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Skin Champion Education

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1 Skin Champion Education
Robert J. Dole VAMC SKIN/Wound care education

2 Objectives Describe the pathophysiology of wound healing
Explain the difference between acute and chronic wounds Identify factors that impair wound healing Describe the benefits of moist wound healing State the principles of wound management Explain pressure ulcer risk, skin, and wound assessment documentation requirements. Discuss the importance of pressure ulcer prevention Describe how a pressure ulcer develops Describe the key elements in pressure ulcer assessment and staging

3 Anatomy of the Skin

4 Epidermis Outermost layer (epi- means upon)
Thickness from 0.1mm to 1.0mm Slightly acidic – avg. pH 5.5 “ACID MEMBRANE” Contains melanocytes – pigment Made up of 4 to 5 layers depending on location

5 Layers of the epidermis
Stratum corneum - horny layer - dead skin cells (keratinized epithelium) -environment Acid mantle protects from some fungi and bacteria Shed and replaced every 4 to 6 weeks Stratum lucidum - clear layer – single cell layer found where thickest – soles of feet Intense enzyme activity prepares cells for stratum corneum even though lacks nuclei Stratum granulosum - granular layer – 1 to 5 cells – flat cells with nuclei – aids keratin formation -

6 Layers of the epidermis
Stratum spinosum – cells begin to flatten as they migrate – protein precursor of keratinized skin cells synthesized Stratum basale / stratum germinativum One cell thick Only layer that undergoes mitosis Forms dermoepidermal junction – protrusions known as rete ridges or epidermal ridges extend into dermis and are surrounded by vascularized dermal papillae Support and exchange of fluid and cells

7 Dermis - deeper layer of skin
Collagen (strength) and elastin (elasticity) fibers produced by fibroblasts Extracellular matrix – gives skin its physical characteristics Blood and lymphatic vessels – transport O2, nutrients and remove wastes Nerve fibers, hair follicles, sweat glands – contribute to sensation, temperature regulation, excretion and absorption Sebaceous glands – sebum lubricates and softens the skin

8 Dermis Two layers of connective tissue
Papillary dermis - outermost layer Composed of collagen and reticular fibers important in wound healing Capillaries transport nourishment Reticular dermis – innermost Thick network of collagen bundles anchor it to subcutaneous tissue, fasciae, muscle and bone

9 Subcutaneous tissue (Hypodermis)
Layer of loose connective tissue that contains major blood and lymph vessels and nerves High proportion of fat cells Fewer small blood vessels than dermis Provides insulation, absorbs shocks to the skeletal system

10 Effects of Aging 50% reduction in cell turnover rate of stratum corneum 20% reduction in dermal thickness Reduction in vascularization and blood flow to the skin Redistribution of subcutaneous tissues to stomach and thighs Reduced adhesion between layers Reduced number of Langerhan’s cells – macrophages that attack invading bacteria 50% decrease in fibroblasts and mast cells involved in inflammatory process Decrease number of sweat glands Decreased absorption Reduced ability to sense pressure, heat and cold

11 Phases of Wound Healing
Hemostasis - vasoconstriction and coagulation collagen fibers in the damaged vessels wall activate platelets Inflammation – defense and healing Neutrophils engulf debris and bacteria Monocytes converted to macrophages Macrophages produce growth factors that attract cells needed for new vessel growth, collagen for granulation and epithelialization

12 Phases of Wound Healing
Proliferation granulation tissue (connective tissue) fills the wound Wound edges retract/contract Epithelium migrates across the wound Maturation Shrinking and strengthening of the scar Continues for months and even years – 80%

13 Hemostasis phase

14 Inflammatory phase

15 Proliferation phase

16 Maturation phase

17 Non-healing wound

18 Acute wounds Occur by intension or trauma Surgical wounds
Begins with a sudden, single insult Proceeds to heal in an orderly manner Surgical wounds Traumatic wounds: unplanned injury to the skin Burns Skin grafting

19 Acute wound

20 Chronic wounds Caused by underlying pathology that produces repeated and prolonged insults to the tissues Frequently complicated by ischemia, necrotic tissue and heavy bacterial loads High levels of inflammatory proteases and low levels of growth factors

21 Chronic wound

22 Factors that affect healing
Nutrition Oxygenation Infection Age Chronic health conditions Medications Smoking

23 Nutrition Malnutrition increases the risk of developing pressure ulcers and delays healing Protein is crucial for proper healing (0.8 to 1.6g/kg/day) Collagen formation is reduced or delayed without adequate protein Fatty acids (lipids) used in cell structures and inflammatory processes Vitamins C, B-complex, A, and E and minerals iron, copper, zinc, and calcium are important Zinc deficiency slows epithelialization and decreases tensile strength

24 Oxygenation Wound healing depends on a regular supply of oxygen
Critical for leukocytes to destroy bacteria and fibroblasts for collagen synthesis Impaired blood flow to the wound or the patients inability to take in adequate O2 Causes of inadequate blood flow to the wound Pressure, arterial occlusion, prolonged vasoconstriction, PVD and atherosclerosis Compromised perfusion more likely to impair healing Causes of inadequate systemic blood oxygenation Acute and chronic conditions such as COPD, hypothermia hypotension, hypovolemia, cardiac insufficiency

25 Infection Systemic infections (pneumonia, TB) increase metabolism and depletes the fluids, nutrients and O2 the body needs for healing Localized from the injury or develops secondary Inflammatory phase lingers delaying wound healing Metabolic by-products of bacterial ingestion accumulate in the wound and interferes with formation of new blood vessels and collagen synthesis Signs: new or increased pain, exudate, redness, heat, induration, edema, malodor

26 Aging Slower turnover rate in epidermal cells
Decreased O2 at the wound – increasingly fragile capillaries and reduction in skin vascularization Altered nutrition and hydration Impaired function of immune or respiratory systems Reduced dermal and subcutaneous mass Healed wounds lack tensile strength and are subject to reinjury Chronic health conditions

27 Chronic health conditions
Pulmonary disease, atherosclerosis, diabetes and malignancies increase risk and interfere with wound healing Impaired circulation common in diabetes and conditions that cause hypoxia Neuropathy associated with diabetes increases risk and can impair leukocyte function Dehydration, ESKD, thyroid disease, heart failure, PVD, vasculitis, and other collagen vascular disorders can delay healing

28 Medications Any medication that reduces movement, circulation, or metabolic function Sedatives tranquilizers Medications that reduce the body’s ability to mount an appropriate inflammatory response Steroids Chemotherapeutic agents

29 Smoking Carbon dioxide binds to the hemoglobin in blood in place of oxygen Reduces the amount of circulating oxygen Occurs with exposure to second hand smoke as well Nicotine causes vasoconstriction and increased coagulability

30 Wounds/Ulcers Principles of Wound Healing


32 Prevention

33 Braden Interventions

34 Sensory Perception 4. No Impairment (Provide routine skin care).
Sensory Perception Able to respond meaningfully to pressure-related discomfort. 4. No Impairment (Provide routine skin care). 3. Slightly limited a. 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 limited a. 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 limited a. Provide all of above as needed.

35 Moisture Degree to which skin is exposed to moisture. 4. Rarely moist
Moisture Degree to which skin is exposed to moisture. 4. Rarely moist a. Instruct resident to request care as needed b. Assess and provide routine skin care as needed to keep skin clean and dry. 3. Occasionally moist a. 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 incontinence c. Consider fecal/urinary incontinence containment device (esp. if existing skin breakdown) 1. Constantly moist a. Provide all of above b. Apply fecal/urinary incontinence device, as able.

36 Activity Degree of physical activity. 4. Walks frequently
Activity Degree of physical activity. 4. Walks frequently a. Encourage activity as tolerated 3. Walks occasionally a. 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 fast a. Provide all of above b. 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. Bedfast a. Provide all above, as needed. b. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)

37 Mobility 4. No Limitation(Provide routine skin care).
Mobility Ability to change and control body position. 4. No Limitation(Provide routine skin care). 3. Slightly limited a. 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 Limited a. Provide above b. Limit W/C to 1-2 hour intervals 1. Completely immobile a. Provide above. b. Consider Wound Care Nurse consult for higher level support surface (esp. if there is existing skin breakdown).

38 Nutrition Usual food intake pattern. 4. Excellent(Provide tray set up and other routine assistance as needed). 3. Adequate a. Encourage meals and assist with meals as needed. b. Offer ordered supplements. c. Assess needs for oral care, assist PRN 2. Probably inadequate a. Provide above b. Consult dietician 1. Very poor b. 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 & Shear 3. No apparent problem (Provide routine skin care) 2. Potential problem a. 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. Problem a. Provide above b. Consider use of assisting devices (i.e. trapeze)

40 Types of Wounds Treat Based on Drainage Specific Treatments
Pressure Ulcers Diabetic Ulcers Venous Insufficiency Ulcers Arterial Ulcers Specific Treatments Incontinence Dermatitis Perineal Candidiasis Skin Tears

41 Diabetic/Neuropathic Ulcers
Types of Wounds Diabetic/Neuropathic Ulcers Found in diabetic patients with peripheral neuropathy; usually on the ball of the foot or tops of toes; prone to infection Approximately 15% of patients with diabetes develop foot ulcers. 23% of this group develop osteomyelitis Incidence of vascular disease is at least four times higher in patients with diabetes and increases with age and disease duration

42 Diabetic/Neuropathic Ulcers- Causes
Pressure, secondary to peripheral neuropathy and/or arterial insufficiency Plantar aspect of foot Over metatarsal heads Under heel Poor microvascular circulation Poor blood sugar control Lack of sensation

43 Diabetic/Neuropathic Ulcer Characteristics
Below the ankle Poor circulation Neuropathy Sites of pressure, friction, shear Sites of trauma Even wound margins Peri-wound callous Round Hemorrhagic callous Increased potential for infection

44 Venous Insufficiency Ulcers
Types of Wounds Venous Insufficiency Ulcers Usually due to minor trauma; pretibial area of shin or above the medial ankle; superficial but difficult to heal

45 Venous Ulcers - Causes Problems with venous blood return to heart
Non-functioning or inadequate calf muscle pump Incompetent perforator valve Incompetent valves in the vein All lead to venous hypertension Venous blood pools in lower extremity and foot

46 Characteristics of Venous Insufficiency Ulcers
Edema Hyperpigmentation Gaiter distribution Ankle flare Atrophy of skin Eczema Lipodermatosclerosis Palpable pulses Irregular borders Usually shallow Weepy Located on medial lower leg and malleolus can be circumferential Pain relieved by elevation Heavily contaminated

47 Types 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

48 Characteristics of Arterial Ulcers
Absence of hair Atrophy below level of occlusion Pain upon elevation Absence of palpable pulse Sites of trauma Often bright red granulation tissue Well defined borders/punched out appearance Minimal drainage Usually full thickness Usually lateral foot, can be anywhere Dependent rubor Tendon exposure

49 Types of Wounds Incontinence Dermatitis
Injury to the skin caused by exposure to excessive moisture, urine, and/or stool Characterized by inflammation, rash, and possibly denuded skin Anywhere in the sacral/coccyx, buttock, or perineal area

50 Types of Wounds Perineal Candidiasis
Fungal/Candida infection characterized by erythematous papules and satellite lesions, and/or scaly borders

51 Types 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 structures Incision-like skin lesion Classified based on the presence and amount of the skin flap

52 Stage 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.

53 Stage 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).

54 Stage 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

55 Stage 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

56 Stage 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.

57 Stage 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.

58 Stage 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.

59 Stage 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.

60 Unstageable 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.

61 Unstageable 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.

62 Suspected 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.

63 Suspected 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.

64 Definitions Eschar: 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 color Granulation Tissue: new connective tissue and tiny blood vessels that form on the surfaces of a wound during the healing process

65 Definitions Undermining: The wound extends under the visible opening; a hollow between the skin surface and the wound bed that occurs when necrosis destroys the underlying tissue Tunneling: 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 formation Maceration: The softening and eventual breakdown of tissue due to excess moisture, making the wound prone to infection

66 Pressure Ulcers—Understanding and Staging Pressure Ulcers

67 Treatment Goals: MOIST wound healing Protect from trauma Moisture balance Dressings serve to protect the wound from trauma and contamination, and facilitate healing by absorption of exudate and protection of healing surfaces Select dressings based on wound drainage: Dry wound (Dessicated): Wet it Moist wound: Maintain it, prevent maceration Mod-High draining wound (Heavy Exudate): contain Use skin prep to protect skin from skin tears. Cleanse ALL wounds with NS or Wound Cleanser Date all dressings

68 Treatment 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 healing Dressings with absorptive qualities include alginates, foams, and hydrofibers

69 Treatment Dessicated Dessicated 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

70 Incontinence Dermatitis
Aloe Vesta Barrier Cream Carrington moisture barrier Butt paste Xenaderm Ointment (Castor Oil/Balsam Peru/Trypsin) Use: Incontinence and Radiation Dermatitis; Superficial skin breakdown causing pain Creates moist wound environment by stimulating capillary bed, promotes epithelium, assists in pain control. Does not require secondary dressing Apply BID & PRN Moisturizing Water-repellent protective barrier Apply BID, PRN

71 Wound Dressings Wound Gel Foam Non-adherent Dressing
Hydrogel (Carrington/Carasyn) Santyl Collagenase Foam Mepitel and Lyofoam Non-adherent Dressing Petrolatum Gauze Oil/Emulsion Dressing (Adaptic)

72 Wound Gel Wound-specific Adds moisture Autolytic debridement
Softens eschar

73 Foam Dressing Mepilex Border Lyofoam(special rx)
Uses: dry, moist, minimal-mod drainage Stage II, Shallow III, skin tears, abrasions, venous stasis ulcers, Change qd, PRN

74 Non-adherent Dressing
Petrolatum Gauze Oil/Emulsion (Adaptic) Uses: Prevent adherence of dressing to wound bed; Keeps wounds/meds moist; Maintains placement of skin grafts; Decreases pain May be used in conjunction with wound vac to prevent adherence of foam to wound Oil based products can cause too much moisture creating macerated tissue over rims Requires secondary dressing Usually change Daily Others: Telfa – lifts no/minimal debris from wound base

75 Enzymatic Debridement
Collagenase ointment Uses: Stage III-IV Pressure Ulcers Debrides mixed viable tissue Must be kept moist Change daily

76 Moist to Low Draining Wounds
Wound Gel Hydrogel (Carrasyn) Foam Mepilex Border Hydrocolloid Restore Hydrocolloid 4x4 Restore Extra Thin 4x4 (caution!) Antimicrobial Gel/Ointment Bacitracin/Bactroban Iodosorb Gel Silvadene Cream

77 Hydrocolloid Dressings
Restore Hydrocolloid 4x4 Restore Extra Thin 4x4 Uses: dry, moist, minimal drainage Stage I & II, shallow III Primary/secondary dressing Change q 3-7 days and PRN soiled/loose May be cut to fit Do not use on infected wounds; caution w/diabetic wounds

78 Antimicrobial Gels/Ointments
Iodosorb Gel Uses: Diabetic Foot ulcers, infected wounds-high drainage Cadexamer Iodide based gel, provides sustained antimicrobial coverage to wounds without causing toxicity, absorbs drainage but does not allow wound to dry out Requires secondary dressing Change daily; potent to 72hours

79 Antimicrobial Gels/Ointments
Silvadene Cream – antibiotic gel Provides silver with significant antimicrobial properties Can not be used on patients allergic to sulfa drugs Requires secondary dressing Change daily

80 Antimicrobial Gels/Ointments
Silvasorb gel For 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.)

81 Moderate to Heavy Draining Wounds
Calcium Alginate (heavy drainage) Calcium Alginate – silver/AG ca+ alginate 7 day potency products Antimicrobial Gel/Ointments (moderate drainage) Iodosorb Gel – 72hr potency Silvadene Cream – 24hr potency

82 Calcium Alginate/Hydrofibers
Calcium Alginate (Restore) Use: mod-large drainage Stage II, III, IV, skin tears, venous stasis ulcers, surgical wounds, Dehisced wounds Change daily , QOD, or PRN strikethrough drainage May be cut to fit Needs secondary dressing Contraindicated for dry wounds and third degree burns - adheres easily Others: Aquacel Ag

83 Tape 1 or 2 inch Paper Tape General purpose
Hypoallergenic and latex-free Preferred choice for wound care to prevent skin stripping Vital use skin prep to protect skin pre-tape

84 Wound Cleanser Cara Klenz Normal Saline Syringe Gentle No rinse
Used to irrigate the wound Non-antibacterial soap

85 Skin Cleansing Aloe vesta foam cleanser No-rinse, gentle cleanser
Moisturizes and conditions skin

86 Skin Prep Hollister prep wipes
Protects Skin from additional breakdown from tape or moisture with plastic, copolymer layer on skin This layer lifted off with tape removal, not repeat lift-off top skin layer.

87 Moisturizers 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 free A&D Ointment Helps heal, protects, smoothes/soothes Carmol Urea 20% Carmol Urea 40% Exfoliates as it moisturizes May sting Primary use by our podiatrist.

88 Ace Bandages, Gauze, & Packing
4x4 Sterile 2x2 Sterile ABD (abdominal pad) Kling- elastic, 3” Kerlix- 4.5” sterile bandage Packing (emphasis ‘filling’) Plain Packing – ¼”, ½”, 1” – nu-gauze Silver alginate

89 Wound Care Reference Guide Pressure Ulcer Policy guidelines for choices and application

90 Consulting Wound Care Nurse
When to call for help: Notify of ALL new admissions with pressure ulcers New onset pressure ulcers Other wound development, from Stage I And/or partial, full-thickness wounds

91 Documentation

92 Requirements Braden Skin assessments are due: On admission
On transfer (both sending and receiving wards) On discharge When there is a change in condition Daily in acute care and ICU Weekly in long-term care

93 Who Can Do Assessments? Only RN can do initial assessment in this VAMC
RN completes CPRS re-assessment with Sometimes input requested of other nsg staff members, LPNs, nurse technicians, nurse assistants, & to add care plan interventions

94 Which Template Do I Use? On admission, use initial skin assessment that is embedded in the Initial Assessment Skin Re-Assessment per embedded re- Assessment template tool Inpatient wound dressing change: Wound assessment/size Applied care completed

95 Initial Skin Assessment Template

96 Part 1 – Braden Scale This 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 summer Next Slide

97 Part 2 – Additional Risk Factors
Highlighted on this slide are the next two questions which address the Additional Risk factors of Skin patches and Special populations Under 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 Abnormal Next Slide

98 Part 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 wound Next Slide

99 Skin Problems The 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.

100 Skin 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

101 Pressure Ulcer Stage and Location
I have selected stage 1 to open up this group for documentation the patient’s stage 1 ulcer. Next slide

102 Pressure Ulcer - Size Here 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.

103 Part 4 - Interventions The 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

104 Interventions On 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.

105 CPRS Final Note This 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

106 Skin Reassessment Template

107 Part 1 – Braden Scale On 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

108 Part 2 - Skin Assessment As 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

109 Skin 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

110 New Pressure Ulcer Since 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.

111 Part 4 - Interventions Shown 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 assessment Next Slide

112 To update ALL current interventions must be entered Here 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

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