Identifying Potential Skin Breakdown Areas

Identifying Potential Skin Breakdown Areas An Active Training Workshop Designed By: Catherine J. McNierney

Contents for Workshop Identifying Potential Skin Breakdown Areas Introduction Background Goal Pre-Workshop Survey Workshop Schedule Materials Needed for Workshop Outline i ii iii iv v vi-viii Workshop 1-11 Appendix Activity 0.1 Activity 0.2 A1 A2 Activity 1.1 A3-7 Activity 1.2 A8 Activity 1.3 A9-10 Activity 1.4 A11-15 Activity 1.5 A16-19 Activity 2.2 A20 23 Activity 3.1 A24 Activity 3.2 A25-30 Activity E.2 A31

Background Every year, pressure sores affect more than one million acute-care and long term care patients. The cost of pressure ulcer treatment is very high, ranging from 1.3 to 6.8 million dollars per year. Pressure ulcers are caused when there is a physical breakdown of the skin layers resulting from continuous pressure at certain points on the body. This breakdown is a result of decrease in blood flow and circulation caused by pressure on the affected area. Combine this with other physical maladies that many of these patients suffer from, and we have a recipe for skin breakdown. Proper documentation of the ulcers is the key to minimizing the cost to the facility along with decreasing the amount of treatment for the patient. The information, along with activities presented in this training will help learners more effectively identify potential skin breakdown areas. The active part of this training will help the participants: Explain a Skin Assessment Form Evaluate skin breakdown lab results Complete a Skin Assessment Form Identifying potential breakdown sites of skin must include a comprehensive look at the patient upon admission. Once these sites are identified, a treatment plan can be put into place.

Goal Given a patient with unidentified potential breakdown sites of skin, the participant will be able to evaluate to prevent further breakdown: Explain a skin assessment form Evaluate skin breakdown lab results Complete a skin assessment form

Identifying Potential Skin Breakdown Areas Workshop Participant Questionnaire In order to better ensure the Preventing Potential Skin Breakdown training will be effective, please take a few moments to respond to the following: 1) My current job position: 2) How many years at your current position? 3) List three major job responsibilities: 1) 2) 3) 4) I need to know more about locating pressure areas of skin. (no need) 1 2 3 4 5 (strong need) 5) I need to learn to evaluate lab values for potential of skin breakdown. (no need) 1 2 3 4 5 (strong need) 6) I need to know how to identify risk factors of skin breakdown. (no need) 1 2 3 4 5 (strong need) 7) How would you rate your current effectiveness as to identifying potential skin breakdown areas to prevent further skin breakdown? (not effective) 1 2 3 4 5 (very effective) 8) How important is it to you to enhance your current effectiveness as to identifying potential skin breakdown areas to prevent further skin breakdown? (not important) 1 2 3 4 5 (very important) 9) List three specific needs or interests that you hope this training will answer for you: a. b. c.

Workshop Schedule Begins @ 9:30 am Ends @ 4:30 pm Opening Exercises 9:00 am 60 min Explain a Skin Assessment Form 10:00 am 105 min 1. Locate Pressure Areas of Skin Breakdown Break 15 min 2. Identifying Skin Breakdown Risk Areas Lunch Break 11:20 75 min Evaluating Skin Breakdown Lab Results 12:35 pm 60 min Complete a Skin Assessment Form 1:35 pm 75 min 1. Assess Potential Skin Breakdown Risk Factors 2. Compile Data of Potential Skin Breakdown Areas Break 15 min 3. Identify Skin Breakdown Areas Review and Closing Activities 3:45 pm 45 min

Materials Needed for Workshop Flip Chart with markers White Board White Board Dry Erase Markers Paper Pencils Worksheets Table & Chairs

Outline Entire Workshop - 340 minutes (plus 75 minutes for lunch, 30 minutes for break) II. Opening Exercises (Duration 60 minutes) A. Introduction and Objectives 1. Introduction a. Activity 0.1 Learning Goal Exercise b. Discussion Group Introduction 2. Objectives: Content Introduction B. Assess the Audience 1. Instant Assessment a. Activity 0.2 Subgroup Discussion III. Building Blocks (Duration 105 minutes) A. Lecture 1 Explain Skin Assessment Record 1. Locate Potential Pressure Areas of Skin a. Activity 1.1 Demonstration Break (15 minutes) b. Activity 1.2 Group Processing c. Activity 1.3 Word Search

2. Contributing Factors to Skin Breakdown Areas a. Activity 1.4 Writing Task 3. Identifying Skin Breakdown Risk Factors a. Activity 1.5 Risks Under Pressure Game Lunch Break (75 minutes) IV. Middle Activities (Duration 60 minutes) A. Lecture II Evaluate Lab Results 1. Identify Skin Breakdown Lab Values a. Activity 2.1 Test Questions 2. Determine Abnormal Values a. Activity 2.2 Information Search V. Advanced Skills (Duration 75 minutes) A. Lecture III Complete Skin Assessment Record 1. Assess Potential Skin Breakdown Risk Factors a. Activity 3.1 Risk Factors Assessment Questionnaire 2. Compile Data of Potential Skin Breakdown Areas a. Activity 3.2 Case Study

Break (15 minutes) 3. Identifying Skin Breakdown Areas a. Activity 3.2 Action Learning Task Force Project VI. Ending Activities (Duration 45 minutes) A. Review Workshop Content 1. Review Potential Skin Breakdown areas a. Activity E.1 Group Processing B. Back-on-the-Job Application 1. Discussion a. Activity E.2 Action Plan

Training Evaluation Questionnaire Course Title: Date: 1. Circle the number that best represents your reaction to the program. a. I feel that I will be able to use what I learned. (never) 1 2 3 4 5 (often) b. The program was presented in an interesting manner. (never) 1 2 3 4 5 (often) c. The training facilities met my needs. (never) 1 2 3 4 5 (often) d. The program covered the stated objectives. (never) 1 2 3 4 5 (often) e. The trainer encouraged participation. (never) 1 2 3 4 5 (often) 2. What did you find most useful in the program? 3. Is there anything in this program that could be improved?

Workshop Entire Workshop 340 minutes (plus 75 min for lunch & 30 min total for breaks) I. Opening Exercises (Duration 60 minutes) Objective: Given an overview of the workshop content and completion of the planned opening exercises, the participant will be able to accurately state the content of the workshop and name the other participants at the workshop and some of their expectations of the training. Narrative: Participants follow the procedure of the Team Building Exercise : Participants are asked to get into groups of four. Each group will be given a Participants Learning Goals Worksheet. (Appendix 1) The participant will have 10 minutes to discuss what their learning goal is and write it down on the worksheet. A representative from the group will share each participant s goal and the worksheet is displayed on the wall. The trainer comments supportively on all goals as to relevance and practicality. These goals can and should be referred to the various stages in the program. A. Introduction and Objectives 1. Introduction a. Activity 0.1: Team Building Exercise (Learning Goals) Participants are asked to name a learning goal for the training. a. Discussion: Participants are given a chance to discuss what their learning goal is for the workshop. 2. Objectives Narrative: The overall goal of the workshop is as follows: Given a patient with unidentified potential breakdown sites of skin, the participant will be able to evaluate to prevent further breakdown. The objectives to reach the goal are as follows: To explain a Skin Assessment Form To evaluate skin breakdown lab results To complete a Skin Assessment Form

(The trainer will point to the objectives which will be projected on a flip chart.) The trainer, to build interest in the lecture, will tell the participants how they will spend their time at this training and what benefits they will receive through this training. After learning these procedures of identification, participants will be able to apply what they have learned to complete a Skin Assessment Form. If an identification of skin breakdown and risk factors are determined by the participant in an early stage, then there will be less time and expense needed for the patient. The participant may be more efficient and the patient will have a decrease in recovery time. This is a desirable affect for the Departments and the entire facility. (This workshop was created for a specific medical facility, therefore majority of the participants have already been introduced to one another. The Team Building Exercise was chosen as an introductory exercise to set the tone for the entire workshop. Creating a list of learning goals, the participants share their expectations of the workshop.) B. Assessment of the Audience: 1. Immediate Learning Involvement a. Activity 0.2 Subgroup Discussion An instant assessment of the audience s knowledge of the subject matter is conducted as follows: 1. The trainer will divide the participants into groups of 5. 2. Each group will receive a picture of a human figure. (Appendix 2) The participants will be asked to identify pressure points of potential skin breakdown and label them on the illustration. 3. After 15 minutes, one representative from each group will tell all participants their findings. The trainer will fill in answers unknown to the participants. (This assessment activity allows the trainer to become familiar with the participants and their level of knowledge about the subject matter. It requires the participants to be instantly engaged in the activity, identifying pressure points of potential skin breakdown. This activities level of threat is minimal because the participants work with patient s everyday and locate redden areas of skin.)

II. Building Blocks (Duration 105 minutes) Objective: Given assessment tools, location of pressure areas, and risk factors of a patient, the participant will be able to explain a Skin Assessment Form. A. Lecture I: Explain a Skin Assessment Form Narrative: The trainer will preview the Lecture I Explain a Skin Assessment Form content. The trainer will give highlights about what will be discussed in the upcoming lecture. At this point, the trainer will inform the participants that they will learn how to locate pressure areas of skin, determine the risk factors that lead to potential skin breakdown, and learn to identify lab values that may relate to potential skin breakdown. The trainer will discuss the need for an accurate identification in order to prevent further breakdown of skin. (Preview of the content is used to capture the interests of the participants and gives them an idea of what the content of the lecture will be. The participants will be given the reasons for the importance of correctly locating potential skin breakdown areas. Activity 1.1 will maximize understanding and retention by using visual backups and identification.) 1. Locate Pressure Areas of Skin a. Activity 1.1 Demonstration A Demonstration will be given on locating the pressure areas on skin that has the potential of breakdown. The activity will be presented as follows: 1. Each participant will receive a handout (Appendix 3) illustrating the 4 stages of wounds. The trainer will give a brief overview of the stages and the importance of identifying potential skin breakdown areas. 2. The trainer will then give out handouts on a patient lying in bed, lying on his/her side in bed, sitting upright in bed, and sitting in a wheelchair. (Appendix 4-7) The trainer will explain and give examples of skin breakdown areas on the human figure, and how to assess these locations on a patient in the four positions. 3. The participants will follow along with the trainer with the handout. The trainer will point to these locations on a diagram on a flip chart. 15 Minute Break

Narrative: The trainer leads a group discussion of the importance of identifying reddened areas and locating potential skin breakdown. b. Activity 1.2 Group Processing 1. The participants will be divided into 4 subgroups of 4-5. A handout of the questions will be given to each group. (Appendix 8) The group will have 10 minutes to discuss. The questions are: 1. What are the benefits of identifying a reddened area of potential skin breakdown? 2. What locations of potential skin breakdown that were presented in the lecture are new for you to consider? 2. A representative of each group will summarize their group s answers to present to the other participants. The trainer and the other participants will discuss the results. c. Activity 1.3 Word Search 1. The trainer will give each participant a Potential Skin Breakdown Areas Word Search. (Appendix 9) 2. The participants will have 10 minutes to complete the word search. Discussion of the answers with others participants will follow along with trainer for feedback. (Appendix 10) (These activities 1.2 and 1.3 are used to reinforce the lecture. At the end of these activities, participants will go away with examples that they can refer to when they have to identify skin potential area breakdown later in the workshop, and back on the job. This activity lays the foundation for the rest of the workshop) Narrative: The trainer will tell participants that this an activity to determine risk factors for potential skin breakdown areas. There are different factors that may place the patient at risk. (Contributing Factors to Skin Breakdown Answer Sheet, Appendix 15) The activity is as follows: 2. Identify Skin Breakdown Risk Areas A. Activity 1.4 Writing Task 1. The trainer will divide the participants into groups of four. Each group will receive one of the Contributing Factor of Skin Breakdown Worksheet. (Nutrition, Systemic Causes, Situational Problems, and Diagnosed Problems Appendix 11-14) 2. The participants will discuss and list on the worksheet the contributing factors. After 15 minutes, one representative will tell the rest of the participants their answers. The trainer will write the contributing factors on a flip chart. The participants as well as the trainer will fill in the additional information to make the list complete.

Narrative: The trainer will tell the participants that since we have identified potential skin breakdown areas and risk factors, the trainer will have the participants recall what they have learned. A game similar to the Family Feud Game and will be played as follows: 3. Recognize Skin Breakdown Risk Factors a. Activity 1.5 Risks under Pressure Game 1. The trainer will divide the participants in groups of two, and will sit facing each other in the room. The participants will be shown on a flipchart certain categories of risk factors. The list of risk factors underneath each category will be covered. The categories are: Nutrition, Systemic Causes, Situational Problems, and Diagnosed Problems. (Appendix 16 19) 2. The participants will take turns and name the risk factor. They will not be able to use the handouts given so far in the workshop, but will recall this information only by memory. If the participant names the risk factor correctly, then the answer is displayed to the group. The next participant from that team will try to name another risk factor. If not, then the other team gets to have a chance. 3. The team with the most answers wins. The trainer will tally the number of correct responses on the white board. 4. After the completion of the game, the trainer will give a handout that lists all the risk factors discussed in this activity. (Appendix 15) (The Activity 1.5 is used reinforce the lecture. This activity was chosen because it is a fast paced activity that keeps the interest of the participants. The participant will recall previous learning and accuracy can be assessed by the trainer.) 75 Minutes Lunch Break

III. Middle Activities (Duration 60 minutes) Objective: Given the assessment tools and the characteristics of normal and abnormal lab values, the participant will be able to evaluate lab results. Narrative: In this lesson, the trainer will address the concept of lab values that are related to skin breakdown. The participants will be given the name of the tests and corresponding normal range values. A. Lecture II: Evaluating Skin Breakdown Lab Results 1. Identify Skin Breakdown Lab Values a. Activity 2.1 Test Questions 1. The trainer will divide the participants into pairs. Each participant will be given a blank paper and pencil. 2. The participants will be given a question: List all the lab tests that would be related to skin breakdown? The pair will be given 15 minutes to gather their answers. 3. The pair s answers will be written on the sheet of paper and one representative will tell the other participants their findings. The trainer will write all the pair s findings on a flip chart. The trainer will add in additional information to complete the list. (This fast paced activity is chosen to get the participants back into the learning environment after the break. Group participation is encouraged in this activity, and is used to build upon the previous learning activities of the Building Blocks.) 2. Determine Abnormal Values a. Activity 2.2 Information Search 1. The Trainer divides the participants into four subgroups of 4-5. Each group will receive a Lab Values Related to Skin Breakdown Form (Appendix 20), Lab Values Related to Skin Breakdown Worksheet (Appendix 21), and List of Normal and Abnormal Lab Value Tests (Appendix 22). 2. After 20 minutes, the trainer will review the results by eliciting group participation. The trainer will use the Lab Values Worksheet Answer Key (Appendix 23)

(Instead of presenting the content in a traditional lecture format, the participants in activity 2.2 will search for the information to promote understanding and retention. Group participation is less threatening for this activity because the participants can learn from each other as well as from the trainer.) IV. Advanced Activities (Duration 75 minutes) Objective: Given the need to evaluate the potential skin breakdown areas of a patient, the participant will complete a Skin Assessment Form. A. Lecture III Complete a Skin Assessment Form Narrative: The trainer will provide an overview of Lecture II, and discuss the importance of evaluating lab values and how it relates to risk factors. The following activity will have the participants continue to assess the risk factors of patients 1. Assess Potential Skin Breakdown Risk Factors a. Activity 3.1 Risk Factors Assessment Questionnaire 1. The participants are given a Risk Factor Assessment Questionnaire (Appendix 24). They will have 5 minutes to complete the questionnaire. 2. The trainer will ask participants for their answers in a group discussion. Feedback from the trainer will also be given. Narrative: The participants will be asked fill out a Skin Assessment Form on a scenario of a patient. This will be done by using what was presented in the previous lecture along with materials given in the training. A case study will be given by the trainer. The trainer during the discussion of the activity will display on a flip chart a completed Skin Assessment Form. 2. Compile Data of Potential Skin Breakdown Areas a. Activity 3.2 Case Study 1. The trainer will divide the participants into groups or two and the pairs are given a case study about the patient that includes personal identification, lab results, and a physical description. (Case Study Worksheet Appendix 25) 2. The participants after reading the case study would fill out the Skin Assessment Form (Appendix 26-28), identifying on this form areas on the patient that can be a potential breakdown site, lab results, and list risk factors. The participants will be given 15 minutes to complete the form.

3. Group discussion among the participants and trainer on how to accurately complete this form and what data needs to be included will follow. The trainer will display the completed Skin Assessment Form on the flip chart. (Appendix 29 30) (These activities 3.1 and 3.2 offer participants an example of real-life situations and will show their understanding of the learning material given. The participant applies what they have learned in the previous lectures, and shows their understanding of the material given.) 15 Minute Break Narrative: The trainer will give the participants a task force project. This action learning activity will be used to practice and apply the skills learned to identify potential breakdown of skin of patients. 3. Identify Skin Breakdown Areas a. Activity 3.3 Action Learning - Task Force Project 1. The trainer will ask the participants for 3 volunteers. These participants will demonstrate to the rest of the group how to identify potential breakdowns of skin on a patient. 2. The participants will use an example of a patient that they previously encountered for this activity. This will include limitations and risk factors. They will have a large diagram of a human figure (front and back view). This group will have 5 minutes to think of an example. These selected participants will point out areas of potential breakdowns and identify them on the diagram, by placing an X. They will also list on the board what should be included in the Skin Assessment Form. 3. Group discussion of this action learning task will be open to the participants for discussion and feedback. The participants will be encouraged to give positive feedback on the proper identification on the patient. (This task force project gives the participants confidence in their ability to identify potential skin breakdown areas. These are the same abilities that are demonstrated back on the job.)

V. Ending Activities (Duration 45 minutes) Objective: Given completed, planned ending activities, the participant will be able to state the workshop content and acknowledge the ways in which they will apply identifying potential skin breakdown areas. Narrative: The Trainer will reinforce to the participants the importance of identification of potential skin breakdown areas. These encompass locating potential skin breakdown areas, contributing risk factors, and test values of a patient. The trainer will hold a final question-and-answer period for the participants to ask their concerns regarding the workshop content. A. Review Workshop Content 1. Review Potential Skin Breakdown Areas a. Activity e.1 Group Processing 1. The trainer will review workshop content for the participants. 2. The trainer will write the following on a flip chart: One thing that still concerns me is.. 3. Each participant will express their concerns to the other participants in the group. If a participant does not have a concerns go to the next participant. The trainer will address the concerns of the participant and elicit group discussion amongst the other participants. Narrative: The trainer will distribute an Action Plan Worksheet to each participant. Participants will be given 10 minutes to develop their action plan. The trainer will ask the participants to think of their training goal in the beginning of the workshop, and consider this goal when writing their action plan. These action plans will be used back on the job and will be reviewed by the participant within 30 days. B. Back-On-The Job-Application 1. Discussion a. Activity e.2 Action Plan Worksheet 1. The participants will be given an Action Plan Worksheet. (Appendix 31) 2. Working in pairs, the participants will develop their action plan for back on the job. 3. The trainer will ask if any participants wish to share their action plan with other group members. Positive feedback from the participants and the trainer will be given.

Narrative: The trainer will thank the participants for attending the workshop and will inform them that they can contact him/her at any time concerning the workshop s content. At this time, a short survey on the workshop will be given to the participants to be completed.. (The action plan exercise is an activity that the participants state their outcomes and the steps to achieving them as a result of the training program. Developing this action plan will be self motivating, and the participant will be committing to use their plan back on the job. Developing an action plan is a familiar tool for these participants. The participants are expected to develop and follow the treatment plans for their patients. Therefore, I believe that this exercise would be a good way to conclude this workshop.)

References Baranoski, Sharon, and Elizabeth A. Ayello. Wound Care Essentials. Philadelphia: Lippincott Williams & Wilkins, 2004. 240-70. Print. Beshara, Monica A., Carol Calianno, Margaret Davis, Roxanne Leisky, and Donna Scemons. Wound Care Made Incredibly Easy. 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007. 129-60. Print. Nurse. Clip Art, Microsoft Image. 20 July 2011. Nurse with Needle. Clip Art, Microsoft Image 8 July 2011. What Are the Different Stages of Wounds? 2011. Vitality Medical, Salt Lake City. Web. 20 July 2011. <http://www.vitalitymedical.com/info/what-are-the-different-stagesof-wounds/>.