CRRN Review Course 2017 Skin and Wound Management Presented by: Jenifer Stevenson BSN, CRRN, CNML
Disclosure The presenter for this presentation has disclosed no conflict of interest related to this topic.
Functions of Skin Thermoregulation Protection from injury Shields underlying tissue Communication with the environment
Pressure Injuries Total National cost of pressure injury treatment is $9.1-$11.6 billion annually Estimated $20,900 to 151,700 per pressure injury 60,000 people die from pressure injury complications each year More than 2.5 million patients per year Lawsuits: More than 17,000 lawsuits are related to pressure injuries annually. It is the second most common claim after wrongful death and greater than falls or emotional distress. Pain: Pressure injuries may be associated with severe pain.
Oldest Name: Bed sores Pressure Ulcers Old Name: Decubitus Ulcers Newer Name: Pressure Ulcers Newest Name: Pressure Injuries (2016)
Definition Of A Pressure Injury Definition: A pressure injury is 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 condition of the soft tissue.
Pressure Injury Formation Local Ischemia: Pathological changes to capillaries and tissues. May occur in less than 2 hours Cell Death: Progression of tissue change in response to obstruction of capillary blood flow. Patient may report pain, warmth to area and slight edema Tissue Collapse: Non reversible. Area will be cool to the touch, may feel hard or indurated, or soft and boggy Infection: No swab cultures as pressure ulcers are generally colonized and may not reveal an underlying soft tissue infection or osteomyelitis
Locations Of Pressure Injuries A. Ischium 24% B. Sacrum 23% C. Trochanter 15% D. Heel 8% E. Malleolus 7% F. Knee 6% G. Iliac Crest 4% H. Elbow 3% I. Pretibial Crest 2% J. Skull 1%
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.
Unstageable Pressure Ulcer
Unstageable Pressure Injury
Unstageable Pressure Injury
Unstageable Pressure Injury
Unstageable Pressure Injury
Stage 1 Pressure Injury Definition: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 1 Pressure Injury
Stage 1 Pressure Ulcer
Stage 2 Pressure Injury Definition: 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).
Stage 2 Pressure Injury
Stage 2 Pressure Injury
Stage 3 Pressure Injury Definition: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 3 Pressure Injury
Stage 3 Pressure Injury
Stage 3 Pressure Injury
Stage 3 Pressure Injury
Definition: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. Stage 4 Pressure Injury
Stage 4 Pressure Injury
Pressure Ulcers with Exposed Cartilage Are Stage IV Pressure Ulcers It is the opinion of the NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage IV.
Deep Tissue Pressure Injury 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 bonemuscle 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.
Deep Tissue Pressure Injury
Deep Tissue Pressure Injury
Deep Tissue Pressure Injury
Medical Device Related Pressure Injury This describes an etiology. 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.
Medical Device Related Pressure Injury
Medical Device Related Pressure Injury
Infected Pressure Ulcer Marked by and increased wound size, perilesional warmth and tenderness, erythema on the surrounding skin, malodorous base, and increased wound exudate
Infected Pressure Injury
Mucosal Membrane Pressure Injury Mucosal membrane pressure injury is found on mucous membranes with a history of medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.
Not a Pressure Injury Skin Tear Sacral Slit Moisture Associated Skin Damage
Not Pressure Injury
Risk Assessment for Pressure Injuries Factors that place persons at risk Inability to perceive pressure/temperature Exposure to incontinence, moisture, chemicals or radiation Decreased activity level Smoking Diabetes Fragile skin
Risk Assessment for Pressure Injuries Continued Inability to reposition-bedfast or chair fast Poor nutritional intake/hydration Friction and shear Medications Skin care products Psychosocial factors/life satisfaction Existing pressure injury
Addressing the Risk Factors for Prevention of Pressure Injuries Turning/repositioning schedule Mattress overlays/beds/wheelchair seating Nutritional supplements Skin protection
Risk Assessment Tools A. Braden Scale - assesses 6 client factors: mobility, activity, moisture, sensory perception, nutrition, friction and shear B. Norton Scale - assesses 5 factors: physical condition, mental condition, activity, mobility and incontinence
Braden Scale Highest possible score is a 23 Lowest possible score is a 6 Mild risk=15-18 Moderate risk= 13-14 High Risk 10-12 Very High Risk <9
Pressure Redistribution Bed bound patients must be repositioned at least every 2 hours and chair bound patients every 15 minutes. Reposition while on special beds and overlays Persons must be turned at least 30 degrees to redistribute pressure from the sacrum Use wedges and pillows to support bony prominences Float heels off the bed surface
Horizontal Support Surfaces DMERC Category I- static overlays, non-powered mattresses and powered mattresses with an air lift< 2.5 inches Durable Medical Equipment Regional Carrier
Horizontal Support Surfaces DMERC Category 2- alternating pressure, air flotation mattress or overlay greater than 3 inches or a powered overlay, mattress or bed
High Air Loss Surface
Assessing the Performance of a Support Surface Bottoming out- the surface is totally compressed-use hand check-should not be able to feel the patient Memory in foam Bunching in gels Deflation in air-filled Hand checks should not be used to assess integrated bed systems
Chair Support Cushions Use Pressure distributing cushions Instruct patient and family members to relieve pressure while seated every 15 minutes (including when patient is in the shower chair or on a commode) Consider tilt/reclining chair for more pressure distribution
Wheelchair Cushions Foam- from 1-4 inches thick and range from soft to firm density; need to be replaced frequently Floatation- air, water or gel-some contain cells that function independently Air cycling-customized inflation and cycling action
Wheelchair Cushions
Interface Pressure Mapping A tool that provides a way for us to assess the interface pressure between an individual and their seating surface. The main purpose of is to look at the distribution of the pressure over their seated surface and note peak areas.
Pressure Mapping Before and after a wedge was added
Pressure Mapping With and without a dressing
Wound Treatment: Debridement Sharp Enzymatic Mechanical
Wound Treatment: Debridement Enzymatic
Wound Treatment: Debridement Mechanical: wet to dry dressings
Wound Treatment: Cleansing Normal Saline Commercially prepared solutions
Wound Treatment: Dressings Gauze Transparent Film Hydro gels Alginates Hydro colloids Foams Absorptive fillers Regranex
Wound Treatments: Absorptive Fillers Absorptive fillers: Used to absorb exudates and fill dead space. Generally covered with transparent film or hydrocolloid dressing
Wound Treatments: Gauze Purpose to absorb; supports moist wound healing if kept moist; used to fill sinuses or dead space; should be packed lightly to prevent impaired circulation Also may be impregnated with petrolatum or gels
Wound Treatments: Transparent Film The first occlusive dressings; insulate; protect; and maintain the moist wound surface. Permeable to oxygen and water vapor but impermeable to fluids and bacteria Non-absorptive
Wound Treatments: Hydro gels Gels that may be poured into the wound; mild absorption; may fill dead space; painless
Wound Treatment: Alginates Alginates: Occur naturally in seaweed, absorb exudates, maintains a moist wound bed and can be used with either shallow or deep wounds
Wound Treatments: Hydrocolloids Hydro colloids: Wafer that protects the moist wound bed yet absorbs exudates; Occlusive and prevents O2 from entering the wound. This occlusion promotes wound healing when growth factors are allowed to proliferate under the dressing
Wound Treatments: Foams Foams: Non-adherent wafers; good absorption; hydrophobic surface repels contaminants
Negative Pressure Wound Therapy Vacuum assisted closure Developed by a plastic surgeon and received FDA approval in 1995 A negative-pressure sponge dressing is placed within the wound to increase blood flow, increase granulation tissue and nutrients to the wound
Wound Treatments: NPWT CONTRAINDICATIONS Malignancy in the wound Untreated Osteomyelitis Non-enteric and unexplored fistula Necrotic tissue with eschar present Do not place dressing over exposed blood vessels or organs
Wound Treatments: NPWT Patients can attend therapy Battery pack Dressing change every 2-3 days
Surgical Management Stage III and IV wounds are often closed by myocutaneous flap Early closure decreases loss of fluid and nutrients, improves the health status of the client, and leads to earlier recovery and mobilization
Myocutaneous Flap
Burns
Burn Patients Suffer the Effects From Loss of Skin Function
Burns Depth (how deep the burn is) How the wound looks Causes Level of Pain (sensation) Healing Time Scarring First Second Third Epithelium No blisters; dry pink Sunburn, scald, flash flame Painful, tender, and sore Two to five days; peeling No scarring; may have discoloration Epithelium and top aspects of the dermis Moist, oozing blisters; Moist, white, pink, to red Epithelium and dermis Leathery, dry, no elasticity; charred appearance Scalds, flash Contact with flame, hot surface, hot burns, chemicals liquids, chemical, electric Very painful Superficial: five to 21 days. Deep: 21-35 days Minimal to no scarring; may have discoloration Very little pain, or no pain Small areas may take months to heal; large areas need grafting. Scarring present
First Degree
Second Degree
Third Degree
Thermal Burns Flash - Explosions of natural gas, propane, gasoline and other flammable liquids. Intense heat for a very brief period of time. Clothing is protective unless it ignites. Flame - Exposure to prolonged, intense heat. House fires, improper use of flammable liquids, automobile accidents, ignited clothing from stoves/heaters. Scalds - Burns caused by hot liquids. Water, oil, grease, tar, oil. Water at 140 degrees F, creates a deep burn in 3 seconds, but at 156 degrees F will cause the same injury in 1 second. (Coffee is 180 degrees F just brewed). Circumferential burns should raise suspicion of non-accidental trauma. Tar needs to be removed either with an adhesive remover solution or petroleum based dressings. Contact - Result from hot metals, plastics, glass or coals. Can be very deep.
Chemical Burns Caused by strong acids or alkali substances. They continue to cause damage until the agent is inactivated. Alkali substances usually cause more severe injury since they react with the lipids in the skin.
Electrical Burns Caused by either AC or DC current. Current follows the path of least resistance and causes injury in areas other than the contact/entry site. They cannot be judged from the external injury alone. High voltage > 1,000 volts, low voltage < 1,000 volts and lightening. Electrical burns are thermal burns from very high heat.
Radiological Burns Caused by alpha, beta or gamma radiation. They may need to have some type of decontamination done to stop the injury.
Rule of Nines The Wallace rule of nines is a tool used in prehospital and emergency medicine to estimate the total body surface area (BSA) affected by a burn. In addition to determining burn severity, the measurement of burn surface area is important for estimating patients' fluid requirements and determining hospital admission criteria. The rule of nines was devised by Pulaski and Tennison in 1947, and published by AB Wallace in 1951. To the estimate body surface area of a burn, the rule of nines assigns BSA values to each major body part.
Rule of Nines
Points to Remember Pre medicate before shower or wound care Allocate enough staff Prepare dressings before change Ensure that temperature and pressure of water can be regulated
Points to Remember Continued Move quickly Clean thoroughly Remove egg white like drainage Pat dry lightly Cover with dressings Compression
A person who cannot move should be repositioned while sitting in the wheelchair every two hours.. True or False?
Scarring will break down faster than unwounded skin True or False?
A low Braden score is associated with and increased pressure risk True or False?
Shear is the force which occurs when the skin sticks to a surface and the body slides. True or False?
Is this a pressure injury? Pressure Injury?
What stage pressure injury? Pressure Injury?
Shear injuries can be prevented with this intervention: Question?