January 14 Management of Skin & Wounds Flashcards by Seun Akinfiresoye

Wounds in Canada Facts

70% of these wounds considered preventable

The prevalence of pressure Injury across all health-care settings estimated to be 26%

Stage 2 pressure injury can cost up to $44,000 per patient; up to $90,000 per patient for Stage 4.

15 per cent of Canadians (345,000 people) living with diabetes will develop a diabetic foot wound in their lifetime

Complications from diabetic foot wounds led to more than 2,000 amputations across Canada in 2011–2012, which cost 10 to 40 times more than initiatives to prevent amputation

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Ostomy and would care

And services 5

Consultation-based practice

Speciality Mattress

Acute care
Triage-base
Nurse initiates consult

Ostomy

Pre/post op
Outpt follow up
Nurse initiates consult

Complex wounds

Acute care
Stage 3, 4 + pressure injury, NPWT, complex surgical wounds, fistulas, etc.
Most responsible physician (MRP) initiates consult

Negative pressure wound therapy

Acute care and community
Specialist initiates consult (i.e. Plastics, General Surgery Vascular)

Phone Consult

Acute Care, Rural, LTC, etc.
Limited in scope
Patient, nurse or MRP initiates consult

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Skin

Largest what
how much does it weigh and how thick
Ph of skin?
Two primary layers?

Largest organ in the body

6 to 8 lbs

0.5 to 6 mm thick

Acidic pH (4.5-6.5)

‘Acid mantle’ protects skin

Two primary layers:
Dermis
Epidermis

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Function of skin 7

Thermoregulation
Regulation of cutaneous blood flow
Insulation
Immunity
Sensory perception
Barrier function / protection
Synthesis of Vitamin D

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6 Risk factors of Skin

Understand loosly? Mostly the headings

Age
-old/young

Comorbidities:
Liver disease
Renal diseases
Autoimmune disease
DM (glycemic control)
Spinal cord injury

Psychosocial:
Poverty
Chronic pain
Stress
Smoking, ETOH

Treatments:
Chemo/RT
Immunosuppression
Anticoagulants
Steroids

Nutrition:
Malnutrition
Calorie, protein and nutrient deficiency

Circulation:
Immobility
COPD
CAD, LEAD
PVD
Vascular/thrombotic disorders

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Risk Factors age:

Decreased elasticity

Decreased adipose layer
Decreased padding, feel cold

Decreased sweat
-Dry, flaky skin

Decreased tensile strength
-Risk for friction, shear, skin tears

Decreased inflammatory response

Increased risks r/t decreased nutrition, hydration, mobility, ability to conduct ADLs (i.e. hygiene)

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Risk Factors Nutrition5

Recent unintentional weight loss

Obesity

Lack of key vitamins and minerals

Low serum albumin

Nutrients that help heal
Protein
Vitamins A, C, and B-complex
Iron, Copper, Zinc

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Braden scale for predicting pressure injury risk

Key benefits: 4

Score 4
15to18
12to14
10to12
9orless

Identification of at-risk patients using consistent tool
Quantifies severity of risk
Informs Nursing Care Plan
Provides Nursing interventions based on level of risk in six specific risk areas.

At risk
Moderate Risk
High Risk
Very High Risk
The smaller it is the worse it is

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Wound Classification
2
and describe

Partial thickness
-Loss of epidermis and possibly part of dermis

Full Thickness
-Damage through epidermis, dermis and into subcutaneous layer, possibly to muscle and bone

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Wound Healing

4 steps

Hemostasis

starts in minutes, last 5-10
initiates healing/growth factor
Vasoconstriction, platelets clump/clot

Inflammation

Injury triggers increased blood flow = warmth redness edema exudate pain
Neutrophils & macrophages digest bacteria, debris to clean wound bed
Growth factors stimulate granulation tissue
Lasts 3-7 days (depending on patient factors)

Proliferation

Granulation tissue, new blood vessels, contraction of wound margin, epithelial cells migrate across surface of granulated tissue
Most surface (rich blood supply
4 to 24 days

Maturation

Remodeling after closure
Scar tissue = strength = collagen
80% of old strength and limited elasticity
2 years plus

Builds bottom to top

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What is granulation?

What is it made up of

What does it look like

How does it bleed

Growth of small blood vessels and connective tissue in a full thickness wound

Collagen + Capillaries + Cells

Red, bumpy with “meaty” appearance

Does not bleed easily

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What is epithelialization?

Where does it come from

Needs what kind of wounds

Delayed until?

Regeneration of epidermis across a wound surface

Migrates from surrounding skin

Needs open wound edges, not rolled

Delayed until granulation forms, as needs a moist, vascular wound bed.

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Skin Assessment

Head to toe
Check hidden area

What do you use document

Head to toe:
Turgor (dehydration?)
Moisture (dry, itchy, wet, weeping?)
Colour (redness, white, bruises?)
Temperature
Swelling / firmness (induration?)
Irritation (breakdown, rash, blisters?)
Healed ulcers/scars

Check “hidden” areas:
Creases / skin folds (breasts, pannus, groin, armpits)
Perineal / perianal
Joints, boney prominences
Braces, casts, orthotic and prosthetic devices

If you find a dressing lift and look

NISS Wound Record

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Name some causes you can eliminate

Name some causes you can decrease

Pressure, friction, shear
Moisture
Infection
Recurring trauma

Poor mobility
Poor nutrition
Poor circulation
Smoking
Blood sugars
Disease process
Neuropathy/ paralysis

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What to do if you find a wound 6

wounds affect pt as a whole

Assess wound
Identify cause
Record
Provide wound care (cleaning or dressing)
Wound management into care plan
Alert most responsible practitioner

MRP directs wound management and provides orders
MRP might initiate consult to Ostomy and Wound Care for assessment of complex wound
or
MRP may initiate consult to specialist (Plastics, Vascular, Dermatology) for assessment of complex wound

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Types of wounds

Skin Tears

understand cause
Skin most at risk
Identify risk
Prevent
Treat

Removal or disruption of the outer layer of skin (tape injury, trauma)
Partial skin flap (put it back over to heal
Elderly, infant, medically fragile
Fragile skin, existing skin tear
Avoid tape, remove carefully
Control bleeding, clean with NS, realign flap, use non adhesive tape (mepilex transfer) as contact layer, use arrow to show direction for removal, use absorbent layer gauze with rolled gauze/netting, change absorbent layer PRN, leave contact layer 5-7 days, use saline to remove

Types of wounds

Friction and shear

understand cause
Identify risk
Prevent
Treat

Rubbing

-Moisture, mobility nutrition age

Reposition q 2 h, shifting weight
‘Tilting’ (pillows, wedges) or complete turns
Mechanical lifts, lift sheets
Keep HOB <30 degrees unless eating
Up into chair for meals if possible
Slight elevation of knees
Pillow under knees
Moisturize bony prominences
Protect bony prominences 
Manage excess moisture

Stages of Pressure injury 4

Stage 1 = not open wound, no tears, does not blanch

2: open, forms ulcer, deeper layer of skin
3: tissue beneath skin, fat may show not muscle tendon or bone
4: muscle and bone

Unstageable: cant tell how dmged

Types of wounds

Pressure injury

Identify risks
assess routinely
Prevent

Moisture, mobility, nutrition, age

Lift the dressing!
Check bony prominences

Monitor nutrition, involve Dietician, OT/PT
Protect vulnerable areas (bony prominences)
Manage moisture
Turn and reposition q2h when in bed, hourly when sitting
Offload
Heels, ankles, coccyx/sacrum, ischium
Consider referral for specialty mattress
(Note: still need routine turn and repositioning)
Respond to Stage I / II pressure injuries

How to use boot

Put foot in boot and elevated off bed

Types of wounds

Moisture-Associated Skin Damage (MASD

Identify Risks
Assess routinely
Prevention

incontinence, exudate, sweat, skin folds, immobility, skin dmg history, no chance to use toilet, excessive linen (plastic pads)

Red, macerated skin that blanches
Evidence of exposure to moisture, urine or stool

Manage incontinence
Promote air circulation
Manage skin care (avoiding scrubbing, protective barrier cream, leave intact, wipe away soiled area

Venous lower leg wound
facts and causes

Goals of care

Caused by venous valve malfunction, fluid build-up in tissues
Ankle to knee
Sometimes blisters, cellulitis
Shallow, irregular, wet
Can be highly exudative
Edema

Exudate control
Wound management
Compression (requires Ankle Brachial Index (ABIs) and MRP order, including level)
MRP may consult Infectious Disease (ID) for cellulitis

Arterial lower leg wound
facts and causes

Goals of care

LEAD

Caused by poor circulation
Distal foot (toes)
Starts as trauma that doesn’t heal (poor blood flow)
Pale or black
Dry

Stabilizing wound management (including strict foot protection)
MRP may consult Vascular Specialist for revascularization or amputation

Lower extremity arterial disease

Neuropathic lower leg wound facts and causes

Goals of care

DIABETIC ISSUE

Caused by pressure or injury worsened by neuropathy, high blood sugars
Plantar surface of foot
May probe to bone (query osteomyelitis)
May be wet or dry
Often overgrowth of callus

Holistic management of diabetes
Wound management
Offloading
May consult ID for osteomyelitis, Plastics/Ortho for debridement and
Total contact cast (TCC) is gold standard

Lower leg wound - Ankle Brachial Index (ABIs) What is it What does it compare Helps diagnose what Conduct test using?

Blood pressure measurement to assess lower limbs for arterial blood flow Compares brachial systolic pressure to ankle systolic pressure Helps diagnose Lower Extremity Arterial Disease (LEAD) -LEAD must be ruled out prior to application of compression stockings or wraps Floor nursing conducts ABIs test with Dopplex (requires certification) -Based on result, MRP determines compression and writes orders Or Based on result, MRP determines consult to Ostomy and Wound Nurse/ Vascular Specialist or orders further testing If its less than .6 you need to be cautious about applying pressure therapy

Basic Wound Care Cleansing What to do for healing or necrotic wound

Flush away exudate without damaging new tissue Healing wound: - NS-soaked gauze to clean surface-level wound - 100 ml bottles NS provide 5-15 psi, gentle flush into wound with depth Necrotic wound: - irrigation to remove poor tissue and debris, to clean into tunnels, undermining - Use low pressure to prevent splash, contamination - 100 ml bottles NS provide 5-15 psi - Rough, non-woven gauze might gently wipe away loosened debris Use normal saline unless otherwise ordered.

``` Is the wound dry/wet? Is there depth that needs to be filled? Is there drainage? How much? Is the periwound skin broken down / at risk? Could there be infection? ```

Is the wound dry/wet? Balance the moisture – not too wet, not too dry! Is there depth that needs to be filled? Fill depth – no dead space! Is there drainage? How much? Manage drainage Is the periwound skin broken down / at risk? Use less traumatic dressings i.e. no tape Could there be infection? Query antimicrobial dressing

Kinds of dressings Fill Wick Contact Cover Fluff don't stuff

Ribbon or sheet that fills depth Accommodates wound contours (i.e. uneven base, undermining) Absorbs / transfers exudate into absorbent dressing Eliminates “dead space” Ribbon that fills tunnels Wicks exudate into secondary dressing Non-adherent to wound bed Maintains moist-wound balance ``` Dressing for superficial wound Secures any fill/wick Protects wound Protects periwound skin Manages drainage ```

Gauze Non-adherent Calcium Alginates Hydrofiber

``` Squares, ribbon, cover dressing Easy to ‘over-pack’ Dries out wound bed Traumatic removal (damages new tissue) Limited absorption Requires frequent dressing changes, so can be more expensive Better as a cover dressing If in contact wound bed, use nonwoven (smooth), fluffed, possibly moistened ``` Squares, small and large Non-adherent to wound bed Allows exudate to move into absorbent dressing ``` Sheet, ribbon May not be appropriate for tunnel (loose fibers) Reduces over-packing Best for wet wounds; “wicks,” balances Atraumatic removal if wound moist Can be left for up to 3 days ``` ``` Sheet, ribbon Similar to alginates, more expensive Reduces over-packing Forms a gel (may keep wound more wet) Atraumatic removal if wound moist Can be left up to 3 days ```

Signs a wound could be infected 12

``` Redness to periwound skin Warmth to periwound skin Increased pain Increased edema/swelling Presence of purulence Increased drainage Foul odour Serous drainage with concurrent inflammation Delayed wound healing (stalled healing) Discoloured or “friable” wound tissue Pocketing at base of wound Wound deterioration ```

Antimicrobials dressing

Dressings contain added silver, iodine, PHMB Attract and kill bacteria Effective against all wound pathogens Variable duration, strength, absorption, antimicrobial mechanism For wounds at high risk of infection For wounds with evidence of critical colonization Wound culture not required May be used in addition to systemic antibiotic

Compression dressing

Compression is the gold standard treatment for venous disease and lymphedema May be used to treat edema and / or cellulitis. Coban 2-layer self-adherent compression therapy comes in Lite or Regular ABIs must be completed prior to application to rule out LEAD MRP must order compression and indicate level (20-30 mmHg or 30-40 mmHg) RN / LPN Certification must be completed prior to application / dressing changes

Negative Pressure Wound Therapy (NPWT) Creates a vacuum to?

``` Reduce edema Improve perfusion Stimulate granulation Expedite healing Decrease infection risk Control excess exudate ``` MRP consults surgeon, surgeon assess, Ostomy and Wound Care provides NPWT ActiVac or InfoVac, surgeon oversees or directs first application, Unit nurse complete dressing change with ostomy and wound nurse support RN / LPN certification must be completed prior to applying NPWT