Wound management: A CNS perspective. Anna Alvarez Jacqueline Wiseman. Objectives. Identify the scope of problem Identify major functions of the skin Identify layers of the skin and repair process Identify wound etiology. Objectives.
Wound management:A CNS perspective Anna Alvarez Jacqueline Wiseman
Objectives • Identify the scope of problem • Identify major functions of the skin • Identify layers of the skin and repair process • Identify wound etiology
Objectives • Discuss correct utilization of skin risk assessment tools • Identify pressure ulcer prevention modalities • Identify pressure ulcer staging • Discuss strategies for dressing selection • Compare and contrast roles between the WOCN and the CNS.
Pressure Ulcers are a National Health Concern • Considered preventable • Costly complication • Average cost of $129,247 or more in direct cost to treat stage IV pressure ulcers • Increases hospital length of stay • Lawsuits. • JC goals • Sentinel Events/CMS never events
Sentinel Events • Sentinel events signal the need for immediate investigation and response. • Any unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. • “Or the risk thereof” includes any process variation for which a recurrence would carry significant chance of a serious adverse outcome. • Serious injury specifically includes but is not limited to loss of limb or function
Sentinel Event • Pressure ulcers are now added to the sentinel events list. • Patient develops an ulcer while in the hospital. • Patient admitted with an ulcer that deteriorates or does not improve during the hospital stay. • This requires an accurate admission assessment plus accurate ongoing assessments plus a plan to prevent and improve the pressure ulcer.
CNS Wound Specialist • Physiology • Wound types and classification • Risk and wound assessment • Pressure Ulcers • Staging • Dressings • Case Study • CNS Role
Skin Layers Epidermis Function: • Protective layer • Prevents dehydration of underlying tissue • Protects tissue from outside contaminates • Protects from UV light • Made of non-living cells • Maintains the acid mantel
Skin Layers Dermis Function: • Living layer • Hair production • Distinguishing pain, hear, cold, touch. • Removes excess fluid, stores protein • Provides support and strength. • Provides elasticity.
Skin Layer Dermis Function • Supplying nutrients and oxygen, removing water and waste • Produces sweat for cooling and sebum to keep skin supple • Controls skin pH • Provides antibacterial and antifungal barrier
Skin Layers Subcutaneous Function: • Adds to the mobility of the skin • Provides insulation • Provides a ready reserve of energy
Normal Aging Effects on Skin: • Dryer (decreased sweat glands). • Thinner (decreased dermal thickness especially over legs and forearms) • Loses the ability to stretch (decreased collagen and elastin fibers) • Has less subcutaneous tissue (leaving the bony prominences less protected • Easy to wrinkle (loss of subcutaneous fat)
Aging Skin (cont.) • Fragile (loss of size of rete ridges allowing the basement membrane to flatten and the epidermis and dermis to separate) • Decreased sensation and metabolism • Decreased circulation (leaving the elderly patient more prone to heat stroke)
Conditions Effecting Skin Heredity Medications Environmental effects Mobility Nutrition Hydration
Phases of Wound Healing Hemostasis Process: • Occurs immediately after injury • Platelets are released to for a clot • Cytokines are released
Healing (cont.) inflammation Process: • Tissue debris and pathogens • Attract macrophages and neutrophils, which are responsible for : • Phagocytosis • Producing biological regulators, bioactive lipids, and proteolytic enzymes
Healing (cont. Proliferative phase Process: • Fibroblasts-synthesize and deposit extracellular proteins • Extracellular matrix and granulation tissue • Collagen and elastin • Angiogenesis- capillary growth into the ECM • Re-epithelialization • Wound Contraction
Healing (cont.) Remodeling Process: • Collagen deposition and remodeling • Differentiation of fibroblasts into myofibroblasts with programmed cell death • Scar formation
Wound Types Acute Chronic • Trauma • Surgical • Requires limited local care to heal. • Typically heals within 4 weeks with no complications • Delayed healing > 4 weeks • Wound healing complicated by underlying conditions • Repeated trauma • Poor perfusion or oxygenation • Pressure, diabetes, malnutrition
Wound Classification • Wounds are identified and classified based on location and etiology. • Arterial ulcers • Diabetic / Neuropathic ulcers • Venous Stasis ulcers • Pressure ulcers • Skin Tears
Arterial Ulcers • Ulcers are usually very painful • Pain increases with elevation • Extremities will usually be cool and pale • Shiny skin and a loss of hair on the legs and toes • Nails may appear rigid and thick • Diminished or absent pedal pulses
Diabetic/Neuropathic Ulcers • Common complication of long term diabetes • Single most common underlying cause of lower-extremity amputation • Underlying pathology usually not reversible, • And most disease processes affecting the diabetic foot will continue to worsen over time.
Diabetic Ulcer (cont.) • Found on any part of the leg, commonly below the ankle and on the foot • Often very small • Deep with “cliff” edges (callous) • Dry and necrotic • Usually painless related to neuropathy
Venous Ulcers • Usually large with generalized edema • Shallow wounds with irregular edges highly exudating • Generally not as painful as ulcers with arterial etiology
Skin Tears • Predictable and difficult-to-prevent problems with the sin of the geriatric patient and patients on long-term steroids. • Due to loss of cohesion between the epidermis and the dermis in this population of patients the two layers separate easily. • Prevention lies in protecting this skin from injury. • Great care should be taken when handling the extremities, positioning the patient and removing adhesives from the skin.
Pressure Ulcers • Any lesion caused by decreased blood flow from unrelieved pressure that results in damage to underlying tissue. • Usually over bony prominence. • Staged to classify the severity. • Contributing factors are pressure, moisture, friction and shear.
Sensory Perception • Patient population at greatest risk? • Diabetics • Brain and cord injuries • CVAs • Patient Impact: Can’t feel the injury, can’t stop the process • Prevention Strategies • Needs someone to check the skin • Turning schedule • Float heels • Specialty support surfaces
Category 1: SensoryPerception • 1. Completely limited: Patient that does not feel discomfort. • 2. Very Limited: Responds to only painful stimuli. Cannot communicate discomfort. • 3. Slightly Limited: Responds verbally but can not always express discomfort. Sensory impairment limiting the ability to feel pain in 1 or 2 extremities • 4. No impairment: Has no sensory deficits
Moisture • Population at Risk: • Incontinence • Diaphoretic • Wound drainage • Care give dependent • Patient Impact: • Over-hydrated skin decreases tensile strength • Fissures develop • Denuding of skin occurs • Prevention Strategies: • Control Incontinence • Bathroom schedule • Diet • Cleanse skin after incontinence • Mild soap • Peri-cleanser spray • Peri-cleaner wipes • Fecal incontinence collectors or external catheters • Under pads or briefs
Category 2: Moisture • 1. Constantly moist: Skin is always moist due to diaphoresis or incontinence. • 2. Very moist: Linen change at least once a shift. Skin is often moist. • 3. Occasionally moist: One extra linen change per day • 4. Rarely moist: Skin is usually dry.
Activity • Population at risk: • Elderly • Physically impaired • Bed bound or Chair fast • Impact on skin: • Friction and shear risk • Pressure injuries • Prevention Strategies • Turning schedule • Float heels • Pillows • Heel lift devices • Chair fast patients • Weight shifts • Fluidized cushions
Category 3: Activity • Degree of physical activity • 1. Bedfast: Confined to bed • 2. Chair fast: Cannot bear own weight and/or must be assisted into chair or wheelchair. • 3. Walks Occasionally: Walks for short distances with or without assistance. Spends majority of shift in bed or in chair. • 4. Walks Frequently: Walks outside the room at least twice daily and inside the room at lease once every 2 hours during waking hours.
Mobility • Population at risk • Inability to turn self or shift weight • Spinal cord injuries • Frail elderly • Impact on skin: • Can’t feel damage • Can’t reposition to relieve pressure • Time and intensity • Prevention Strategies: • Turn and position every 2 hours. • Use draw sheets • Float heels • Up in chairs requires weight shifts
Category 4: Mobility • Ability to turn and reposition. • 1. Completely Immobile: Does not make even slight changes in position without assist. • 2. Very limited: Attempts to make changes but needs help. • 3. Slightly impaired: Makes small independent body movements. • 4. No limitations: Turns without assistance.
Nutrition • Population at risk: • Elderly • Chronically ill • Mentally or physically impaired • Impact on Skin: • Muscle wasting, loss of subcutaneous tissue • Dry skin, hair and mucosal membranes • Poor wound healing • Prevention Strategies: • Help with eating. • Encourage family to be present for meals. • Supplements and snacks • Protein rather than carbohydrates. • Plan activities around meals.
Category 5: Nutrition • Usual food intake pattern: • 1. Very poor: Never eats complete meal or rarely > 1/3 of offered foods. Poor fluid intake, no supplements, NPO or clear liquids >5/days • 2. Probably inadequate: Rarely eats complete meal, generally eats only about ½ of what is offered. Occasionally will take dietary supplement. Protein intake is only 3 servings of meat or dairy/day.
Nutrition (cont. • 3. Adequate nutrition: Eats over half of most meals and has 4 servings of protein or dairy foods. Occasionally refuses meals but will take supplements if offered. OF is on TPN or tube feeding which meets most nutritional needs. • 4. Excellent nutrition: Eats most of every meal without refusing. Usually eats a total of 4 or more servings of protein. Occasionally eats between meals and does not require supplements.
Nutrition (cont.) • Observe the patients patterns of eating. • Protein, fluid and supplement intake • Stress and smoking can lower protein stores • Wounds require increased protein intake to promote healing
Friction / Shear • Population at risk: • Elderly, malnourished, immobile • Population on long term steroids • Impact on skin: • Compromised blood supple creates ischemia • Ischemia leads to cellular death and tissue necrosis. • Prevention Strategies • 30 degree or < for head of bed • Trapeze when indicated • Protect elbows, heels, sacrum, and back of head. • Draw sheets • Special wraps, devices protective covers.
Friction without shear but not shear without friction Friction shear • Examples: • Abrasions • Superficial friction rubs • Blisters • The resistance to motion in a parallel direction. • Results when two surfaces move across one another • Examples: • Skin tears • Tape striping • Undermining in pressure ulcers • Mechanical force that acts on an area of skin in a direction parallel to the body’s surface.
Category 6: Friction/Shear • 1. Problem: Requires moderate/max assist in moving. Complete lift without sliding against sheet not possible. Frequently slides down in bed or chair. • 2. Potential problem: Moves feebly or requires minimal assist. Skin probably slides against sheet during moves. Maintains posture but slides down sometimes. • 3. No apparent problem: Moves independently, maintains good position in bed or chair
Adding it UP? • Each subset contains a range of number 1-4 • Risk score = total of numeric rating from each of the subsets. • 6 is the lowest possible score and 23 is the highest. • Scale scores • 15-18= patent is at risk • 13-14= patient is at moderate risk • 10-12=patient is at high risk: less than 9 = very high risk