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.

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

Key Benefits

6 Categories of Braden Scale

Sensory Perception Moisture Activity Mobility Nutrition Friction & shear

Sensory Perception Ability to respond meaningfully to pressure-related 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 30o

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

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.

Moisture (Incontinence)

Updated 6/17/13

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.

Moisture (Incontinence)

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 90o 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 non-blanchable 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 tissue-

intact but red

Location Top of left foot

Wound bed Intact, non-

blanchable 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 1st 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

Drainage- moderate 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

Edema Swelling Inflammation Infection

Dressing changes Adhesives Dry wound beds Debridement

Assess for & relieve causes/contributors to pain: Pain medication is needed with wounds.

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, 6th ed. Wolters-Kluwer, 2007. www. Braden scale.com.

References

Bryant, Ruth. Acute and Chronic Wounds, 3rd 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.