Professional Documents
Culture Documents
Volume 4, Issue 2
10
Top Issues
Affecting Your
Practice
Take the survey today!
How to bear
SKIN
TEARS
RESPECT:
What does it
mean to you?
“DR. MARLA”
battles
breast
cancer FREE PAGE
CE! 18
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HEALTHY SKIN
Improving Quality of Care Based on CMS Guidelines
Editor
Sue MacInnes, RD, LD Contents
Clinical Editor Survey Readiness
Margaret Falconio-West, RN, APN/CNS, 20 Untangling the Terms
ET, CWOCN, DAPWCA 48 Wound Care Competency Day
60 Love Them Two Times
Clinical Team
Cynthia A. Fleck, RN, ET/WOCN, Treatment
CWS, DAPWCA, MBA, FCCWS 12 Understanding Skin Tears
Janet L. Jones, RN, PHN, ET, CWOCN, 22 What’s That Noise?
DAPWCA 34 Seat Cushions Page 23
Joyce Norman, RN, CWOCN, DAPWCA 40 Taking the Fear out of Male Catheterization
Elizabeth O’Connell-Gifford, RN, 45 If the Shoe Fits…
CWOCN, DAPWCA, MBA 53 Perineal Skin Care for the Incontinent Resident
54 Case Study: Using Olivamine in a Skin Cream to Improve
Carol Paustian, RN, ET, CWOCN,
Skin Quality in Diabetic Patients
DAPWCA
56 Easing the Pain
Amin Setoodeh, RN
Deb Tenge, RNC, MS, CWOCN, Special Features
Licensed Administrator 5 Top 10 Issues Affecting Your Clinical Practice Today Survey
Jeannine Thompson, RN, CWOCN 6 Two Important National Initiatives for Improving Quality of Care Page 34
Jackie Young, RN, ET, CWCN, DAPWCA 11 Advancing Excellence Campaign Goals
26 The Perils of Ineffective Handwashing
Wound Care Advisory Board 31 The Key to Hand Hygiene
Mona Baharestani, PhD, ANP, CWOCN, 38 Incontinence
FCCWS, FAPWCA 64 Anurse in WOUNDerland
Ann Blackett, MS, RN, COCN, CWCN, 74 Sharpening the Saw
CPHQ, CNS
Patricia Coutts, RN Forms & Tools
88 Guidelines for Wound Photography
Pat Emmons, RN, MSN, CNS, CWOCN
89 Prevention of Skin Tears – In-Service Outline Page 60
Cindy Felty, RN, CNP, MSN, CWS, FCCWS 90 Bates-Jensen Wound Assessment Tool
Lynne Grant, CNS, MS, RN, CWOCN 92 PUSH Tool 3.0
Teresa Kellerman, MSN, ARNP, WOC/CNS 94 Quick Guide to Lab Values
Bette Kussmann, RN, CWCN, COCN
95 Foley Catheter Selection Guide
Andrea McIntosh, RN, BSN, CWOCN, APN Regular Features
Cathy Milne, MSN, APRN, CS, CWOCN, ANP 4 Letter from the Editor
Laurie Sparks, RN, ET 8 News Flash
Shelia Thomas, RN, CWOCN 16 CE-Credit Crossword Puzzle: Understanding Skin Tears
51 Hotline Hot Topic Page 78
Dot Weir, RN, CWCN, COCN, CWS
58 Product Spotlight: Silicones
Lynne Whitney-Caglia, RN, MSN, CNS, CWOCN
Laurel Wiersema-Bryant, RN, BC, ANP Caring for Yourself
Linda Woodward, RN, OCN, CWOCN 70 Respect
78 “Dr. Marla” Battles Breast Cancer
© 2007 Medline Industries, Inc. Healthy Skin
84 Best Day/Worst Day is published by Medline Industries, Inc.
86 Recipe: Berries & Cream Pound Cake One Medline Place, Mundelein, IL 60060
1-800-MEDLINE (633-5463)
ABOUT MEDLINE
Medline, 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 than
700 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.
Recently, CMS released the final PPS rule for If you would, please take a moment to
hospitals. This is a significant policy change complete the survey on the following page
that will ultimately improve the quality of and tell us your biggest challenges. We
care by no longer paying for preventable want to direct future content to address your
conditions that are acquired in hospitals. pressing concerns by first sharing the results
These conditions include pressure sores, in our next issue and then by tailoring future
UTIs and falls. articles to give you those practical solutions
that target your needs.
What do you think will happen next? It’s
only a matter of time before reimbursement We know that your concerns on the job
for LTC and home health are also centered also include daily interactions with peers
around patient outcomes and more cost- and motivating your staff. To that end,
effective healthcare by putting the focus on we’ve included an article titled “Respect” to
prevention. Patient hand-off between health- remind us of how important it is to manage
care providers will be a major focus in the the interaction between our co-workers and We all can agree
future. To that end, we intend to continue professionals from other healthcare entities. that we should do
to bring you industry news and examples thing right ... but
of successful collaborations. We invite you Finally, we are thrilled to feature an article it is our goal to
to share your experiences – both good by Dr. Marla Shapiro, the well-known make it hard for
and bad – so that others can learn and Canadian physician, columnist, TV personality the healthcare
benefit. Please feel free to contact me at and breast cancer survivor, to inspire us all worker to do
smacinnes@medline.com with anything to remember the importance of our families things wrong.
you would like to share. and friends. Her story is touching and her
message a wake-up call to take care of
Once again included in this edition are the ourselves and to balance our lives between
key initiatives in home health and long-term our work, family and self.
care (see Page 6). Notice the icons at the
bottom of this page. You will see these icons Best regards,
throughout the magazine whenever an
article supports one of these quality goals.
Then, on Page 11, follow the crosswalk of Sue MacInnes, RD, LD
national initiatives. The Web site addresses
of these organizations are provided so that
you can explore the resources available to
assist you in your practice.
Content Key
We’ve coded the articles and information in this magazine to indicate which National Quality
initiatives they pertain to. Throughout the publication, when you see these icons you’ll know
immediately that the subject matter on that page relates to one or more of the following
national 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.
4 HEALTHY SKIN
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Origin: A new coalition-based, two-year campaign initiated on September 26, 2006 to improve quality of life for nursing
home 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 existing
quality 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 coalition
has adopted goals that seek to improve clinical care, incorporate nursing home resident and family satisfaction
surveys into continuing quality improvements and increase staff retention to allow for better, more consistent
care for nursing home residents.
Participating providers will commit to focusing on at least three of the eight measurable goals, including at least
one clinical goal and one operational/process goal.
Advancing Excellence
The Advancing Excellence in America's Nursing Homes campaign kicked off in the fall of 2006 at a national Nursing
Home Quality Summit in Washington, D.C. 5,705 facilities nationwide have committed to work on at least three of
the campaign's goals.
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Special Features
TASK 1: ASSISTING PROVIDERS IN DEVELOPING THE CAPACITY FOR AND ACHIEVING EXCELLENCE
NATIONAL CAMPAIGN
Stay tuned! First year results will be published in the January 2008 issue of Healthy Skin!
The rule adopts eight conditions, including three serious preventable events, for which CMS will not provide higher payments if
the selected event occurs while a patient is under the care of the hospital. The changes will take effect for FY 2009 and will
include:
• Object left in surgery • Pressure ulcers
• Air embolism • Vascular catheter-associated infections
• Blood incompatibility • Mediastinitis after coronary artery bypass graft
• Catheter-associated urinary tract infections • Falls
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.
According to the Survey & Certification Memorandum that accompanies the guidance, the interpretive guidelines clarify areas such as
resident supervision, hazard identification and resident risk, falls, unsafe wandering/elopement, environmental assessment of hazards
and 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.
8 HEALTHY SKIN
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Update on
HAIs from CDC: Celebrating the 21st Annual
A new report from the Centers for
Disease Control and Prevention NADONA/LTC
(CDC) contains the following updated National Conference, Caesars Palace,
estimates of healthcare-associated Las Vegas, Nevada
infections (HAIs):
• An estimated 1.7 million Held June 23 to 27, 2007 this year’s conference and exposition had
more than 800 in attendance.
infections and 99,000 associated
deaths occur each year Kicking off the event was the keynote speaker, Andrea Higham,
• Equivalent to 1 death every Director of Corporate Equity and the Johnson & Johnson Campaign
6 minutes For Nursing’s Future, which highlighted “The Promise of Nursing.” This
• Annually add $5 – $6.7 billion session was not only inspirational; it also set the tone of the conference
to U.S. healthcare costs and emphasized the bright future of nursing.
• Types of infections:
Molly Morand, President of the Morand Group, LLC was once again
— 32 percent of all
on hand to deliver her presentation titled “Just Say No to Mandatory
healthcare-associated In-Services” to a packed audience.
infections are urinary
tract infections “Compassion Fatigue – Preparing Professionals to be Resilient”
— 22 percent are surgical explored the signs and coping measures for compassion fatigue and
site infections offered strategies to assist in developing resiliency. This session was
presented by Barbara Rubel, MA, BCETS, CBS, CPBC, Executive
— 15 percent are pneumonia
Director of the Griefwork Center, Inc.
(lung infections)
— 14 percent are Medline Industries, Inc. introduced their revolutionary educational
bloodstream infections packaging (EP Packaging) for advanced wound care to all DONs
Hand hygiene is one way to (Directors of Nursing) who attended this meeting.
decrease the spread of infection.
With more than 6,000 members, The National Association Directors
Learn how to make hand hygiene a
of Nursing Administration in Long-Term Care, or NADONA/LTC, is the
success in your facility by reading
largest educational organization committed exclusively to nursing and
“The Perils of Ineffective Handwashing” administration professionals in the Long-Term Care and Assisted-
and “The Key to Hand Hygiene” on Living professions.
pages 26 and 31.
Mark your calendars for June 21 to 25, 2008 when the 22nd Annual
Reference: NADONA/LTC National Conference will be held in Nashville,
The Centers for Disease Control and Tennessee at the Gaylord Opryland Hotel and Conference Center.
Prevention. Estimates of Healthcare-
Associated Infections. Available at:
www.cdc.gov/ncidod/dhqp/hai.html.
NADONA/LTC
Accessed August 23, 2007. attendees share their
knowledge.
www.cdc.gov
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Special Features
Advancing Excellence
Campaign Goals:
A cross-reference outlining the clinical
and performance goals included in all
four 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 of
long-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 Web
site, where they offer detailed information and educational tools.
Treatment
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™
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16 HEALTHY SKIN
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XXX
EVERY STEP
OF THE WAY
Medline is a registered trademark of Medline Industries, Inc. ©2007 Medline Industries, Inc.
17 HEALTHY SKIN
Mundelein, IL 60060 Improving Quality of Care Based on CMS Guidelines 17
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Crossword Puzzle
Understanding Skin Tears:
the “Whys” and “Hows”
hour of
To receive one r your
CE credit, entene at
answers onli sity.com
niver
www.medlineu
1 2 3
7 8 9
10
11 12
13
14
15 16 17
18
19
20
21 22
www.medlineuniversity.com
1. Register (free) or log in
2. Click Free Courses tab
3. Locate the puzzle and click
Learn More, then Begin Course
4. Certificates are available online
after puzzle completion
18 HEALTHY SKIN
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Across Down
2 Choose dressings that keep the wound 1 The dermis and epidermis move as one in
optimally moist without causing further _____ young skin.
_____. 3 Skin tears occur most commonly in the
5 Between the epidermis and dermis is the _____ extremities.
_____ membrane, a moving junction that 4 It is _____ to look at dressing choices and
both separates and attaches the epidermis choose products that allow you to avoid
and the dermis. adhesives, decrease dressing changes and
6 Keeping the patient well _____ can be the maintain a moist wound healing environment.
difference between a bruise, a bump and a 6 Advancing age and a _____ of previous
skin tear. skin tears put residents at risk for skin tears.
7 Remember key measures such as cleaning, 8 To protect the injury during dressing
moisturizing and nourishing the skin with change, indicate the _____ in which the
advanced skincare _____. dressing should be removed.
10 There are several _____ products that can 9 The _____ has an irregular shape
help alleviate the discomfort of skin tears. resembling downward, finger-like projections
11 As skin ages, the rete ridges or pegs begin called rete ridges or pegs.
to _____ between the dermal-epidermal 12 _____ skincare products that deliver
junctions. endermic nutrition and antioxidants can
13 When injury occurs, there is an increase in assist in preventing skin tears.
_____ absorbed by the skin. 14 _____ handling of skin tears in important.
15 Skin tears cause a resident to suffer _____. 16 Dermal-epidermal flattening is typically
16 Certain medications, such as _____, can seen by the _____ decade of life.
make the skin more prone to injury. 17 Hydration and the appropriate _____ are
18 The use of protective sleeves or elastic the key objectives to healing and
tubular support bandages can help to preventing skin tears.
_____ dressings in place. 19 Skin tears of _____ origin make up one half
19 The dermis has _____ projections. of the total skin tear population.
20 It is estimated that at least 1.5 _____ skin 21 Patients and residents who are totally
tears occur in institutionalized elderly each dependent on others for activities of daily
year. living are at the _____ risk for skin tears.
21 One dressing that can handle the initial 22 Compromised nutrition, fluid volume deficit,
fluid is a _____ sheet. confusion, limitations in mobility, lack of
independence and ecchymotic skin are all
_____ for skin tears.
Survey Readiness
Can you explain the differences between these commonly confused terms?
References
1 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.
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Treatment
Auscultation should be done on all lobes, moving from left to right for a
minimum of two to four breaths. This enables comparison of the lobes to
each other and time to listen for abnormal or adventitious sounds.
Bronchial or vesicular? Coarse crackles are usually louder, lower in pitch and
Normal lung sounds are described as bronchial or vesicu- longer in duration than fine crackles. The most common
lar. Bronchial sounds are what are heard over the large conditions associated with coarse crackles are CHF and
airways. These sounds have been compared to the sound bronchitis. Coarse crackles have been described as similar
of air being blown through a tube. They are louder at the to the sound opening a Velcro® fastener would make.
expiratory phase. Bronchial sounds can be heard over the
tracheal area, over the lung apices and between the Rhonchi are continuous sounds, as they usually last more
scapulas. than one quarter of a second. Rhonchi can be described
as a coarse rattling sound, somewhat like snoring, and
Vesicular sounds are heard over the chest, away from are usually caused by secretions in the larger airways.
large airways. These sounds have been compared to the They usually clear with coughing. These sounds can be
sound of wind blowing through the trees. Vesicular sounds heard in patients with chronic COPD and acute or
are decreased in patients with COPD and over sites severe bronchitis.
of pneumonia.
Wheezes are high-pitched whistling sounds often
Absent or diminished? described as musical. Bronchospasm, airway edema,
Abnormal breath sounds are classified as absent or secretions, endobronchial tumors and compression of the
diminished. Absent breath sounds are just what the name airway can cause this adventitious sound. It might also be
suggests – they are inaudible. Diminished breath sounds heard in patients with CHF due to increased fluid in the
have softer-than-typical loudness. These sounds can peribronchial lymphatics, causing airway compression.
reflect reduced airflow to a portion of the lungs, overinfla-
tion of a segment of the lungs (such as with emphysema), Know your resident
air or fluid around the lungs and even increased thickness The lung sounds described above are the most commonly
of the chest wall. A decrease in the intensity of sounds in heard lung sounds. Knowing your residents’ normal lung
a given area can be the first sign of a disease process. sounds and being able to assess changes will be a
valuable tool for their care.
“Adventitious” another word for “abnormal”
Rales, rhonchi and wheezes are the most common of
adventitious lung sounds. Pleural rubs and stridor are also
classified as adventitious, but are less commonly heard.
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Co-Hosted by
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Special Features
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.
klebsiella
Improving Quality of Care Based on CMS Guidelines 27
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pseudomonas
While they are not diligent or reliable
hand-washers, Americans are enthusi-
astic handshakers, and thereby cordially
pass on their shigella (diarrhea), kleb-
facilities because of a willingness of
their staffs to follow infection risk-
reduction protocols, obey mandated
cleaning of rooms and equipment,
siella (wound infections), Haemophilus wear disposable gowns and, of course, An estimated
(conjunctivitis), E. coli (urinary tract
infections), pseudomonas (infections),
wash their hands. American healthcare
administrators contend that enforcing
103,000
bacteroides (infection), Influenza A cleanliness rules is too expensive and people die
(pneumonia), Clostridium difficile difficult. Apparently, it is easier and
(colitis), assorted rhinoviruses (upper perversely acceptable to allow one in
every year
respiratory infections/colds) and 20 hospital patients to contract an from HAIs
staphylococcus (infection), among infection than it is to solve the infection
other critters. Apparently, physicians problem with its associated human and related to
and nurses – being typical American financial losses.
poor staff
workers – have chalked up their own
set of dire statistics by disregarding There has been a visible public move- hygiene.
handwashing, as evidenced by the ment toward self-protection. DVDs,
outrageous iatrogenic death rates books and the Internet all tout aggres-
in hospitals. sive methods of keeping yourself – and
your loved ones – safe in healthcare
What’s the solution? facilities. It would appear too few
So, what can we do? Certainly, the people are taking advantage of them.
problems associated with ineffective
hand hygiene are well recognized. Perhaps we should enlist patients
Even the Illinois General Assembly has
expressed concern, introducing a bill
in February 2007 that would require
Influenza A
and their families to help eradicate
infection risk. Residents can speak up
and tell their caregivers that they want
schoolchildren to wash their hands doctors to have clean hands before
with antiseptic soap before eating. touching them. We have actually creat-
Politicians, including President Bush, ed a large blue button printed with
Vice President Cheney, Al Gore and “Please wash your hands, my health
Barack Obama carry hand sanitizers depends on it” that can be fastened to
with them at all times to help reduce patient gowns. Residents should also
their risk of infection during glad-handing be encouraged to speak these very
season (which is now perpetual). words to every caregiver with whom
A
tion to incite a change in hygiene son of hand hygiene agents in a hospital. Clin. Infect.
Dis. 2003 Jun 1;36(11):1383-90.
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.
o viruses
Improving Quality of Care Based on CMS Guidelines 29
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Also available:
Sterillium Rub
for surgical hand
antisepsis
that Sterillium Comfort Gel achieves reductions of ≥ 5 log10 (≥ 99.999 percent) on a broad
by using up to 50 percent less volume per application.* Independent in vitro testing demonstrated
Special Features
evidence suggests that an aliquot as small as 2.4 should be functional. In a recent study, only
mL might well be sufficient to cover both hands 77 percent of a certain type of wall dispenser
with the preparation and also fulfill U.S. efficacy were found to be functional after 16 months.6
requirements, especially if the preparation has A malfunctioning or difficult-to-use wall dispenser
a high ethyl alcohol content. From a practical is likely to discourage healthcare workers to
point of view, and given the nature of the clinicians’ perform hand antisepsis. Pocket bottles provided
work environment – where time is short and to staff serve dual purposes. Their availability
patient load is demanding – products that can leads to increased compliance and reduces the
deliver required efficacy with minimal application amount of “contraband” product brought into
volume are desirable. facilities without the necessary compatibility
testing typically required.
Dermal tolerance
Handwashing contributes to irritant contact Key conclusions
dermatitis on the hands of healthcare workers, Appropriate selection of a hand antiseptic –
which can result in dry and rough skin, redness including taking into account its dispensing
and loss of integrity of the skin barrier. That technology and packaging configuration – is key
is why it is crucial to wash hands only when in achieving optimum efficacy and comfortable
absolutely necessary. In all other clinical situa- use of hand antiseptics. Meeting these goals will
tions, an alcohol-based hand antiseptic should likely have an impact on patient safety.
be applied to decontaminate hands. The hand
About the author
antiseptic should not be sticky and should ideally
Mary Beth Fry, BS, CIC, is currently the infection
improve the skin condition, e.g., by reducing
control coordinator at the University of Illinois Medical
skin roughness or increasing skin hydration,4
Center, Chicago, Ill. She has more than 32 years of
which can increase the hand hygiene compliance
experience as a clinical microbiologist and with all
rate.5 If a preparation is unpleasant or uncom-
aspects of infection control.
fortable to use, it will likely be rejected by health-
care workers. This can result in a low compliance
References
rate and, ultimately, cross transmission of noso- 1. Kampf G, Kramer A. Epidemiologic background of hand hygiene
comial pathogens. As a result, while implement- and evaluation of the most important agents for scrubs and rubs.
Clinical Microbiology Reviews. 2004;17(4):863-893.
ing a good hand hygiene program is intended to 2. Boyce JM, Pittet D. Guideline for hand hygiene in healthcare set-
tings. Recommendations of the healthcare infection control practices
have a positive impact on infection rates, product advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene
selection decisions can lead to the opposite task force. Morbidity & Mortality Weekly Report. 2002;51:1-45.
3. Kampf G, Rudolf M, Labadie J-C, Barrett SP. Spectrum of antimicro-
effect if the products are perceived by staff to be bial activity and user acceptability of the hand disinfectant agent
Sterillium Gel. Journal of Hospital Infection. 2002;52(2):141-147.
damaging to the skin and therefore go unused. 4. Kampf G, Muscatiello M, Häntschel D, Rudolf M. Dermal tolerance
and effect on skin hydration of a new ethanol-based hand gel. Journal
of Hospital Infection. 2002;52(4):297-301.
Easy access 5. Kampf G. The six golden rules to improve compliance
in hand hygiene. Journal of Hospital Infection. 2004;56
In addition to being effective and gentle on (Suppl. 2) :S3-S5.
the skin, hand antiseptics must be easily and 6. Kohan C, Ligi C, Dumigan DG, Boyce JM. The importance of evalu-
ating product dispensers when selecting alcohol-based handrubs.
conveniently available. Pocket bottles and wall American Journal of Infection Control. 2002;30(6):373-375.
32 HEALTHY SKIN
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Pulse Oximetry
at a budget-friendly price
Blood oxygenation – it’s the sixth Features of the PM-50 • Stores up to 100 patient IDs
vital sign! Our economical PM-50 • Noninvasive and painless and 200 measurements
Handheld Pulse Oximeter allows you • Convenient size and weight • Data transferable to PCs for
to easily and accurately monitor the for spot-check monitoring storage or printing
amounts of oxygen that are being • Automatic standby and • Convenient AA alkaline or
delivered to your residents. power-off rechargeable batteries
Item # Description
HCSPM50 PM-50 Handheld Pulse Oximeter
medline.com i 1-800-MEDLINE
© 2007 Medline Industries, Inc. Medline is a registered trademark
of Medline Industries, Inc.
Improving Quality of Care Based on CMS Guidelines 33
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Treatment
Seat Cushions:
Padding Your
Pressure Ulcer
Prevention Strategy
Cynthia Fleck
MBA, BSN, RN, APN/CNS, ET/WOCN, CWS, DNC, DAPWCA, FCCWS
Diane L. Holland
BS, PT, CWS, WCC, C. Ped.
34 HEALTHY SKIN
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XXX
CMS Tag F314 Frequently asked questions two inches of space behind the knees. It
states, “Appropriate
support surfaces or
devices should be
1 Why are they called “bedsores”
when pressure ulcers also occur
in seated individuals?
is important that the leg rest height is
correct so the client’s knees are not
positioned too high. Also, a client’s thighs
chosen by matching Approximately 68 percent of pressure
should be adequately supported. This will
a device’s potential ulcers occur on the pelvis and are the
distribute the pressure load and decrease
therapeutic benefit result of sitting upright.2 Clients who are
pressure on the ischial and sacral areas.
with the resident’s confined to a wheelchair for a significant
specific situation.”1 amount of time during the day are at
It is essential to look at issues such as
hypertonicity (high muscle tone) and
highest risk. Individuals with comorbidities
intervene to control and improve position-
such as diabetes, renal and respiratory
ing. A client with limited range of motion
failure, poor hydration and nutritional
(ROM), such as decreased hip rotation,
concerns are also in danger of developing
will compensate with postural changes
a pressure ulcer. Even a client with good
in the torso. In this case physical therapy
sitting posture can experience skin
or a referral to a positioning professional
breakdown. Common locations where
may be needed for assessment and
pressure ulcers develop when confined
wheelchair modification. Wheelchairs
to a wheelchair are the sacral area (tail
with sling seat upholstery should be
bone) and ischial tuberosities (sitting
discouraged when clients spend a
bones). Skin breakdown may also be
substantial amount of time in a wheelchair.
related to an individual’s body structure
The sling causes internal rotation of the
and to the atrophy or loss of muscle
femurs (legs), adduction (rolling inward)
from nonuse.
of the lower extremity, a posterior pelvic
tilt (sliding down) and a kyphotic trunk
Clients can sit in a wheelchair for more
(slouched over) posture. Over a period of
than 16 hours a day; therefore, a combina-
time this can lead to decreased range of
tion of interventions must be implemented
motion, scoliosis and decreased function
and assessed when ordering a new
and weakness in the abdominal and
wheelchair cushion. The primary goal of
spinal musculature.3,4
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
2
What are the different types of
wheelchair cushions and which
one is the best?
reduce circulation cause them. To help
There are many pressure redistributing
prevent skin breakdown, a wheelchair
devices on the market that vary in cost
and wheelchair cushion must fit the client
and quality. Most of the larger wheelchair
in width, support the thighs and leave
5
powered or non-powered. There are Cushions wear out, go flat and do not
also custom wheelchair cushions and I didn’t realize the number of cushions perform optimally forever. We would not
backs as well. that are available and the various uses dream of purchasing a new automobile
for them. Is there any way to make it and never changing the oil, having a
Published studies have compared several less confusing? tune-up or checking the tire pressure,
types of cushions by judging their ability Wheelchair cushions can be confusing right? Yet, often this is what happens
to prevent skin redness or by measuring and wheelchair positioning and pressure after a cushion is purchased. This can
interface pressure, which is the pressure relief is a specialty in its own right. mean problems for the user and potential
that occurs when a body comes in contact Choice is important because a cushion pressure ulcers and other challenges.
7
with a surface or cushion. The over- should last for an extended period of time.
whelming result of this research indicates Other factors that must be considered What is “bottoming out” and why do
that no single cushion is best for all when ordering a cushion include conti- I need to check the cushion all of
people.5 It depends on the client and nence, transfers, amount of time per day the time?
their particular needs. spent in the wheelchair, muscle tone and It is important to check the cushion
3
mobility. Another issue to consider is client every day to determine if it has bottomed
I have seen egg crate and foam rings compliance and choice. Educating the out. That may seem excessive but if the
used, are they suitable? client on the cushion and evaluating client is not “floating” on the surface or
Foam or air “invalid” rings are not which products improve position, offer suspended, their tissue and bony areas
appropriate for pressure reduction.6,7 effective pressure reduction, optimize are not being protected. To test for bot-
The ring increases pressure around function and offer versatility for transfers toming out, simply don a glove and slide
the sacral region and decreases blood and daily life are important steps. Your your hand between the client and the
flow, which may cause problems. The facility’s rehabilitation department or a cushion. If it is difficult to do, you can
ring can also cause deep tissue injury to wheelchair clinic in the community is a good place your hand inside a pillowcase to
a high-risk client because the unnatural place to start. Look for a Rehabilitation help it slide under the client more easily.
shape does not conform to the anatomy Engineering and Assistive Technology There should be about an inch of material
of the buttocks. Additionally, egg crate Society of North America (RESNA) (air, gel, fluid, foam, etc.) between the
cushions offer no pressure relief and certified clinician or technician. To become client and the bottom of the surface.
can bottom out, causing the client to certified they must study and pass a rigorous Have you ever stayed at a motel and
touch the bottom of the wheelchair and exam in this specialty area. Once certified, slept on a bed with the springs poking
not float on the surface. These products they are trained in wheelchair assessment you in the back all night? That is
should be avoided. and proper wheelchair selection and often bottoming out.
utilize special computerized mats to assess
a client’s needs.8
36 HEALTHY SKIN
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XXX
The client’s skin should be checked for suppliers who have Certified Rehabilitation Cynthia A. Fleck,
persistent redness each time they are Technology Suppliers, or the credential MBA, BSN, RN,
APN/CNS, ET/WOCN,
moved. This will measure whether the CRTS. These individuals have passed a
CWS, DNC, DAPWCA,
cushion is doing its job and whether rigorous credentialing exam and have at
FCCWS is a certified
weight shifts or moving the client back least two years of experience. They can wound specialist and
to bed should be done more frequently. be found by visiting the National Registry dermatology advanced
8
of Rehabilitation Technology Suppliers practice nurse, author,
What are the surveyors looking for (NRRTS) Web site at www.nrrts.org. speaker, Secretary/Treasurer of the American
Academy of Wound Management (AAWM),
and what does CMS state? Another legitimate credential is the
Member of the Board of Directors of the
Key information regarding repositioning Assistive Technology Supplier (ATS),
Association for the Advancement of Wound
and assessment of a client’s skin integrity, certified by RESNA.12 Care (AAWC), Diplomat of the American
especially in the immobile, is emphasized Professional Wound Care Association and
in the CMS Guidance to Surveyors.11 Clinicians who are Assistive Technology Vice President, Clinical Marketing for Medline
Appropriate support surfaces should be Practitioner (ATP) certified provide Industries, Inc., Advanced Skin and Wound
Care Division. Cynthia can be reached at
utilized wherever the client’s skin is in analysis of a client’s needs with regard
cfleck@medline.com.
contact with a surface area for a prolonged to all areas of seating, positioning and
period of time (beds, mattresses, chairs, assistive technology. These individuals Diane L. Holland, BS,
wheelchairs, etc.). The document further must possess a minimum of an associate’s PT, CWS, WCC, C. Ped
describes the use of sheepskin-type degree and three years’ experience in is a physical therapist
products, pillows and wedges and warns his or her field, such as physical or and Certified Wound
Care Specialist practicing
that they should only be used for comfort occupational therapy.
at Bellevue Hospital in
or reduction of friction, not pressure
New York City. She was
redistribution. The use of donut-type formerly employed at
cushions is not recommended, nor are the Hospital for Joint Diseases, Diabetic Foot
wheelchairs with sling seats that may Center, also in New York City. Diane can be
not be optimal for prolonged sitting during reached at holland6@optonline.net.
activities or meals.
9
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.
Who can help? 10 Fleck CA. The new cms pressure ulcer guidelines. ECPN. January/February 2005:36-42.
Again, clinicians and providers with 11 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.
expertise in seating and positioning 12 Rehabilitation Engineering and Assistive Technology Society of North America (RESNA).
should be a part of the team. Look for Available at: www.resna.org. Accessed August 21, 2007.
CO
be broken down into seven types:
NT
it’s estimated that with little control over the bladder (also known as overactive bladder,
25 million Americans spastic bladder or reflex incontinence).
will experience
transient or chronic • Overflow incontinence: Residents with overflow incontinence
incontinence.1 cannot completely empty their bladders. This leads to frequent
urination or a constant dribbling of urine, or both.
Why not take a • Functional incontinence: This is the most common type of
IN
moment to review
incontinence among elderly residents with arthritis, Parkinson’s
the facts on
incontinence? disease or Alzheimer’s disease. The limitations these residents
Perhaps doing so have with moving, thinking or communicating make them unable
will mean that to effectively control their bladders.
you’ll have just • Mixed incontinence: Residents experiencing mixed incontinence
the right words
have two types of incontinence simultaneously, typically stress
EN
to reassure
incontinence and urge incontinence. The causes of the two forms
your residents!
of 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 or
calcium channel blockers.2
The revolutionary
design of the
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For more information fit and enhanced dignity for
on Air Active briefs, your resident...all at significant cost
contact your Medline
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savings. In addition, this state-of-the-art
1-800-MEDLINE brief features an advanced three-part
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decreases odor and refastenable,
stretchable tape tabs that won’t
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©2007 Medline Industries, Inc. Medline is a registered trademark of Medline Industries. Molicare is a trademark of PAUL HARTMANN AG.
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:27 PM Page 40
40 HEALTHY SKIN
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Treatment
Taking the
F e a r out of
Male Catheterization By Victor Senese, RN, CURN
T his is a true story that took place about 10 years ago. I was paged to see a patient in the
hospital 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 had
already tried and failed to insert a catheter into his distended bladder, and he was not looking
forward to my poking around. Half kidding, I told him I am an expert and I can insert this
catheter in “one shot.” He took me up on my bet and, sure enough, I was able to insert his
catheter in one try.
The first thing I do is introduce myself to the patient and inform him I am an “expert” in
catheterization. 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 a
novice, this introduction goes a long way in relaxing an apprehensive patient. Remember, the
sphincter is under voluntary control. If a nervous patient tightens up, catheterizations can
become a cruel tug-of-war, with the patient’s sphincter often winning. Now that the patient is
convinced 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?
When available, I instill 2 percent lidocaine jelly into the urethra. If this is not available or your
institution 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 urethra
as well as lubricate the passage. Next, place the catheter into the urethral opening and instruct
the patient to relax the muscles in his legs. The sphincter and leg muscles are both skeletal
muscles and relaxing the legs will help relax the sphincter. Advance the catheter with a steady
pressure. Stop if you meet resistance.
Catheterization Recommendations
1 Recommendation #1: If you feel resistance, rest your arm against the patient's leg and ask
him to relax. When you feel the leg muscle relax against your arm, push the catheter forward
and it will probably slide right in.
2 Recommendation #2: Be sure to insert the catheter up to the balloon’s “Y” port. Don't
assume that if you see urine the catheter is in. Examine a Foley catheter and you will notice
the 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 this
careless act.
3 Recommendation #3:Assess your patient for balloon size. An elderly gentleman can easily
pull a 5 cc balloon to his prostate. I usually prefer to use a 30 cc balloon catheter on all males
and inflate the balloon to 15 to 30 cc, depending on the patient's level of orientation.
4 Recommendation #4:Tape that tube! The last step is to secure the tube to the patient's leg
with tape. This will prevent accidental trauma to the bladder, and is often the most overlooked
step in catheterization.
Occasionally you will not be able to pass a catheter due to strictures or scars found within the
urethra. This is when you need to call it quits and request your fellow urologist. If you follow my
recommendations 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 the
nickname "One Shot" and brags to anyone who will listen about that eventful day when I was
able to get a catheter into his bladder in one try!
42 HEALTHY SKIN
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SILVERtouch ™
Foley Catheter
Let us help you fight to eliminate catheter-associated urinary tract infections.
References
1. Rupp M et al. Effect of silver-coated urinary catheters. AJIC.
To learn more, contact your Medline 2004;32(8):445-50.
2. Haley RW, Culver DH, White JW, Morgan WM, Emori TG. The nation-wide
representative, call 1-800-MEDLINE or nosocomial infection rate. A new need for vital statistics. Am J Epidemiol.
visit www.medline.com. 1985;121:159-67.
3. Paradisi F, Corti G, Mangani V. Urosepsis in the critical care unit.
Crit Care Clin. 1998;14:165-80.
©2007 Medline Industries, Inc. Mundelein, IL 60060 4. Vincent JL, Bihari D, Suter PM, et al. The prevalence of nosocomial
Medline is a registered trademark of Medline Industries, Inc. infection in intensive care units in Europe—The results of the EPIC study.
Silvertouch is a trademark of Medline Industries, Inc. JAMA. 1995;274:639-44.
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:28 PM Page 44
MEDLINE UNIVERSITY
You’ve made it this far …
Let Medline University keep you going
Special Features
What causes neuropathy? how to determine changes in sensa- to three times per year, and podiatric
The most common causes for loss of tion with the use of a monofilament care every 61 days. These benefits
sensation are neuropathies related to and other tools. When these subtle help prevent further damage.
diabetes mellitus, but it can also be changes start to occur, it is appropri-
related to alcoholic neuropathy, herpes, ate to obtain proper footwear. The Inspection & protection
cancer and spinal cord lesions. footwear should fit well and help to The importance of inspecting and
Neuropathy is a change in sensation maintain proper alignment of the foot. protecting diabetic feet cannot
as a result of nerve damage that can be overemphasized.
cause an individual to have no feeling Beyond neuropathy
or an increase in pain. The client may Another problem that occurs with It is important to be aware of the feet,
describe symptoms such as burning, poorly controlled DM is neuromuscu- the changes in the feet and what can
tingling and unusual pain. Traditional lar changes that affect the structure be done to protect the feet. Simple
pain medications are often not effec- and form of the feet. The toes can daily inspection and protection can
tive, making other medications, treat- start to hammer and have other make a huge difference.
ments and modalities necessary. deformities, and the foot itself can
change in appearance and form,
Danger ahead which affects the ability of the patient
Managing a patient with diminished to wear regular shoes. Working with
or no sensation can be dangerous a doctor of podiatric medicine (DPM),
and difficult. The patient may be orthotist or pedorthotist is important
unaware of items in or on their because they can help to accommo-
footwear and may continue to wear date footwear and align the foot so
shoes that cause injuries, have for- that the changes in structure do not
eign objects in them or that simply cause ulcers and damage. When
do not fit correctly. Because of the orthotics and other accommodations
lack of sensation caused by neuropa- of the footwear are not enough,
thy, the patient does not feel the special shoes may be necessary.
source of the problem, continues to Depending on the degree of damage
wear improper footwear until there to the foot, the patient may be able to
are apparent signs of injury such as purchase them or they may need to
odor, drainage adhering to footwear, be custom-made.
or a problem controlling their blood
sugar levels. Other features that can help protect
the feet are well-fitting footwear with a
Injury can be avoided deep toe box in the shoe to decrease
The problem with diabetes mellitus is rubbing and reduce undue injury to
that these complications do not have the foot. The footwear can be a
to occur. Literature indicates that as sandal-type or full shoe, with devices
many as 80 percent of ulcers could built in or attached to help keep pres-
be preventable. In fact, they are usually sure off of the affected area. When a
related to poor management of the client has accommodative foot wear
disease over time. The disease has it is not the end of the condition.
an impact on many systems. Because Footwear needs to be reexamined
of the damage to the small vessels, on a regular basis depending on
the eyes, kidneys, heart and peripheral the wear and amount of damage to
system can be affected. As the the foot. An individual with diabetes
complications worsen and an individual should see their healthcare profes-
loses the ability to feel their feet, sional at least annually.
diligent monitoring is essential.
CMS has recognized the importance
Someone with DM should have their of proper footwear and provides cov-
feet examined at least once a year by erage under Medicare for one to two
a professional healthcare provider. shoes per foot per year, insoles or
The clinician needs to be trained in orthotics for better foot alignment up
46 HEALTHY SKIN
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Survey Readiness
48 HEALTHY SKIN
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Q
and position flow sheet at the bedside
change to a nurse (CNA).
was not signed. The staff really enjoyed
seeing how many things they could
find wrong and comparing results with
5 Identify wound ad/or dressing conditions that indicate
the need for a dressing change (LPN/RN).
one another as to how well they did.
6 Discuss documentation requirements for wound
A
Participants who recognized all of the assessment and care (LPN/RN).
potentials for skin breakdown were
given a small prize.
50 HEALTHY SKIN
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Janet Jones
BSN, RN, PHN, CWOCN, DAPWCA
A
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 “... spread the paste
(Second Generation Barrier Paste) as a protective layer.”
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
DO YOU HAVE A WOUND
and will not wash off even with repeated episodes of incontinence, thus OR SKIN CARE QUESTION?
creating a “physical dressing.” If turning and repositioning are appropriately
Call the Educare Hotline! Medline’s
done, healing usually occurs without any difficulty.
toll-free hotline is supervised by a
Helpful hints board-certified enterostomal therapy/
Some important tips when using a second generation barrier: wound, ostomy and continence nurse.
> 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
Just pick up the phone and call
stool. If any barrier cream residue remains on the skin, merely apply 1-888-701-SKIN (7456).
another thin layer of barrier cream on top.
We’re here to help!
> 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.
About the Author
Janet Jones, BSN, RN, PHN,
A second generation barrier cream is an excellent option when dealing with CWOCN, DAPWCA is a board-
superficial injury to the skin and continence issues are a problem. certified wound, ostomy and
continence nurse. She has
extensive experience in long-term
See you on the Hotline! 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!
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 52
A I R - P E R M E A B L E P R E M I U M D R Y PA D
ONE
1 pad
The innovative backsheet on
for healthier skin: ONE
1 pad for easier care:
can be used on both
allows air to flow standard beds and air-support
through the pad while still acting as a therapy beds.
barrier to moisture.* The result is superior
skin dryness and comfort. Advanced Technology
ONE
1 pad for lower cost:
are so strong and
absorbent that they eliminate the need
for multiple pads. They can also reduce
Soft, Non-Woven Topsheet AquaShield Film
the need for draw sheets, linens or – softer against skin for – traps moisture, providing
increased comfort better leakage protection
reusable underpads. This results in a
Advanced SuperCore® Innovative Backsheet
dramatically lower cost. Absorbent Sheet – air permeability
– thermo-bonded to provide better means better skin comfort
*MVTR of 3600 +- 1000 g/m2/24h
pad integrity and superior skin dryness
0 1 2 3 4
Continent Usually Occasionally Frequently Incontinent
Includes use of Continent Incontinent Incontinent Has inadequate
indwelling urinary Bladder – Bladder – two or Bladder – two control.
catheter or ostomy incontinent more times a week, or more times a Bladder – multiple
device that does episodes once a but not daily; Bowel week, but not daily episodes;
not leak stool week or less; Bowel – once a week daily; Bowel – Bowel – almost all
– less than weekly once a week the time
Remedy Dimethicone
Protect
Remedy Dimethicone
Protect
m
Improving Quality of Care Based on CMS Guidelines 53
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:29 PM Page 54
Case Study
Using Olivamine* in a Skin Cream to
Improve Skin Quality in Diabetic Patients
By Dawn R. Fortna, RN, CDF, CWOCN
Ephrata Community Hospital, Ephrata, Pa.
PROBLEM
CM
Our diabetic population presents with skin
is 91-year-old female has had type 2 diabetes for more than 20 years. She presents with
issues often resulting in skin injury and
xerosis, fine lines, scaling and pain in her legs, which is increased at night (Figure 1a). She
increased costs. Autonomic neuropathy causes
describes the pain as “deep pain” and scores it as a number “8” on the scale of 0-10 . Since
a decrease in the sweat and oil production,
daily application of the Olivamine-containing product, she has had no xerosis, fine lines
resulting in xerosis. Our goal was to decrease
and scaling have decreased and her skin appears much healthier. She states that the pain
these issues and costs of secondary injuries
resolves completely for several hours after application of the product (Figure 1b).
and improve quality of life for our patients.
METHODOLOGY
Fifty patients were selected to participate in a
skincare product trial. Criteria for inclusion
was a diagnosis of diabetes, high risk for skin
breakdown and characteristics of xerosis,
defined as abnormally dry skin with fine lines,
scaling and fissures. Untreated xerosis may lead
to itching and scratching, pain and cellulitis.
Excluded were confused or non-verbal
patients. Skin cream containing Olivamine was Figure 1a Figure 1b
applied daily to the patients’ legs and feet,
after cleansing, for a period of four weeks. Skin PM
was evaluated weekly for integrity. Pain was is 63-year-old female has had type 2 diabetes for approximately five years. She also has
documented using a 0-10 pain scale. Patients troublesome venous stasis disease and has an ongoing battle with severe xerosis, scaling
were queried regarding itchiness. and 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 that
OUTCOMES she has “less of a pulling sensation” on her legs. Daily cleansing, moisturizing and protecting
Olivamine delivers amino acids, antioxidants the skin with the Olivamine-containing product has greatly improved the general condition
(hydroxytyrosol), vitamins and methylsul- of her skin (Figure 2b).
famethane to the skin. Transepidermal water
loss (TEWL) is preserved with dimethicone base,
preventing damage from dehydration and
decreasing pruritis.
CONCLUSIONS
A program of cleansing, moisturizing, and
protecting the skin with the Olivamine-
containing product improved skin outcomes
including skin integrity, prevention of break-
down of fragile skin and decreased pain and Figure 2a Figure 2b
itching for patients.
RM
is 46-year-old male has had type 2 diabetes for more than 10 years. He has had multiple
toe amputations and additional foot surgeries due to osteomyelitis. He presents with a
recent 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 skin
and itching (Figures 3a and 3b). He has noticed marked improvement of his symptoms
with daily application of the Olivamine product (Figure 3c).
54 HEALTHY SKIN
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Treatment
Figure 3a Figure 3b
References
1. 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 patients
with diabetes. Available at:
http://multimedia.mmm.com. Accessed
August 22, 2007.
6. Remedy. Available at:
www.medline.com/woundcare/products/
Figure 3c remedy. Accessed August 22, 2007.
7. Scarborough-Roessler P. Keeping the foot
attached to the leg. Presentation. January
Assessed Criteria Patients meeting Improved after 2003. Educators 2000 Plus.
Criteria 4 weeks 8. Van Gills C, Stark L. Diabetes mellitus
XEROSIS 47 47 (100%) and the elderly: special considerations for
FINE LINES 50 50 (100%) foot ulcer prevention and care. Ostomy
SCALING OF SKIN 40 40 (100%) Wound Manage. 2006;52(9):50-56.
ITCHING 26 22 (84.6%)
PAIN 4 4 (100%)
Conclusion
All 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 experienced
decreased itching following daily application of the Olivamine product.e participants
stated 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 much
improved 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, all
experienced pain reduction of at least 3-4 points on the 0-10 pain scale after application
of the Olivamine product. e small number of participants with pain as a major concern
is 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. ere
are obvious limitations to the effect of any product regarding pain in this study. ese
results demonstrate that a program of cleansing, moisturizing and protecting the skin
with 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 about
purchasing the product as a result of their satisfaction with the product’s results.
Improving pain
management at
your facility
In both the QIO’s Nursing Home Quality Initiative and Advancing Excellence in
America’s Nursing Homes, clinical performance measures and clinical goals include
improvement 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 has
any pain.
2. Institute pain screening tools appropriate for cognitively impaired residents and create a
easy-to-carry pocket card.
3. Designate responsibility and accountability to specific staff positions for screening of pain at
admission 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 would
for 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 assure
appropriate 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 the
resident 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 provide
guidelines at each nurses’ desk.
12. Incorporate non-pharmacologic approaches to pain management. (e.g., relaxation, hot or
cold packs, acupuncture, etc.).
13. Conduct regular in-services about pain management, focusing on myths of pain, the elderly
and 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.
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PRODUCT SPOTLIGHT
58 HEALTHY SKIN
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Extra-wide,
W e don’t have to tell you how important Skin Safe
Refastenable
it is that the disposable brief you chose pro- Tape Tabs
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©2007 Medline Industries, Inc. Medline is a registered trademark & Comfort-Aire is a trademark of Medline Industries, Inc.
JBK2_HSV_v8.qxd:Layout 1 8/24/07 8:30 PM Page 60
Love Them
Times
2 Products designed for you
and your residents
In this edition of Healthy Skin, we’re excited to introduce you to two products
whose implementation can benefit all involved!
60 HEALTHY SKIN
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Survey Readiness
• Introducing Medline's New Green Tree line of toilet paper and hand towels made of 100
percent 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.
Cool tips
Aluminum Energy
• By recycling one aluminum can per • Keep the temperature of your water
day, we can save enough energy to heater at home down to 120 degrees
operate a television set for Fahrenheit. It will be hot enough for
three hours. everyday use but will keep energy
usage lower.
Automobiles • Invest in a programmable thermostat
• Three major items from our to make adjustments for you when
automobiles cause problems in you are not home or when you are
landfills: oil, tires and car batteries. sleeping at night.
Recycle motor oil with local oil and • Unplug an underutilized freezer
lube shops so that it can be used in or refrigerator.
commercial operations as fuel. If your
local recycling facility accepts tires, the Paper
rubber can be used for playgrounds, • Think before you print a document –
flooring, asphalt or burned as fuel. do you really need a paper copy?
Car batteries contain lead and sulfuric If so, is there an economy print mode
acid – but all elements can be reused on your printer that will use less ink?
in new batteries. • Paperless billing – having statements
• Share a ride with coworker or friend sent to your email address and
and you’ll cut your emissions in half. paying your bills online eliminates
paper, stamps, envelopes, etc.
Electronics
• Put your computer in sleep mode Trees
when you are not using it. • Plant a tree. If every American family
• Do not add electronic waste to planted one tree, more than a billion
landfills. A computer monitor, for pounds of greenhouse gases
example, might be 6 percent lead would be removed from the
by weight. atmosphere every year.
Glass
• Recycle glass – the energy saved from
one glass bottle will light a 100-watt
light bulb for four hours.
Cool tips
Improving Quality of Care Based on CMS Guidelines 63
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by Jeannine Thompson
BSN, RN, CWOCN
Clinical Education Specialist
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Special Features
Do you remember 7. The queen who blamed Alice for everything bad that had happened to her.
the story of Alice 8. A court hearing where the witnesses were of no help to Alice.
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.”
matter – physically, financially Anurse can no longer waste her time with the Mad Hatter and March Hare and not reach
and emotionally. the goal in a reasonable amount of time. Becoming aware that the pressure ulcer has
Alice didn’t have a global position- not progressed at the time of discharge, end of the certification period, when the state
ing system to help her get from her surveyors review the charts or when the lawyers appear at the facility is unacceptable.
home to the rabbit, but Anurse
does. All Anurse has to do is use How can you show healing?
the reliable and validated pressure Validated assessment tools that use objective data to monitor pressure ulcer progression
ulcer healing tools that have been can help determine if a specific treatment modality is appropriate.
provided to her.
Anurse knows the three phases of wound healing are inflammatory, proliferative and
Using the GPS system model, maturation. Anurse also knows that the inflammatory phase typically begins on day
Anurse inputs the starting and one and lasts for five days, the proliferative phase typically begins on day five and lasts
ending destinations and the best until day 25, and the maturation phase typically begins on day 25 and lasts up to18
way to get there in the plan of care. months. In general, a clean pressure ulcer with adequate blood supply and innervation
If the wound does not progress as should show evidence of stabilization or some healing within two to four weeks. However,
planned, the GPS system alerts many pressure ulcer healing rates are like Alice’s white rabbit, who states “I’m late,
Anurse immediately. I’m late for a very important date,” thus making them chronic ulcers, which can linger
for weeks, months and even years.
Anurse is already proficient in assess-
ment, planning and implementation, Validated tools for monitoring pressure ulcer healing have existed since 1997. The
but what about timely evaluation? 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
Pay for Performance (P4P) is here. Status Tool (PSST)) can be Anurse’s pressure ulcer GPS. If Anurse uses a monitoring
Poor healthcare practices will no tool on a routine basis, usually weekly, to assess the progression of the pressure ulcer,
longer be paid for. Documentation she will know if the wound is progressing through the inflammatory phase as expected.
must indicate that Anurse’s treatment If the tool indicates slow to no progression, Anurse knows that she needs to notify the
modality is appropriate for the doctor that a change to the plan of care might be necessary to promote healing and
pressure ulcer and that the pressure move the wound out of the inflammatory phase.
ulcer is progressing positively.
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.
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)
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XXX
Each element is assigned a number, which is then added together to obtain a total score. References
That score is placed on the Pressure Ulcer Healing Graph. Changes in the score over Anna and Harry Borun Center for
Gerontological Research.
time provide an indication of the changing status of the ulcer. If the score decreases, The Bates-Jensen Wound Assessment
the wound is improving or healing. If the score increases, the wound is deteriorating. Tool Page. Available at:
borun.medsch.ucla.edu/modules/Pressur
e_ulcer_prevention/pubwat.pdf.
Sussman Wound Healing Tool (SWHT) Accessed August 15, 2007.
Developed by Sussman and Swanson in 1997, this two-part tool measures pressure National Pressure Ulcer Advisory Panel.
ulcer wound healing. The focus of the tool is to track a change in tissue status and The PUSH Tool page. Available at:
http://www.npuap.org/PDF/push3.pdf.
wound measurement, assess whether the wound is healing and track the impact of Accessed August 15, 2007.
physical therapy technologies for wound healing.
Sussman C, Swanson G. Utility of the
sussman wound healing tool in predict-
Part I of the tool assesses 10 variables that address wound tissue attributes. The attributes ing wound healing outcomes in physical
therapy. Advances in Wound Care.
are classified as “good for healing” or “not good for healing.” The scoring system is
1997;10(5):74-77.
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.
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?”
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.
The End
Improving Quality of Care Based on CMS Guidelines 67
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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) ❚ Emergency
and 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) ❚ Infection
Control (4) ❚ Medical Records (2) ❚ Medicare (4) ❚ Nutrition (2) ❚ Pain Management (2) ❚ Pressure Ulcers
and Skin Care (2) ❚ Public Relations and Marketing (2) ❚ Quality Assurance (2) ❚ Quality Indicators and
Quality 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)
By Teresa Kellerman,
RN, WOC, ARNP
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themselves …
• You feel fatigued in the morning when you get up
Julie Morath
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.
Within the Midwest community where I practice, a • You have become uncharacteristically irritable.
coalition was formed to address pressure ulcer prevention • You feel overwhelmed all the time. Even routine
involving acute, rehab, long-term, health department, tasks feel like enormous challenges to be overcome.
home and hospice care entities. A noted need and subse- • You have trouble concentrating.
quent goal of this group was to improve communication • You feel emotionally drained and "used up" at the
and care between services with regards to pressure ulcer end of the workday.
issues. Open dialogue has occurred and recognition of the • Physical problems may include sleeplessness,
need for further work has been established. But, as with chronic fatigue or loss of appetite.
any quality improvement initiative, identification of
the problem must be done. All involved parties must
The causes
acknowledge and accept responsibility for the needed
• Lack of respect among co-workers or employees
change(s). Solutions must be discovered collaboratively
and managers.
with the focus of best outcomes for patients while
• Lack of control over one's workload, schedule
maintaining respectful interaction and behaviors.
and deadlines.
• A feeling that one's ideas are not valued or listened to.
• Absence of feedback, so employees cannot see or
About the author
The remedies
Specialist Group.
• Let others know you are having difficulty and ask for
References
help. Be specific in your requests.
The Joint Commission. The FAQs for The Joint Commission’s
2007 National Patient Safety Goals page. Available at: • If you believe you are nearing the burnout stage,
www.jointcommission.org/patientsafety/nationalpatientsafetygoals. seek professional guidance and support.
Accessed August 10, 2007. • 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.
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Special Features
S H A R P E N I N G T H E S AW
Reason #1: The employee does not know they are supposed to
do the job in a specific way. This is always the first question to
ask in any instance of nonperformance. I advise the manager
to go to the employee and say, "Tell me what you are supposed
to do in this situation." Note how closely their answer matches
your mental vision of what is supposed to happen in the
given situation.
In our work with management teams we often hear, sure they have received plenty of constructive training
"Everyone knows they are supposed to do this, it is to do it, and they are still not doing it, ask "Does this
just common sense." I think you will be surprised how person have the mental and/or physical capacity to
often your vision differs from that of your staff. In fact, do this job?"
the common sense you think everyone has might not
be common at all. Correcting this miscommunication The answer may be the employee does not have
will fix many of your nonperformance challenges. the capacity to do the job effectively with the amount
of training you are willing to provide to them.
Reason #2: They know what they are supposed to do, Alternatively, you might have made a hiring mistake
but do not know how to do it. This is essentially an and the person is not suited for the job you are asking
issue of training. In this circumstance, employees want them to do.
to perform, they just do not know how because they
have not been trained properly. Once you are sure Reason #4: They know what to do, how to do it and
they know what they are supposed to do, the next they have the capacity to do it, but choose (for many
question to ask is, "Am I sure they have been trained reasons) not to do it. This is willful noncompliance.
to do it the way I want them to do it?" We are always The noncompliance may stem from these
surprised at the number of institutions that add thought patterns:
instructional language to their policy and procedures • My way is better
manual and then assume that training has been done • Your way will not work
regarding application or compliance with the new • I do not want to change
requirements. Managers must give their staff the tools • I am unable to do it because
to be able to comply with the requirements of the job. of institutional obstacles
• I do not want to do it
Remember that telling is not training. Just telling • I will not be supported if I do it
an employee they should "do it this way" is not
sufficient. Effective training includes four elements: The manager must determine why the employee is
1. Explanation not performing and address the reason immediately.
2. Demonstration This response involves three components:
3. Practice 1. Provide convincing information that the
4. Reinforcement and feedback organization's way is better than the
employee's way
If what you consider training does not include 2. Provide positive rewards for good performance
these four elements, the employee has not been 3. Provide negative consequences for
trained properly. nonperformance
Reason #3: They know what they are supposed to do, Knowing and using these four reasons for nonperfor-
but do not have the physical and/or mental capacity mance have helped me tremendously during my
to perform it. In other words, no matter how much military career and in cofounding and leading two
training you give them, they are unable to do the successful businesses. Whenever I have been confronted
job. This is often the most misdiagnosed reason for with nonperformance I ask myself, "Which of the four
nonperformance. Experts estimate that up to 80 reasons is the cause?" If it is reason #1 or #2, I provide
percent of the time supervisors are incorrect when training to fix the problem. If it is reason #3, it is best
they determine this is the reason for nonperformance. to let the employee go as soon as possible. We do not
do the employee or the organization any favors by
Therefore, if you are positive the employee knows keeping them in a job they are not capable of perform-
what they are supposed to do, and you are absolutely ing. If it is reason #4, and I am unable to change the
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Stephen W. Harden
LifeWings President
LifeWings Partners LLC was founded by a former U.S.
Navy Top Gun instructor and commercial airline pilot.
The firm specializes in applying aviation-based teamwork
training 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
“ Dr. Marla”
battles breast
cancer
By Marla Shapiro, MD
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I wasn't anxious. I knew that this was fairly routine. If the breast tissue is
dense, 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 and
became a patient. It was foreign territory for me, and now, having spent 14
months there, I have to admit the journey has not been easy. The biopsy
led to surgery that ultimately confirmed I was suffering from invasive
breast cancer.
In many ways, where Dr. Marla ended and just Marla began was poorly
defined. My profession was inextricably woven into the very fabric of who
I was – someone taught to be a clear thinker and problem solver whose
decisions are based on evidence, even if it's just the best that science can
offer at the moment.
However, this disease does not only affect women. The NBCF also notes
that approximately 1,700 men are diagnosed with breast cancer each year.
It will kill roughly 450 of them.
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Reference
breastcancer.org. Symptoms and diagnosis.
Available at: http://www.breastcancer.org/symptoms/.
Accessed August 21, 2007.
BEST day
Everyone has them, but often we do not take time to reflect and learn from whatever made the day
either the best or the worst we’ve encountered. Many lessons could be learned from taking a few
minutes to sift through details and analyze data so that we can choose to either replicate or
eliminate 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 about
your own best and worst days!
“
“When I interview people for nursing
jobs, I’m very clear that this is not a
place of joy and happiness all the
time. Now that I’m older and I have
some experience, I feel it’s an honor
to be there at the time of death. But it
takes a piece of you every time.
Usually, I’m more happy after work
than sad. I sometimes miss the lights
and sirens, but I wouldn’t trade my
worst day here for my best day at any
other job.”
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WORST day
“Ironically, the best day I ever spent in my eight years in hospital PR was also the worst. Our local
high school had a shooting this past spring and the victim was brought to the hospital. The entire
Communications Department, save me, was out of the office at a seminar three hours away. Being a
part-time writer, I had to step up and do interviews with national news agencies, over the phone with
NPR, etc., which was a huge learning experience. And we were the heroes, because our staff saved
this kid’s life (he was shot four times, three in the torso). But not soon after, his mom is in the paper
trashing the hospital for not covering his bills, etc. The good and the bad.
That’s working in a hospital for me.”
”
of a local businessman with lots
of money (bad).”
We want to hear
from you!
Please email stories about your
best and worst days at work
to smacinnes@medline.com.
We will share many of the
responses in future issues
of Healthy Skin!
Once the cake is cooled, take a knife and slice the cake into
two layers. Spread 1⁄3 of the whipped topping on the bottom
layer of cake. Top with a layer of strawberries and sprinkle with
the other berry options. Dab some additional whipped topping
on top of the berries and cap off with the top layer of the cake.
Spread the remaining whipped topping on top of the cake. Add
an additional layer of strawberries, then decorate with blueberries,
raspberries and blackberries. Cool in the refrigerator and serve.
To learn more about the complete line of Medline Seaspray Eggplant Khaki
scrubs, contact your Medline sales
representative or call 1-800-MEDLINE.
Table of Contents
Bates-Jensen Wound 90
Assessment Tool
Foley Catheter 95
Selection Guide
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!
General tips • Take the photo from the same angle each time.
• Digital photos are always preferred. It’s best to have the camera pointing perpendicular
• Grid or disposable camera shots are not to the wound instead of down from the top.
acceptable. • Taking all of the photos at the same time of the
• Need three completed case studies with a day will help with consistency in lighting.
beginning, middle and end photo. • Camera movement is the most common cause
of photo blurriness. Stand firm with your feet
Patient selection shoulder width apart and tuck your elbows tight
• Approach each resident as if their wounds will to your sides to prevent any shaking.
become a poster/case study. • Take a minimum of four shots at each visit per
• Get in the habit of using good photography wound site:
techniques every time to improve your photo > Location shot at four feet
outcomes. > Two-foot close-up – 90 percent person and
• Allow time to compose your shot and your patient. 10 percent background
> Two-foot with zoom – highlight tissue
Permission texture, drainage
Be sure to obtain a photo permit as required by your > Preview shots taken to ensure that pictures
agency or facility. are clear and visible
Background
Your objective is to showcase the wound on a solid
background. Drape the patient in a dark blue or black
cloth, which helps to absorb the flash and decrease the
reflection off the patient’s skin. Avoid white because it
will 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.
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RBCs contain hemoglobin, which allows the transport Below normal range
and exchange of oxygen and carbon dioxide to tissues. • Anemia
• Bone marrow failure
Below normal range • Cirrhosis
• Anemia • Dietary deficiency
• Lymphomas, leukemia • Hematalogic cancers
• Cirrhosis • Hemorrhage
• Dietary deficiency: iron, vitamin B12 • Prosthetic valves
• Fluid overload
• Hemorrhage Above normal range
• Normal pregnancy • Congenital heart disease
• Renal disease • Severe dehydration: severe diarrhea, burns
• Severe COPD
Above normal range
• Congenital heart disease Total protein
• Severe chronic obstructive pulmonary Normal value
disease (COPD) • 6 to 9 gm/dL
• Severe dehydration: severe diarrhea or burns
Protein is the building block of many body components,
White blood cells (WBC) including muscle, skin, hair, internal organs and blood.
Normal value
• 5.0 to 10.0 K/mm3 Below normal range
• Burns
WBCs fight infection and react against foreign bodies • Inflammatory diseases
or tissue. If the body makes poor or malformed cells, • Malnutrition
wound healing slows or halts and the wound might be • Protein-losing processes
left in a state of chronic inflammation. • Overhydration
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The longer a resident is kept on a catheter, the higher their risk of developing a
catheter-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 appropriate
catheter. Use your answers to the questions below to select the catheter that best
fits each resident’s needs.
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Each package is
a 2-Minute Course ™
in Advanced
Wound Care
Ta ke a lo o k
For 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.