Causes of Skin Damage: Pressure, Shear, Friction, Moisture Examples of Friction: Heels and elbows which aid in movement for bedridden patients.Agitated patients or those experiencing seizures. Superficial abrasion or blistering
ShearShear is the interaction of gravity and friction causing twisting or kinking of blood vessels.Shear occurs when the skeleton moves, but the skin remains fixed to an external surface.
Examples of Shear: Pulling patient up in bedPatient in Fowler’s position who slides down in bed Slide patient from bed to stretcher.
FrictionFriction contributes to pressure ulcer formation by damaging the skin at the epidermal- dermal interface, the basement membrane. Friction ulcers are generally superficial and easily reversed, unless the cause is not removed.
Factors Increasing Risk Advanced Age : decreased elastic fibers.More than 50% of pts with pressure sores >70 Decreased sensory perception Peripheral Vascular Disease Impaired Circulation Edema Vasoconstriction drugs MI/ Stroke, Trauma/fractures GI bleed
Highest risk factors >70 years stroke impaired mobility pneumonia current smoking CHF low BMI fever altered mental state sepsis urinary and fecal hypotension incontinence dry and scaly skin malnutrition history of pressure restraints ulcers cancer anemia diabetes lymphopenia hypoalbuminemia
ALL patients require aR. A at Admission & every 24 hours.
Skin Safety: Risk Assessment Reassessment: Every 24 hours(Pressure ulcers can develop within 24 hours of insult or take as long as 5 days to present.) Change in condition (surgery, nutrition, level of mobility, etc)
Braden Scale The Braden score is the total of the subcategory scores. Sensory Perception Moisture Activity Mobility Nutrition Friction and Shear
Sensory Moisture Activity Mobility Nutrition Friction & perception shearNo impairment Rarely moist Walks No Excellent 4 No apparent 4 4 frequently 4 limitation 4 problem 3 Slightly Occasionally Walks Slightly Adequate 3 Potential limited 3 moist 3 Occasionally 3 limited 3 problem 2Very limited Moist 2 Chairfast 2 Very Properly Problem 2 limited 2 inadequate2Completely constantly Bedfast 1 Immobile 1 Very poor 1 limited 1 moist 1 Total Total Total Total Total TotalGrand total = ---------------
Risk for Pressure Ulcers Norton scale• A score of 14 or less indicate risk for pressure ulcers; score under 12 indicates high risk Physical Mental condition Activity Mobility Continence condition Good 4 Alert 4 Walks frequently full 4 Good 4 4 Fair 3 Apathetic 3 Walks with help 3 Slightly Occasional limited 3 incontinence 3 Poor 2 Confused 2 Sit in chair 2 Very limited Frequent 2 incontinence 2 Very poor 1 Stuporous 1 Remain Bed 1 Immobile 1 Urine & fecal incontinence 1 Total Total Total Total TotalGrand total = ---------------
Sensory PerceptionDefined as:The ability to respond meaningfully to pressure related discomfort. Score on scale of 1-41. Completely limited Unresponsive or inability to feel pain2. Very limited Sensory impairment, moaning or restlessness3. Slightly limited Some sensory impairment, can’t communicate need to be turned.4. No limitations Has no sensory deficits
Moisture Defined as: the degree to which skin is exposed to moisture. Score on scale of 1-4: 1. Constantly Moist Sweating, incontinent, noticed each time pt is turned or moved. 2. Moist Often moist, linen changed 1x/ shift 3. Occasionally moist Extra linen change 1x/day 4. Rarely moist Skin is usually dry, linen changed routinely
Friction & Shear Score on scale of 1-3 1. Problem Requires max assist for moving Sliding against sheets is impossible Frequently slides down in bed Agitation leads to almost constant friction 2. Potential Problem Requires minimal assist for moving Skin slides to some extent on sheets Occasionally slides down in bed or chair 3. No apparent problem Moves independently Lifts up completely during move Maintains good position in bed or chair
Activity Defined as: the degree of physical activity. Score on scale of 1-4: 1. Bed fast Confined to the bed 2. Chair fast Ability to walk is almost non-existent, must be assisted into chair. 3. Walks occasionally Short distances, infrequent, most of time in bed or chair. 4. Walks frequently Walks outside of room 2x/day Walks inside of room q 2 hours.
Nutrition Defined as “usual food intake pattern.” Score on scale of 1-4 1. Very poor Never eats complete meal Takes fluid poorly NPO/ IV fluids only >5 days 2. Probably inadequate Rarely eats a complete meal Occasionally will take supplement 3. Adequate Eats ½ of most meals Will take supplement if miss meals On TPN or adequate tube feedings 4. Excellent Eats every meal Does not require supplements
Presure Ulcer Staging Stage II • Stage 2: Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater.
PrPresure Ulcer Stagingessure UlcerStaging skin lossFull thickness Stage IIIinvolving damage to, ornecrosis of, subcutaneoustissue that may extend downto, but not through,underlying fascia. The ulcerpresents clinically as a deepcrater with or withoutundermining of adjacenttissue.
Unstageable/Unclassified:The top layer of the sore is covered bydead tissue, which may have a yellow, tan,gray, green, or brown color. It may alsolook like a scab. The dead tissue or scabcovers a deeper, more serious wound andneeds to be removed to be evaluated.
Assessment:Assesses total skin condition at least twice adayDry skin, Moist skin, Breaks in skinErythemaBlanching responseWarmthOozing & OdorEvaluates level of Mobility Restrictive devicesPeripheral Pulses, Edema.
Minimize pressure for All patients Consider pressure relieving devices: Special bed: Matrix mattresses and Bari-beds Z-flow positioning pillows Increase mobility and activity status whenever possible. Minimally, turn patients every 2 hours Encourage weight shifting every 15 min in chair. Reposition every 1 hour if patient is unable to do it themselves.
Mobility*Use lifts and hovermats withpositioning.Turn q 1-2 hoursPost turning scheduleEncourage ambulatingoutside of the roomat least BID.
• Skin Care• Skin inspection daily at end of the shift, Look closely at bony areas for redness or temperature changes.• Wash skin with warm (not hot) water and use a mild soap. This will reduce irritation and dryness.• Apply lotion to keep the skin from Drying Out.• Gently Massaging intact skin may help with circulation and comfort. Avoid massaging bony areas.• Keep clothes and bed sheets dry. Protect the skin from sweat and urine.
• Minimizing Friction and Shearing is also important through Proper Repositioning, Transferring, and Turning techniques. Bed Sheets & Blankets are Dry and Wrinkle-Free (smooth).• Malnutrition should be treated• Active and Passive range-of-motion
MoistureImplement toileting schedule.Cleanse skin gently Do not use hot water Apply skin barrier after each cleansing Protect skin with duodermContain urine, stool, wound drainage, etc.Keep skin folds dry.
Friction & Shear Use transfer devices Use minimum of 2 people + draw sheet to pull pt up in bed. Don’t drag the patient Keep HOB at or < 30 degrees Use trapeze Pad skin surfaces (duoderm) (elbows/heels)
Do not raise the head of the bed too high. . Cause skin damage to the lower back and buttocks areas.Use a bed sheet or other device to help move the person.Do not allow the person to lie or sit on a pressure ulcer. Move and change the person’s position regularly.
Reassessment: Re-inspect and palpate ALL patients every 8- 24 hours. Re-inspect when transferring between units. Re-inspect after long procedures, ie: dialysis, MRI’s, etc.
Pressure Ulcers are “mostly” Preventable causes
Pressure Ulcer Treatment Admit Treatment assessment Plan Quality Improvement/ Monitor Program Weekly Re-assess
Surgical intervention Débridement Incision and drainage Bone resection Skin grafting.
Measure wounds upon admission and weekly (or with significant changes). Note the location, size, depth, color of wound bed and surrounding tissue and describe the drainage.
Size: Measure length, width and depth of wound. Measuring tools are available in unit storerooms. Describe wound as a clock withpatient’s head at 12:00 and their feet at 6:00 to promote consistency in descriptions.
Types of debridement• Autolytic – (Occlusive Dressings) the body heals itself• Mechanical – using gauzes• Enzymatic – chemical enzymes (Collagenase, Papain, )• Sharps – scalpel, laser, surgery• Biosurgical – maggots, leeches
Signs of Infection• Delayed Healing• Change in Exudate• Change in Pain• Change in Granulation Tissue• Change in Smell• Change in Size• Fever• Leukocytosis
Topical Dressings• Occlusive Dressings• Divided into polymer films, polymer foams, hydrogels, hydrocolloids, alginates, and biomembranes.• Dressings left in place until fluid leaks from the sides (3 days to 3 weeks)
Transparent Film• Autolytic debridement• Partial thickness wounds• *Stage I or II pressure ulcers• Superficial burns
Hydrocolloids (Autolytic)• Primary or secondary dressing• *Partial and full thickness wounds• Pressure ulcers• *Necrotic wounds• Granular wounds preventative dressing• Used as a secondary dressing or under compression
Hydrogels• Stage 2 to stage 4 pressure ulcers• Partial and full thickness• *Painful wounds• Skin tears• Minor burns• *Necrotic wounds
Collagens• *Infected Wounds• Tunneling Wounds• Surgical Wounds• Can be used with other topical agents• *Not for necrotic wounds
Negative Pressure Therapy• VAC Device• For Nonhealing wounds and fecal incontinence• Removes Interstitial Fluid from the wound
Antimicrobial Dressings• Infected Wounds• Controls bacteria bioburden• Effective against a broadspectrum of microorganisms• IODOSORB• AQUACEL• IODOFLEX
Saline –soaked Gauze Dressings• Saline soaked and not allowed to dry• Similar to occlusive dressings• However, Time intensive for nursing• *Used for Partial and full thickness wounds• Draining wounds• Wounds requiring debridement packing,Or management of tunnels, tracts or dead space• Surgical incisions/Burns/pressure ulcers
FOAM• Nonocclusive absorptive wound dressing• Partial and full thickness wounds…minimal to heavy drainage• Stage II to IV press. Ulcers• *Infected and non-infected
Skin Safety Team Team Members: Physicians Administrative sponsor Clinical Educators Nutrition Director of PT/OT Nursing Managers Nursing Head Nurses Performance Improvement Respiratory Therapy Many staff nurses Ad hoc: Product manager Ad hoc: Electronic Medical Records staff member