Presentation on theme: "Skin Champion Education Robert J. Dole VAMC SKIN/Wound care education."— Presentation transcript:
Skin Champion Education Robert J. Dole VAMC SKIN/Wound care education
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
Anatomy of the Skin
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
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 -
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
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 O 2, 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
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
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
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
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
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%
Acute wounds Occur by intension or trauma 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
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
Factors that affect healing Nutrition Oxygenation Infection Age Chronic health conditions Medications Smoking
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
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
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
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
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
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
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
Wounds/Ulcers Principles of Wound Healing
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.
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.
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)
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).
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 a. Provide above b. Consider WOCN consult for higher level support surface (esp. if existing skin breakdown)
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)
Types of Wounds Treat Based on Drainage Pressure Ulcers Diabetic Ulcers Venous Insufficiency Ulcers Arterial Ulcers Specific Treatments Incontinence Dermatitis Perineal Candidiasis Skin Tears
Types of Wounds 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 Diabetic/Neuropathic Ulcers
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
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
Types of Wounds Usually due to minor trauma; pretibial area of shin or above the medial ankle; superficial but difficult to heal Venous Insufficiency Ulcers
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
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
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
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
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
Types of Wounds Fungal/Candida infection characterized by erythematous papules and satellite lesions, and/or scaly borders Perineal Candidiasis
Types of Wounds 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 Skin Tears
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.
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 ).
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
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
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.
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.
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.
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.
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.
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.
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.
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.
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
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
Pressure Ulcers—Understanding and Staging Pressure Ulcers
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
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
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
Wound Dressings Wound Gel Hydrogel (Carrington/Carasyn) Santyl Collagenase Foam Mepitel and Lyofoam Non-adherent Dressing Petrolatum Gauze Oil/Emulsion Dressing (Adaptic)
Wound Gel Adds moisture Autolytic debridement Softens eschar Wound-specific
Foam Dressing Uses: dry, moist, minimal- mod drainage Stage II, Shallow III, skin tears, abrasions, venous stasis ulcers, Change qd, PRN Mepilex Border Lyofoam(special rx)
Non-adherent Dressing 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 Petrolatum Gauze Oil/Emulsion (Adaptic)
Enzymatic Debridement Uses: Stage III-IV Pressure Ulcers Debrides mixed viable tissue Must be kept moist Change daily Collagenase ointment
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
Hydrocolloid Dressings 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 Restore Hydrocolloid 4x4 Restore Extra Thin 4x4
Antimicrobial Gels/Ointments 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 Iodosorb Gel
Antimicrobial Gels/Ointments Provides silver with significant antimicrobial properties Can not be used on patients allergic to sulfa drugs Requires secondary dressing Change daily Silvadene Cream – antibiotic gel
Antimicrobial Gels/Ointments 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.) Silvasorb gel
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
Calcium Alginate/Hydrofibers 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 Calcium Alginate (Restore) Others : Aquacel Ag
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
Wound Cleanser Cara Klenz Gentle No rinse Normal Saline Syringe Used to irrigate the wound Non-antibacterial soap
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.
Moisturizers Aloe Vesta Protective Ointment 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.
Wound Care Reference Guide Pressure Ulcer Policy guidelines for choices and application
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
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
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
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
Initial Skin Assessment Template
Part 1 – Braden Scale
Part 2 – Additional Risk Factors
Part 3 – Current Skin Assessment
Skin Problems - Pressure Ulcer
Pressure Ulcer Stage and Location
102 Pressure Ulcer - Size
Part 4 - Interventions
105 CPRS Final Note
Skin Reassessment Template
Part 1 – Braden Scale
Part 2 - Skin Assessment
Skin Problems Pressure Ulcer Information from Previous Assessment
New Pressure Ulcer
Part 4 - Interventions
To update ALL current interventions must be entered