Twin Cities District Dietetic Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE Mary Murphy, RN, MA, CWOCN
Objectives • Identify anatomy and physiology of skin • Describe prevention strategies to reduce incidence of pressure ulcers • Describe an interdisciplinary approach to prevention and treatment of pressure ulcers • Define nutritional treatment modalities for wound healing.
Why should we care? • Complications to patients • Lead to pressure ulcers • Painful • Infection • Quality of Life
Why should we care? • Cost • Hospitalizations • Health care workers • Skin Care Products • Reduction in payment from regulatory bodies
Incidence of Pressure Ulcers (PU)Data from the NPUAP • Volume: 1-3 million people in US develop PU/year • Mortality: 60,000 people die from PU complications/year • Quality of Life: PU reduce quality of life due to pain, treatments, increased length of institutional stay, etc. • Finances: Cost of treating PU ranges from 5-8.5 billion dollars/year • Legal: 87% of verdicts from NH cases goes to Plaintiff • Average award is $13.5 million • Highest award is $312 million in one case!
Clinical Practice Guidelines by NPUAP/EPUAP: • Evidenced-Based Practice • Best scientific research available • Systemic review of literature • Provides tools for best judgment • Allows decision-making on more than “expert opinion” alone. • DOES NOT dictate practice or replace clinical reasoning or judgment – it ENHANCES these! • These are guidelines • Policies are absolute
An interdisciplinary approach to prevention and treatment of pressure ulcers • Hospital skin team • Registered Dietitian • Wound, Ostomy, Continence nursing • Occupational Therapy/Physical Therapy • Physicians – primary/specialty • Plastic surgery • RN staff • Respiratory Therapy • Education staff • Nursing Manager • Pharmacist
Interdisciplinary Approach All disciplines need to assess for risk and put prevention interventions into place: • Occupational Therapy • Cognitive screening • Assistive Technology • Speech Therapy • Memory assessment • Cognition • Communication • Assistive Technology • Physician • C-collar inspection orders • Nursing • Pressure Ulcer Protocol • Nutrition • High protein, high calorie diet with snacks and supplements • Physical Therapy • Wheelchair cushion pressure mapping • Avoiding shear during transfers
Prevention: Risk Assessment Co-morbidities Previous PU Smoking hx Long OR time Long ED stays Critically ill – ICU= 4x more Wheelchairs Obese/thin
Guidelines to Preventing Pressure Ulcers • Combination of Risk Assessment + Skin Inspection + Clinical Judgment • Reassess RISK • Upon admission • At regular frequency • Change in condition • Skin Inspections • Head to toe inspection regularly • Individualized plan of care • Use Interdisciplinary Approach • MD, Nutrition, PT/OT, Speech Therapy
Anatomy and Physiology of Skin • Largest organ of the body • Weight: up to 15% of body weight – about 6 pounds • Size: Average adult – 3000 square inches • Receives 1/3 of body’s circulating blood volume • Constantly exposed to changing environments • Has capability to self-regenerate
Skin Layers: Epidermis • Outermost layer made of epidermal cells • Thin and avascular • Regenerates every 4-6 weeks • Melanocytes reside in epidermis • Melanin is pigment responsible for color of skin
Skin Layers • Dermis • Thicker layer • Contains: • blood vessels • hair follicles • lymphatic vessels • sebaceous glands • sweat and scent glands • nerve endings
Skin Layer: Dermis • Collagen: • Major structural protein • Gives skin strength • Anchors dermis to hypodermis layer • Elastin: • Responsible for skin recoil and resiliency • Allows skin to stretch
Skin Layers: Hypodermis • Subcutaneous Tissue • Composed of adipose and connective tissue • Filled with major blood vessels, nerves and lymphatic vessels • Attaches dermis to underlying structures • Provides insulation and cushioning to body • Acts as a ready reserve of energy
Functions of Skin • Body Image • Maintenance of body form • Appearance, attributes and expression • Sensation • Abundant nerve receptors in skin • Touch • Heat/Cold • Pain • Pressure • Moisture
Functions of Skin • Regulation of body temperature • 98.6 F / 37 C • Thermoregulatory mechanisms: • Circulation • Blood vessels dilate to dissipate heat • Blood vessels constrict to shunt heat to body organs • Sweating • 2-5 million sweat glands
Functions of Skin • Protection • Safety against sunburn • Melanin in the epidermal cells protects against ultraviolet light • Metabolism • Vitamin D formation • Presence of sunlight • This activates the metabolism of calcium and phosphate and minerals (important in bone formation)
Functions of Skin • Protection • Barrier to germs and poisons • Normal floral = • Staph Aureus • Diphtheroids • Gram neg bacilli • NOT Candida – That comes from GI tract • Chemical defenses • Sweat, oils, wax from skin glands contain lactic acid and fatty acid • These acids make skin pH acidic to kill bacteria and fungi
Functions of Skin • Maintenance of water balance • Prevents loss of water through evaporation • <10% moisture – cells shrink = increase invasion of bacteria • >30-40% moisture level = maceration • Increased permeability • Increased risk of injury from friction
Theory of pH • pH refers to management of acid or base levels • Acidic is 0-6 • Neutral is 7 • Basic is 8-14 • Rain is 5.6 • Seawater is >7 • Milk is <7 • Gastric juices are acidic • Saliva and blood are neutral
Skin pH • Skin pH is 4-6.8 with mean of 5.5 • Depends on area of body • Urine, stool, soap and frequent cleansing will increase pH to more basic levels • Pooled urine changes pH to 7.1 – or alkaline shift = this contributes to overgrowth of bacteria • Patients with fecal incontinence are 22x more likely to develop pressure ulcers
Skin Changes • Age-Related changes: • Functions decline • Epidermal/dermal junction flattens • Decreases skin strength • Increases risk for tearing • Melanocytes shrink (decrease in volume) • Increases sensitivity to sun
Skin Changes • Age-Related changes: • Decreased sweat production • Leads to increased dryness and flaking • Nutrition changes • Medications
Guidelines to Preventing Pressure Ulcers • Skin Inspections • Checking all bony prominences • Check under skin folds • Check under medical devices • Check where there is limited sensation • Educate professional staff on skin conditions for early identification • Technique for blanching response • How to assess warmth, edema, and induration • Set time frame for on-going inspections
What are Pressure Ulcers? • Pressure ulcer definition: • A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure or pressure in combination with shear. • Different from: Neuropathic ulcers Arterial ulcers Venous ulcers Trauma injuries
Stage I Pressure Ulcers • Intact skin with non-blanchable redness of a localized area- usually over a bony prominence.
Stage II Pressure Ulcers • Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. • May also present as an intact or ruptured serum-filled blister.
Stage III Pressure Ulcers • Full thickness tissue loss. Subcutaneous fat may be visible but not bone, tendon, muscle. • Slough may be present, but does not obscure the depth of tissue loss. • May include undermining and tunneling
Stage IV Pressure Ulcers • Full thickness tissue loss with exposed bone, tendon or muscle. • Slough/eschar may be present. • Often includes undermining/tunneling.
Unstageable Pressure Ulcers • Full thickness tissue loss in which actual depth of ulcer is completely obscured by slough and/or eschar.
Suspected Deep Tissue Injury • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure/ shear.
Assess for Risk by RN • Braden Risk Assessment (by Barbara Braden) • Reliable research based risk assessment tool • Sensory • Mobility • Activity • Friction/Shear • Nutrition • Moisture
Risk due to Sensory Impairment • Can they feel? • Prevention: • If they can’t feel – someone must look at skin!! • Check under devices • Check for proper fitting shoes and socks • Need redistribution mattress
Risk due to Mobility Impairment • Can they move themselves? • Prevention: • Must be turned every 2 hours • Must be trained in proper pressure relief • Must have pillows elevated
Risk due to Activity • Can they walk? • Are they bedfast? Chair fast? • Prevention: • Do they have a PT/OT consult? • Do they have a proper fitting wheelchair cushion? • Must have training in pressure relief
Risk due to Friction and Shear • Are they sliding in bed or wheelchair? • Prevention: • Watch transfers from w/c to bed • If concerned, get PT/OT consult • Manage spasticity • Report concerns to MD • Keep knee gatch up in bed to prevent sliding in bed
SKIN INSPECTIONS: Bony Prominences To Check
Support Surfaces • How to make sense of the confusion????
What Do We Know- Evidence • Pressure = Force/Area • Pressure is caused by perpendicular force = • Treatment = pressure redistribution • Pressure redistribution = depth of pressure without bottoming out • Shear is parallel force = • Treatment = prevent sliding
Features of Support Surfaces • Air Fluidized • A feature that provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment
Features of Support Surfaces • Low Air Loss • A feature that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin.
Features of Support Surfaces • Foam • Elastic foam or Visco-elastic foam
Features of Support Surfaces • Gel • A feature that is a solid, jelly-like material that can have properties ranging from soft and weak to hard and tough. It is a soft molding layer that contours around the shapes and bumps of the human body. Consider gel products for zone redistribution
Features of Support Surfaces • Alternating Pressure • A feature that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude and rate of change parameters.
Repositioning – Evidence A • Relieve/redistribute pressure • 30 degree side lying is important • Alternate positions • Avoid shear • Avoid lying on medical devices • Avoid slouching in w/c – use footplates • Avoid HOB elevation: HOB = shear/pressure • Elevate heels • Consider “zone” positioning changes • Consider: Every layer on top of surface changes the surface support • Think of chux/linen/briefs = change in performance of bed
Wheelchair cushions • Check w/cushion – pressure mapping • Check chair position • Back tilt w/ legs up • Upright w/ foot rests • Limit sitting time
Risk due to Moisture • Is their skin too moist? • Prevention: • Avoid plastic diapers • Avoid extra pads that retain heat • Skin barrier protection is critical