Wound and Skin Care What every nurse needs to know! Ruhama Bond, RN Updated 14 February 2013/ Updated 6/17/13 Updated 10/28/13
Objectives Demonstrate the use of the Braden Scale Pressure Ulcer Risk Assessment Tool in simulated patient situations Discuss interventions to reduce patient's risk of skin breakdown Identify pressure ulcers according to NPUAP staging system Discuss essential factors for a comprehensive wound assessment
Wounds - CMS and Joint Commission CMS and TJC endorsed the concept that pressure ulcers are directly linked to hospital quality The national treatment cost is estimated at $5-8 billion annually Experts agree that costs to treat pressure ulcers is much greater than costs of prevention In 2008, CMS classified pressure ulcers as a PREVENTABLE hospital acquired condition and is no longer reimbursable.
Expectations at CFV Skin and wound assessments are completed on admission Skin assessment is completed every shift If patient has a wound, the wound assessment is done with dressing changes or as noted with the skin assessments Braden Risk Assessment is completed on admission and whenever there is a change in the patient s condition or change in care plan interventions for prevention of a pressure ulcer
Expectations at CFV.cont Perform head to toe, front to back skin assessment: Include HOT SPOTS (bony prominences) Occiput, ears, knees, toes, scapula, thoracic spine, sacrum, posterior buttocks, heels Remove non-surgical dressings and assess the wound (surgical dressings typically have specific physician orders ) Initiate the Skin /Wound Protocol if indicated or follow physician wound orders (obtain wound VAC orders) If pressure ulcers are not documented within 24 hrs of admission it is considered to be hospital acquired
Expectations at CFV-..cont Orders should be initiated immediately when they are written including specialty beds, wound care consults Don t forget critical referrals such as Nutrition Good nutrition is critical for healing monitor intake Ask MD to order supplements The primary nurse should attend to the patient when the wound care nurse assesses the wound/pressure ulcer
Braden Scale A Pressure Ulcer Risk Assessment Tool
What is the Braden Scale? Tool to assess risk of Pressure Ulcer Category scores added to indicate risk Lower score = higher risk Clinically validated Reliable
Key Benefits Short Good reminder Consistency for nurses with varied experience Focuses prevention in 6 key areas It only takes about 30 seconds to complete an accurate Braden score.
Key Benefits Proven track record: Nosocomial pressure ulcers 40-60% Severity of nosocomial pressure ulcers Cost of care by inappropriate use of specialty beds Cost of treating ulcers
6 Categories of Braden Scale Sensory Perception Moisture Activity Mobility Nutrition Friction & shear
Sensory Perception Ability to respond meaningfully to pressurerelated discomfort. 1. Completely Limited Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR Limited ability to feel pain over most of the body. This is the quadriplegic patient or the patient in a vegetative state.
Sensory Perception 2. Very Limited Responds only to painful stimuli. Cannot communicate discomfort except by moaning or restlessness. OR Has a sensory impairment which limits the ability to feel pain or discomfort over ½ of body. This is the paraplegic patient or the patient who is weak.
Sensory Perception 3. Slightly Limited Responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR Has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. This is the patient that is weak, has had a stroke and affects extremities, or diabetic patient with neuropathy.
Sensory Perception 4. No Impairment Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.
Moisture Degree to which skin is exposed to moisture. This is based on linen change. 1. Constantly Moist Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. This is the patient that is febrile, post menopausal, obese, and third spacing. The sheets could be changed each time the patient is moved or turned.
Moisture 2. Very Moist Skin is often, but not always moist. Linen must be changed at least once a shift. Despite patient or family members objections, linen may need to be changed more often than only during bath time. Please provide patient education as to the rationale for maintaining dry linen.
Moisture 3. Occasionally Moist Skin is occasionally moist, requiring an extra linen change approximately once a day. This extra linen may be done on either shift. This is part of communication SBARR and Nurse to Nursing assistant collaboration. If extra linen changes are not communicated, the Braden scale will be scored incorrectly.
Moisture 4. Rarely Moist Skin is usually dry, linen only requires changing at routine intervals. Look on the communication board in your patients room to see when the patient prefers to have their linen changed. When linens changed, update white board.
Activity Degree of physical activity 1. Bedfast - Confined to bed Immobility is what leads to pressure that deprives an area of it's blood supply and that this is the underlying cause of a pressure ulcer. This patient might be comatose, in traction, and contracted.
Activity 2. Chairfast Ability to walk severely limited or non-existent. Cannot bear weight and/or must be assisted into the chair or wheelchair. This patient is total care or one that you sit on the side of the bed have the chair next to the bed pivot and place in the chair.
Activity 3. Walks Occasionally Walks occasionally during the day, but for very short distances, with or without assistance. Spends majority of each shift in bed or chair. This patient might only walk in the room or to the bathroom.
Activity 4. Walks Frequently Walks outside room at least twice a day and inside room at least once every two (2) hours during waking hours. The patient is walking without assistance. Please take note of the frequency and where the patient is walking.
Mobility Ability to change and control body position. 1. Completely Immobile Does not make even slight changes in body or extremity position without assistance. This is the quadriplegic patient or the patient in a vegetative state.
Mobility 2. Very Limited Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. This is the paraplegic patient, the patient who is weak, or the patient that has just had a stroke and has not learned the use of the non affected extremity to pull the affected extremity and turn.
Mobility 3. Slightly Limited Makes frequent though slight changes in body or extremity position independently. 4. No Limitation Makes major and frequent changes in position without assistance.
Nutrition Usual food intake pattern. 1. Very Poor Never eats a complete meal. Rarely eats more than 1/3 of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR Is NPO and/or maintained on clear liquids or IV s for more than 5 days
Nutrition 2. Probably Inadequate Rarely eats a complete meal and generally eats only about ½ of any food offered. Protein intake includes only 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement. OR Receives less than optimum amount of liquid diet or tube feeding.
Nutrition 3. Adequate Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered. OR Is on a tube feeding or TPN regimen which probably meets most nutritional needs.
Nutrition 4. Excellent Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation.
Friction and Shear 1. Problem Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in the bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation leads to almost constant friction.
Friction and Shear 2. Potential Problem Moves feebly or requires minimum assistance. During move skin probably slides to some extent against sheets, chair, restraints or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.
Friction and Shear 3. No Apparent Problem Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair.
Score Interpretation 15-18 At Risk 13-14 Moderate Risk 10-12 High Risk 9 or below Very High Risk Score of 16 or below: initiate the skin breakdown prevention orders
Daily skin inspection is vital Note red areas Initiate interventions Head to toe skin inspection takes roughly 4 minutes Are your patients worth it?
Interventions Objective: Discuss interventions to reduce patient's risk of skin breakdown
Mobility/Activity/Sensory Establish Turning Schedule Avoid positioning on trochanter HOB elevated no more than 30 o Elevate knee gatch Float heels off of bed If pillows used, place under calves do not use towel or blanket rolls, this puts extra pressure on the back of the calf and Achilles tendon
Moisture (Incontinence) Clean with approved perineal cleanser after each episode of incontinence Apply protective ointment after each episode of bowel/bladder incontinence Use only 1 polymer pads On Clinitron & Envision beds only 1 draw sheet and 1 blue care pad, extra linen defeats the purpose of the bed, no air flow Do not use diapers! Use external urine collection device (if needed/applicable)
Moisture (Incontinence) Guidelines for Use of Patient Under pads Blue Procedure Pad Use to protect surfaces during procedures such as dressing changes, blood draws, clean-up, labor & delivery or draining wounds covered with a dressing. Updated 6/17/13
Moisture (Incontinence) Green Underpad Use to protect surfaces from drainage/body fluids if patient is not at risk for skin breakdown. Place one pad only under patient. Do not stack pads. Updated 6/17/13
Moisture (Incontinence) Ultrasorbs AP White Under pad Use to protect patient s skin from drainage/body fluids if patient is at risk for skin breakdown and needs assistance to move. Pad draws moisture away from the skin and feels dry to the touch in minutes. Use with low air loss mattress therapy- protects the bedding and permits air flow (clinitron,p500) Place one pad under the patient. Do not stack pads under the patient. Updated 6/17/13
Fecal Incontinence Collector Use fecal incontinence appliance (if applicable) REMEMBER the Fecal Incontinence Collector Does Not require a MD/DO/PA/NP order.
Flexi Seal Flexi Seal is a fecal management system. Use of this device REQUIRES a MD/DO/PA/NP Order. This is not optional one cannot place this device at anytime without the order. So one cannot place this during the night with the intent of getting the order in the morning.
Friction The rubbing of the skin on the surface due to the slide down, or repetitive movements (like restless legs), or incomplete lifting of the body when being pulled up in the bed dragging instead of lifting.
Shear Great definition: A mechanical force that acts parallel rather than perpendicular. The skin is moist, sticks to the sheets, while the skeleton slides down inside the skin. The blood vessels can then be stretched or torn causing ischemia to the tissue.
What causes a patient to slide down in the bed??? Head of the bed > 30 degrees!!
Friction and Shear Protective ointment daily on all bony prominences Transparent dressing, hydrocolloid or silicone foam on bony prominences Moisturize skin after bathing Turning sheet Heel and elbow protectors as needed Remove every shift to assess When patient is OOB: Use a chair pad Elevate legs 90 o to hip
On a side note: Partial-thickness tissue loss is skin only. No granulation tissue formation; heals by resurfacing, so NO SCAR FORMATION. Full-thickness tissue loss is tissue damage past the skin; sub-q, fascia, muscle, tendon, or bone involved. Heals by remodeling / granulation, so SCAR IS FORMED.
Nutrition Dietary consult Increase protein intake Increase calorie intake Vitamin supplements Assist at mealtimes
To Find the Wound Nurse Consult Note: In Valley Link, look under patient record. On left side of screen use drop down box; go to Wound Nurse evaluation. Click on Comments and assessment.
Pressure Ulcers Objective Identify pressure ulcers according to NPUAP staging system
Staging Pressure ulcers Pressure ulcers are staged according to the level of tissue destruction / damage. There are 6 stages: Stage I-IV, Unstageable and Suspected Deep Tissue Injury. Only pressure ulcers are staged!!!
Incontinence Associated Dermatitis: Red, broken skin from moisture, heat (diapers)
Pressure Ulcer A pressure ulcer is 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.
Stage I Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching: its color may differ from the surrounding area.
Stage 1 Description Stage 1 may be difficult to detect in individuals with dark skin tones. May be painful, firm, soft, warmer, or cooler than adjacent tissue. May indicate at risk persons.
Stage 1 pressure Ulcer Copyright Medline, 2007 used with permission
Stage 1 pressure Ulcer
What Do You See? Stage I: intact nonblanchable red skin Location-bilat heels, ankles Drainage none( color and amount) ( no drainage) Odor- none Surrounding tissue- WDL
Deep Tissue Injury Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Deep Tissue Injury- DTI DTI may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler than adjacent tissue. May be difficult to detect in individuals with dark skin tones. May begin as thin blister over dark wound bed. May rapidly expose additional layers of tissue even with optimal treatment.
Deep Tissue Injury
Deep Tissue Injury
What Do You See? Wound bed- purple/red blood filled blister Drainage- none Odor- None Surrounding tissueintact but red Location Top of left foot Wound bed Intact, nonblanchable purple tissue Drainage none Odor none Surrounding tissue WDL
Stage 2 Pressure Ulcer Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. NO SCAR FORMATION!!
Stage 2 DO NOT use to describe: Skin tears Tape burns Perineal dermatitis Maceration or denudation
Stage 2
Stage 2
Stage 3
Stage 3 Pressure Ulcers Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present, but does not obscure the depth of tissue loss. Full thickness tissue loss.
Stage 3 Pressure Ulcers The depth of a Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable.
Stage 3
What do You See? Location left heel Wound bed color Beefy red, minimal tan slough Drainage serosanguinous Odor None Surrounding tissue Scarring from larger wound, thick wound edges, thick skin
Stage 4
Stage 4 Full thickness tissue loss with exposed bone, tendon, joint or muscle. Slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling.
Stage 4 The depth of a Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have adipose tissue and these ulcers can be shallow. Do not mistake them for Stage 2 or 3 pressure ulcers. Stage 4 ulcers can extend into muscle and/or supporting structures i.e., fascia, tendon or joint capsule making osteomyelitis likely to occur. Exposed bone/tendon is visible or directly palpable.
Stage 4
Stage 4
What Do You See? Location Sacrum Wound bed 90% red, 10% yellow / tan / grey Full thickness tissue loss with palpable bone Drainage Moderate amount of serosanguinous Odor Musty Surrounding tissue Intact, dry
Unstageable Full thickness tissue loss in which the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black). Unable to view wound bed (Not enough wound tissue is exposed to reveal the actual depth of tissue damage).
Unstageable Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
Unstageable
Unstageable
Unstagable
What Do You See? Location Right heel Wound bed Dry, black eschar ( unstageable pressure ulcer) Drainage None Odor? Surrounding tissue Pink/red
Wounds Unlocking the Secrets Objective: Discuss essential factors for a comprehensive wound assessment
Why do YOU Need to Know? Every nurse will encounter some kind of wound Chronic, trauma, surgical Nurses must know how to accurately assess a wound.
Why do YOU Need to Know? Systemic factors affect wound healing Comprehensive assessment on all patients: Age Body type Chronic disease Nutritional status Vascular insufficiencies Immunosuppression Radiation therapy
Wound Assessment - Etiology Understanding cause 1 st step in treatment Venous stasis ulcer Pressure ulcer Other causes
Wound Assessment - Infection Signs and symptoms of infection redness purulent drainage increased edema foul odor only after wound has been cleaned increased pain systemic temperature < 96.8 or> 100.4
Wound Assessment - Location Use anatomical terminology Be as precise as possible Identify by underlying bony prominence Ex: buttock wound = ischial wound Other terminology - Medial, lateral, proximal, superior, inferior
Wound Assessment Wound Bed Accurate assessment imperative for dressing/treatment selection. Color and type of wound tissue. Granulation tissue- living tissue presents as beefy red (granular). Non-granular tissue- living tissue presents as pale red or pink (slick).
Wound Assessment Wound Bed Non-viable or necrotic (dead) tissue Slough yellow, tan or grey often slimy or moist May be firm or loose and stringy Eschar Hard, leathery may be dark brown or black Do not mistake for a scab
Granular Tissue
Red / Pink non-granular tissue
Slough
What do you see? Location L buttock Wound bed- 30% yellow, nonviable tissue, 70 % pink Drainagemoderate amount serosanguinous drainage Odor- none Surrounding tissue-red, denuded skin from wet 4x4 gauze dsg
Eschar
Wound Bed Documentation Type of tissue within the wound bed in percentages totaling 100%. Example: 80% granulation tissue in the center of the wound bed with 20% yellow stringy slough on outer edges.
Wound Assessment Odor Various dressings may create foul odor as they absorb drainage Clean wound BEFORE assessing odor Foul odor may indicate infection - report to MD/DO
Wound Assessment Drainage Made up of dead cells liquefied necrotic tissue white blood cells natural growth factors Assess amount, type, color, odor and consistency
Wound Assessment Drainage Amount - small, moderate or heavy Note how long dressing was in place saturated after 12 hours vs. saturated after 2 days. drainage may indicate bioburden/ infection- report to MD/DO/PA/NP
Wound Assessment -Periwound Skin condition around wound is good indicator of wound healing. Use clock method to describe position Maceration- skin too moist. Can cause further breakdown Redness 3-5cm beyond wound edges may indicate cellulitis.
Possible Cellulitis Copyright Medline, 2007 used with permission
Wound Assessment -Periwound Assess color sensation induration edema Hyperkeratosis- hard, white/grey tissue Epithelialization- flat, pale white, pink/lavender, dry, shiny skin
Epithelialization
Epithelialization
Wound Undermining & Tunneling Undermining- Tissue destruction underlying intact skin along the margins of a wound. Undermining can travel in more that one direction. (think of swishing your tongue over your teeth under your lip) Tunneling/Sinus Tract- A canal or passage under the wound surface that travels in one direction. (think of sticking your finger up your nose)
Wound Assessment- Pain Assess for & relieve causes/contributors to pain: Pain medication is needed with wounds. Edema Swelling Inflammation Infection Dressing changes Adhesives Dry wound beds Debridement Always give pain medication prior to dressing changes.
Wound Assessment- Documentation Essential to: Paint a picture - The next provider will know what the wound looks like before removing the dressing by your documentation. Communication - Among the health care team - SBARR
Wound Assessment- Documentation Plan care plan of care includes interventions. Change these interventions as necessary Remember this is a legal record; if the assessment or interventions are not documented, they were not done. Completed in a timely, concise, and accurate manner
References National Pressure Ulcer Advisory Panel Update 2007. http://www.npuap.org/pr2.htm Hess, Cathy Thomas. Clinical Guide to Wound Care, 6 th ed. Wolters-Kluwer, 2007. www. Braden scale.com.
References Bryant, Ruth. Acute and Chronic Wounds, 3 rd ed. St. Louis: Mosby, 2006. Medline Industries Inc. The Wound Care Handbook. Mundelin, IL: Medline Industries, 2007. Handout from presentation by Lori McNicole RN, BSN, CWOCN, 2005.