermis and the dermis flattens causing increased fragility. Elasticity diminishes and surface moisture decreases. There is also decrease in subcutaneous fat and loss of nerve structure. These are just some of the anatomic and physiologic changes that occur and when those are added to comorbidities, it should be realised that prevention is the mainstay of care. Smoking, alcohol and illicit drug use can impair tissue perfusion and delay wound healing.

Assessment: Location, size, shape and depth and if more than Stage 2, the condition of the edges should be documented. The length and width should be measured in centimetres and documented. Up to 4 centimetres from the edge of the wound should be assessed. The depth of the ulcer can be obtained by inserting a sterile cotton tipped applicator into the wound bed and marking it at skin level. The applicator is then measured using a metric ruler. In the same way the tunnel depth should be measured using a sterile cotton swab and recorded. Its direction should be documented by using the clock method (5cm at 3 o’clock).

Circumferential redness of up to 2 inches is indicative of cellulitis and induration is an indication of infection. Good assessment and documentation is of the utmost importance. Wound exudate should be described as to amount and as clear, bloody, serosanguineous, thick yellow or greenish. Describe eschar, tunneling or undermining. Indicate the presence of odors.

Treatment: Treatment plans are based on the findings from the assessment and its most major use is to prevent undirected and inappropriate care. Adequate wound cleaning is very important as well as debridement. Bacterial growth is promoted by necrotic tissue and wound healing is impaired until eschar is removed. Warming solutions and ointments before they come in contact with the skin is not only soothing for the resident but also speeds healing.

LTC facilities must develop and implement a wound care program with a systematic approach to prevention and treatment protocols as well as diligent staff education. Utilizing the use of a wound care physician or a certified wound care nurse is an option used by many facilities. Wound care rounds should be done weekly. This includes measurements, observations of the healing process and results of the current treatments. With this option there is also less disruption of the residents’ day and lower costs from transportation back and forth from the wound clinic.

I will not attempt to discuss treatment as they are so varied and each facility has its own protocol. I firmly believe in consistency in care and good observations are paramount to improvement. Some European hospitals are finding excellent results from Manuka honey. Decrease in wound measurement is indicative of healing and if a wound covered with epithelium without drainage it is considered healed.

The resident’s and family’s perception of wound care need to be considered. The nurse should not give unrealistic expectations, especially for residents with grossly compromised medical status whose wounds may never heal.

Weekly assessment and documentation are an essential component of wound care. Many LTC facilities use photographs of wound progress as It can visually monitor wound healing (or failure to heal). It is an adjunct to assessment documentation. It can clarify what is often not easy to describe. “A picture is worth a thousand words”. It is part of the medical record and can be beneficial in protecting against liability.

Informed consent must be obtained prior to photography. The photographs should be titled and dated and become  part of the medical record. They should not be left lying in the open. HIPAA (Health Insurance Portability and Accountability Act) regulations must be maintained.

Strategies for Hospital Readmission Reduction

The Hospital Readmission Reduction Program (HRRP) was established in the Affordable Care Act (ACA) to provide an incentive for hospitals to lower readmission rates. Reducing readmissions is a shared responsibility and Long Term Care facilities (LTCF) must do their share to ensure the success of the program.

The LTCF should have a procedure in place to identify the HRRP diagnoses and should establish monitoring parameters for these residents when they are admitted. They should also identify the hospitals that most frequently transfer residents to the facility and build a rapport with them. Residents should have frequent assessments for serious risks, such as falls.

According to the available literature many hospital readmissions are considered to be preventable, avoidable and unnecessary. Many factors and incentives influence the decision to send the resident to the hospital and the risk factors must certainly be considered.

Without doubt, there are times when the resident must be hospitalized without delay and as nurses we must be well aware of these situations. We must always perform our duties to the patients morally and legally.

However, it is important that nursing staff realise the very negative effect frequent transfers have on residents. They are transported from a safe and friendly environment by strangers to an unknown destination. Most often they are unaccompanied, as family members, if available, frequently agree to meet them at the hospital emergency department. Frequent transfers from Long Term Care (LTC) facilities to hospitals and returns increase the risks of residents acquiring or transmitting healthcare associated infections (HAI). One certainly cannot overlook the tremendous cost factor involved in these resident transfers.

Solutions to prevent readmissions to hospitals should include assessments, planning and communication.

Knowing the resident and using good assessment skills to prevent changes in condition becoming too severe. Some conditions can be managed in the LTC facility when it is feasible and safe advanced care planning can identify incurable diagnosis, and use palliative care options when appropriate.

Open and honest communication with family members, informing them of the resident’s condition can alleviate  their request for hospital transfers when change occurs, also reassuring them that appropriate care can be provided in the LTC facility.

Communication between the LTC facility and the hospital needs improvement. Poor communication at discharge can lead to inadequate follow up care by the LTC providers.  Identifying readmission risks and communicating these to the LTC facility staff to enable them actively manage these risks would be very beneficial.  The use of electronic messaging and records will help the hospital and LTC facility coordinate care.

Preventing care gaps by the discharge physician providing prescriptions for ongoing medications would greatly reduce  time wasted in contacting the LTC physician to initiate these orders. Arranging with the pharmacy for timely delivery of medication would also eliminate delays in administering prescribed medication.

The Centers for Medicare and Medicaid Services (CMS) has provided  “Interventions to reduce Acute Care transfers”  (INTERACT).  This is a quality improvement tool  to help assess  LTC residents with acute changes in condition.

The primary care physicians (PCP) frequently complain that nurses do not provide an adequate description of the resident's condition and omit important details when giving reports. Due to this, the physician states he is unable to make appropriate diagnosis and treatment of a resident’s condition. He feels it is safer to send the resident to the emergency room to diagnose and treat (D&T). This problem can be solved with good knowledge and better communication skills.

In one facility where I worked I had received this complaint from the medical director when I had questioned the frequent orders for D&T. I decided to provide additional education for the nurses on all shifts. I developed a scenario of the most common illnesses and occurrences. Based on the INTERACT program, I had the nurses identify signs and symptoms, the appropriate information to provide to the physician and suggestions for inhouse care and treatment. I gave the nurses one week to complete each written assignment and where necessary, I provided additional inservice and also reinforced the documentation aspect.

All nurses were very compliant with the task and after three months the results were phenomenal. We had greatly decreased the number of residents transferred for D&T, the physicians were very impressed with the improved reporting skills of the nurses. The nurses had increased their knowledge and self confidence. Many nurses thanked me by saying “I learned so much”. They became more aware of the disease entities and appropriate observation skills.  Above all, the residents were treated quickly and appropriately and resources were not wasted.

We should always understand and use the tools available to us. The INTERACT program was always available but had not been used appropriately.

Many physicians and some facilities have Nurse Practitioners (NP) assigned to the practices and residents. This can be an added benefit as the NP can see the resident within a brief period of time and can provide a diagnosis and treatment plan. However, the PCP and the family must be notified timely. Documentation must be complete and thorough.

I hope this blog provided some useful information on what can be done as nurses to help decrease hospital readmissions in your facility. Never forget that we are the residents advocates and it is our responsibility to be prudent and resourceful in our care.

Infection Control Programs in Long Term Care Facilities

In last month’s blog I discussed the precautionary measures in place to prevent the transmission of infections that can occur in residents of Long Term Care (LTC) facilities. Now, I will discuss the most important aspects of a good Infection Control (IC) program and the nurse who is in charge of it.

The Centers for Medicare and Medicaid (CMS) regulations address the need for a comprehensive program that include surveillance of infections, implementation of methods for preventing the spread of infections; including the use of isolation measures when necessary, hand hygiene practices and the appropriate handling, processing and storage of linens. Health protocols for preventing infections by employees and residents should also be included. Policies and procedures relevant to Infections must be in place and readily available.

LTC facilities are required to establish and maintain

an IC program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.

During a survey, surveyors will request to see this program and a list of residents/employees who had acquired infections during the previous year.

CMS has also established a final rule requiring LTC facilities offer annually, to each resident, immunization against influenza and offer a lifelong immunization against pneumococcal disease. Furthermore, each resident or their legal representative must receive education on the benefits and potential side effects of the immunizations prior to administration of the immunizations. A written consent and acknowledgement of the information must be signed by the resident/legal representation and maintained as part of their medical record. Review of residents admitted to facility with infections or on antibiotics should be included and should indicate “admitted with”.

The IC nurse is an essential component of a good infection control program who is  designated by the facility to be responsible for it. They should be a registered nurse, who has received formal infection control training and has the ability to interact tactfully with personnel, physicians, residents and their families. It would be beneficial for the IC nurse to belong to a professional organization, in order to keep abreast of any current prevention and control information. Peer networking is also very valuable. Based on the size and staffing of the facility, this should be a full-time position if possible.

All direct care nurses should be observing their residents for any signs of infections as well as observing the medication administration record (MAR). I have always advised my nursing staff that there are two reasons for a resident receiving an antibiotic, (1) they have an infection or (2) it is prescribed prophylactically.

One of the better Infection Control Programs I have seen

included the following components:

• The direct care nurse identified the resident with an infection, notified the physician and received appropriate orders.
• The nurse then filled out the IC report sheet.
• By the end of the shift, this form was given to the IC nurse.

The information in the report should include:

(1) Residents name and room number.

(2) date and time of onset of symptoms

(3) date and time of physician and family notification.

(4) cultures or x-rays if ordered.

(5) Antibiotics ordered, including name, dose, and duration.

(6) Type of isolation if indicated.

Upon receiving this report the IC nurse begins surveillance of the infection. This should be done timely and includes record review, laboratory and radiology reports, treatment reviews, antibiotic usage data and clinical observations as sources of data. It should also be determined if this was a healthcare associated infection (HAI). This surveillance should be performed for each infection identified. The  causative organism should be added to the report when identified.

Analysis of the surveillance reports should be done weekly or monthly. Computerized graphs and charts can assist in compiling data and it is important to identify causative organisms and trends in areas of the facility where similar infections occur. Other elements necessary for a good IC program include: outbreak control requires a system for detection, investigation and control of epidemics. Preparation for this event should be in readiness at all times.

Isolation: An isolation and precaution system to reduce the risk of transmission. Keep in mind that elderly residents can become easily depressed when isolated, therefore isolation should be for the shortest possible duration and modified if appropriate.

Education: continuing education in IC prevention and control is mandatory. Education on the principles of IC for employees should begin in orientation. We are all aware of the high rate of employee turnover in LTC facilities. Frequent review of the many aspects of the Infection Control Program should be presented and random monitoring of correct handwashing technique is very necessary.

Resident and employee health programs. Follow federal and state requirements and the facility policies. Disease reporting to public health authorities may vary from state to state. Infection control protocols for facility management, including environmental control, laundry services, waste management, sterilization and disinfection must be in place and followed.

Antibiotic stewardship is of vital importance. Antibiotic utilization and appropriateness should be monitored for each resident. Antibiotic resistant bacteria pose a significant hazard in LTC facilities and this resistance has been strongly associated with antibiotic use. Antimicrobials are the most frequently prescribed medications in LTC facilities.

The IC nurse should oversee all aspects of the program and should have well defined support from administration and have additional support staff depending on the size of the facility. Some LTC facilities have an infection control oversight committee in place to review IC data, review policies and monitor program goals and activities. The committee should meet monthly and should consist of IC nurse, administrator, medical director and nursing supervisor or their designee. Written records of the meetings should be kept.

Over the last three months, I presented blogs on infections, precautions and control programs. I hope they have been beneficial.