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Sunshine Care Training Sarah Yorwerth & Tara Hollinshead Skin Integrity
A pressure ulcer is an injury to the skin or tissue over a bony area. A pressure ulcer is also called a pressure sore, bedsore, or decubitus ulcer. • Most at Risk:Are seriously ill (including someone in an intensive care unit). • Are not very mobile (for example, you may be confined to a chair • or a bed), particularly if you are not able to change your position. • Have had a spinal cord injury (paralysis) • Have a poor diet. • Are wearing a prosthesis, a body brace or a plaster cast. • Are a smoker. • Are incontinent of urine or faeces (this causes damp skin which is • more easily damaged). • Have diabetes (this can affect sensation) • Have chronic obstructive pulmonary disease (COPD) • or heart failure. • Have Alzheimer's disease, Parkinson's disease or • rheumatoid arthritis. • Have recently had a broken hip or undergone hip surgery. • Have peripheral vascular disease (poor circulation).
Pressure Ulcers Continuous pressure: Pressure happens when you sit or lie on a bony area for too long. Pressure on bony areas slows down or stops the blood from flowing to the skin. Pressure may hurt the skin and the layers of tissue underneath it. This may cause the tissue to become damaged, or even die. Pressure can begin to cause damage to your skin and tissue within 2 hours. Shearing or friction:Shearing or friction happens when delicate skin is dragged across a surface, such as using sheets. This may cause your skin to tear or a blister to form. Fragile skin can tear if it is moved up or down in bed or moved from the bed to a chair. Your skin can also tear when muscle spasms cause your arms or legs to jerk and rub the sheets.
Other Factors: Incontinence: • Incontinence occurs when you cannot control when you urinate or have bowel movements. • You may be at risk for pressure ulcers if you sit or lie in urine or bowel movement which can lead to infections. Malnutrition and dehydration: • Malnutrition means that your body is not getting enough calories and nutrients, such as protein and fat. • Dehydration means that your body is not getting enough healthy liquids, such as water. • Malnutrition and dehydration may cause your skin to be injured more easily. • You may have less tissue and fat over bony areas of your body. Less padding may increase the pressure over a bony area. Lack of movement: • Pressure will build on body areas if you stay in a chair or bed most of the time. • The risk that an ulcer will form increases the longer you leave pressure on a bony area. • Medical conditions that may lead to a lack of movement include spinal cord injury, stroke, and hip fracture. Numbness: • Your skin may become damaged without your knowing it. • Medical conditions that may cause numbness include multiple sclerosis and nerve damage from diabetes. Previous pressure ulcer: • You may have a higher chance of getting a pressure ulcer if you have had a pressure ulcer before.
Water low Score: Judy Waterlow, now in her seventies, designed and researched her pressure ulcer risk assessment tool in 1985, while working as a Clinical Nurse Teacher. The tool was originally designed for use by her students. Consider the Service Users you care for and score them under each category
Waterlow treatment: The reverse side provides guidance on nursing care, types of preventative aids associated with the three levels of risk status, wound assessment and dressings
Stage 1. Look For: • Reddened, discoloured or darkened area (darker skin may look purple, bluish or shiny). • It may feel hard and warm to the touch. • A pressure sore has begun if you remove pressure from the reddened area for 10 to 30 minutes and the skin colour does not return to normal after that time, stay off the area. • Test the skin with the blanching test: • Press on the red, pink or darkened area with your finger. • The area should go white; • remove the pressure and the area should return to red, pink or darkened colour within a few seconds, indicating good blood flow. • If the area stays white, then blood flow has been impaired and damage has begun. • Warning: What you see at the skin’s surface is often the smallest part of the sore, and this can fool you into thinking you only have a little problem. • But skin damage from pressure doesn't start at the skin surface. • Pressure usually results from the blood vessels being squeezed between the skin surface and bone, so the muscles and the tissues under the skin near the bone suffer the greatest damage.
Stage 1. Look For: • Skin is not broken but is red or discoloured, • May show changes in hardness or temperature compared to surrounding areas. • When you press on it, it stays red and does not lighten or turn white (blanch). The redness or change in colour does not fade within 30 minutes after pressure is removed. • What to do: • Stay off area and remove all pressure. • Keep the area clean and dry. • Eat adequate calories high in protein, vitamins (especially A and C) and minerals (especially iron and zinc). • Drink more water. • Find and remove the cause. • Inspect the area at least twice a day. • Call the health care provider if it has not gone away in 2-3 days. • Healing time: • Pressure sore at this stage can be reversed in about three days if all pressure is taken off the site.
Stage 2. Look For: • The topmost layer of skin (epidermis) is broken, creating a shallow open sore. • The second layer of skin (dermis) may also be broken. • Drainage (pus) or fluid leakage may or may not be present. • What to do: • Get the pressure off. • Follow steps in Stage 1. • Call the District Nurse ASAP • Healing time: • Three days to three weeks.
Stage 3. Look For: • The wound extends through the dermis (second layer of skin) into the fatty subcutaneous (below the skin) tissue. • Bone, tendon and muscle are not visible. ( redness around the edge of the sore, pus, odour, fever, or greenish drainage from the sore) • Possible necrosis (black, dead tissue). • What to do: • If you have not already done so, get the pressure off and contact the health care provider right away. • Wounds in this stage frequently need special wound care. • Your client may also qualify for a special bed or pressure-relieving mattress that can be ordered by your health care provider. • Healing time: • More than one to four months.
Stage 4. Look For: • The wound extends into the muscle and can extend as far down as the bone. • Usually lots of dead tissue and drainage are present. • There is a high possibility of infection. • What to do: • Always consult the health care provider right away. • Surgery is frequently required for this type of wound. • Healing time: • Anywhere from three months to two years. *Remember* These can be life threatening. Infection can spread to the blood, heart and bone. Amputations. Prolonged bed rest Less active when healing a pressure sore. Higher risk for respiratory problems or urinary tract infections (UTIs).
Deep Tissue Injury. Look For: • Full thickness tissue loss in which the base of the sore is covered by slough (dead tissue separated from living tissue) • Yellow, tan, grey, green or brown colour, and/or eschar (scab) of tan, brown or black colour 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. • Stable (dry, adherent, intact without erythema (abnormal redness) or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.
The Un-Stageable. Look For: • Purple or maroon localized area of discoloured intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. • The area may be surrounded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to nearby tissue. • Deep tissue injury may be difficult to detect in individuals with dark skin tones. • Progression may include a thin blister over a dark wound bed. • The wound may further evolve and become covered by thin eschar (scab). • Progression may be rapid exposing additional layers of tissue even with optimal treatment.
Prevention. • Pressure Ulcers can develop very quickly, sometimes within an hour. They can be very serious if left untreated. • The can damage not just the skin, but also deeper layers of tissue under the skin. This can destroy bone or muscle, so they can take a very long time to heal. • They can be life threatening, causing infections and blood poisoning • Keep Moving. Every 2 hours in recommended to change position. • Mattresses and Cushions. Air Flow, Pressure Relief, Gel Cushions are all designed to reduce the amount of pressure on any one area of the body. • Skin Assessments. Health Care Professionals will be looking for any reddened areas, blisters, heated skin or swelling. • Diet. It is very important to consider the right vitamins within diet and also drinking enough water. Dietary advice can be offered by the Nurse. It is recommended to encourage Vitamin C, protein and Zinc. • Self Care. It is important to encourage self care but checking skin integrity daily.
Treatment. The Nurse should look at the pressure ulcer regularly, at least once a week, and check for any changes. To relieve the pressure on the ulcer, and consider the best ways of keeping mobile, changing position or using supporting structures. Dressings Pressure Ulcers may need various dressings. To help healing time as quickly as possible. • Hydrocolloids- an adhesive dressing that gels over the wound but sticks to the surrounding skin • Hydrogels- a simple gel that keeps wounds moist and can help clean wounds. • Foams- to absorb and retain fluid. It may be necessary to remove dead tissue from the ulcer to encourage it to heal. This type of treatment is called debridement.
Ulcers. Ulcers are breaks in the layers of the skin that fail to heal. They can also be accompanied with inflammation. Sometimes they don’t heal and become chronic. Chronic foot and leg ulcers mainly affect the elderly. People who suffer with Diabetes Mellitus are at special risk of developing foot Ulcers, and foot care is an important part of Diabetes management. • The most common causes of Chronic Leg Ulcers is poor blood circulation in the legs. These are known as Arterial and Venous leg ulcers, others can include: • Injuries- Traumatic Ulcers. • Diabetes- Poor circulation/Nerve damage. • Certain skin condition. • Vascular diseases (Stroke, Angina, Heart Attack) • Tumours • Infections.
Arterial Ulcers Approximately 10 % of all leg Ulcers are Arterial Ulcers. Feet and legs often feel cold and may have a whitish or bluish, shiny appearance. Arterial leg ulcers can be painful. Pain often increases when your legs are at rest and elevated. • To reduce pain, it is recommended to sit on the edge of the bed with your feet on the floor. • Gravity will then encourage more blood flow into your legs.
Diabetes and Ulcers The Long-term effect of diabetes on the nerves causes a reduction in sensation in the feet. This increases the likelihood of accidental trauma to the feet, which makes ulcers more likely to appear. • But these Ulcers are often neglected because they do not cause pain. If Ulcers aren’t treated, they can lead to more serious problems, such as gangrene and even amputation. Arteries are the tubes that carry oxygen-rich blood from the heart to the body’s tissues. The tissues receive oxygen and nutrients from the blood. • The used blood, which now contains carbon dioxide and other by-products, is carried via the veins from the tissues back to the heart. • Arterial leg ulcers are caused by poor blood circulation as a result of narrowed arteries due to atherosclerosis where a fatty deposit builds up inside the arteries. As a result of this, the tissues are starved of the oxygen and nutrients they need and so break down, forming an ulcer. Diabetes also directly damage the small blood vessels and also increases the risk of developing Atherosclerosis.
Claudication People with arterial leg ulcers often suffer from intermittent claudication. This condition can cause cramp-like pains in the legs when walking. This is cause the leg muscles don’t receive enough oxygenated blood to function properly. Claudication pain usually goes away if you stand still for a few minutes (as this allows the exercising muscle time to refresh its oxygen supply). But it is a sign or severe narrowing of the arteries due to Atherosclerosis, and this needs medical attention. Not all sufferers have or develop leg ulcers. Stop smoking and lose weight, Reduce the amount of fat in your diet and keep cholesterol levels low. Exercising will force blood vessels to form new branches to improve circulation, it is normal to feel slight pain doing this. While sitting down, move feet around in circles, then up and down, this will activate the venous pump.
Claudication • Take good care of your feet: • Make sure shoes fit correctly and are not too small. • Keep feet warm and try to avoid injuries to feet and legs. • Examine feet and legs daily for any changes in colour or the development of sores. • Visit a chiropodist regularly. • Keep any dry patches of skin well moisturised to prevent the cracks and breaks that can develop into Ulcers.
Venous Leg Ulcers Approximately 70% of all leg ulcers are venous ulcers. A leg with venous problems has a very characteristic appearance. • The leg is swollen • The skin surrounding a Venous Ulcer is dry, itchy and sometimes thickened and brownish in colour. If the swelling (oedema) is very bad, the skin may be stretched, smooth and shiny. • Eczema may appear (Varicose eczema) where the skin becomes cracked and scaly. • The Ulcer has a weeping, raw appearance and is usually painless unless infected. • If infected, the Ulcer may give off a very unpleasant smell and ooze pale yellowish/green fluid. • Venous leg ulcers are often located just above the ankle, typically on the inside of the leg.
Venous Leg Ulcers Most of Venous leg ulcers occur because the valves connecting the superficial and deep veins are not functioning properly, so blood doesn’t drain from the legs as it should. As a result, the fluid in the tissues of the leg builds up causing an increase in pressure that prevents a healthy flow of oxygen and nutrients through the tissues. The venous system is made up of superficial and deep veins. • Superficial- are located between the skin and the muscles. • Deep veins are located between the muscles. These have one way valves to ensure the blood flows properly, if these fail, especially with age, it causes blood to flow from the deep veins back out to the superficial ones- a major cause of Varicose Veins. This problem is aggravated by the effects of gravity which forces blood to pool in the lower leg. Exercise will help circulation and push blood back up.
Many old people sleep in chairs rather than going to bed at night. But sleeping with legs down on the ground increases the risk of venous Ulcers,. It is important keep legs raised on a stool or cushion to reduce the effects of gravity. The elderly should be encourage to sleep horizontally and even take a nap in bed during the afternoon if they have problems with Venous Ulcers. • Previous Ulcers that may have caused damage. • A fracture or other injuries • Surgery • Deep vein thrombosis (blood clot) • Work that requires a lot of sitting or standing. • Inflammation in the veins (phlebitis) • Pregnancy • Obesity
Prevention of Venous Leg Ulcers • Activate calf muscles regularly by walking and exercising • Reduce the amount of fat in diet. Eating more fruit and vegetables. • Losing weight (if overweight) can help prevent ulcers. • Sitting with legs raised- above heart level if possible. • Avoid sitting with legs cross, as this impairs blood circulation • If seated for a long time, moving feet up and down occasionally to improve circulation. • Support stockings may be useful, but get advise from District Nurse or Doctor. • Inspecting feet and legs daily, check for sores or changes in colour. • Visit chiropodist regularly.
Compression Stockings. • Compression stockings help to maintain the flow of blood in your leg veins. • They are used to treatment and prevent a number of conditions including Varicose veins and Deep Vein Thrombosis. (DVT) • If your having surgery, you may need to wear compression stockings before and for some time after your operation. • You may need to wear compression stockings if you’re having an operation or are travelling and at risk of DVT. • Compression stockings aid to reduce swelling. • Compression Stockings work by putting pressure on the veins in your leg to increase the speed at which blood moves around them and improves the flow back towards the heart. • Need to be worn constantly during the day, and take them off at bedtime. • A gentle moisturiser should be used to prevent dry skin. • Check legs regularly for sore marks (at the top of stockings), broken skin, purple tinge or numbness or tingling. Stop wearing and speak to GP.
Varicose Veins. • Varicose veins are swollen and enlarged veins • Usually blue or dark purple in colour • May also be lumpy, bulging or twisted in appearance • They mostly occur in the legs. Varicose veins develop when the small valves inside the veins stop working properly. In a healthy vein, blood flows smoothly to the heart. The blood is prevented from flowing backwards by a series of tiny valves that open and close to let blood through. If the valves weaken or are damaged, the blood can flow backwards and can collect in the vein, eventually causing it to be swollen and enlarged (varicose). At least 3 in 10 people are at risk, and most of these are women. Treatments include: • Avoid sitting or standing for long periods • Take rest breaks, rest with legs elevated on pillows • Exercise regularly
Deep Vein Thrombosis. • Deep vein thrombosis (DVT) is a blood clot in one of the deep veins in the body. • Blood clots that develop in a vein are also known as venous thrombosis. • DVT usually occurs in a deep leg vein, a larger vein that runs through the muscles of the calf and the thigh • It can cause pain and swelling in the leg and may lead to complications such as pulmonary embolism. • This is when a piece of blood clot breaks off into the bloodstream and blocks one of the blood vessels in the lungs. • DVT and pulmonary embolism together are known as venous thromboembolism (VTE). • Pain, swelling and tenderness in one of your legs (usually your calf) • A heavy ache in the affected area • Warm skin in the area of the clot redness of your skin, particularly at the back of your leg, below the knee
Oedema. • Oedema, also known as dropsy, is the medical term for fluid retention in the body. • The build-up of fluid causes affected tissue to become swollen. This is usually the case with oedema that occurs as a result of certain health conditions, such as heart failure or kidney failure. • As well as swelling or puffiness of the skin, oedema can also cause: • skin discolouration • areas of skin that temporarily hold the imprint of your finger when pressed (known as pitting oedema) • aching, tender limbs • stiff joints • weight gain or weight loss • raised blood pressure and pulse rate
What causes oedema? • Oedema is often a symptom of an underlying health condition. It can occur as a result of the following conditions or treatments: • pregnancy • kidney disease • heart failure • chronic lung disease • thyroid disease • liver disease • malnutrition • medication, such as corticosteroids or medicine for high blood pressure (hypertension) • the contraceptive pill • Oedema that occurs in the leg may be caused by: • a blood clot • varicose veins • a growth or cyst • Oedema can also sometimes occur as a result of: • being immobile for long periods • hot weather • exposure to high altitudes • burns to the skin
Oedema. What treatments may be offered? • Treatment will depend on the likely cause of the oedema. Most cases will be managed by a GP but you may be referred for further investigation and treatment at a hospital. Treatments include: • Regular exercise such as walking or swimming. • Losing weight if overweight. • Raising legs on a footstool when possible. • 'Water pills' (diuretics) - only if prescribed. • Treating the underlying condition - e.g., heart failure. Be aware of: You should call an ambulance if your client experiences severe shortness of breath or chest pain. Mild puffiness of your clients ankles that gets better when you lie down for a few hours, may not need any treatment. In all cases, should seek GP advice to find out if there is an underlying cause.
Cellulitis. Cellulitis is an infection of the skin and the tissues just below the skin surface. Any area of the skin can be affected but the leg is the most common site. A course of antibiotics will usually clear the infection. If there is swelling of the leg, as much as possible keep your foot raised higher than your hip. This helps to prevent excess swelling, which may ease pain. Cellulitis is an infection of the deep layer of skin (dermis) and the layer of fat and tissues just under the skin (the subcutaneous tissues).Erysipelas is an infection of the skin which is nearer to the skin surface (more superficial) than cellulitis. (both conditions are pretty much the same) Cellulitis is caused by bacteria that gets under the skin through a tiny cut, ulcer or even a scratch. The bacteria may then multiply and spread along under the skins surface.
Cellulitis. • Cellulitis is a common problem and it can affect anybody. • You may be more prone if you: • Have athletes foot • Skin abrasions • Swollen legs, or overweight. • Previous episode of cellulitis • Poor immune system. • Poorly controlled diabetes • Intravenous drug user • Had an insect bite • Eczema or other skin conditions. • Symptoms include: • Skin feels warm, may look swollen and looks red and inflamed. • Tender to touch. • Blisters. • Swelling of the glands around the groin area. • Fever or temperature
Cellulitis. Cellulitis can spread from a small area of infection to a large, so it can be serious. Without early treatment, it is a battle between the immune system and the invading bacteria. Possible complications of untreated cellulitis include: • Septicaemia (blood poisoning) • An abscess • Muscle or bone infections • Infecting in the heart valves from bacteria in the blood stream. Treatment: • Antibiotics will usually clear cellulitis- a 7 day course is usually needed. • Elevation to prevent excess swelling and ease pain (leg higher than hip)