SKIN ASSESSMENT AND PRESSURE ULCER PREVENTION Denise Gutwein, MSN, RN, CCRN ICU Clinical Coordinator Putnam Community Medical Center

Educational Objectives The learner will be able to: Describe the best approach to prevention Identify the major risk factors for developing pressure ulcers Demonstrate how to use the Braden Scale assessment tool Select the proper surface for assessment findings Give an overview of wound care utilizing dressings, irrigation, debridement and/or wound vac appropriate to the characteristics of the pressure ulcer.

SKIN FACTS: Largest organ of the body Covers approximately 3000 square inches Receives 1/3 circulating blood volume From birth to maturity, the skin will undergo a sevenfold expansion Weighs about 6 pounds 1cm 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 follicles Is capable of self-generation Can withstand limited mechanical and chemical assault

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)

What is a Pressure Ulcer ? Any lesion caused by unrelieved pressure usually over a bony prominence that results in damage to underlying tissue

Pressure Ulcer Begins with unrelieved pressure resulting in damage of underlying tissue. U.S. Department of Health and Human Services Agency for Healthcare Research and Policy www.ahrq.gov

BEST TREATMENT OPTION AVOIDANCE!

Risk Factors Risk Factors for Pressure Ulcer Development: Inability to perceive pressure Incontinence/moisture Decreased activity level Inability to reposition Poor nutritional intake Friction and shear

Etiology Factors Contributing to Pressure Ulcers Etiologic factors contributing to pressure ulcer occurrence: Pressure Shear Friction PRESSURE: Squeezing together of soft tissue caused by weight SHEAR: 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.

Factors affecting Tissue Tolerance Tissue tolerance factors affecting pressure ulcer development: Vascular competency Glycemic control in diabetes mellitus Body weight/malnutrition Age

FORCES IN PRESSURE ULCER DEVELOPMENT INTRINSIC NUTRITION TISSUE OXYGENATION COMORBIDTIES INFECTION EXTRINSIC PRESSURE SHEAR FRICTION MACERATION TEMPERATURE ERGONOMICS

Risk Assessments Using Valid and Reliable Tool The risk assessment tool selected for LifePoint Hospital’s adult patient population is the Braden Scale Score the risk assessment Braden Scale Interpret 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)

Braden Risk Assessment Scale Braden Risk Assessment Scale (abridged version) Sensory Perception 1 Completely limited 2 Very limited 3 Slightly limited 4 No impairment Moisture 1 Constantly moist 2 Very moist 3 Occasionally moist Activity 1 Bedfast 2 Chairfast 3 Walks Occasionally 4 Walks frequently Mobility 1 Completely immobile 4 No limitation Nutrition 1 Very poor 2 Probably inadequate 3 Adequate 4 Excellent Friction and Shear 1 Problem 2 Potential problem 3 No apparent problem

Base the Plan on Patient Needs (subscale scores) Immobile = reposition q 2 hrs in bed Inactive = reposition q 1hr in w/c Incontinent = protect skin from exposure Malnourished = supplement oral intake Shearing = keep HOB as low as possible Limited awareness= assess skin daily

Nutritional Screening Screen for Nutritional Deficits Provide nutritional support to patients with nutritional risks & pressure ulcer risks Complete nutritional assessment by the dietician as indicated Estimation of nutritional requirements Compare nutrient intake with estimated requirements Identify best feeding route Provide nutritional supplements as orders between regular meals in order NOT to influence normal food and fluid intake during regular mealtimes. Monitor nutritional outcome Reassess nutrition status when there is a change in the individual’s condition.

Conduct a Thorough Skin Assessment Assess on admission and routinely (Braden Scale or as per P&P) Document finding and incorporate into plan of care Assess 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)

Pressure ulcer stages Stage 1: epidermis; non-blanching erythema Stage 2: epidermis/dermis; shallow opening; blisters Stage 3: subcutaneous tissue/fascia Stage 4: fascia + bone, tendon, muscle, cartilage Unstageable Note: stages define level of tissue injury and NOT progression of ulcer development or healing.

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 ulcers While 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.

Physiological condition affecting nutrition Nutritional Care Evaluate appropriate lab data Albumin normal adult range: 3.2 - 5.0 mg/dl Pre-albumin normal adult range: 16 – 42 mg/dl Hemoglobin normal adult (Female) range: 12 - 16 mg/dl normal adult (Male) range: 14 – 18 mg/dl Hematocrit normal adult (Female) range: 37 – 47% normal adult (Male) range 40 – 54%

Documentation Documentation should reflect: Assessment and screening findings History & 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 include Location, 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&P Plan of Care: cleansing, positioning, turning, barrier meds, surface chosen for offloading, dressing care/change, other interventions Interventions as instituted and patient response. Patient/family education Consults Reports to MD with orders received

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.

Preventive Skin Care Reduce exposure to irritants Clean immediately after incontinence Apply skin protectants Keep linens clean/wrinkle free Check fit of braces, splints, medical devices (e.g., oxygen tubing, NG tube, stockings) and skin underneath Maintain environmental humidity Individualize frequency Document

Positioning Devices Teach individual to reposition using the trapeze Use lifting devices to move individuals who cannot assist Place pillows/wedges between knees and ankles

Head of Bed Elevation Maintain lowest possible elevation Avoid more than 30° head-of-bed elevation unless medically needed

Side Lying Position Avoid positioning directly on the trochanters Use the 30° lateral inclined position

Elevate Heels Ensure space between bed and heels (float heels) Use pillows to elevate heels off the bed surface Avoid hyper-extension of the knees Check for injury from splints when used for heel elevation

No Donuts Do NOT use plastic rings or donuts for pressure relief as this can cause larger area of tissue injury because of intense pressure along the donut X

No Massage Avoid Massage of Red Areas Massage may decrease rather than increase blood flow

Let the skin breathe Incontinence Management DO: Use gentle soap or skin cleanser Apply topical barrier to protect skin DON’T Scrub the skin Use plastic incontinence pads on low air loss beds

Reduce Shear & Shearing Shear diminishes blood supply to skin Use positioning, transferring & turning techniques to minimize friction/shear injury

Support Surfaces Patients at high risk for the development of a pressure ulcer or those with existing pressure ulcer will need a support surface.

Change Support Surfaces Most pressure reducing devices are more effective than standard hospital mattress

Types of Support Surfaces Category 1 Static overlays and mattresses Foam, air, gel Category 2 Alternating pressure and air flotation Category 3 Air fluidized Low air loss bed/mattress

Support Surfaces in Chairs If patient spends a prolonged time in a wheelchair: Use pressure reducing cushion Instruct to also relieve pressure with hand Lifts if possible every 15 minutes Change chair to tilt/recline for more pressure distribution

Assessing Performance of a Support Surface Bottoming out Surface totally compressed Use hand check, should not be able to feel person Memory in foam Shape remains Bunching in gels Deflation in air filled or leakage of fluid or gel

Hand-off communication Communication to the nurse of new findings is important to discuss in a timely manner. New areas of redness, maceration or breakdown Change in incontinence pattern or diarrhea Odor to wound Dressing soilage or drainage through dressing Temperature, low blood pressure and/or lethargic as a sign of infection Change of shift hand-off communication: Status of skin New areas of redness or breakdown Last turn position Changes in the patient condition Location of decubitus and treatment intervention applied Pain, temperature, vs abnormalities and lethargy

Documentation THERE 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 CAREGIVERS THERE 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

PREVENTION OF MACERATION KEEP PATIENTS DRY AND CLEAN DO NOT USE DIAPERS UNLESS THE FAMILY INSISTS. THIS MUST BE DOCUMENTED. USE CLOTH CHUX USE PH BALANCED PERINEAL CLEANSER NOTIFY NURSE TO GET AN ORDER FOR INCONTINENT BARRIER CREAM (CALMOSEPTINE) MAKE ALL EFFORTS TO CONTINUE HOME BOWEL AND BLADDER PROGRAM

PRESSURE ULCER DUE TO MACERATION

STAGING

Pressure Ulcer Staging Stage I Stage 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.

Pressure Ulcer Staging Stage I Dark Skin

Pressure 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. Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

Pressure Ulcer Staging Stage II Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

Pressure Ulcer Staging Stage II

Pressure Ulcer Staging Stage II

Pressure Ulcer Staging Stage II

Pressure Ulcer Staging 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. 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

Pressure Ulcer Staging Stage III 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

Pressure Ulcer Staging Stage III

Pressure Ulcer Staging Stage IV Full 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 ulcers Stage 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

Pressure Ulcer Staging Stage IV

Pressure Ulcer Staging Stage IV

Pressure Ulcer Staging Stage IV Stage 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

Pressure Ulcer Staging Stage IV Stage 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

Pressure Ulcer Staging UNSTAGEABLE

Venous Ulcers Due to venous insufficiency Medial Aspect of the leg Beefy Red Jagged Painless Treat with compression

Venous Ulcers

Venous Ulcers

Diabetic Ulcer

SKIN TEARS

SKIN TEARS

Remember . . . Even on a rough day, someone is having a day that is worse! The End The End

THE END