Presentation on theme: "SKIN ASSESSMENT AND PRESSURE ULCER PREVENTION"— Presentation transcript:
1 SKIN ASSESSMENT AND PRESSURE ULCER PREVENTION Denise Gutwein, MSN, RN, CCRNICU Clinical CoordinatorPutnam Community Medical Center
2 Educational Objectives The learner will be able to:Describe the best approach to preventionIdentify the major risk factors for developing pressure ulcersDemonstrate how to use the Braden Scale assessment toolSelect the proper surface for assessment findingsGive an overview of wound care utilizing dressings, irrigation, debridement and/or wound vac appropriate to the characteristics of the pressure ulcer.
3 SKIN FACTS: Largest organ of the body Covers approximately 3000 square inchesReceives 1/3 circulating blood volumeFrom birth to maturity, the skin will undergo a sevenfold expansionWeighs about 6 pounds1cm of skin has 15 sebaceous glands, 3 yards of blood vessels, 100 sweat glands, 3,000 sensory cells, 4 yards of nerves, 300,000 epidermal cells and 10 hair folliclesIs capable of self-generationCan withstand limited mechanical and chemical assault
4 Early Pressure Relief: “I myself think that a few, very small pillows placed here and there and moved about whenever there seems to be pressure are really preferable . . .” Florence Nightingale (letter to family with bed-bound child)
9 Risk Factors Risk Factors for Pressure Ulcer Development: Inability to perceive pressureIncontinence/moistureDecreased activity levelInability to repositionPoor nutritional intakeFriction and shear
10 Etiology Factors Contributing to Pressure Ulcers Etiologic factors contributing to pressure ulcer occurrence:PressureShearFrictionPRESSURE: Squeezing together of soft tissue caused by weightSHEAR: Shearing forces stretch or tear the blood vessels, reducing the amount of pressure needed to occlude them.FRICTION: Mechanical force that opposes the movement of one surface across another.
11 Factors affecting Tissue Tolerance Tissue tolerance factors affecting pressure ulcer development:Vascular competencyGlycemic control in diabetes mellitusBody weight/malnutritionAge
12 FORCES IN PRESSURE ULCER DEVELOPMENT INTRINSICNUTRITIONTISSUE OXYGENATIONCOMORBIDTIESINFECTIONEXTRINSICPRESSURESHEARFRICTIONMACERATIONTEMPERATUREERGONOMICS
13 Risk Assessments Using Valid and Reliable Tool The risk assessment tool selected for LifePoint Hospital’s adult patient population is the Braden ScaleScore the risk assessment Braden ScaleInterpret the significance of the score (high, moderate or low risk levels)Reassess at frequency defined in policy and with significant changes or transfer to another department (to surgery, for example)
14 Braden Risk Assessment Scale Braden Risk Assessment Scale (abridged version)Sensory Perception1 Completely limited2 Very limited3 Slightly limited4 No impairmentMoisture1 Constantly moist2 Very moist3 Occasionally moistActivity1 Bedfast2 Chairfast3 Walks Occasionally4 Walks frequentlyMobility1 Completely immobile4 No limitationNutrition1 Very poor2 Probably inadequate3 Adequate4 ExcellentFriction and Shear1 Problem2 Potential problem3 No apparent problem
15 Base the Plan on Patient Needs (subscale scores) Immobile = reposition q 2 hrs in bedInactive = reposition q 1hr in w/cIncontinent = protect skin from exposureMalnourished = supplement oral intakeShearing = keep HOB as low as possibleLimited awareness= assess skin daily
16 Nutritional Screening Screen for Nutritional DeficitsProvide nutritional support to patients with nutritional risks & pressure ulcer risksComplete nutritional assessment by the dietician as indicatedEstimation of nutritional requirementsCompare nutrient intake with estimated requirementsIdentify best feeding routeProvide nutritional supplements as orders between regular meals in order NOT to influence normal food and fluid intake during regular mealtimes.Monitor nutritional outcomeReassess nutrition status when there is a change in the individual’s condition.
17 Conduct a Thorough Skin Assessment Assess on admission and routinely (Braden Scale or as per P&P)Document finding and incorporate into plan of careAssess bony prominences and other areas of exposure to etiologic factors. (Roll patient over to inspect front and back)Observable indications of tissue ischemia (defined in stages)
18 Pressure ulcer stages Stage 1: epidermis; non-blanching erythema Stage 2: epidermis/dermis; shallow opening;blistersStage 3: subcutaneous tissue/fasciaStage 4: fascia + bone, tendon, muscle,cartilageUnstageableNote: stages define level of tissue injury and NOT progression of ulcer development or healing.
19 The Medical History & Physical Exam History and Physical Exam findings may lead to the diagnosis of pressure ulcer.The etiology of a wound establishes the type of wound and it’s management. Not all wounds are pressure ulcersWhile staging may be performed by other clinicians, the stage documented and determined by the physician constitutes the diagnosis.Assure staging documented by various clinicians is not contrary to the stage documented by the physician.The physician is responsible to examine the patient and stage the pressure ulcer. While clinicians may collaborate, the physical exam findings and staging is the responsibility of the physician.
20 Physiological condition affecting nutrition Nutritional CareEvaluate appropriate lab dataAlbumin normal adult range: mg/dlPre-albumin normal adult range: 16 – 42 mg/dlHemoglobinnormal adult (Female) range: mg/dl normal adult (Male) range: 14 – 18 mg/dlHematocritnormal adult (Female) range: 37 – 47% normal adult (Male) range 40 – 54%
21 Documentation Documentation should reflect: Assessment and screening findingsHistory & physical exam findings, reason for hospitalization, lab & other test results, weight and recent change, nutritional screening results, Braden’s score, stage of decubitus, prior treatment and results.Description of skin breakdown to includeLocation, size in length and width, depth & tissue identified at base of ulcer, exudate, smell, color, firmness/bogginess, tunneling, skin condition at integuma, presence of excar.Reassessment findings at frequency defined in P&PPlan of Care: cleansing, positioning, turning, barrier meds, surface chosen for offloading, dressing care/change, other interventionsInterventions as instituted and patient response.Patient/family educationConsultsReports to MD with orders received
22 Back to the Basics ALL PATIENTS WILL BE KEPT CLEAN & DRY Moisture from incontinence contributes to pressure ulcer development by macerating the skin. Fecal incontinence is a greater risk factor for pressure ulcer development than urinary incontinence because the stool contains bacteria and enzymes that are caustic to the skin.
23 Preventive Skin Care Reduce exposure to irritants Clean immediately after incontinenceApply skin protectantsKeep linens clean/wrinkle freeCheck fit of braces, splints, medical devices (e.g., oxygen tubing, NG tube, stockings) and skin underneathMaintain environmental humidityIndividualize frequencyDocument
24 Positioning Devices Teach individual to reposition using the trapeze Use lifting devices to move individuals who cannot assistPlace pillows/wedges between knees and ankles
25 Head of Bed Elevation Maintain lowest possible elevation Avoid more than 30° head-of-bed elevation unless medically needed
26 Side Lying Position Avoid positioning directly on the trochanters Use the 30° lateral inclined position
27 Elevate Heels Ensure space between bed and heels (float heels) Use pillows to elevate heels off the bed surfaceAvoid hyper-extension of the kneesCheck for injury from splints when used for heel elevation
28 No DonutsDo NOT use plastic rings or donuts for pressure relief as this can cause larger area of tissue injury because of intense pressure along the donutX
29 No Massage Avoid Massage of Red Areas Massage may decrease rather than increase blood flow
30 Let the skin breathe Incontinence Management DO:Use gentle soap or skin cleanserApply topical barrier to protect skinDON’TScrub the skinUse plastic incontinence pads on low air loss beds
31 Reduce Shear & Shearing Shear diminishes blood supply to skinUse positioning, transferring & turning techniques to minimize friction/shear injury
32 Support SurfacesPatients at high risk for the development of a pressure ulcer or those with existing pressure ulcer will need a support surface.
33 Change Support Surfaces Most pressure reducing devices are more effective than standard hospital mattress
34 Types of Support Surfaces Category 1Static overlays and mattressesFoam, air, gelCategory 2Alternating pressure and air flotationCategory 3Air fluidizedLow air loss bed/mattress
35 Support Surfaces in Chairs If patient spends a prolongedtime in a wheelchair:Use pressure reducing cushionInstruct to also relieve pressure with handLifts if possible every 15 minutesChange chair to tilt/recline for more pressure distribution
36 Assessing Performance of a Support Surface Bottoming outSurface totally compressedUse hand check, should not be able to feel personMemory in foamShape remainsBunching in gelsDeflation in air filled or leakage of fluid or gel
37 Hand-off communication Communication to the nurse of new findings is important to discuss in a timely manner.New areas of redness, maceration or breakdownChange in incontinence pattern or diarrheaOdor to woundDressing soilage or drainage through dressingTemperature, low blood pressure and/or lethargic as asign of infectionChange of shift hand-off communication:Status of skinNew areas of redness or breakdownLast turn positionChanges in the patient conditionLocation of decubitus and treatment intervention appliedPain, temperature, vs abnormalities and lethargy
38 DocumentationTHERE MUST BE DOCUMENTATION THAT WE MADE EVERY ATTEMPT TO PREVENT THE PATIENT FROM DEVELOPING A PRESSURE ULCER.THERE MUST BE DOCUMENTATION THAT WE COMMUNICATE SKIN CARE ISSUES BETWEEN CAREGIVERSTHERE MUST BE DOCUMENTATION THAT WE NOTIFY THE PHYSICIAN OF PATIENTS SKIN ASSESSMENT FINDINGS AND WE RECEIVE ORDERS FOR ANY CARE WE PROVIDE TO THE PATIENT
39 PREVENTION OF MACERATION KEEP PATIENTS DRY AND CLEANDO NOT USE DIAPERS UNLESS THE FAMILY INSISTS. THIS MUST BE DOCUMENTED.USE CLOTH CHUXUSE PH BALANCED PERINEAL CLEANSERNOTIFY NURSE TO GET AN ORDER FOR INCONTINENT BARRIER CREAM (CALMOSEPTINE)MAKE ALL EFFORTS TO CONTINUE HOME BOWEL AND BLADDER PROGRAM
42 Pressure Ulcer Staging Stage IStage I - An observable pressure related alteration of intact skin whose indicators as compared to the adjacent or opposite area on the body may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel) and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.
44 Pressure Ulcer Staging Stage IIStage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
45 Pressure Ulcer Staging Stage IIPartial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.
49 Pressure Ulcer Staging Stage IIIFull thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.Stage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
50 Pressure Ulcer Staging Stage IIIStage III - Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to, but not through, underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue
52 Pressure Ulcer Staging Stage IVFull thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (ie., tendon, joint, capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcersStage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers
55 Pressure Ulcer Staging Stage IVStage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers
56 Pressure Ulcer Staging Stage IVStage IV - : Full thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (e.g. tendon, joint capsule). Undermining and sinus tracts also may be associated with Stage IV pressure ulcers