Taking the PressureOut of Ulcer Management
Contents
1. Trauma and damage to the skin can lead to functional impairments Aging Shirt Ye Gerontodermatological Changes e Over the lifespan skin becomes drier less elastic less perfused vulnerable to damage from pressure friction shear moisture malnutrition etc a XN Aging skin Gerontodermatological Changes e Skin aging is a complex process Most major changes occur in the dermis e Two independent aging processes Normal aging gt slow irreversible degeneration of tissue Extrinsic aging gt AKA photoaging due to staal i of ily UV i Photos www dermnet com Aging Skin Xe Gerontodermatological Changes e Combination of normal aging and photoaging results in altered wound healing processes Progressive loss of skin function Increased vulnerability to the environment Decreased homeostatic ability Healing is delayed but is as effective as that of younger adults Aging Skin Gerontodermatological Changes e Replicative senescence gt Epithelial and fatty layers thinner Collagen and elastic fibers shrink 1 per year Sweat glands decrease in number and size Skin vascularity decreases Vessel walls thin Ateriosclerotic changes occur in small and large vessels e XN Aging skin Gerontodermatological Changes e With these changes Oxygen carbon dioxide exchange decreases Tissue turnover slows Increase occurrence of ecchymosis2. immunosuppression multisystem trauma corticosteroid history significant obesity or fractures cachexia diminished pain awareness co morbid conditions poor circulation paralysis druas that impair wound resident refusal eine dune previous PrU history altered blood pressure So what do you do Difference Between Skin Assessment and PrU Risk Assessment e Skin Assessment Goal e PrU Risk Assessment Gather info to describe Goal the current health of Gather info about the skin specific factors such Detect variations from as immobility poor normal erythema nutrition etc that place rashes lesions a resident at risk for dryness etc developing a PrU Identify age related or disease related changes thinning decreased elasticity trophic changes etc Risk Assessment e The implementation and consistent use of a risk assessment tool can reduc the incidence of pressure ulcers by 60 Utilized upon admission weekly thereafter for four weeks quarterly and at discharge D Prevention and Risk Factors Risk assessment identifies specific factors that place a resident at risk for the development of a PrU Each risk factor must be addressed in the care plan with appropriate interventions Risk Assessment Prevention and early Intervention of at risk residents is essential Requires thorough history amp systems review Observation and palpation of resident s skin Palpation
3. skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combinatio with shear and or friction NPUAP Diagrams from www dick ford com 10 a h 2 Pressure Ulcer Considerations e The amount and duration of pressure and the severity of shearing forces influence pressure ulcer herein PrU formation These forces combine causing a distortion of the capillary network limiting 0 0100 miley e Additional compounding factors nutritional deficiencies immobility decreased immunity and excessive moisture Diagrams from www dick ford com Shear force 31 Friction and Shear Force Friction Mechanical force exerted on the skin when moved against any surface May result in a skin abrasion Shear A distortion of the tissue caused by two opposing parallel or horizontal forces Friction Gravity Shear Shear has its greatest effect on the deep tissues of the body Pressure Ulcers e Anatomical sites at risk calcaneous greater trochanter ischial tuberosities sacrum medial lateral malleoli knee all aspects olecranon process scapulae occiput ears toes tight sheets thoracic vertabrae areas exposed to tubes lines and or external devices casts splints etc Residents AT RER tor Pressure Wa Ulcers mental impairment diabetes altered cognition dehydration B malnutrition bed rest chronic immobility incontinence E iatrogenic
4. NOT DO one or more of the following Evaluate the resident s clinical condition and pressure ulcer risk factors Define and implement interventions that are consistent with resident needs goals and recognized standards of practice Monitor and evaluate the impact of the interventions Revise the interventions if appropriate CMS Unavoidable Pressure Ulcers e Resident developed a pressure ulcer even though the facility Evaluated the resident s clinical condition and risk factors Defined and implemented interventions that are consistent with resident needs goals and recognized standards of practice Monitored and evaluated the impact of the interventions Revised interventions as appropriate Documentation issues e Until the MDS is revised reverse staging must be used for completion of the RAI For example if upon observation a healing Stage lll ulcer has the appearance of a Stage Il ulcer it should be coded as a Stage Il ulcer on the MDS Correct staging and descriptions should be in the wound care nursing notes e Healing Stage III ulcer recorded as Stage Il on the MDS e A PrU should progress toward healing in 2 4 weeks If not the reason for continuing the current treatment must be documented 57 a le 2 F314 amp Documentation Ye e The F314 addresses the minimum requirements for documentation for a resident with a PrU Protocol for asse
5. cushion for chair Avoid use of excessive linens or padding under resident while in bed Inspect residents skin during positioning bathing changing clothes providing ADLs etc Apply pH balanced lotion to skin at bath time and PRN Decreases pressure on the heels and may decrease shear and friction Reduces effects of pressure Too many layers of linen between resident and pressure redistribution mattress will decrease the Identify any redness of skin or skin breakdown so appropriate treatment or prevention measures can be Keeps skin soft supply and moisturized NEA Summary of PTO Prevention Strategies Apply barrier ointment to the skin of an Helps protect skin from excessive incontinent resident moisture Report frequent incontinence to Decreases the change of ensure that appropriate methods of complications from incontinence containment or treatment will be promptly implemented Encourage resident to eat a healthy Helps maintain and or improve balanced diet and to maintain healthy nutritional and hydration status which fluid intake Encourage resident to is necessary for healing skin and to eat drink prescribed nutritional support wound healing supplements Keep bed linens and clothing clean Helps prevent shear friction and and wrinkle free possible moisture against skin NEA Summary of PTO Prevention Strategies Use positioning devices pillow foam Minimized pressure shear and fr
6. healthy granulation tissue and may lead to excessive bleeding and increased pain A facility should be able to show that its treatment protocols are based upon current standards of practice and are in accord with the facility s policies and procedures as developed with the medical directors eview and approval Summary of PTO Prevention Strategies Turn and or reposition non ambulatory residents every 2 hrs at minimum Reposition immobile residents every 1 hour while up in chair Teach and encourage residents to weight shift every 15 minutes assisting as necessary while up in chair Assist or provide resident with devices to maintain mobility Lift resident off bed do not drag when moving Use a lift sheet to help when moving or turning a resident Protect heels and elbows with clothing or protectors Rotates the sites of pressure and allows blood flow to return to an area where blood flow had been restricted Prevents pressure points from developing and allows blood flow to return Helps prevent pressure ulcers from developing on the lower portion Lessens residents risk for development of a pressure ulcer or Minimizes shear and friction that can tear the skin and damage the capillaries supplying blood to the skin NEA Summary of PTO Prevention otrategies Elevate heels by placing a pillow lengthwise under the residents calves Place resident on proper pressure redistribution mattress and
7. is particularly important for residents with noncausian skin Tissue Tolerance e Definition The ability of the skin and its supporting structures to endure the effects of pressure without adverse effects e Every person s tissue tolerance is different e Some residents may tolerate an hour in the wheelchair without breakdown and others may not e Skin inspection for tolerance Inspect for any skin discoloration note darker skin tones my not show any change in color Assess sensation pain and itching Palpate for any changes in temperature warm or cold or consistency firm or boggy Tissue Tolerance Note that after pressure is relieved from any area of the body a hyperemia redness response will appear from the blood flow going back to that area again note darker skin tones may not present with this If this response doesn t resolve right away check again within 45 minutes to an hour due to the changes associated with aging skin it takes them longer to reperfuse f it is still discolored and nonblanching then it is a Stage ulcer This process will allow you to determine if the turning intervals are adequate for the individual resident ne XN Assessment e CMS considers a PrU to be a sentinel event in a resident of a long term care facility who had been assessed as being at ow risk for a PrU e According to CMS the only residents who are at high risk automatically are those
8. Inflammatory response decreases Tissue regeneration is slower which can delay healing and make tissue more susceptible to infection All these factors can ultimately lead to skin breakdown and impair or delay healing Se 2 Now What Ye Knowing the basic anatomy and physiology of the skin and understanding changes associated with aging skin What can we do to help reduce the risk of injury or trauma especially pressure friction and shear D Identify Threats To Skin Integrity lt Q Pressure friction shear Moisture Malnutrition dehydration Immobility Cognition impairments Medications topical and systemic Comorbidities and other health complications Assess appropriateness of support surfaces bed chair Exogenous endogenous iatrogenic factors These threats are more pronounced in older individuals the majority of long term care residents mamans 7 Skin Assessment x Understanding changes associated with aging skin Identifying threats to the skin Recognizing residents comorbidities and overall health status All create a picture of the individuals skin health and risk of breakdown Skin Assessment Thorough skin assessment is paramount Prevention is key Address all modifiable risk factors Early intervention is critical Sy Se y To Prevent and Reduce These Pressur Ta Ulcers Pressure Ulcer Definition A pressure ulcer is localized injury to the
9. Ye Taking the MSIE of Ulcer Management Heather Hettrick PT PhD CWS FACCWS MLT Vice President Academic Affairs and Education American Medical Technologies Na Disclaimer e The information presented in this presentation constitutes an introduction to a topic that has been prepared and provided for educational and informational Purposes only It is for the attendees sense knowledge and is not a substitute for legal or medical advice Legal and or medical advice requires appropriate licensure expert consultation and an in depth knowledge of your situation Although every effort has been made to provide accurate information herein laws and precedents are always changing and will vary from state to state and jurisdiction to jurisdiction As such the material provided herein is not comprehensive for all legal and medical developments and may ina VENUE contain errors or omissions This review we hope will give a starting point for thinking about the way you practice wound care in that you begin to understand the need for Mitel knowledge and careful documentation about the care of the residents American Medical Technologies shall not be held liable for any situation that may result dir ctly or indirectly from use or misuse of this information Content Overview Anatomy and physiology of the skin and associated systems relating to the development of pressure ulcers Definition of pressure ulcer Risk factors
10. ans cells are a component of the immune system Protective layer Highlighted in green Outermost layer with cells that are desquamated and turn over every 30 days Comprised of 15 20 layers of non nucleated keratinized cells i i am lus DEL a Lalu From trc ucdavis edu skin epi0 epi4 html Transparent layer found mainly in the soles and palms i e thick epidermis Transitional layer that is 1 5 layers thick From trc ucdavis edu skin epi0 epi4 html Epidermis Stratum Granulosum Granular layer that is 1 5 cells thick Forms a waterproof barrier that functions to prevent fluid loss Synthesizes keratonyaline which is the precursor to keratin From trc ucdavis edu skin epi0 epi4 html NEA Epidermis Stratum Spinosum e This is the prickle cell layer e This layer contains desmosomes which terminate in spiny projections which hold the cells together and help protect the skin from abrasion Langerhan s cells also provide antigens to T lymphocytes immune response From trc ucdavis edu skin epi0 epi4 html Epidermis Stratum Germanitivum Single cell layer Provides germinal cells necessary for the regeneration of the epidermis Contains melanocytes which are responsible for the pigment of the skin Basement Membrane The epidermal dermal junction where cells reside that are responsible for mitotic growth and epidermal regeneratio
11. cers e Stage Il Partial thickness loss of dermis presenting as a May also present as an Presents as a shiny or dry shallow ulcer without slough or bruising e Bruising indicates suspected deep tissue ok ee Injury PANEL STAGE 2 Clinical Presentation of Pressure Ulcers Stage Ill Slough may be present but does not obscure the depth of tissue loss The bridge of the nose ear occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow In contrast areas of significant adiposity can develop extremely deep stage IIl pressure ulcers Bone tendon is not visible or directly palpable STAGE 3 Clinical Presentation of Pressure Ulcers e Stage IV Slough or eschar may be present on some arts of the wound bed ften include undermining and tunneling 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 4 Exposed bone tendon is visible or directly palpable xs Clinical Presentation of Pressure Ulcers e Unstageable by slough yellow tan gray green Or brown and or eschar tan brown or black in the wound bed Until enough slough and or eschar is removed to expose the base of the wound the true depth and therefore stage cannot be determined Suspected Deep Tissue injury NON due to
12. 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 DTI 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 thin eschar Evolution may be rapid exposing additional layers of tissue even with optimal treatment Suspected Deep tissue Injury NES Tissue injury that appears as dark discoloration deep bruising hematoma Borders are irregular and not well demarcated Typically acute formation Long OR times Falls Splints Single episode of pressure Damage to deeper structures has already occurred Skin may still be intact because of its higher resistance to hypoxia Heralding sign of an impending stage Ill or IV Clinical Presentation of Pressure Ulcers e Other PrU characteristics Wound exudate varies in amount PrU usually round and well defined shape may be irregular depending upon pressure causing agent catheter and location butterfly shape common at sacrum Periwound usually dry unless clinical signs of infection Pain is variable To facilitate healing must eliminate mechanical trauma forces pressure friction shear CMS Avoidable Pressure Ulcers e Resident developed a pressure ulcer and the facility DID
13. for the development of pressure ulcers Comprehensive nursing assessment to identify risk factors for pressure ulcer development Importance of early identification of risk factors for pressure ulcer development Development and implementation of interventions to preventthe development ofpressure ulcers IT CAN TURN LUMP OF COAL INTO A FLAWLESS DIAMOND OR AN AVERAGE PERSON INTO A PERFECT BASKETCASE D A amp P Review of the Skin In a 150 pound person the skin is comprised of 18 square feet and weighs about 12 pounds In 1 square inch the skin contains e 65 hairs 100 sebaceous glands 78 yards of nerves 650 sweat glands 19 yards of blood vessels 9 500 000 cells i 1 300 nerve endings Les ae 20 000 sensory cells 32 ta 32 000 000 bacteria www dermnet com D A amp P Review of the Skin e Skin is the largest organ of the body The skin has three functional layers e Epidermis e Dermis e Hypodermis or sub Seheceous olh Gland cutaneous layer Hair Follicte Erector Pili D A amp P Layers of the Skin e Epidermis Five layers of cells superficial to deep Ooo mem ae Cu Functional components Made up of tough flattened cells of the protein keratin Cells provide barrier to injury contaminants light retain water Keratinocytes secrete protein keratin Melanocytes produce melanin pigment Basal and prickle cells regenerate epidermis produce Vit D Langerh
14. iction wedges to maintain 30 degree lateral which can tear the skin and damage position and separation of bony the capillaries supplying blood to the prominences skin Maintain head of bed at the lowest Minimizes exposure to shearing which degree of elevation consistent with occurs with head of bed elevation medical conditions and other restrictions elevate knee gatch on bed to prevent sliding while head of bed is See 2 Summary amp Awareness is the first step in prevention Implement care that is consistent with best practice and the standard of care Prevention and early intervention are critical so be proactive with skin assessment and risk assessment Implement interventions in the plan of care that are specific to the resident and his her clinical condition s 2 Resources or Standards of ea Practice AHRQ Guidelines ahrq gov clinic cpgonline htm AMDA Guidelines amda com cmedirect pressureulcers index cfm NPUAP npuap org PDF treatment_curriculum pdf WOCN Guidelines Guideline gov summary summary aspx ss 15 amp doc_id 3860 amp nbr 3071 CMS RAI User s Manual cms hhs gov medicaid mds20 man_form asp NHqualitycampaign org Table 2 Overview of Recent Evidence based Guidelines Guideline AAWC Conceptual Framework of Quality Systems for Wound Care AAWC Content Vali dated Venous Ulcer Guideline The Association for the Advancement of Wound Care Summary algorithm fo
15. mis to detach from the dermis eading to tearing of the ee Tin layers of the skin especially in the older adult population e This leads to skin tears bruising or ecchymosis and an increased susceptibility to damage from pressure friction and shear From Advances in Skin amp Wound Care Volume oen aay 315 321 Preventing and Treating Skin Tears Fleck Cynthia A MBA BSN RN ET WOCN S DNC DAPWCA FCCWS Layers of the Skin e Dermis Two layers of irregular connective tissue e Papillary layer anchors dermis to epidermis e Reticular layer contains dense deep accessory organs Functional components of the dermis hair follicles nerve endings pain heat cold touch pressure lymph vessels remove excess fluid store protein capillaries supply nutrients and O remove water and wasie collagen bulk strength support elastin and reticulin extensibility integrity sweat glands sebaceous glands sebum controls pH antibacterial and antifungal effects Layers of the Skin Subcutaneous tissue Functional components e adipose or fat je e connective and elastic tissue PAS insulate support cushion and store energy E VON Functions of the Skin e Dynamic organ continuously engaged in biological and biochemical activity Protection emperature regulation Fat and water storage Vitamin D synthesis Excretion of waste Cosmesis Touch sensation
16. n occurs approximately every 30 days Fibronectin is the major protein in the basement membrane It is an adhesive glycoprotein the glue that holds it together Layers are lamina lucida and lamina densa Rete pegs epidermal attach with the dermal papillae to support the epithelium and dermis Layers of the Skin e The epidermis has an irregular shape resembling downward finger like projections called rete ridges or rete pegs see next slide The significance of this anatomical structure is that the dermis has upward projections The upward and downward projections fit together very much like a waffle iron These protuberances connect anchoring the epidermis to the dermis This bond also helps to prevent the epidermis from sliding back and forth across the dermis with normal movement and skin manipulation e In healthy young skin the 2 layers of skin move as one This is not the case in elderly skin skin over the age of 60 e This is why shear and friction can cause skin tears in the elderly PET A Reticular layer of dermis Ee os Note the dark pink fingerlike projections These are the rete pegs Layers of the Skin e As the skin ages the rete ridges begin to flatten between the dermal epidermal junction Such epidermal dermal flattening typically appears by the sixth decade With this anchoring now diminished there is an increased otential for the epider
17. r ve nous ulcer care with annotations of available evidence The Wound Ostomy and Continence Nurses Association Guideline for management of wounds in patients with lower extremity venous disease The Wound Ostomy and Continence Nurses Association Guideline for prevention and management of pressure ulcers Paralyzed Veterans of America Pressure ulcer prevention and treatment following spinal cord injury Best Practice Statement Care for the Older Person s Skin Minimising Trauma and Pain in Wound Management Compression Hosiery Wound Healing Society Prevention Guideline 1 Guidelines for the prevention of venous ulcers 2 Guidelines for the prevention of pressure ulcers 3 Guidelines for the prevention of diabetic ulcers 4 Guidelines for the prevention of lower extremity arterial ulcers Wound Healing Society Clinical Treatment Guidelines 1 Guidelines for the treatment of venous ulcers 2 Guidelines for the treatment of pressure ulcers 3 Guidelines for the treatment of diabetic ulcers 4 Guidelines for the treatment of arterial insufficiency ulcers Registered Nurses of Ontario Risk Assessment and Prevention of Pressure Ulcers Pressure Ulcer Prevention National Guideline Clearinghouse NGC Guideline Synthesis Nursing Standard of Practice Protocol Pressure Ulcer Prevention amp Skin Tear Prevention SOLUTIONS wound care algorithm From Moues Heule Legerstee Hovius Five Millenia of Wound Care Products What Is new A Lite
18. rature Review Ost Wound Mgmnt 2009 55 3 16 32 Source availability www o wm com article 6393 www quidelines gov www quidelines gov www quidelines gov www quidelines gov www wounds uk com Wound Repair Regen 2008 16 2 Page 147 150 Page 151 168 Page 169 174 Page 175 188 Wound Repair Regen 2006 14 2 Page 649 662 Page 663 679 Page 680 692 Page 693 670 www rnao ora bestpractices www quideline gov www consulgerirn org topic www quidelines gov Questions For more information about this presentation or other educational activities please contact info amtwoundcare com
19. s e Preventive measures_undertaken Clinical Presentation of Pressure Ulcers Blanchable erythema e Variations in skin color Edema and increased tissue temperature If pressure relieved skin can return to normal in 24 hours If not damage ensues NPUAP February 2007 The National Pressure Ulcer Advisory Panel has redefined the definition of a pressure ulcer and the stages of pressure ulcers including the original 4 Stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers NPUAP Pressure Ulcer definition pressure ulcer is localized injury to the skin and or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear and or friction A number of contributing or confounding factors are also associated with pressure ulcers the significance of these factors is yet to be elucidated Clinical Presentation of Pressure Ulcers e Stage Intact skin with non blanchable redness of a localized area usually over a bony prominence Darkly pamens skin may not have visible blanching its color may differ from the surrounding area The area may be painful firm soft warmer or cooler as compared to see tissue May be difficult to detect in individuals with dark skin tones May indicate at risk persons a heralding sign of risk STAGE 1 Clinical Presentation of Pressure Ul
20. ssment Mandated daily monitoring Mandated weekly or dressing change monitoring Protocol for Assessment Differentiate type of ulcer pressure related versus non pressure related Determine stage if pressure or depth of tissue involvement for non pressure related ulcers partial or full thickness Describe and monitor the ulcer s characteristics Monitor the progress toward healing and potential complications Determine if infection is present Assess treat and monitor pain Monitor dressings and interventions Mandated Daily Monitoring Evaluation of ulcer if no dressing is present Evaluation of the status of the dressing if present s it intact Is there drainage Is it leaking Status of the peri ulcer area Area around the ulcer that can be observed without removing the dressing Presence of possible complications Increased redness swelling drainage e Whether pain if present is being adequately controlled Mandated Weekly or Dressing Change Monitoring Size depth and the presence location and extent of undermining or tunneling sinus tract Exudate if present type color amount odor Pain if present nature and frequency Wound bed color and type of tissue Evidence of healing or necrosis Description of wound edges and periwound Rolled edges erythema induration maceration Pr Intervention Considerations e Interventions should be selected based upon
21. the clinical presentation of the wound as well as that of the resident You should be able to justify your interventions provide rationale and demonstrate that they are based upon the standard of care and current clinical practice guidelines see last few slides e You should also modify change your interventions as needed and be able to explain why you did so Dressing and Treatment Caveats Thomas JAMDA Oct 2006 Stage III IV ulcers should be covered Determination of the need for a dressing for a Stage Il ulcer is based upon individual practitioner s clinical judgment and facility protocols based upon current clinical standards of practice Current literature does not indicate significant advantages of any single specific product Current literature suggests that PrU dressing protocols may use clean technique rather than sterile Appropriate sterile technique may be needed for those wounds that have recently been surgically debrided or repaired Debridement Caveats Thomas JAMDA Oct 2006 Variety of methods available Mechanical sharp surgical enzymatic autolytic e Must be appropriate for the resident and clinical wound presentation Stable dry intact and adherent eschar on the foot heal should not be debrided unless signs symptoms of local infection or instability Wet to dry dressings a form of debridement or irrigations may be appropriate in limited circumstances but repeated use may damage
22. who have impaired transfer or bed mobility are comatose or malnourished any other resident is at low risk until assessed as otherwise Assessment Identify and document all risk factors Identify pre existing signs of skin trauma Assess and document pain Include the Resident Assessment Instrument RAI Identify the resident with multi system organ failure end of life condition refusal of care and treatment Address all factors that have been identified as having an impact on the development treatment and or healing of pressure ulcers A Nt VA Incidence Reports Ye e 22 VAC 40 72 100 A Incident Reports Q would a PrU be considered a major incident that has negatively affected or that threatens the life health safety or welfare of a resident that has to be reported YES e Stage Il Ill amp IV PrU must be reported whenever identified on or after admission to a facility VA Incidence Reports e 22 VAC 40 72 100 A Incident Reports he acceptable description of the incident as required at 22 VAC 40 72 100 c 7 will include but is not limited O e Location of the wound s e Measurements and appropriate stage e Exudate description amount color consistency e Presence of odor after cleansing Actions and outcomes c 9 10 will depend upon the extent of the clinical intervention but at a minimum will include e Nurse and or physician contacts e Treatment order
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