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Skin integrity and Wound Care
- 1. Skin Integrity and Wound Care 103A
- 2. Pressure Ulcers Localized injury to skin and underlying tissue, usually over a bony prominence. Often results from pressure in combination with shear and/or friction. May be caused by devices such as oxygen equipment, orthopedic devices, straps or tubing, as well as pressure from beds or chairs.
- 4. Risk Factors for Pressure Ulcer Development Impaired sensory Shear perception/ Alterations in LOC Impaired mobility Nutrition and Hydration Friction Moisture
- 6. Stage II Partial-thickness Skin Loss or Blister
- 7. Stage III Full-thickness Skin Loss (Fat Visible)
- 8. Stage IV Full-Thickness Tissue Loss (Muscle/Bone Visible)
- 9. Suspected Deep- Tissue Injury Depth unknown.
- 10. Unstageable Full-thickness Skin or Tissue Loss-Depth Unknown
- 11. PAIN Theassessment of pain and management of pain must be included in plan of care Provide analgesic 30 minutes prior to wound care Consider nonpharmacological interventions
- 12. Nursing Knowledge Base Prediction and prevention of pressure ulcers Norton Scale Physical and mental condition, activity, mobility, and continence Braden Scale Sensory perception, moisture, activity, mobility, nutrition, and friction and shear
- 13. Assessment Skin Presence of ulcers Mobility Nutrition and fluid status Pain Existing wounds, appearance, character Wound culture
- 14. Nursing Diagnosis and Planning Impaired Skin Integrity Risk for Infection Impaired Nutrition: less than body requirements Acute or Chronic Pain Impaired Physical Mobility Ineffective Tissue Perfusion Impaired Tissue Integrity Disturbed Body Image
- 15. Implementation Health promotion Topical skin care Protect bony prominences, skin barriers for incontinence. Positioning Turn every 1 to 2 hours as indicated. Support surfaces Decrease the amount of pressure exerted over bony prominences.
- 16. Implementation Nutrition and Hydration Appropriate Wound Treatments Pain Management Education of Patient and Caregivers Psychosocial Aspects
- 17. Summary Nursing interventions for reducing and treating pressure ulcers need to be evaluated to determine if the client has met the identified outcomes or goals. Take a Holistic, Multidisciplinary Approach. Do a Thorough Assessment…more than once. Develop an Individualized Care Plan. Put Interventions into Place Without Delay. Commit to Care.
Notas del editor
- As a geriatric nurse, I have seen many instances whereby patients have had skin integrity disturbances. You don’t work in the field of long-term care for very long without realizing that the potential for skin breakdown is great. We’re going to talk about Pressure Ulcers, specifically, in these slides because it’s such a huge problem. Each year more than 2.5 million people in the US develop pressure ulcers. The treatment of pressure ulcers can be as much as $75,000 per occurrence . There are multiple reasons to be concerned with pressure ulcer prevention. Some of us have seen first hand how devastating pressure ulcers can be to the patient who suffers from pain, inconvenience, financial costs, extended hospital stays, infection and even, perhaps, death. We are also aware of the cost to the hospital in personnel and financial resources, time and money spent on treatments and healing efforts, quality of care concerns, negative publicity, and costs associated with litigation. Additionally, changes in reimbursement bring the threat of negative financial impact which can be a substantial loss of revenue. So we can see that the prevention of pressure ulcers and/or the decrease in incidence is vital work on many fronts. And what I want you to walk away with today is the knowledge that you have a huge role to play in the prevention and treatment of pressure ulcers.
- Pressure ulcers are considered to be either avoidable or unavoidable . The National Pressure Ulcer Advisory Panel takes the position that most, but not all, pressure ulcers are avoidable. But MOST are avoidable. A pressure ulcer (correct term ) but may also be known as decubitus ulcer or bed sore is a localized injury to the skin and underlying tissue, usually over a bony prominence. What is a bony prominence ? (Where bones protrude slightly below the skin). What are areas of bony prominence ? (skull, ears, shoulder, scapulae, elbows, sacrum, coccyx, trochanter (femur), knees, ankles, heels). It results from pressure in combination with shear and/or friction . Pressure is the major contributor to pressure ulcers. Not just caused by beds or chairs, but also caused by oxygen equipment, orthopedic devices (boots), straps or tubing. If pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia (decrease in blood supply) occurs. If left untreated, tissue death results.
- What I want you to realize is that pressure ulcers don’t just occur in bed (which is why the term bed sore is inaccurate) . They can just as easily occur when a patient spends extended periods of time in chairs such as wheelchairs . (I have difficulty with patients spending all day in a wheelchair. WC’s are transportation devices, not chairs. They can easily contribute to the formation of pressure ulcers.) Discuss “ weight shifting .” Discuss common sites/bony prominences shown on picture .
- These six factors contribute to pressure ulcer formation. Clients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations. So, a patient who can’t feel or sense pain or pressure is at risk for the development of pressure ulcers ( nerve damage, comatose ). Clients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves ( dementia , expressive aphasia, coma ). Clients who are unable to independently change positions (impaired mobility) are at risk because they cannot change or shift off of bony prominences ( stroke, spinal cord injuries ). Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface (such as bed linens). Shear is the force exerted parallel to skin resulting from both gravity pushing down on the body and resistance (friction) between the client and a surface. This often occurs when the HOB is elevated and the sliding of the skeleton starts but the skin is fixed to the bed. Also occurs with transfers when skin adheres to bed. Nutrition : It is not possible to heal pressure ulcers without an adequate supply of calories and protein . Healing requires the assimilation of protein as well as energy found in calories. Often, when a patient develops a PU or is at risk to develop one, we involve our dietitian s or nutritionists in treatment. Wound screening can identify individuals who are malnourished or at risk for malnutrition. One blood test which will be done is to check albumin (spell) levels. Decreased levels negatively impact wound healing. Vitamins and minerals are also used in wound healing , although there is some controversy as to their effectiveness and dosage levels. Often Zinc is ordered because cellular proliferation requires adequate zinc amounts (15-30 mg/day). However, the data on this is not well documented for effectiveness and large doses can be toxic. You will also see Vitamin C ordered because Vit C is an essential component of healing 100-1000 mg/day). The data is a little more clear here for effectiveness. Extra protein will often be ordered in the form of drinks (healthshakes, Carnation instant) or powders (1-1.5 g/kg/day) Calories: 35-40 kcal/kg/day because protein is needed to support wound healing. Adequate hydration is also important so that there is an essential fluid environment for cell function (30-35 ml/kg/day) Water is best 6-8 glasses day unless contraindicated. The presence and duration of moisture on the skin reduces the skin’s resistance to other physical factors. Prolonged moisture softens skin, making it more susceptible to damage . What are type of moisture ? (urine, feces, wound drainage, perspiration). It is important to reduce exposure to body fluids and when exposure occurs you need to provide meticulous hygiene and wound care . Barrier creams and lotions are often effective, but only when used on clean, dry skin.
- The National Pressure Ulcer Advisory Panel (NPUP) has defined pressure ulcers. Stage I: Skin is intact with non-blanchable redness. This means that when you press on the site, the area does not blanch (turn white). Area may be warm, hard or have edema. May be difficult to detect in individuals with dark skin tones. This is a precursor to skin which, if you do nothing, will likely open. What’s the first thing you do when you discover a Stage I pressure ulcer ? (Reposition off it.)
- Stage II: Partial-thickness skin loss or blister. Presents as a shallow ulcer which is open. The wound bed is red or pink without slough (stringy, dead tissue). May also present as intact blister. Be careful not to confuse this stage with skin tears, tape burns, dermatitis, maceration or excoriation. If there is necrotic tissue or slough (yellow contamination) or the blister is blood filled, it is not a Stage II.
- Stage III : Full-thickness Skin Loss (Fat Visible). Bone, tendon or muscle is not exposed. Can have undermining (a “cave” around the wound edges) or tunneling (tunnel of separated tissue). Now, it’s getting serious.
- Stage IV : Full-thickness tissue loss (muscle and bone visible). Exposed bone, tendon and muscle. Often includes undermining and tunneling. Slough or eschar (dead tissue) may be present. Extremely serious. Osteomyelitis (infection of the bone) possible.
- Suspected Deep-Tissue Injury-Depth unknown: Purple or maroon localized area of discolored intact skin or blood filled blister caused by damage of underlying soft tissue from pressure and/or shear. May be painful, firm, mushy, boggy, warmer or cooler than surrounding skin. Difficult to detect in those with dark skin tones. Evolution may be rapid and likely to deteriorate to Stage III or Stage IV ulcer.
- Unstageable : Base of the wound cannot be visualized and the stage is unknown. Actual ulcer is completely obscured by slough and/or eschar of wound bed. Until slough and/or eschar are removed to expose base of wound depth cannot be determined and stage cannot be known.
- Never believe that severe pressure ulcers aren’t painfu l. They can be extremely painful and we need to assist the patient to manage that pain. The assessment of pain and management of pain must be included in every plan of care for a pressure ulcer . Ask the patient to describe the pain . When does it occur? What makes it better or worse ? Always provide an analgesic 30 minutes prior to a dressing change if the patient finds the experience to be painful. Consider nonpharmacological interventions such as relaxation techniques, repositioning, distraction, conversation, heat and cold, accupuncture. Pain can lead to anxiety, depression and the patient’s unwillingness to cooperate with treatment. Pain should be assessed and reassessed at regular intervals.
- When a client develops a pressure ulcer, he suffers from pain, inconvenience, financial costs, extended hospital stays, infection, and, even, perhaps, death (Christopher Reeve). Also cost to the hospital in personnel and financial resources, time and money spent on treatments and healing, quality of care concerns, negative publicity and litigation. Pressure ulcers, especially in the elderly are so much easier to prevent than to heal . Prevention is key and there are several tools available to help you predict a patient’s risk for obtaining a pressure ulcer. The Norton Scale is one such tool . It was the first pressure ulcer scoring system to be created and it was developed in England in 1962 by Doreen Norton , especially for use with elderly patients. The patient’s physical and mental status, activity, mobility and continence are assessed and numbers are assigned from 1-4. Scores of 14 or less rate the patient at risk for development of a pressure ulcer. Today, the Norton scale has come under some criticism for being lacking in research and evidence-based practice . P The Braden Scale (page 1185 8 th ed of P & P and hand out ) was a tool developed in 1987 by Barbara Braden and Nancy Bergstrom . It uses the categories of sensory perception, moisture, activity, nutrition, and friction and shear and also assigns a number value of 1-4 for each category. In the Braden scale, a score of 12 or less represents a high risk to develop a pressure ulcer. You’ll also see a lot of hybrid scales in facilities which are a mix of the Norton and/or Braden scale or a scale someone made up. But, you should use an evidence-based scale such as the Braden scale for the sake of accuracy and consistency. Pressure Ulcer risk assessments are generally done with any patient in the hospital, rehabilitation or long-term care setting within 24 hours of admission . The sooner the better. Please be aware, however, that completing the scale is only the first step in the process . If the patient is at high risk for the development of pressure ulcers, or already has a pressure ulcer, putting appropriate interventions in place immediately is key. Get that air mattress and gel cushion . Put in a dietitian consult. Prop those heels up pillows . Don’t wait for the wound care nurse to make her rounds tomorrow. You do something today! Prevention is key. And remember that assessments are ongoing, not just once and done. So much easier to prevent than to heal ! Prevention includes special beds and mattresses, chair cushions, pillows and positioning devices, good hygiene, good nutrition, adequate hydration, and impeccable nursing care . Keep skin dry (impeccable peri care ), keep patient mobile ( or turn and position, including in chairs ), you must have adequate calories and protein, hydration. Constant vigilance in skin inspection. Prophylactic interventions (don’t wait til you have a problem to act.)
- Baseline assessments as well as continual assessments all provide valuable data that will indicate skin integrity as well as any risks for pressure ulcer development. Vigilance is the key. Observe pressure points, which include bony prominences. Check devices which may cause pressure such as oxygen tubing, drainage tubes, straps. When you find reddened areas, gently press the area with a gloved finger to assess the ability of the tissue to blanch. If the area does not blanch, suspect tissue injury. Check perineal area for reddened, irritated skin. Check sites of previous skin breakdown. Areas of previous skin breakdown do not heal to the same strength as intact noninjured skin (which is why skin breaks down at the same site again and again). Determine if potential or actual breakdown is present and institute prevention and treatment strategies. Record findings. Excellent documentation is also key. Communicate to your team. Think outside the box.
- Use NANDA approved diagnoses . Write client goals and outcomes personalized to that patient.
- ( Read Topical Skin Care and Positioning ). Support surfaces include mattresses, integrated bed systems, mattress replacement, overlay or cushions. Also utilize pillows to “float” heels (boots can cause breakdown).
- We’ve talked about the essential role adequate nutrition and hydration play in the healing of wounds as well as the importance of pain management. There are many, many types of dressings available . Selection depends on the type of wound, the amount of drainage, where the wound is located, , the phase of wound healing and the presence of infection. There are also treatments available such as hyperbaric oxygeniation whereby the patient breathes oxygen at a high pressure. This provides oxygen to stimulate and support wound healing . Electrical stimulation is a treatment whereby low electric currents are applied to wounds to promote healing. Debridement of the wound may be necessary and can be sharp (scalpel) or chemical (ointments, creams). Don’t forget to involve the patient and the family in the plan of care . A variety of educational tools (booklets, DVD’s) are available to you. Answer questions to avoid anxiety, fear and depression. Wound care is multidisciplinary , and that means involving the patient and family as well as the physician, physical therapist, dietitian, direct care givers. Remember the psychosocial aspects of wound care. Pressure ulcers negatively affect quality of life and activities of daily living . Odors from wounds can be offensive and people fear social rejection so they avoid other people. Quality of sleep can be affected because of pain or inability to reposition in order to get comfortable. Pain makes people feel depressed and anxious . Individuals suffering from wounds often have a decreased ability to care for themselves, or they lack the physical energy to do so . Frequent dressing changes can impact one’s ability to work, and treatments are expensive and time consuming. Wounds may impact the individual’s ability to be provide care for the family , so negatively affect their sense of the role they wish to play. Do you see why we say prevent rather than treat? Never underestimate the psychosocial aspect of pressure ulcers.
- ( Read Nursing Interventions ). You will want to take a holistic approach to wound management. “Treat the whole patient, not just the hole in the patient,” (Diane Krasner). You will want to work with the dietician, wound care nurse, physician and pharmacist to ensure all client needs are met. Involve the patient and family. Client education is a must. An individualized plan of care must be developed for each client, taking into account age, nutrition, present medical conditions, and other contributing factors. Remember to assess for the presence of pain. Use a proven scale such as the Braden scale to do a thorough assessment and document well. Continually assess. Put interventions in place without delay. Prevent rather than treat. The human touch…reaching out to patients, families and caregivers..builds the trust and confidence that heals wounds, patients and lives .
- Thank you for allowing me to teach you today. I hope that you’ll take to heart the things we’ve spoken about and realize that you play such an important role in the quality of life for your patients with skin disorders. Questions/comments? 6/18/12/JB