Presentation on theme: "Skin Champion Education"— Presentation transcript:
1Skin Champion Education Robert J. Dole VAMCSKIN/Wound care education
2Objectives Describe the pathophysiology of wound healing Explain the difference between acute and chronic woundsIdentify factors that impair wound healingDescribe the benefits of moist wound healingState the principles of wound managementExplain pressure ulcer risk, skin, and wound assessment documentation requirements.Discuss the importance of pressure ulcer preventionDescribe how a pressure ulcer developsDescribe the key elements in pressure ulcer assessment and staging
4Epidermis Outermost layer (epi- means upon) Thickness from 0.1mm to 1.0mmSlightly acidic – avg. pH 5.5“ACID MEMBRANE”Contains melanocytes – pigmentMade up of 4 to 5 layers depending on location
5Layers of the epidermis Stratum corneum - horny layer - dead skin cells (keratinized epithelium) -environmentAcid mantle protects from some fungi and bacteriaShed and replaced every 4 to 6 weeksStratum lucidum - clear layer – single cell layer found where thickest – soles of feetIntense enzyme activity prepares cells for stratum corneum even though lacks nucleiStratum granulosum - granular layer – 1 to 5 cells – flat cells with nuclei – aids keratin formation -
6Layers of the epidermis Stratum spinosum – cells begin to flatten as they migrate – protein precursor of keratinized skin cells synthesizedStratum basale / stratum germinativumOne cell thickOnly layer that undergoes mitosisForms dermoepidermal junction – protrusions known as rete ridges or epidermal ridges extend into dermis and are surrounded by vascularized dermal papillaeSupport and exchange of fluid and cells
7Dermis - deeper layer of skin Collagen (strength) and elastin (elasticity) fibers produced by fibroblastsExtracellular matrix – gives skin its physical characteristicsBlood and lymphatic vessels – transport O2, nutrients and remove wastesNerve fibers, hair follicles, sweat glands – contribute to sensation, temperature regulation, excretion and absorptionSebaceous glands – sebum lubricates and softens the skin
8Dermis Two layers of connective tissue Papillary dermis - outermost layerComposed of collagen and reticular fibers important in wound healingCapillaries transport nourishmentReticular dermis – innermostThick network of collagen bundles anchor it to subcutaneous tissue, fasciae, muscle and bone
9Subcutaneous tissue (Hypodermis) Layer of loose connective tissue that contains major blood and lymph vessels and nervesHigh proportion of fat cellsFewer small blood vessels than dermisProvides insulation, absorbs shocks to the skeletal system
10Effects of Aging50% reduction in cell turnover rate of stratum corneum20% reduction in dermal thicknessReduction in vascularization and blood flow to the skinRedistribution of subcutaneous tissues to stomach and thighsReduced adhesion between layersReduced number of Langerhan’s cells – macrophages that attack invading bacteria50% decrease in fibroblasts and mast cells involved in inflammatory processDecrease number of sweat glandsDecreased absorptionReduced ability to sense pressure, heat and cold
11Phases of Wound Healing Hemostasis - vasoconstriction and coagulationcollagen fibers in the damaged vessels wall activate plateletsInflammation – defense and healingNeutrophils engulf debris and bacteriaMonocytes converted to macrophagesMacrophages produce growth factors that attract cells needed for new vessel growth, collagen for granulation and epithelialization
12Phases of Wound Healing Proliferationgranulation tissue (connective tissue) fills the woundWound edges retract/contractEpithelium migrates across the woundMaturationShrinking and strengthening of the scarContinues for months and even years – 80%
18Acute wounds Occur by intension or trauma Surgical wounds Begins with a sudden, single insultProceeds to heal in an orderly mannerSurgical woundsTraumatic wounds: unplanned injury to the skinBurnsSkin grafting
20Chronic woundsCaused by underlying pathology that produces repeated and prolonged insults to the tissuesFrequently complicated by ischemia, necrotic tissue and heavy bacterial loadsHigh levels of inflammatory proteases and low levels of growth factors
22Factors that affect healing NutritionOxygenationInfectionAgeChronic health conditionsMedicationsSmoking
23NutritionMalnutrition increases the risk of developing pressure ulcers and delays healingProtein is crucial for proper healing (0.8 to 1.6g/kg/day)Collagen formation is reduced or delayed without adequate proteinFatty acids (lipids) used in cell structures and inflammatory processesVitamins C, B-complex, A, and E and minerals iron, copper, zinc, and calcium are importantZinc deficiency slows epithelialization and decreases tensile strength
24Oxygenation Wound healing depends on a regular supply of oxygen Critical for leukocytes to destroy bacteria and fibroblasts for collagen synthesisImpaired blood flow to the wound or the patients inability to take in adequate O2Causes of inadequate blood flow to the woundPressure, arterial occlusion, prolonged vasoconstriction, PVD and atherosclerosisCompromised perfusion more likely to impair healingCauses of inadequate systemic blood oxygenationAcute and chronic conditions such as COPD, hypothermia hypotension, hypovolemia, cardiac insufficiency
25InfectionSystemic infections (pneumonia, TB) increase metabolism and depletes the fluids, nutrients and O2 the body needs for healingLocalized from the injury or develops secondaryInflammatory phase lingers delaying wound healingMetabolic by-products of bacterial ingestion accumulate in the wound and interferes with formation of new blood vessels and collagen synthesisSigns: new or increased pain, exudate, redness, heat, induration, edema, malodor
26Aging Slower turnover rate in epidermal cells Decreased O2 at the wound – increasingly fragile capillaries and reduction in skin vascularizationAltered nutrition and hydrationImpaired function of immune or respiratory systemsReduced dermal and subcutaneous massHealed wounds lack tensile strength and are subject to reinjuryChronic health conditions
27Chronic health conditions Pulmonary disease, atherosclerosis, diabetes and malignancies increase risk and interfere with wound healingImpaired circulation common in diabetes and conditions that cause hypoxiaNeuropathy associated with diabetes increases risk and can impair leukocyte functionDehydration, ESKD, thyroid disease, heart failure, PVD, vasculitis, and other collagen vascular disorders can delay healing
28MedicationsAny medication that reduces movement, circulation, or metabolic functionSedativestranquilizersMedications that reduce the body’s ability to mount an appropriate inflammatory responseSteroidsChemotherapeutic agents
29SmokingCarbon dioxide binds to the hemoglobin in blood in place of oxygenReduces the amount of circulating oxygenOccurs with exposure to second hand smoke as wellNicotine causes vasoconstriction and increased coagulability
34Sensory Perception 4. No Impairment (Provide routine skin care). Sensory PerceptionAble to respond meaningfully to pressure-related discomfort.4. No Impairment (Provide routine skin care).3. Slightly limiteda. Encourage turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas. When in W/C assist with position changes to alter pressure points at least every hour. Instruct and encourage active patient/family participation as able.b. Consider elevation of heels off of the bed surface with longitudinal pillows.c. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).d. When elevating HOB, gatch the knee area (elevate degrees)e. Consider wheelchair cushion (esp. if existing skin breakdown)2. Very limiteda. Provide above.b. Limit W/C to 1-2 hour intervals.c. Instruct to shift weight in W/C q 15 minutes.d. Use a turn sheet to lift up in bed or turn.1. Completely limiteda. Provide all of above as needed.
35Moisture Degree to which skin is exposed to moisture. 4. Rarely moist MoistureDegree to which skin is exposed to moisture.4. Rarely moista. Instruct resident to request care as neededb. Assess and provide routine skin care as needed to keep skin clean and dry.3. Occasionally moista. Provide above with use of incontinent care products as needed (No Rinse pH balanced cleanser, protective ointment, absorbent briefs with protective liner to prevent trapping of moisture against skin.)b. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).c. When elevating HOB, gatch the knee area (elevate degrees)2. Very moist.a. Provide all of above as needed.b. Assess and address cause for fecal/urinary incontinencec. Consider fecal/urinary incontinence containment device (esp. if existing skin breakdown)1. Constantly moista. Provide all of aboveb. Apply fecal/urinary incontinence device, as able.
36Activity Degree of physical activity. 4. Walks frequently ActivityDegree of physical activity.4. Walks frequentlya. Encourage activity as tolerated3. Walks occasionallya. Provide above.b. Teach patient/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes.c. Consider wheelchair cushion (esp. if existing skin breakdown)2. Chair fasta. Provide all of aboveb. Obtain wheelchair cushion.c. Limit W/C to 1-2 hour intervals. Instruct to shift weight in W/C q 15 minutes.d. Assist as needed with turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas.e. Consider elevation of heels off of the bed surface with longitudinal pillows.1. Bedfasta. Provide all above, as needed.b. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)
37Mobility 4. No Limitation(Provide routine skin care). MobilityAbility to change and control body position.4. No Limitation(Provide routine skin care).3. Slightly limiteda. Assist as needed with turning and reposition q 2 hours when in bed. Utilize pillows to separate pressure areas.b. Instruct to shift weight in W/C q 15 minutes. Consider W/C cushion (esp. if existing skin breakdown).c. Consider elevation of heels off of the bed surface with longitudinal pillows.d. Consider use of foam wedges to help maintain positioning.e. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).f. When elevating HOB, gatch the knee area (elevate degrees)2. Very Limiteda. Provide aboveb. Limit W/C to 1-2 hour intervals1. Completely immobilea. Provide above.b. Consider Wound Care Nurse consult for higher level support surface (esp. if there is existing skin breakdown).
38NutritionUsual food intake pattern.4. Excellent(Provide tray set up and other routine assistance as needed).3. Adequatea. Encourage meals and assist with meals as needed.b. Offer ordered supplements.c. Assess needs for oral care, assist PRN2. Probably inadequatea. Provide aboveb. Consult dietician1. Very poorb. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)
39 Friction & Shear 3. No apparent problem (Provide routine skin care) Friction & Shear3. No apparent problem (Provide routine skin care)2. Potential problema. Use a turn sheet to lift up in bed or turn.b. When elevating HOB, gatch the knee area (elevate degrees)c. Consider keeping HOB at or below 30 degrees. HOB may be elevated for meals then lowered within one hour p.c. (unless contraindicated).d. Consider heel/elbow pads or socks.1. Problema. Provide aboveb. Consider use of assisting devices (i.e. trapeze)
40Types of Wounds Treat Based on Drainage Specific Treatments Pressure UlcersDiabetic UlcersVenous Insufficiency UlcersArterial UlcersSpecific TreatmentsIncontinence DermatitisPerineal CandidiasisSkin Tears
41Diabetic/Neuropathic Ulcers Types of WoundsDiabetic/Neuropathic UlcersFound in diabetic patients with peripheral neuropathy; usually on the ball of the foot or tops of toes; prone to infectionApproximately 15% of patients with diabetes develop foot ulcers.23% of this group develop osteomyelitisIncidence of vascular disease is at least four times higher in patients with diabetes and increases with age and disease duration
42Diabetic/Neuropathic Ulcers- Causes Pressure, secondary to peripheral neuropathy and/or arterial insufficiencyPlantar aspect of footOver metatarsal headsUnder heelPoor microvascular circulationPoor blood sugar controlLack of sensation
43Diabetic/Neuropathic Ulcer Characteristics Below the anklePoor circulationNeuropathySites of pressure, friction, shearSites of traumaEven wound marginsPeri-wound callousRoundHemorrhagic callousIncreased potential for infection
44Venous Insufficiency Ulcers Types of WoundsVenous Insufficiency UlcersUsually due to minor trauma; pretibial area of shin or above the medial ankle; superficial but difficult to heal
45Venous Ulcers - Causes Problems with venous blood return to heart Non-functioning or inadequate calf muscle pumpIncompetent perforator valveIncompetent valves in the veinAll lead to venous hypertensionVenous blood pools in lower extremity and foot
46Characteristics of Venous Insufficiency Ulcers EdemaHyperpigmentationGaiter distributionAnkle flareAtrophy of skinEczemaLipodermatosclerosisPalpable pulsesIrregular bordersUsually shallowWeepyLocated on medial lower leg and malleoluscan be circumferentialPain relieved by elevationHeavily contaminated
47Types of Wounds Arterial Ulcers Due to arterial occlusive disease which results in tissue necrosis; usually occur on the ankle or bony areas of the foot; painful, dry, and pale; pedal pulses diminished or absent
48Characteristics of Arterial Ulcers Absence of hairAtrophy below level of occlusionPain upon elevationAbsence of palpable pulseSites of traumaOften bright red granulation tissueWell defined borders/punched out appearanceMinimal drainageUsually full thicknessUsually lateral foot, can be anywhereDependent ruborTendon exposure
49Types of Wounds Incontinence Dermatitis Injury to the skin caused by exposure to excessive moisture, urine, and/or stoolCharacterized by inflammation, rash, and possibly denuded skinAnywhere in the sacral/coccyx, buttock, or perineal area
50Types of Wounds Perineal Candidiasis Fungal/Candida infection characterized by erythematous papules and satellite lesions, and/or scaly borders
51Types of Wounds Skin Tears Traumatic wound occurring principally on the extremities of older adults as a result of friction and/or shearing forces which separate the epidermis from the dermis, or separate both the epidermis and the dermis from underlying structuresIncision-like skin lesionClassified based on the presence and amount of the skin flap
52Stage I Pressure Ulcers 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.
53Stage I Pressure Ulcers The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk persons” (a heralding sign of risk).
54Stage II Pressure Ulcer Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.May present as an intact or open/ruptured serum filled blister or a shiny or dry shallow ulcer without slough or bruising
55Stage II Pressure Ulcer Presents as a shiny or dry shallow ulcer without slough or bruising.* This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. *Bruising indicates suspected deep tissue injury
56Stage III Pressure Ulcer 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. May include undermining and tunneling.
57Stage III Pressure Ulcer The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers.
58Stage IV Pressure Ulcer Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.
59Stage IV Pressure Ulcer The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g. fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
60Unstageable Pressure Ulcer Full thickness loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
61Unstageable Pressure Ulcer 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 heels serves as “the body’s natural (biological) cover” and should not be removed.
62Suspected 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
63Suspected Deep Tissue Injury Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by a thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
64DefinitionsEschar: wound is covered with thick, dry, black necrotic tissue. Eschar may be allowed to slough off naturally, or it may require surgical removal (debridement)Slough: a mass or layer of dead tissue separated from the surrounding or underlying tissue, usually cream or yellow in colorGranulation Tissue: new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process
65DefinitionsUndermining: The wound extends under the visible opening; a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissueTunneling: A narrow opening or passageway underneath the skin that can extend in any direction through soft tissue and results in dead space with potential for abscess formationMaceration: The softening and eventual breakdown of tissue due to excess moisture, making the wound prone to infection
66Pressure Ulcers—Understanding and Staging Pressure Ulcers
67TreatmentGoals:MOIST wound healingProtect from traumaMoisture balanceDressings serve to protect the wound from trauma and contamination, and facilitate healing by absorption of exudate and protection of healing surfacesSelect dressings based on wound drainage:Dry wound (Dessicated): Wet itMoist wound: Maintain it, prevent macerationMod-High draining wound (Heavy Exudate): containUse skin prep to protect skin from skin tears.Cleanse ALL wounds with NS or Wound CleanserDate all dressings
68Treatment Heavy Exudate An absorptive dressing should be employed to avoid build up of chronic wound fluid that can lead to wound maceration and inhibition of cell proliferation and healing.An appropriate wound dressing can remove excess wound exudate while maintaining a moist environment to accelerate wound healingDressings with absorptive qualities include alginates, foams, and hydrofibers
69TreatmentDessicatedDessicated ulcers lack wound fluids, which provide tissue growth factors to facilitate re-epithelialization.Pressure ulcer healing is promoted by dressings that maintain a moist wound environment while keeping the surrounding intact skin dry.Choices for a dry wound include saline moistened gauze, transparent films, hydrocolloids, hydrogels, and Tenderwet
74Non-adherent Dressing Petrolatum GauzeOil/Emulsion (Adaptic)Uses: Prevent adherence of dressing to wound bed; Keeps wounds/meds moist; Maintains placement of skin grafts; Decreases painMay be used in conjunction with wound vac to prevent adherence of foam to woundOil based products can cause too much moisture creating macerated tissue over rimsRequires secondary dressingUsually change DailyOthers: Telfa – lifts no/minimal debris from wound base
75Enzymatic Debridement Collagenase ointmentUses: Stage III-IV Pressure UlcersDebrides mixed viable tissueMust be kept moistChange daily
76Moist to Low Draining Wounds Wound GelHydrogel (Carrasyn)FoamMepilex BorderHydrocolloidRestore Hydrocolloid 4x4Restore Extra Thin 4x4 (caution!)Antimicrobial Gel/OintmentBacitracin/BactrobanIodosorb GelSilvadene Cream
77Hydrocolloid Dressings Restore Hydrocolloid 4x4Restore Extra Thin 4x4Uses: dry, moist, minimal drainageStage I & II, shallow IIIPrimary/secondary dressingChange q 3-7 days and PRN soiled/looseMay be cut to fitDo not use on infected wounds; caution w/diabetic wounds
78Antimicrobial Gels/Ointments Iodosorb GelUses: Diabetic Foot ulcers, infected wounds-high drainageCadexamer Iodide based gel, provides sustained antimicrobial coverage to wounds without causing toxicity, absorbs drainage but does not allow wound to dry outRequires secondary dressingChange daily; potent to 72hours
79Antimicrobial Gels/Ointments Silvadene Cream – antibiotic gelProvides silver with significant antimicrobial propertiesCan not be used on patients allergic to sulfa drugsRequires secondary dressingChange daily
80Antimicrobial Gels/Ointments Silvasorb gelFor wounds with dry to moderate exudate.Use SilvaSorb Gel for a three-day (72hr) antimicrobial barrier, plus the moisture donating benefits of hydrogel.(we do not have this at RJD, at this time.)
81Moderate to Heavy Draining Wounds Calcium Alginate (heavy drainage)Calcium Alginate – silver/AG ca+ alginate7 day potency productsAntimicrobial Gel/Ointments (moderate drainage)Iodosorb Gel – 72hr potencySilvadene Cream – 24hr potency
82Calcium Alginate/Hydrofibers Calcium Alginate (Restore)Use: mod-large drainageStage II, III, IV, skin tears, venous stasis ulcers, surgical wounds, Dehisced woundsChange daily , QOD, or PRN strikethrough drainageMay be cut to fitNeeds secondary dressingContraindicated for dry wounds and third degree burns - adheres easilyOthers: Aquacel Ag
83Tape 1 or 2 inch Paper Tape General purpose Hypoallergenic and latex-freePreferred choice for wound care to prevent skin strippingVital use skin prep to protect skin pre-tape
84Wound Cleanser Cara Klenz Normal Saline Syringe Gentle No rinse Used to irrigate the woundNon-antibacterial soap
86Skin Prep Hollister prep wipes Protects Skin from additional breakdown from tape or moisture with plastic, copolymer layer on skinThis layer lifted off with tape removal, not repeat lift-off top skin layer.
87Moisturizers Aloe Vesta Protective Ointment Carmol Urea 20% Provides an effective barrier that seals out moisture, contains emollients to moisturize and is non-sensitizing and fragrance freeA&D OintmentHelps heal, protects, smoothes/soothesCarmol Urea 20%Carmol Urea 40%Exfoliates as it moisturizesMay stingPrimary use by our podiatrist.
92Requirements Braden Skin assessments are due: On admission On transfer (both sending and receiving wards)On dischargeWhen there is a change in conditionDaily in acute care and ICUWeekly in long-term care
93Who Can Do Assessments? Only RN can do initial assessment in this VAMC RN completes CPRS re-assessment withSometimes input requested of other nsgstaff members, LPNs, nurse technicians, nurse assistants, & to add care planinterventions
94Which Template Do I Use?On admission, use initial skin assessment that is embedded in the Initial AssessmentSkin Re-Assessment per embedded re-Assessment template toolInpatient wound dressing change:Wound assessment/sizeApplied care completed
96Part 1 – Braden ScaleThis slide shows the first section of the initial assessment template.At the top of the document you will noticed we have included the minimum documentation guidelines per the VHA directive.Highlighted in red is the Braden Skin risk assessment. I have entered in the patient’s information for each of the 6 components of the scale. At this time users must still do a manual total of the score and select the range in the second section and then select the individual score. A future patch release will revised this section and create a auto sum component and scoring for the scale – Anticipate release of this by the end of the summerNext Slide
97Part 2 – Additional Risk Factors Highlighted on this slide are the next two questions which address the Additional Risk factors of Skin patches and Special populationsUnder skin patches a yes response will present a free text box to describe each patch and location.A positive response to Major risk factors will present a check list to select those that apply.The next section of the template is the Current Skin Assessment. Seen on this slide with a response of either normal or abnormal. A selection of normal will allow the user to move forward to interventions with no addition input. However a response of abnormal will open up additional documentation to address skin temperature, moisture color and turgor. For this example we will select AbnormalNext Slide
98Part 3 – Current Skin Assessment At the top of the slide you will see I have selected the response of abnormal skin assessment, I have then selected the responses for the individual components for my patient.The next question asks if the patient has any skin problems such as wounds, bruising, rash, burns or pressure ulcers. A positive response here will allow us to continue documentation of our pressure ulcer and surgical woundNext Slide
99Skin ProblemsThe next slide shows that when yes to skin problems is selected the user is presented with a check list of the different types of “skin problems”On this slide I have selected wound and then documented in the text field the patients surgical wound. Bruising, rash, burns, and other will present the user with a text field to enter in description and location of the problems.Selection of pressure ulcer will again open up a series of additional questions – I will review those on the next series of slides.
100Skin Problems - Pressure Ulcer Here I have selected Pressure Ulcer - the next section of the template is list the various stages of pressure ulcers with a brief description per the NPUAP guidelines.Next Slide
101Pressure Ulcer Stage and Location I have selected stage 1 to open up this group for documentation the patient’s stage 1 ulcer.Next slide
102Pressure Ulcer - SizeHere I have selected sacrum/coccyx from the pick list as my location. I have copied this information into the size of pressure ulcer section and entered in the size of 2X2.If the patient had multiple stage one ulcers I would need to add each of these and then document the size in the field here.If the patient had multiple stages of ulcer you would document each using the same process under the stage for ulcer.
103Part 4 - InterventionsThe final part of the template is the interventions. Interventions are required if the patient’s Braden score is 18 or less or nursing judgment indicates there should be interventions. The user will be presented with a list of categories of interventions and default consult/alerts to other services for additional interventions.Next slide
104InterventionsOn this slide I have selected pressure-reducing measures and manage moisture and then a couple of interventions from each of these categories.For the CACs on the call – these interventions are set up as categories and health factors so that we can create a health summary object to pull in the selected interventions into our future notes.
105CPRS Final NoteThis slide shows our final CPRS note documenting our initial assessment including the Braden Skin risk Assessment, skin assessment, stage 1 pressure ulcer and selected interventions
107Part 1 – Braden ScaleOn this slide you will see at the top I have highlighted the previous Braden Scales that have been completed – Patients score range between Below this the score you will see that we have posted the minimum documentation requirements that I just presented. This text is set up as a Template filed and sites will be able to edit and customized the text to meet you local standards.Ok, because my patient had a change in condition I am going to document a new Braden Scale – I selected the check box to activate this section. Complete the Braden scale and total the score. My new Braden Score is 12.If a Braden scale was not indicated at this time and all I was doing was documenting a Skin Inspection I would not select the Braden scale but just move down the template
108Part 2 - Skin AssessmentAs we move down the template the next section is the Skin Assessment section. Again highlighted in red is my prior skin assessment which was documented earlier. On the template you are given two selections at this point - No change from prior skin assessment or Change from prior skin assessment (which refers back to the information highlighted in red on this slide). Since in our example here that patient is no pale and cool I will select the choice Change from prior skin assessment. I would now go ahead and document the color, temperature, moisture and turgor. Next Slide
109Skin Problems Pressure Ulcer Information from Previous Assessment The next section asks if there are any new skin problems such as a wound or ulcer – Again I will select yes because we found a new ulcer.When you respond yes at the prompt asking about skin problems you are presented with a list of potential problems. I have selected Pressure ulcer present. Once again in the expanded selection you would be presented with information about previous documentation of pressure ulcers – For the CACs on the call is one of the health summary objects that you will create on when you load in the templates at your sites. In our example here you will see that the patient previously enter pressure ulcer has been pulled into our template. Next Slide
110New Pressure UlcerSince this is a new pressure ulcer since the last assessment I will select the new pressure ulcer since last assessment choice. This selection with open another section of the template that we will use to document the stage , location and size of our new ulcer. If I had multiple ulcer I would document each of them at this time. The is the same process that reviewed in the Initial Assessment template earlier.
111Part 4 - InterventionsShown here is a screen capture of the Intervention section of the template. Highlighted in red are those intervention that had been selected earlier for this patient. The user can elect to make changes to these intervention or to continue them. Again the process is the same as under the intervention for the initial assessmentNext Slide
112To update ALL currentinterventions must be enteredHere I have selected the choice to make change sin my intervention since at this point I want to add in additional measures. To update the intervention the users must reselect all of the previous interventions entered. This will then be placed into the final progress note.END