Healing Factors and Aging Skin. Challenges In Wound Care NPUAP. Case #1 Clinical. Case #1

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1 Healing Factors and Aging Skin Catherine A. Eager BSN, RN,BC, ET/WOCN, CWS March 2014 Disclosure of relevant financial relationships; Catherine Eager has disclosed that she has no relevant financial relationships with any commercial interests related to this presentation. Challenges In Wound Care Lack of knowledge of NPUAP Staging Difficulty identifying Full v. Partial thickness wounds Understanding Deep Tissue Injury, and unstageable ulcers Utilizing proper Cleansing Absence of Care plans that meet AHRQ Guidelines Absence of a complete documentation tool that covers all wound elements Lack of a system that tracks healing and deterioration using measurable graphs or numbers Communicating end of life and reasons for failure to heal with patients and family NPUAP National Pressure Ulcer Advisory Panel Agency that offers information and teaching tools related to pressure ulcers deline2006.pdf Case #1 Admitted to NH from Hospital 3/18 following MS crisis. By 3/25 areas on buttocks were black (7 days) Initial skin report from hospital, four Stage II ulcers. The NH nurses state: The decubes are stage II because of the slough, so the ulcers can not be staged higher. Resident has limited mobility and activity and is on a turning schedule. Noncompliant with turning. (Need for turning explained). Up in W/C most of day Case #1 Clinical Hgb 9.9 (receives supplement) Protein 5.9 Foley catheter, has frequent UTI Albumin 3.0 (3/18), 2.3 (3/25) Ulcers described as red and black slough no measurements. Admit wt (3/18), 161.2(3/25) Resident readmitted to the hospital with sepsis, deep sacral ulcer down to thigh, Stage IV ankle, Stage III buttocks 1

2 Case #2 Elderly Black Male, 86 years of age 2PPD for 70 years (smoking history) Has lost 25 to 30 lbs in the last few months Neuropathy of lower extremities r/t diabetes Severe peripheral vascular disease and Atherosclerosis of both lower extremities Anemia (H/H 7.0/21.6, Alb. 2.1, Pre-Alb 9.6) Body Mass Index 18 Bone infection Rt. Foot, Type II Diabetes, (BS ) Elevated Creatinine and HTN Hospital Admission Activity Case #2 Admitted Hospital from home 8/21 for fem/pop by-pass 8/21 Arteriography 8/24 Surgery for LE Shunt/Bypass (4.5 hrs) Post-Op immobile 4.0 hrs. 8/24 Received Packed RBC s 8/27 2 nd Surgery, amputation distal Rt. Foot (2.5 hrs) 8/30 Discharge to NH Case Study #2 NH admit, difficulty with walking, transfers, stairs, sitting and turning self, confusion Ht. 5 11, weight 131 lbs. Appetite poor, history of 1 pint of alcohol daily. Maximum eaten 25% Frequently incontinent of urine. Is not aware of his incontinence. Frequent UTI s Bruised area over coccyx and sacrum (18cm) In 7 days area dark and mushy (no measurements) In 14 days area is black with eschar Case #2 Four weeks later, a colostomy was performed MRSA was diagnosed in the urine A feeding tube was placed after additional 25 lbs of weight loss. Pt. wt was 105 (10/30) Extreme confusion and aspiration episode r/t NG tube (11/13) Hospital Re-admission Died 12/5 (3 ½ months after elective surgery ) Agency for Healthcare Research and Quality Pressure Ulcer Costs Pressure Ulcer Cases in ,000 Pressure Ulcer Cases in ,000 Pressure Ulcer Cases in 2009 one million Pressure Ulcer Cases by million Chronic Wounds are a symptom not a disease Hospital Charges for treatment of a Stage III Pressure Ulcer Average - $37,800 Total cost to closure can be as high as $100,000 An estimated 8 million people suffer from chronic wounds Krasner & Kane, Chronic Wound Care 2007 AHRQ

3 Skin & Body Oils Skin Barrier Skin has a two-way barrier function (body oils & ph) A loss of the skin ph results in loss of water to the external environment Loss of skin ph increases risk of contamination from external substances and organisms Products such as trypsin and Triclosan, Alcohol based cleansers disrupt the biochemical balance of the skin Skin Changes in the Elderly Sebum secretion decreases Regeneration prolonged Inflammatory response slow Anchoring disappears Collagen decreases Base temperature lowers ( ) Functional Losses with Aging Skin Barrier weakens Lack of immunologic response Poor inflammatory response slows healing Thermoregulation is poor Reduced oils lead to cracking and fissures Reduced Vitamin D production Changes in Elderly Skin Dryness is the most common cause of Pruritus and skin injury Dry itchy skin is the most common dermatologic problem in the elderly Contact Allergic Reactions increase due to loss of skin moisture, skin barrier and acid mantle (ph) Patients indicate that pain and quality of life issues are the most important concerns in their life How Far Have We Come? Medical technology has made many advances. Utilizing these advances is not always the best plan of action. Because we can do it does not mean we should. 3

4 What Effects Healing? Retrospective, cohort study involving 440 patients, all co-morbidities monitored Greater than 0ne wound raised risk of non-healing by 44% regardless of size of wounds or age of patient Low Hgb influenced incident of non healing and mortality by >66% Monitoring Hgb must be part of evaluation Elevated Temp. increases risk of PU s Takahashi PY et al, OWM 2009, Curry K et al, OWM 2012 Absence of Adequate Hemoglobin Results in Absence of Oxygen Transport Tissue Tolerance for Pressure Normal human tissue possesses both structural and functional mechanisms designed to protect it from pressure injury. 70% to 80% of external pressure is transferred and redistributed through elastin and collagen 60% of Pressure ulcers occur in hospitals inc. surgery, x-ray, ER Greatest risk factors are aging and neurologic impairment Messer M, JWOCN 2010 What Determines Pressure Ulcer Formation? Sufficiently high pressure (x-ray table demonstrated interface pressure of 97.7 to 126.9mm/Hg) Length of time (>1hour) and Individual s tissue tolerance determines level of hypoxia. Blood levels of Hgb. and RBC s determine tolerance Higher pressure for short periods can produce as much damage as lower pressure for longer periods Deep tissue necrosis occurred with 100mm/Hg in 2 hours Garcia AD, Thomas DR. Med Clin North Am NPUAP, Avoidable v. Unavoidable Pressure Ulcers 2007 Inadequate RBC s reduce the number of hemoglobin molecules and hypoxia results Pressure Ulcer Formation Surfaces without adequate pressure relief produced pressure ulcers at levels of 60mm/Hg of pressure in one hour 4

5 Tissue Tolerance for Oxygen Common processes that alter oxygen supply to tissues and increase incident of pressure ulcers: Loss of Temperature regulation (>35C) Impaired reactive hyperemia Infection Low blood pressure Low Hgb Low RBC s J Clin Nurs Defloor OWM, 2009 Takahashi, Morrison M. Mgm Chronic Wounds 1997 Tolerance for Oxygen Studies demonstrate a relationship between the number of hypotensive periods and pressure ulcer incidence Lengthy procedures can frequently result in hypotensive episodes in the ill elderly Fever increases oxygen demand by 10% for each degree of elevation Externally applied heat elevates O2 and nutritional demands Age Intrinsic Factors Co-morbid conditions Previous pressure ulcers (history of skin problems increases incident of PU s) Nutritional Status Body size Mobility and activity level Body temperature Gerontology 2003 Stress and the Elderly Stress can result from economic issues, mental and physical illness, depression, pain, poor care. Acute stress from illness results in catabolism and hypermetabolism. Stress can cause multiple organ dysfunction (MODS) The elderly do not recover from extensive surgeries without undergoing a period of extreme stress. The Role of Stress in Healing Numerous studies show that stress has a significant effect on healing and the ability to recover from an illness. Stress lowers the immune system allowing for infections. Elevated cortisol levels remain over many months following trauma, critical illness and surgery Skin Failure and the Critically Ill Adult MODS Multi-organ dysfunction syndrome Presence of altered organ function such that homeostasis cannot be maintained without intervention Sepsis can induce MODS A systemic inflammatory response syndrome precedes MODS OWM May 2012 Campbell et al, 1998 Reger et al, OWM 2007 Cox J. OWM

6 MODS and Skin Failure Skin failure skin and underlying tissues die due to hypoperfusion concurrent with a critical illness, is considered to be unavoidable Low albumin levels and low Hgb levels were present in all patients studied Associated causes include increase in oxygen demand, vasoconstriction, and micro vascular dysfunction Compromised skin integrity is closely associated with mortality (68.9%) Capillary Action Skin Failure in Critically Ill Adults Skin Failure can be expected in patients with; Albumin level <3.5 mg/dl, Cr >1.5 Weight >150 lbs, age >50 yrs Renal Failure Respiratory Failure Failure of more than one organ system Generalized Edema Ventilator use One or more sedatives/analgesics Pressure Relief 96% of elderly who develop PU were on a pressure reducing device 75% of orthopedic patients will develop a PU regardless of pressure reducing device No data supports the view that a particular pressure reducing device can prevent a pressure ulcer No bed device was more effective than any other in preventing a PU Specialize beds do not change PU incidence Beds Regular repositioning has efficacy similar to that of costly low-air loss systems Pressure relief mattress is comparable to an air mattress Even small position changes can change blood flow Rotation beds continue to require 2 hour position change Reddy M, Gill S. JAMA 2008 Pressure Ulcers May begin to develop after only two hours of unrelieved compression and manifest completely two to seven days after the event After the pressure is released, damage can also occur from reperfusion and byproducts of the inflammatory response Hartoch RS, McManus JG. Emerg Med Clin North Am

7 Vulnerable Patients 30% of hip fracture patients develop a new pressure ulcer. Most occur during acute care stay (hospital) DTI may not appear for 7 to 10 days Post-op Pressure Ulcers Pressure ulcers occur post-op in 38% to 66% of patients Current hospital cost of pressure ulcers is 55 billion per year Over one million patients are subjected to pressure sores related to surgery Mortality rate is 23 to 37% AORN Journal 2009 Bacteria Count 60% of chronic wounds cultured had bacterial counts >105 cfu/cm2 Number of bacteria did not correlate with wound healing Worsening wounds frequently had low bacterial counts Host resistance proves to be more significant than bacteria numbers Host resistance is directly related to nutritional status, Hgb level & albumin Post-op infectious organisms came with the patient 85% of the time Radliff CR, et al,wounds 2008 Resistive Organisms Two studies demonstrate that resistive organisms were present 18% of the time in chronic wounds present 6 to 8 months Somprakas B, Panray TR, Singe TB 2008 Honey Dressings Cochrane Collaboration analyzed 25 clinical studies that evaluated honey in acute and chronic wounds. Findings indicate that honey may delay healing There is insufficient evidence to guide clinical practice and clinicians should refrain from using these products until sufficient evidence of effect is available Honeystudy.com/OWM Topical Antibiotics Use only when infection is present Avoid polysporin, neosporin, gentimycin type OTC topicals Monitor for resistance, sensitivity Effective in reducing bioburden Do not use indiscriminately SSD (Silvadine) is not effective in treating open wounds Use for appropriate length of time for effectiveness (14 days) 7

8 Topical Antibiotics Misuse of topical antibiotics have been shown to select for resistant organisms Routine use of topical antibiotics in lower extremity ulcers has been shown to be of no benefit Metronidazole is used for malodorous fungating wounds Systemic antibiotics are the gold standard for any wound demonstrating systemic infection White, O/W mgt Ph-Balanced Cleansers & Conditioners Clean skin without resulting in dryness Maintain skin ph Rehydrate dry, irritated skin Vulnerable - Surgical Many patients develop deep tissue injury following surgery. The majority of these ulcers are visible in 1 to 3 days appearing as a burn or bruise It frequently takes 7 to 10 days post-op for these closed ulcers to deteriorate to stage III or IV AHRQ 2007 Vulnerable Patients Surgical process requiring combination of procedures Low Hgb.(<12) Hct. (<38) Ejection Fraction 35% or less Nutritional Status Prealbumin <18, Albumin <3.5 Body Mass Index <19 or >25 Estimated time in OR >3 hours Body Temperature over time <96.5 or >99.0 degrees Post Operative Infections Recent CDC studies demonstrate that 85% of patients enter the hospital with bacteria that results in infection Community Acquired MRSA can be found in the nares and require preoperative treatment CDC 2013 Predisposing Factors Intrinsic Processes Health and Nutrition (lifetime eating and behavior habits, i.e. smoking, exercise) Body Type (recent wt. loss) Mobility Incontinence/diaphoresis Neurological factors/dementia Vascular (diabetes, ASHD,CAD, History of smoking) Metabolic problems (anemia, renal, pulmonary) 8

9 Pressure Predisposing Factors Extrinsic Issues Friction (epidermal insult) Shear (deep tissue insult) Maceration, moisture (epidermal insult) Foreign object SCALE End of Life; defined as a phase of life when a person is living with an illness that will worsen and eventually cause death. It is not limited to the short period of time when the person is moribund Skin Failure; An acute episode where the skin and subcutaneous tissues die due to hypoperfusion that occurs concurrent with severe dysfunction or failure of other organs SCALE Expert Panel 2008 SCALE Skin Changes at Life s End Weakness, progressive limitation of mobility Loss of appetite, wt. loss, wasting, low albumin, low Hgb, dehydration Diminished tissue perfusion, discolored skin and necrosis Loss of skin integrity from a variety of sources Impaired skin oxygen, decreases in skin temperature SCALE: Skin Changes at Life s End Total skin assessment performed regularly, describe the skin or wound completely Investigate reason for skin breakdown and chart findings, include family in discussion Educate patient and family on why PU s occur, describe the progression of a PU. SCALE, Wounds 2009 SCALE, Wounds 2009 End Of Life Wounds Wounds present at end of life do not close or heal, particularly as the body s organs shut down. Often overlooked and not included in patient/family education is that the skin fails along with other organs On going wt. loss is a symptom of SCALE Goal should be comfort, and supportive care, not cure Nutrition Healing requires 40 calories per kilogram of body wt. for healing Maintaining weight requires 30 calories per kilogram Deterioration occurs with weight loss. Increased infection will follow weight loss Lack of appropriate calories increases body stress and skin breakdown High does of Vit. C interfere with protein absorption, increases renal problems and bleeding 9

10 Anorexia of Aging Unintentional weight loss remains unexplained in the elderly It is associated with increased sickness and death Many elderly complain about feeling overly full. Wt. loss is a symptom of end stage disease Supplements and drugs have not been shown to increase appetite FDA has not approved any drug to increase appetite in the elderly M.Lipman M.D New York Medical College Cleveland Clinic J of M, 2001 Thomas Am J. Alzheimer s & Dementias,2003, Coller Am J. Alz & Dementias, 2010, Liese, Benias Archives of Internal Medicine, 2012, Brown Univ. Malnutrition and the Elderly Failure to take in or absorb adequate calories. Vit. C & zinc do not increase healing Antidepressants depress appetite Swallowing problems and loss of chewing ability No evidence for increased survival with supplements, stimulants or feeding tubes Problems increase with feeding tubes including; aspirations, pneumonia, diarrhea, and infections. Nutritional Considerations Albumin of less than 3.3, wounds will not heal TLC of 1,500 or less, ulcers will not heal Renal Syndromes compromise individual s ability to absorb protein End-stage patients who do not feed themselves will develop malnutrition Albumin Affected by production and loss of protein Suppressed by end-stage disease, stress, infections Lost through kidney syndromes including elevated BUN and Creatinine Excessive forced protein will increase the BUN and Creatinine, increasing kidney syndromes Albumin Low levels are a marker for poor outcome regardless of the amount of protein or food intake. Nutrition Protein-calorie malnutrition and dehydration impair skin turgor. Hunger and thirst are diminished and impair metabolism Wound healing will not occur Activity and mobility decrease and lead to tissue ischemia Langemo, OWM, May

11 Feeding Tubes and Pressure Ulcers Recent study compared elderly hospital and nursing home patients with and without feeding tubes 35.6% of Patients with feeding tubes developed pressure ulcers 19.8% of patients without feeding tubes developed pressure ulcers The incidence of pressure ulcers in feeding tube patients was 2.27 to 3.2 times greater Brown Univ. Dept Public Health, Archives of Internal Med 2012 Pressure Ulcer Definition A localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. A number of contributing or confounding factors are also associated with pressure ulcers NPUAP Consensus Statement Avoidable v. Unavoidable NPUAP Consensus Conference Consensus Statement 2011 There are clinical circumstances in which a pressure ulcer is unavoidable. PU is a complex process that may not be halted, even with excellent multidisciplinary care (Thomas, 2003). The skin integrity is dependent upon the function of all other organ systems for nutrition, circulation and immune function (Langemo & Brown, 2006). NPUAP Consensus The burden of disease can overwhelm the skin, even with appropriate preventive interventions (Witkowski & Parish, 2000). The facility or agency must adopt best practices in order to minimize prevalence and incidence of PU s (Ayello & Lyder, 2008). Definitions Avoidable: Evaluate clinical condition, define PU risk factors, implement interventions according to goals and standards of practice, change interventions as appropriate NPUAP Consensus Conference

12 Definition Definition Unavoidable: A PU can develop even though the individual s clinical condition is evaluated and risk factors are determined, interventions are consistent with needs, goals and standards of practice, and are revised as appropriate. OWM 2011, NPUAP Unavoidable: Not all pressure ulcers are avoidable because there are patient situations where pressure cannot be relieved and perfusion cannot be improved. OWM 2011, NPUAP Consensus Conf. NPUAP Avoidable v. Unavoidable Unavoidable situations: Hemodynamic instability Inability to maintain nutrition and hydration Health status that prevents removal of adequate pressure from the skin, including end-stage disease Pressure from medical devices needed for treatment Additional study is required to address and identify the limits of prevention Best Practice and Guidelines for Care Based on the current literature of the specialty Prevention of Pressure Ulcers Turn/reposition q2hrs while in bed, q1h when in chair (recommendation not a standard) Use pressure relieving surfaces in the bed and chair Prevent skin to skin contact Use draw sheet or trapeze systems for movement Provide pressure relief for heels Elevate HOB no greater than 30 degrees unless otherwise indicated Prevention of Pressure Ulcers Position using the 30 degree side lying rule Treat dry skin with moisturizers Cleanse skin at time of soiling Use protective barrier ointment if skin is irritated or broken due to feces or urine Avoid massage over bony prominences Obtain dietary consult 12

13 Best Practice if a Pressure Ulcer is present Assess and document the wound including: condition of wound bed, evidence of healing or deterioration presence of eschar/ necrosis status of surrounding skin, warmth, redness Amount of drainage is equal to amount of damage Infection signs and symptoms Location Measurements Length Width Depth All Wounds Require Documentation of: Undermining / sinus tracts, tunnels Staging AHRQ 2007 Tissue in bed of wound Exudate Odor Edges Pain Determining Healing All wounds must be tracked for healing Assessment at time of dressing change must include measurable information Wound progress must be demonstrated in a measurable way such as a graph Descriptions such as improved, looks better should be avoided Ayello, 2008 Adv, Skin & Wound Care Care Plan Standard Consider referral to specialists (no change or deterioration) Relieve pressure on the affected site Dressing protocol to meet needs of wound Nutritional assessment and intervention if indicated Evaluate weekly for evidence of healing If no healing, modify treatment plan to address the reason (wt. loss, infection etc) Prevention of nosocomial pressure ulcers, JWOCN 2007 Guidelines Palliative Care Not all wounds can be healed Medical intervention can interfere with quality of life Communication with patient and family provides many options related to quality of life Quality of life includes adequate pain relief Optimize the patient s function as long as possible Key Points End of Life Care Prevent complications, promote dignity & quality of life Palliative care patients are at high risk for skin breakdown General principles of wound care should be applied unless they do not meet the goals of patient care Individuals at end of life with a wound should be placed in palliative care Prevalence rates vary between 13% and 47% The vast majority of wounds are PU s and are unavoidable and attributable to the individual s compromised condition Langemo, OWM May

14 Palliative Goals Review of Basic Wound Care: Wound pain management Appropriate dressing Infection management Odor control Periwound protection 1. Cleanse thoroughly 2. Protect peri-skin 3. Fill dead space 4. Cover wound 5. Secure dressing 6. Change dressing based on drainage and soiling Wound Cascade To Healing Documentation Pressure Ulcer Scale for Healing (PUSH Tool) Bates-Jensen Wound Assessment Tool (BBJ Tool) Skin Care Progress Record Numerical system to determine healing Pressure Ulcer Status for Healing Score Based on: Length x width Amount of drainage Type of tissue in the wound NPUAP, PUSH Tool 3.0: 9/15/98 Checklist & Wound Healing Desiccation; stops cell migration Infection or bacterial presence; stops healing and increases deterioration Maceration; urinary & fecal incontinence can alter skin integrity Necrosis; must be removed before wound can progress to repair Pressure; blood supply in the capillary network is disrupted and delays healing Trauma & edema; deprives tissue of needed oxygen Body type; obese patient compromises the wound healing due to poor blood supply to adipose tissue 14

15 Checklist & Wound Healing Lab values: Measuring Hgb level assesses the oxygen carrying capacity of the blood. Hepatic, renal and thyroid functions determine the patient s healing capacity Nutritional: Albumin and prealbumin levels, TLC and transferrin levels are markers for malnutrition and must be assessed. Cell growth stops when adequate protein is deficient Vascular insufficiency: Impacts oxygen and blood supply regardless of the site of the wound. Immunosuppression and Chronic disease: CAD, PVD, Cancer and diabetes will greatly compromise any wound healing. Patient s and family must be informed of the greater risk for pressure ulcers and non healing Hess CT. Clinical Guide to Skin & Wound Care Determining Healing All wounds must be tracked for healing Assessment at time of dressing change must include measurable information Wound progress must be demonstrated in a measurable way such as a graph Ayello, 2008 Adv, Skin & Wound Care 15