1. Wounds and skin Ch. 48

2. 5/11/20152NRS 105.320

3. 5/11/20153NRS 105.320

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5. STAGE I ULCER- GREATER TROCHANTER 5/11/2015NRS 105.3205

6. Stage 1 Pressure Ulcer

7. STAGE II ULCER – ISCHEAL TUBEROSITY 5/11/2015NRS 105.3207

8. Stage 2 Ulcer

9. STAGE III 5/11/2015NRS 105.320 S20099

10. Stage 3 Pressure Ulcer

11. STAGE IV ISCHEAL TUBEROSITY AND SACRUM 5/11/2015NRS 105.320 S200911

12. Stage 4 Ulcer

13. 5/11/2015NRS 105.32013

14. 5/11/2015NRS 105.320 S200914

15. 5/11/201515NRS 105.320

16. Risks for Pressure Ulcers Immobility Immobility –Unable to move independently Impaired Perception [numbness, paralysis] Impaired Perception [numbness, paralysis] –Unable to sense pain/pressure Altered LOC Altered LOC –Confused – perceive pressure/pain but can’t communicate/ relieve pressure –Coma: no perception + immobility

17. Shearing Skeleton, muscle slide one way, skin stays or moves the other way Skeleton, muscle slide one way, skin stays or moves the other way –Raising HOB, transferring pt by sliding – stretching of skin, tears capillaries, necrosis leads to undermining of tissues

18. Friction Top layers of skin Top layers of skin Sliding across coarse linens, seats Sliding across coarse linens, seats Position changes w/o lifts Position changes w/o lifts

19. Wound healing Primary Intention [surgical wound] Primary Intention [surgical wound] –Clean edges, approximated [closed] –Low risk of infection –Quick healing, fine scar Secondary Intention Secondary Intention –Trauma, ulcer, dehisced wound –Open – wound healing, filled by scar tissue, granulation over time – deep scar –Slow healing, ↑ risk of infection

20. Wound Dressings Protection Protection – against contamination, pain from air Homeostasis Homeostasis –[pressure, clot, edges] ↑ Healing ↑ Healing –Absorb drainage, debride depending on type Moist environment [+ or -] Moist environment [+ or -] –Healing by 2° intention [- if infected]

21. Which Dressing? Depends on wound assessment, purpose Depends on wound assessment, purpose –Purpose is to provide the right environment to enhance & promote wound healing. –moist healing environment stimulates cell proliferation & encourages epithelial cells to migrate –Provide barrier against bacteria and absorb fluid –Decrease or eliminate pain

22. Wound Vac Removes drainage, increases perfusion

23. Assessments Is the wound copiously draining? Is the wound copiously draining? Is it dry? Does it need added moisture Is it dry? Does it need added moisture Does it need debridement? Does it need debridement? Is it infected? Is it infected?

24. Surgical Wound - CDI

25. Infected surgical wound

26. Dehiscence

27. Infected & dehisced wound

28. Types of dressings and Uses Gauze Gauze – draining wounds; necrotic wounds – those requiring debridement or packing – wounds with tunnels, tracts, or dead space – surgical incisions; burns – dermal ulcers; and pressure ulcers May be impregnated w/ antimicrobial – May be impregnated w/ antimicrobial – – IV sites, trach, drains, full-thickness wounds

29. Wound Dressing Tray

30. Transparent films let oxygen pass through to the wound and moisture vapor escape let oxygen pass through to the wound and moisture vapor escape –Partial-thickness wounds – Stage I and II pressure ulcers –superficial burns –donor sites. –as a secondary dressing Not always absorbent Not always absorbent

31. Tegaderm

32. Foam Nonadherent and nonocclusive Nonadherent and nonocclusive –Hydrophilic, polyurethane or film-coated gel –Stages II through IV pressure ulcers – partial- and full-thickness wounds with minimal to heavy drainage –surgical wounds – dermal ulcers, –under compression wraps Check to see if indicated for infected wound Check to see if indicated for infected wound

33. Nonadhesive Foam Dressing

34. Composite dressings Combinations of two or more different products in one Combinations of two or more different products in one –bacterial barrier, absorptive layer, foam, hydrocolloid, or hydrogel –semi-adherent or nonadherent –Partial and full-thickness wounds, minimally to heavily draining wounds, dermal ulcers, and surgical incisions –Check package for pressure ulcers (Baranoski, S. (2008) Nursing2008 v1No. 1 pg 60-61)

35. Heat and Cold Therapy Heat increases blood flow Heat increases blood flow –Limit time… eventually → vasoconstriction Cold decreases swelling and pain Cold decreases swelling and pain –Limit to 10-20 minutes r/t ischemia, eventual vasodilatation

36. Pressure Ulcer Impaired skin integrity (damage to the skin) R/T unrelieved, prolonged pressure AEB full- thickness pressure ulcer on L heel Impaired skin integrity (damage to the skin) R/T unrelieved, prolonged pressure AEB full- thickness pressure ulcer on L heel –AKA: Pressure sore, decubitus ulcer, bedsore 5/11/2015NRS 105.32036

37. Nursing Diagnosis Impaired Skin Integrity r/t pressure/ischemia 2* to immobility AEB stage III ulcer on L leg, on bedrest, Braden score = 5 Impaired Skin Integrity r/t pressure/ischemia 2* to immobility AEB stage III ulcer on L leg, on bedrest, Braden score = 5 5/11/201537 NRS 105.320

38. Nursing Diagnoses for Skin/ Wound Risk for infection Risk for infection Imbalanced nutrition: less than body req. Imbalanced nutrition: less than body req. Pain [acute/chronic] Pain [acute/chronic] Impaired Mobility Impaired Mobility Impaired skin integrity [+ risk for…] Impaired skin integrity [+ risk for…] Ineffective tissue perfusion Ineffective tissue perfusion Impaired tissue integrity Impaired tissue integrity Alteration in body image Alteration in body image

39. Plan On-going skin assessment On-going skin assessment Nutritional assessment Nutritional assessment Pressure relief for affected areas Pressure relief for affected areas Preventative care for intact skin Preventative care for intact skin Restorative care for wounds Restorative care for wounds 5/11/201539 NRS 105.320

40. Goals 1. Pressure ulcer will not increase in size [this shift] / during hospitalization [baseline = 1cmX2cm] 2. Pt will be free of s/sx of Infection in pressure ulcer this shift / during hospitalization 3. Pt will eat a balanced, high protein diet today / while in facility 4. Patient and family will develop a plan (with nursing staff/ dietician) for preventing further skin breakdown within 2 days 5/11/2015 NRS 105.320 40

41. 5/11/2015415/11/201541 TYPES OF INTERVENTIONS NURSE INITIATED NURSE INITIATED –INDEPENDENT PHYSICIAN INITIATED PHYSICIAN INITIATED –DEPENDENT COLLABORATIVE COLLABORATIVE –INTERDEPENDENT NRS 105.320

42. Interventions RN to assess skin q shift, document including size and appearance of wound[s] RN to assess skin q shift, document including size and appearance of wound[s] RN will provide Wound care per policy q shift and prn RN will provide Wound care per policy q shift and prn Dietician to complete nutritional assessment and recommend a diet within 24 hours Dietician to complete nutritional assessment and recommend a diet within 24 hours RN/ CNA to offer health shake/ protein cup between meals RN/ CNA to offer health shake/ protein cup between meals CNA will Reposition patient q 2 hours: supine, left, right; prop w/ pillows; document on position record CNA will Reposition patient q 2 hours: supine, left, right; prop w/ pillows; document on position record RN will Meet w/ pt and family, dietician by Friday to discuss meal plan RN will Meet w/ pt and family, dietician by Friday to discuss meal plan RN will Educate pt/ family re: immobility, skin, pressure today and reinforce with handout/demo RN will Educate pt/ family re: immobility, skin, pressure today and reinforce with handout/demo 5/11/201542 NRS 105.320

43. Rationales (with Citations) Decreasing the duration of pressure on skin will prevent further skin breakdown. ( Perry and Potter, p. 1281 ) Decreasing the duration of pressure on skin will prevent further skin breakdown. ( Perry and Potter, p. 1281 ) Wound healing requires proper nutrition. ( Perry and Potter, p. 1290 ) Wound healing requires proper nutrition. ( Perry and Potter, p. 1290 ) Family caregivers require education and counseling to be effective. ( MSU 2009) Family caregivers require education and counseling to be effective. ( MSU 2009) 5/11/2015NRS 105.32043

44. Outcome Evaluation 1. Goal not met: By discharge date, patient had developed stage I ulcer on Rt hip, L heel still full thickness –Revise/ update plan for ulcer prevention [because it isn’t working]; elevate heels while in bed 2. Goal met: pt afebrile, wound culture negative. Continue with plan 3. Goal met: Patient has gained 3lbs this month and serum proteins have increased. - Continue w/ plan - Continue w/ plan 4. Goal met: Family has decided on transfer to LTC for further patient care. - Plan: provide skin history and assessment to LTC facility 5/11/2015NRS 105.32044

45. IMAGES Disclaimer Some of these images are upsetting Some of these images are upsetting

47. Lacerations

51. Degloving pre-op

57. Key Points Chapter 48 Pressure ulcers → pain, ↓ mobility, ↑ cost and length of stay. They are preventable Pressure ulcers → pain, ↓ mobility, ↑ cost and length of stay. They are preventable Learn Braden Scale and Staging Learn Braden Scale and Staging Assess all pts for risks to skin integrity Assess all pts for risks to skin integrity Wound assessment and documentation Wound assessment and documentation Control bleeding, clean, protect [1 st aid] Control bleeding, clean, protect [1 st aid] Wound care – least to most contaminated Wound care – least to most contaminated ↑ protein, Vit C, calories for healing ↑ protein, Vit C, calories for healing