Recognizing Pressure Injury

Transcription

1 Recognizing Pressure Injury Karen Zulkowski, DNS, RN Hawaii Recorded on March 8,

2 A Little About Myself Executive editor of the Journal of the World Council of Enterostomal Therapists (JWCET) and WCET International Ostomy Guidelines (2014). Member of the editorial board of Ostomy Wound Management and Advances in Skin and Wound Care. Legal consultant and former NPUAP board member. Retired associate professor at Montana State University. 2

3 What Is It? Pressure, moisture or friction Moisture or pressure 3

4 Moisture or pressure injury? Pressure injury or skin tear? 4

5 Skin issues can have more than one problem: Moisture and pressure Pressure and shear Co-morbidities 5

6 For Example pressure moisture 6

7 Pressure Injury Localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and conditions of the soft tissue. 7

8 Staging Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 8

9 Stage 1 Not Easy To Determine 9

10 But Are Especially Difficult To See In Darkly Pigmented Skin 10

11 Assessment Tips For Darkly Pigmented Skin 1. The color may remain unchanged. 2. Area of pressure may feel warm or cool, hard or boggy. 3. Site of any previous pressure injury may be different color (slightly lighter) or area of healing may look lighter. 4. Person may complain of pain in the area. 11

12 Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. 12

13 Unstageable Pressure Injury: Obscured Full-thickness Skin And Tissue Loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 13

14 Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 14

15 One Of These Is A Bruise Bruise 15

16 Medical Device Related This describes an etiology. Is staged Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system 16

17 Mucosal Membrane Pressure Injury Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue these injuries cannot be staged. 17

18 Skin Assessment Head to toe. You have to touch and feel the skin. This is especially important in darkly pigmented skin. 18 Head-to-Toe Skin Assessment INSPECT AND PALPATE Document all skin issues including: Skin color Skin temperature Skin moisture status Skin integrity - Pressure injury - Healed pressure injury - Moisture - Moles - Bruises - Rashes - Incisions - Scars - Burns Any abnormalities Remember to pay special attention to the feet and heels

19 Because What You See Is Not The Entire Picture 19

20 Standard Protocol for Comprehensive Skin Assessment Explain to the patient and family that you will be checking the patient s entire skin. Explain what you are looking for with each site. Conduct the assessment in a private space. Make sure the patient is comfortable. Wash and sanitize your hands before and after the assessment. 20

21 Standard Protocol for Comprehensive Skin Assessment Wear gloves and change them as needed. Minimize exposure of body parts. Provide privacy with a sheet or cover. Ask for help to turn the patient as needed. Know your facility s policies and procedures. 21

22 Standard Protocol for Comprehensive Skin Assessment Pay special attention to: Skin beneath and around any devices or compression stockings. Bony prominences (heels, sacrum, occiput). Skin to skin areas, such as the penis, back of knees, inner thighs and buttocks. All areas where the patient: Lacks sensation to feel pain. Had a breakdown previously. Also pay special attention if the patient is getting epidural/spinal pain medicines. 22

23 Improving Comprehensive Skin Assessment Encourage staff to: Ask a colleague or expert to confirm their skin assessments. This hones skills and prevents errors. Ask questions as needed. Report any possible skin abnormalities they come across during routine care. 23

24 Five Parameters of Comprehensive Skin Assessment 1. Temperature 2. Turgor (firmness) 3. Color 4. Moisture level 5. Skin integrity Skin intact Open areas, rashes, etc. 24

25 Parameter 1: Skin Temperature Palpate with your hand to assess skin temperature. Skin warmth or coolness can indicate skin damage, including: Stage I pressure injury Suspected deep tissue injury Pre-ulceration in the diabetic foot Inflammation or infection 25

26 Parameter 2: Skin Turgor (Firmness) Skin normally returns to its original state quickly when stretched. Can you tent the skin? Skin may be slow to return to its original shape in older or dehydrated patients. 26

27 Parameter 3: Skin Color Compare adjacent areas of skin for color. Redness can indicate many skin problems Pressure ulcer Rash Infection, cellulitis Deficiencies can also affect skin: Vitamin C deficiency causes purplish blotches on lightly traumatized areas. Zinc deficiency causes redness of the nasolabial fold and eyebrows. 27

28 Parameter 3: Skin Color Blanchable versus nonblanchable erythema Purple or bruised looking skin Paper-thin skin Dark or reddened areas Darkly pigmented skin does not blanch. 28

29 Parameter 3: Skin Color Redness Reddened skin on the sacral area can be from a variety of etiologies. Make sure to get the etiology right so you can treat the cause appropriately. Moistureassociated skin damage Stage I pressure ulcer 29

30 Parameter 4: Skin Moisture Moisture-associated skin damage: Skin can be dry (verosis) or damaged from too much wetness (maceration). Etiology can be: Incontinence, urine, stool, or both Wound exudate Perspiration, including patients with a fever Between skin folds (especially in bariatric patients) Ostomy or fistula that leaks Make sure to get the etiology right so you can treat the cause appropriately. 30

31 Parameter 5: Skin Integrity Skin should be intact. If skin is not intact, identify the etiology of the skin problem. Etiology could be: Pressure Peripheral vascular (venous or arterial) Neuropathic/diabetic Skin tears (especially forearm of older adults) Trauma Make sure to get the etiology right so you can treat the cause appropriately. 31

32 Treating Comprehensive Skin Assessment As Separate Process Frequency of comprehensive skin assessment: Depends on the needs of the unit. May be as often as every shift. Is most often daily and when the patient is: Newly admitted. Moved to a different level of care. Transferred. Discharged. 32

33 Integrating Skin Assessment Into Normal Workflow Each time you: Apply oxygen, check the patient s ears for pressure areas from tubing. Check bowel sounds, look at skin folds. Reposition the patient in bed, check the back of the patient s head. 33

34 Integrating Skin Assessment Into Normal Workflow Each time you: Auscultate lung sounds or turn the patient, check the patient s shoulders, back and sacral/coccyx region. Check a male patient s catheter, check his penis. Position pillows under the patient s calves, check the heels and feet. Use a hand-held mirror to adequately visualize the area. 34

35 Integrating Skin Assessment Into Normal Workflow Each time you: Check IV sites, look at the patient s arms and elbows. Lift the patient or provide care, check exposed skin, especially on bony prominences. Remove equipment, check adjacent skin. This includes TENS units, restraints, splints, oxygen tubing and endotracheal tubes. 35

36 Start At The Top 1. Head, face and neck (front and back). 2. Arms and fingers. 3. Chest (in skin folds and under breast). 4. Legs and feet. 6. Back and buttocks. 36

37 Then- Assess The Wound T Tissue both in and around the wound granulation, slough, necrotic black, pink, mix I Infection- any open area always has the potential for infection M Moisture (exudate)- this determines type of dressing needed to maintain balance E Edges are they contracted, rolling, undermining (D) Dimensions 37

38 Documenting Results Document the results of comprehensive skin assessment in each patient s medical record even if there are no problems. Have a standardized place to record results in the medical record. Make sure all staff know how and where to document results. 38

39 Pressure Ulcer Identification Pocket Pad 39

40 Reporting Results Include results in all shift reports. If there are problems, report results to team members and to the patient s health care provider. 40

41 Most Important Remember You must have pressure and/or shear for a pressure injury 41

42 Mahalo (Thank you) 42