September 2012 NIA WOCN

Transcription

1 Joyce Black, PhD, RN, DNP (Hon),CWCN, FAAN Associate Professor, University of Nebraska Medical Center } Causes of pressure ulcers Deep tissue injury etiology Friction out Microclimate in } Intertriginous Dermatitis } Deep Tissue Injury Pathophysiology } Biofilms Silver Resistance? } Pressure Perpendicular force in excess of capillary flow to tissues, hypoxia develops and tissue dies } Shear Pull and stretch blood vessels as tangential force is applied to tissue, tissue becomes hypoxic Friction is no longer seen as an etiology No pressure component Heat builds up and leads to blistering 1

2 } Pressure on muscle cell disrupts the cell membrane (Gefen, ) Loss of function Cell death } Historically, part of the extrinsic factors Measured by Braden Moisture Subscale } Known association with incontinence Moist skin does not tolerate sliding, the tackiness of the skin increases risk of wounds Skin with severe IAD does not glide on bed linens } Sweat gland found in dermis } Controlled by nerve from sympathetic nervous system (fight or flight) } Body temperature regulation } Profuse sweating leads to water and sodium loss 2

3 } 100 mg Hg indenter warmed to 25, 35, 40 and 45 degrees and applied to skin 25 degrees = no skin or muscle damage 35 degrees = moderate muscle damage 40 degrees = skin necrosis and muscle damage 45 degrees = full skin necrosis, deep tissue damage? Burns at 45 degrees Kokate, 1995 } Skin temperature and humidity at the interface between skin and the surface Relatively ignored until recently } As temperature of skin rises, the metabolic needs of the skin for oxygen and glucose rises 10% increased need for each 1 degree These substrates cannot be delivered if the skin is under pressure Dressing Injury Candidiasis Stool on the skin IAD Deep tissue injury Zinc oxide 3

4 Heat and humidity accumulate between the skin and the surface Low air loss cannot cool those areas unless the patient turns If LAL could control microclimate, we would have air hockey } Sweat produced to cool the body Obese patients Febrile (fever) patients } Sweat produced due to stress on the sympathetic nervous system Low Blood Pressures (shock states) Myocardial Infarction (heart attack) Shortness of breath/breathlessness Head injury/brain bleeds } Sweat produced due to lack of control Neurological disease Spinal cord injury Stroke 4

5 } Or is the damage from moisture? Presumption was that skin folds would grown Candida Literature suggests that skin fold can also contain Pseudomonas Staphyloccus 5

6 } Patients with skin folds seen on admission } History included conditions that could impair skin and increase infection } Cultures taken of skin folds before use of InterDry Axilla: Proteus mirablilis Enterococcus faecalis Staphlococcus coag neg Candida albicans VRE Pannus: Staphyoloccus coag neg Proteus mirabilis Enterococcus faecalis Candida albicans Escherichia coli Breast: Proteus mirabilis Staphyoloccus coag neg Diphtheroids Groin: Staphyoloccus coag neg Candida albicans Diptheroids Proteus mirablis Enterococcus faecalis Knee: Proteus mirablilis Staphylococcus coag neg } Incisions placed through skin folds? } Bathing of skin folds and contamination of surgical sites? Bath basins heavily contaminated } Pretreatment of surgical sites? Really unable to clean patients in preop Unable to use chlorhexidine on open skin 6

7 } Koziak s model shows ulcers developing in 2 hours at 600 mmhg pressure } And ulcers developing after 10 hours at 200 mg Hg pressure } Are these ulcers different? } Starts with 3 hours of ischemia Irreversible after 6 hours } Elevations in CPK Variant of rhabdomyolysis } Model of DTI development created from a real patient who was unconscious on a cell phone for 3 days } The simulated DTI appeared in muscle tissue in proximity to the bone after approximately 1.5 h, and within less than 10 additional minutes it reached the muscle fat boundary. Linder-Ganz,

8 } An event of confinement always preceded the first notation of purple skin by 48 hours } Within 48 hours of the identification of purple skin, blisters were noted from epidermal sloughing Thin blisters, not fluid filled Often called Stage II pressure ulcers Black, Berke, 2005 } Area sustaining highest pressures is infarcted } Surrounded by rings of ischemic and injured tissue that is rescuable } } Pressure creates the injury } Shear extends it to other tissue Undermining Extension 8

9 } Initial purple area became progressively larger until entire buttock ulcerated } Probably most chronic wounds } Wounds with slough or eschar Slough is dried drainage Eschar is dead tissue } Heavily draining wounds Biofilm promotes inflammation Inflammation produces drainage 9

10 } Mechanical or sharp debridement } Antiseptic dressings Silver dressings Silver does not always penetrate thick slough Bacterial resistance appears to not be possible Iodine Honey } Not a good idea to pack with long term plan gauze dressings Deep Tissue Injury Diagnosis and Treatment Dressings as a Prevention Medical Device Ulcers OR Pressure Ulcers Microclimate Management Reducing Injury with Turning and Repositioning } Retrospective review of 82 cases of pressure ulcers that began as purple areas following a period of immobility } Cases were litigants Sample bias is recognized } Demographics Mean age 70 (range 24-98) Gender 52% male Ethnicity (42% Caucasian, 21% Black) Emergent admission 70% 10

11 Deep tissue injury evolution Thin blisters as epidermis sloughs Often develops eschar 11

12 } Location Occur on tissue subjected to pressure not always bony prominences } Timing Color change is delayed sometimes after pressure is relieved } Color Purple or maroon, not red } Rate of deterioration Rapid, becoming full thickness quickly } History of trauma } Fractured pelvis with pelvic hematoma } May lead to purple skin and epidermal slough } Morel-Lavallee lesions (internal degloving injury) with pelvic trauma This patient had a history of fall at high rate of speed onto concrete. } Bruising with a history of trauma } Often anticoagulated } Can be difficult to distinguish from deep tissue injury in the same area } Consider Morel- Lavallee lesions 12

13 } Bruising with a history of trauma } Can be difficult to distinguish from deep tissue injury in the same area } Consider Morel- Lavallee lesions } Rapidly progressive infection Staphylococcus Streptococcus Occ, anaerobes, spores } Purple on edge } Usually not a pressure area } Patient is septic } Rapidly developing ulcer appearing about 48 hours prior to death } Etiology unknown Low perfusion during which the skin cannot recover from usual pressures? Skin infarction? Variant of DTI? 13

14 } Seen with prolonged hypotension and Levophed/ Dopamine use } Peripheral tissue only, not subjected to pressure } Patients with poor perfusion may develop purple skin in dependent tissues } Purple color changes with motion Demarcated tissue of flap used to cover DTI was is cold Patient had multiple infections Contribute to ischemia? 14

15 Outside to Inside with Low Pressure (Classic) Stage I Fluid-filled blisters Stage II Inside to Outside with High Pressure DTI Stage II with epidermal loss Unstageable with eschar or blister Stage III or IV 15

16 } Relieve pressure completely from areas likely to have DTI Side to side turning Support surfaces Heels in boots } Relieve pressure from all purple skin } Building evidence for MIST therapy Honaker, 2011 } No evidence today to support: Early debridement HBO Group Comparisons DEMOGRAPHICS CONTROL GROUP TREATMENT GROUP NO. OF PATIENTS IN STUDY GENDER RATIO MALE 48% 42% AVERAGE AGE 69 YRS 75 YRS AVG. LENGTH OF STAY 19 DAYS 21 DAYS DIABETES 48% 60% ESRD 26% 28% CHF 24% 19% COPD 26% 16% PVD 17% 33% HTN 71% 79% ANEMIA 83% 88% SMOKER 43% 28% } Retrospective chart review; March 09 - March sdti s 63 were treated with SoC only 64 with SoC and MIST } Inclusion consisted of patients identified with sdti with in 4-5 days of onset. All patient received standard of care Treatment group received MIST and standard of care Honaker,

17 SECONDARY CONDITIONS Low albumin/prealbumin CONTROL GROUP TREATMENT GROUP 67% 70% Fecal Incontinence 67% 74% Urinary Incontinence 26% 28% End of Life/Palliative care Operating Room time > 3.5 hr 45% 33% 5% 5% Vasopressors 36% 35% Vent Support 50% 44% } Wound Color/Tissue Assessment 1 = Pink/Normal skin tone 2 = Red wound bed dermal layer exposure 3 = Maroon Nonblanchable 4 = Purple Nonblanchable 5 = Subcutaneous tissue exposure, but no bone, muscle, or tendon exposure 6 = Black/Grey/Yellow/Brown Necrotic Tissue 7 = Bone, muscle, and/or tendon exposure } Total Surface area Size 1 = 1 cm 2 2 = 1.1cm 2 5cm 2 3 = 5.1cm 2 10cm 2 4 = 10.1cm 2 15cm 2 5 = 15.1cm 2 20cm 2 6 = 20.1 cm 2 35 cm 2 7 = 35.1 cm 2 50 cm 2 8 = 50.1cm 2 } Skin Integrity 1 = Intact 2 = Blister/Bulla formation 3 = Epidermis broken Scores can range from 3 to 18 } Control Group Mean sdti Score Time 1 = 9.62 Final score for Time 2 = Difference = 1.06 } Treatment Group Mean sdti Score Time 1 = 9 Final score for Time 2 = 7.55 Difference = 1.45 } Significant Difference = p <.000 (T = 5.67) 17

18 } Scott Triggers (Suzie Scott-Williams, 2011) ASA score 3 or higher Age over 62 Albumin less than 2.5 } Add in length of time planned for surgery over 3 hours (NPUAP, 2009) } Evaluate OR table cover If 2 elastic foam with cover may not be adequate Replace with 3-4 inches of visco-elastic foam } Consensus Group Examined Literature on Dressings to Reduce Pressure, Shear and Friction } Group members from EU, US and Australia } Examined bench data from Evan Call lab on dressings reducing pressure by dispersing it shear by absorbing it into layers of dressing friction by slick outer surface microclimate by absorbing sweat } Brindle: PrU rate lower in OR (2012) Brindle: PrU rate lower in ICU (2010) Chaiken: PrU rate fell from in ICU (2012) Cherry: ICU rate fell to 0 (2012) September

19 } Choose or make a dressing larger than body area at risk allows pressure and shear forces to be deflected into tissue outside the area of risk } Multiple dressings may be needed September } Dressing shown to reduce pressure in immobile patients in OR } Time to develop OR ulcers is generally greater than 3 hours September } Shear injury when HOB elevated can be reduced with layered dressing } Sacral DTI with HOB up September

20 } Heels at high risk for pressure Immobile legs, neuropathy, arterial disease September } Heel at risk for shear injury Shear forces tear layers of skin/tissue Leads to blisters } Shear forces best prevented by layered dressings September } Comparisons of every 2 and 4 hours done in Belgium Elders on visco-elastic foam mattresses with intact skin and nonblanchable erythema (stage I pressure ulcers) assigned to turning groups Experimental group (N=122) 2 hours in lateral positions 4 hours in supine positions Control group (N=113) Repositioned every 4 hours Outcomes Pressure ulcers in experimental group=16.4% (stage II, III, IV) Pressure ulcers in control group=21.2% (stage II, III, IV) Different not statistically significant } Are these outcomes adequate to change practice? Vanderwee K, et al. J Adv Nurs. 2008;57(1):

21 } Back injury very common in healthcare workers 1/3 of back injuries are due to moving patients Nurses aides, orderlies and attendants are number 2 in the top 10 occupations for back injury In 2009, there were 25,160 on-the-job injuries 60% required 5 days off; 12% required 8 days off Nurses use 30% more sick leave annually due to back pain } The cost of on-the-job musculoskeletal injury is high $20 billion on worker s compensation $100 billion on indirect costs American Nursing Association. / Background.aspx. Accessed May 15. Bureau of Labor and Statistics. / archives/osh2_ pdf. Accessed May 15. Bureau of Labor and Statistics. release/archives/osh2_ pdf. Accessed May 15. Occupational Safety and Health Administration. Accessed May 16. } If turning takes 5 minutes per turn x 12 turns per day =1 hr In acute care, RN=$38 per day per patient In a 200 bed hospital, turning half the patients=$3800 for salary if alone How many patients can be turned alone? How many patients can be turned in 5 minutes? } Considered a pressure ulcer } If cartilage is visible or palpable } Stage IV } Mucous membrane ulcers are not staged 21

22 } General care items Bedpans Foley tubing NG tubes Bed trash Suture } Bedpans left under patients can create intense pressure Fatal wounds } Strap injury from boots } Injury to other leg when patient on his side } Nerve/tendon injury when leg not maintained in neutral alignment Prevents leg rotation 22

23 } Elastic devices can impair blood flow to the legs TED sores? Ulcers on shin, toes, calf } Must be removed daily to inspect the skin } Fit the device to the patient Measure TEDs Use proper sized boots } Be aware of edema } Devices can be lost in bariatric patient skin folds } Remove or move device on each shift } Examine skin beneath device and do not replace device back onto injured tissues Move ET tubes Do not tighten O2 cannulas Secure to face Move pulse oximetry probes Splint NG tubes Remove TEDs BID } Return devices that are defective!! 23

24 } Litigation risk Increasing numbers of cases Never event setting the stage for plaintiffs Skin failure and skin changes at life s end helping the defense } Reducing your risk --- nothing new here Skin assessment on admission with proper classification of wounds found Accurate risk assessment with linked interventions Assignment of upscaled beds or turning Documentation A sloth in the wound? 3 toed? } Check the credentials of providers } Be aware of a tendency to debride every wound Often with a curette and topical Lidocaine No bleeding from wound No removal of necrotic tissue, in that healing is not promote } CMS aware of rising charges for débridements Some states limiting coverage 24

25 } Call for podium presentations on DTI Do you have data? Your participation in advancing the science and practice remains important for quality patient outcomes 25