1. CRRN Review-2016 Skin and Wound Management
Jenifer Stevenson
BSN, CRRN, CNML

2. Disclosure
The presenter for this presentation have disclosed no conflict of interest related to this topic.

3. Functions of Skin Thermoregulation Protection from injury
Shields underlying tissue
Communication with the environment

4. Pressure Injuries
Total National cost of pressure injury treatment is $9.1-$11.6 billion annually
Estimated $20,900 to 151,700 per pressure injury
60,000 people die from pressure injury complications each year
More than 2.5 million patients per year
Lawsuits: More than 17,000 lawsuits are related to pressure injuries annually. It is the second most common claim after wrongful death and greater than falls or emotional distress.
Pain: Pressure injuries may be associated with severe pain.

5. Pressure Ulcers Oldest Name: Bed sores Old Name: Decubitus Ulcers
Newer Name: Pressure Ulcers
Newest Name: Pressure Injuries (2016)

6. Definition Of A Pressure Injury
Definition: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue.

7. Pressure Injury Formation
Local Ischemia: Pathological changes to capillaries and tissues. May occur in less than 2 hours
Cell Death: Progression of tissue change in response to obstruction of capillary blood flow. Patient may report pain, warmth to area and slight edema
Tissue Collapse: Non reversible. Area will be cool to the touch, may feel hard or indurated, or soft and boggy
Infection: No swab cultures as pressure ulcers are generally colonized and may not reveal an underlying soft tissue infection or osteomyelitis

8. Locations Of Pressure Injuries
A. Ischium 24%
B. Sacrum 23%
C. Trochanter 15%
D. Heel 8%
E. Malleolus 7%
F. Knee 6%
G. Iliac Crest 4%
H. Elbow 3%
I. Pretibial Crest 2%
J. Skull 1%

9. Unstageable Pressure Injury
Obscured full-thickness skin and tissue loss.
Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.  If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

10. Unstageable Pressure Ulcer

11. Unstageable Pressure Injury

12. Unstageable Pressure Injury

13. Unstageable Pressure Injury

14. Unstageable Pressure Injury

15. Stage 1 Pressure Injury
Definition:Non-blanchable erythema of intact skin.
Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

16. Stage 1 Pressure Injury

17. Stage 1 Pressure Ulcer

18. Stage 2 Pressure Injury
Definition: Partial-thickness skin loss with exposed dermis
Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.  This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions).

19. Stage 2 Pressure Injury

20. Stage 2 Pressure Injury

21. Stage 3 Pressure Injury
Definition:Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds.  Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

22. Stage 3 Pressure Injury

23. Stage 3 Pressure Injury

24. Stage 3 Pressure Injury

25. Stage 3 Pressure Injury

26. Stage 4 Pressure Injury
Definition:Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

27. Stage 4 Pressure Injury

28. Pressure Ulcers with Exposed Cartilage Are Stage IV Pressure Ulcers
It is the opinion of the NPUAP that cartilage serves the same anatomical function as bone. Therefore, pressure ulcers that have exposed cartilage should be classified as a Stage IV.

29. Deep Tissue Pressure Injury
Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin.  This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface.  The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

30. Deep Tissue Pressure Injury

31. Deep Tissue Pressure Injury

32. Deep Tissue Pressure Injury

33. Medical Device Related Pressure Injury
This describes an etiology. Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

34. Medical Device Related Pressure Injury

35. Medical Device Related Pressure Injury

36. Infected Pressure Ulcer
Marked by and increased wound size, perilesional warmth and tenderness, erythema on the surrounding skin, malodorous base, and increased wound exudate

37. Infected Pressure Injury

38. Mucosal Membrane Pressure Injury
Mucosal membrane pressure injury is found on mucous membranes with a history of medical device in use at the location of the injury. Due to the anatomy of the tissue these ulcers cannot be staged.

39. Not a Pressure Injury Skin Tear Sacral Slit
Moisture Associated Skin Damage

40. Not Pressure Injury

41. Risk Assessment for Pressure Injuries
Factors that place persons at risk
Inability to perceive pressure/temperature
Exposure to incontinence, moisture, chemicals or radiation
Decreased activity level
Smoking
Diabetes
Fragile skin

42. Risk Assessment for Pressure Injuries Continued
Inability to reposition-bedfast or chair fast
Poor nutritional intake/hydration
Friction and shear
Medications
Skin care products
Psychosocial factors/life satisfaction
Existing pressure injury

43. Addressing the Risk Factors for Prevention of Pressure Injuries
Turning/repositioning schedule
Mattress overlays/beds/wheelchair seating
Nutritional supplements
Skin protection

44. Risk Assessment Tools
A. Braden Scale - assesses 6 client factors: mobility, activity, moisture, sensory perception, nutrition, friction and shear
B. Norton Scale - assesses 5 factors: physical condition, mental condition, activity, mobility and incontinence

45. Braden Scale Highest possible score is a 23
Lowest possible score is a 6
Mild risk=15-18
Moderate risk= 13-14
High Risk 10-12
Very High Risk <9

46. Pressure Redistribution
Bed bound patients must be repositioned at least every 2 hours and chair bound patients every 15 minutes.
Reposition while on special beds and overlays
Persons must be turned at least 30 degrees to redistribute pressure from the sacrum
Use wedges and pillows to support bony prominences
Float heels off the bed surface

47. Horizontal Support Surfaces
DMERC Category I- static overlays, non-powered mattresses and powered mattresses with an air lift< 2.5 inches
Durable Medical Equipment Regional Carrier

48. Horizontal Support Surfaces
DMERC Category 2-alternating pressure, air flotation mattress or overlay greater than 3 inches or a powered overlay, mattress or bed

49. High Air Loss Surface

50. Assessing the Performance of a Support Surface
Bottoming out- the surface is totally compressed-use hand check-should not be able to feel the patient
Memory in foam
Bunching in gels
Deflation in air-filled
Hand checks should not be used to assess integrated bed systems

51. Chair Support Cushions
Use Pressure distributing cushions
Instruct patient and family members to relieve pressure while seated every 15 minutes (including when patient is in the shower chair or on a commode)
Consider tilt/reclining chair for more pressure distribution

52. Wheelchair Cushions
Foam- from 1-4 inches thick and range from soft to firm density; need to be replaced frequently
Floatation- air, water or gel-some contain cells that function independently
Air cycling-customized inflation and cycling action

53. Wheelchair Cushions

54. Interface Pressure Mapping
A tool that provides a way for us to assess the interface pressure between an individual and their seating surface.
The main purpose of is to look at the distribution of the pressure over their seated surface and note peak areas.

55. Pressure Mapping
Before and after a wedge was added

56. Pressure Mapping
With and without a dressing

57. Wound Treatment: Debridement
Sharp
Enzymatic
Mechanical

58. Wound Treatment: Debridement
Enzymatic

59. Wound Treatment: Debridement
Mechanical: wet to dry dressings

60. Wound Treatment: Cleansing
Normal Saline
Commercially prepared solutions

61. Wound Treatment: Dressings
Gauze
Transparent Film
Hydro gels
Alginates
Hydro colloids
Foams
Absorptive fillers
Regranex

62. Wound Treatments: Absorptive Fillers
Absorptive fillers: Used to absorb exudates and fill dead space.
Generally covered with transparent film or hydrocolloid dressing

63. Wound Treatments: Gauze
Purpose to absorb; supports moist wound healing if kept moist; used to fill sinuses or dead space; should be packed lightly to prevent impaired circulation
Also may be impregnated with petrolatum or gels

64. Wound Treatments: Transparent Film
The first occlusive dressings; insulate; protect; and maintain the moist wound surface.
Permeable to oxygen and water vapor but impermeable to fluids and bacteria
Non-absorptive

65. Wound Treatments: Hydro gels
Gels that may be poured into the wound; mild absorption; may fill dead space; painless

66. Wound Treatment: Alginates
Alginates: Occur naturally in seaweed, absorb exudates, maintains a moist wound bed and can be used with either shallow or deep wounds

67. Wound Treatments: Hydrocolloids
Hydro colloids: Wafer that protects the moist wound bed yet absorbs exudates; Occlusive and prevents O2 from entering the wound. This occlusion promotes wound healing when growth factors are allowed to proliferate under the dressing

68. Wound Treatments: Foams
Foams: Non-adherent wafers; good absorption; hydrophobic surface repels contaminants

69. Negative Pressure Wound Therapy
Vacuum assisted closure
Developed by a plastic surgeon and received FDA approval in 1995
A negative-pressure sponge dressing is placed within the wound to increase blood flow, increase granulation tissue and nutrients to the wound

70. Wound Treatments: NPWT
CONTRAINDICATIONS Malignancy in the wound Untreated Osteomyelitis Non-enteric and unexplored fistula Necrotic tissue with eschar present Do not place dressing over exposed blood vessels or organs

71. Wound Treatments: NPWT
Patients can attend therapy
Battery pack
Dressing change every 2-3 days

72. Surgical Management
Stage III and IV wounds are often closed by myocutaneous flap
Early closure decreases loss of fluid and nutrients, improves the health status of the client, and leads to earlier recovery and mobilization

73. Myocutaneous Flap

74. Burns

75. Burn Patients Suffer the Effects From Loss of Skin Function

76. Burns First Second Third Depth (how deep the burn is) Epithelium
Epithelium and top aspects of the dermis
Epithelium and dermis
How the wound looks
No blisters; dry pink
Moist, oozing blisters; Moist, white, pink, to red
Leathery, dry, no elasticity; charred appearance
Causes
Sunburn, scald, flash flame
Scalds, flash burns, chemicals
Contact with flame, hot surface, hot liquids, chemical, electric
Level of Pain (sensation)
Painful, tender, and sore
Very painful
Very little pain, or no pain
Healing Time
Two to five days; peeling
Superficial: five to 21 days. Deep: days
Small areas may take months to heal; large areas need grafting.
Scarring
No scarring; may have discoloration
Minimal to no scarring; may have discoloration
Scarring present

77. First Degree

78. Second Degree

79. Third Degree

80. Thermal Burns
Flash - Explosions of natural gas, propane, gasoline and other flammable liquids.  Intense heat for a very brief period of time.  Clothing is protective unless it ignites. Flame - Exposure to prolonged, intense heat.  House fires, improper use of flammable liquids, automobile accidents, ignited clothing from stoves/heaters. Scalds - Burns caused by hot liquids.  Water, oil, grease, tar, oil. Water at 140 degrees F, creates a deep burn in 3 seconds, but at 156 degrees F will cause the same injury in 1 second.  (Coffee is 180 degrees F just brewed).  Circumferential burns should raise suspicion of non-accidental trauma.  Tar needs to be removed either with an adhesive remover solution or petroleum based dressings. Contact - Result from hot metals, plastics, glass or coals. Can be very deep.

81. Chemical Burns
Caused by strong acids or alkali substances.  They continue to cause damage until the agent is inactivated.  Alkali substances usually cause more severe injury since they react with the lipids in the skin.

82. Electrical Burns
Caused by either AC or DC current.  Current follows the path of least resistance and causes injury in areas other than the contact/entry site.  They cannot be judged from the external injury alone.  High voltage > 1,000 volts, low voltage < 1,000 volts and lightening.  Electrical burns are thermal burns from very high heat.

83. Radiological Burns
Caused by alpha, beta or gamma radiation.  They may need to have some type of decontamination done to stop the injury.

84. Rule of Nines
The Wallace rule of nines is a tool used in pre-hospital and emergency medicine to estimate the total body surface area (BSA) affected by a burn. In addition to determining burn severity, the measurement of burn surface area is important for estimating patients' fluid requirements and determining hospital admission criteria.
The rule of nines was devised by Pulaski and Tennison in 1947, and published by AB Wallace in 1951.
To the estimate body surface area of a burn, the rule of nines assigns BSA values to each major body part.

85. Rule of Nines

86. Points to Remember Pre medicate before shower or wound care
Allocate enough staff
Prepare dressings before change
Ensure that temperature and pressure of water can be regulated

87. Points to Remember Continued
Move quickly
Clean thoroughly
Remove “egg white” like drainage
Pat dry lightly
Cover with dressings
Compression

88. True or False?
A person who cannot move should be repositioned while sitting in the wheelchair every two hours…..

89. Scarring will break down faster than unwounded skin…
True or False?
Scarring will break down faster than unwounded skin…

90. True or False?
A low Braden score is associated with and increased pressure risk…

91. True or False?
Shear is the force which occurs when the skin sticks to a surface and the body slides….

92. Pressure Injury?
Is this a pressure injury?

93. Pressure Injury?
What stage pressure injury?

94. Question?
Shear injuries
can be prevented with this intervention: