January 14 Management of Skin & Wounds Flashcards
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
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
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
Function of skin 7
Thermoregulation Regulation of cutaneous blood flow Insulation Immunity Sensory perception Barrier function / protection Synthesis of Vitamin D
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
Risk Factors age:
6
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)
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
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
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
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
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
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.
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
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
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
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
