Wound management: A CNS perspective

1. Wound management:A CNS perspective Anna Alvarez Jacqueline Wiseman

2. Objectives • Identify the scope of problem • Identify major functions of the skin • Identify layers of the skin and repair process • Identify wound etiology

3. Objectives • Discuss correct utilization of skin risk assessment tools • Identify pressure ulcer prevention modalities • Identify pressure ulcer staging • Discuss strategies for dressing selection • Compare and contrast roles between the WOCN and the CNS.

4. Pressure Ulcers are a National Health Concern • Considered preventable • Costly complication • Average cost of $129,247 or more in direct cost to treat stage IV pressure ulcers • Increases hospital length of stay • Lawsuits. • JC goals • Sentinel Events/CMS never events

5. Sentinel Events • Sentinel events signal the need for immediate investigation and response. • Any unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. • “Or the risk thereof” includes any process variation for which a recurrence would carry significant chance of a serious adverse outcome. • Serious injury specifically includes but is not limited to loss of limb or function

6. Sentinel Event • Pressure ulcers are now added to the sentinel events list. • Patient develops an ulcer while in the hospital. • Patient admitted with an ulcer that deteriorates or does not improve during the hospital stay. • This requires an accurate admission assessment plus accurate ongoing assessments plus a plan to prevent and improve the pressure ulcer.

7. CNS Wound Specialist • Physiology • Wound types and classification • Risk and wound assessment • Pressure Ulcers • Staging • Dressings • Case Study • CNS Role

8. Skin Layers Epidermis Function: • Protective layer • Prevents dehydration of underlying tissue • Protects tissue from outside contaminates • Protects from UV light • Made of non-living cells • Maintains the acid mantel

9. Skin Layers Dermis Function: • Living layer • Hair production • Distinguishing pain, hear, cold, touch. • Removes excess fluid, stores protein • Provides support and strength. • Provides elasticity.

10. Skin Layer Dermis Function • Supplying nutrients and oxygen, removing water and waste • Produces sweat for cooling and sebum to keep skin supple • Controls skin pH • Provides antibacterial and antifungal barrier

11. Skin Layers Subcutaneous Function: • Adds to the mobility of the skin • Provides insulation • Provides a ready reserve of energy

12. Normal Aging Effects on Skin: • Dryer (decreased sweat glands). • Thinner (decreased dermal thickness especially over legs and forearms) • Loses the ability to stretch (decreased collagen and elastin fibers) • Has less subcutaneous tissue (leaving the bony prominences less protected • Easy to wrinkle (loss of subcutaneous fat)

13. Aging Skin (cont.) • Fragile (loss of size of rete ridges allowing the basement membrane to flatten and the epidermis and dermis to separate) • Decreased sensation and metabolism • Decreased circulation (leaving the elderly patient more prone to heat stroke)

14. Conditions Effecting Skin Heredity Medications Environmental effects Mobility Nutrition Hydration

15. Phases of Wound Healing Hemostasis Process: • Occurs immediately after injury • Platelets are released to for a clot • Cytokines are released

16. Healing (cont.) inflammation Process: • Tissue debris and pathogens • Attract macrophages and neutrophils, which are responsible for : • Phagocytosis • Producing biological regulators, bioactive lipids, and proteolytic enzymes

17. Healing (cont. Proliferative phase Process: • Fibroblasts-synthesize and deposit extracellular proteins • Extracellular matrix and granulation tissue • Collagen and elastin • Angiogenesis- capillary growth into the ECM • Re-epithelialization • Wound Contraction

18. Healing (cont.) Remodeling Process: • Collagen deposition and remodeling • Differentiation of fibroblasts into myofibroblasts with programmed cell death • Scar formation

19. Wound Types Acute Chronic • Trauma • Surgical • Requires limited local care to heal. • Typically heals within 4 weeks with no complications • Delayed healing > 4 weeks • Wound healing complicated by underlying conditions • Repeated trauma • Poor perfusion or oxygenation • Pressure, diabetes, malnutrition

20. Wound Classification • Wounds are identified and classified based on location and etiology. • Arterial ulcers • Diabetic / Neuropathic ulcers • Venous Stasis ulcers • Pressure ulcers • Skin Tears

21. Arterial Ulcers • Ulcers are usually very painful • Pain increases with elevation • Extremities will usually be cool and pale • Shiny skin and a loss of hair on the legs and toes • Nails may appear rigid and thick • Diminished or absent pedal pulses

23. Diabetic/Neuropathic Ulcers • Common complication of long term diabetes • Single most common underlying cause of lower-extremity amputation • Underlying pathology usually not reversible, • And most disease processes affecting the diabetic foot will continue to worsen over time.

24. Diabetic Ulcer (cont.) • Found on any part of the leg, commonly below the ankle and on the foot • Often very small • Deep with “cliff” edges (callous) • Dry and necrotic • Usually painless related to neuropathy

26. Venous Ulcers • Usually large with generalized edema • Shallow wounds with irregular edges highly exudating • Generally not as painful as ulcers with arterial etiology

28. Skin Tears • Predictable and difficult-to-prevent problems with the sin of the geriatric patient and patients on long-term steroids. • Due to loss of cohesion between the epidermis and the dermis in this population of patients the two layers separate easily. • Prevention lies in protecting this skin from injury. • Great care should be taken when handling the extremities, positioning the patient and removing adhesives from the skin.

30. Pressure Ulcers • Any lesion caused by decreased blood flow from unrelieved pressure that results in damage to underlying tissue. • Usually over bony prominence. • Staged to classify the severity. • Contributing factors are pressure, moisture, friction and shear.

31. Skin Risk Assessment Tools

32. Braden Risk Assessment

33. Sensory Perception • Patient population at greatest risk? • Diabetics • Brain and cord injuries • CVAs • Patient Impact: Can’t feel the injury, can’t stop the process • Prevention Strategies • Needs someone to check the skin • Turning schedule • Float heels • Specialty support surfaces

34. Category 1: SensoryPerception • 1. Completely limited: Patient that does not feel discomfort. • 2. Very Limited: Responds to only painful stimuli. Cannot communicate discomfort. • 3. Slightly Limited: Responds verbally but can not always express discomfort. Sensory impairment limiting the ability to feel pain in 1 or 2 extremities • 4. No impairment: Has no sensory deficits

35. Moisture • Population at Risk: • Incontinence • Diaphoretic • Wound drainage • Care give dependent • Patient Impact: • Over-hydrated skin decreases tensile strength • Fissures develop • Denuding of skin occurs • Prevention Strategies: • Control Incontinence • Bathroom schedule • Diet • Cleanse skin after incontinence • Mild soap • Peri-cleanser spray • Peri-cleaner wipes • Fecal incontinence collectors or external catheters • Under pads or briefs

36. Category 2: Moisture • 1. Constantly moist: Skin is always moist due to diaphoresis or incontinence. • 2. Very moist: Linen change at least once a shift. Skin is often moist. • 3. Occasionally moist: One extra linen change per day • 4. Rarely moist: Skin is usually dry.

37. Activity • Population at risk: • Elderly • Physically impaired • Bed bound or Chair fast • Impact on skin: • Friction and shear risk • Pressure injuries • Prevention Strategies • Turning schedule • Float heels • Pillows • Heel lift devices • Chair fast patients • Weight shifts • Fluidized cushions

38. Category 3: Activity • Degree of physical activity • 1. Bedfast: Confined to bed • 2. Chair fast: Cannot bear own weight and/or must be assisted into chair or wheelchair. • 3. Walks Occasionally: Walks for short distances with or without assistance. Spends majority of shift in bed or in chair. • 4. Walks Frequently: Walks outside the room at least twice daily and inside the room at lease once every 2 hours during waking hours.

39. Mobility • Population at risk • Inability to turn self or shift weight • Spinal cord injuries • Frail elderly • Impact on skin: • Can’t feel damage • Can’t reposition to relieve pressure • Time and intensity • Prevention Strategies: • Turn and position every 2 hours. • Use draw sheets • Float heels • Up in chairs requires weight shifts

40. Category 4: Mobility • Ability to turn and reposition. • 1. Completely Immobile: Does not make even slight changes in position without assist. • 2. Very limited: Attempts to make changes but needs help. • 3. Slightly impaired: Makes small independent body movements. • 4. No limitations: Turns without assistance.

41. Nutrition • Population at risk: • Elderly • Chronically ill • Mentally or physically impaired • Impact on Skin: • Muscle wasting, loss of subcutaneous tissue • Dry skin, hair and mucosal membranes • Poor wound healing • Prevention Strategies: • Help with eating. • Encourage family to be present for meals. • Supplements and snacks • Protein rather than carbohydrates. • Plan activities around meals.

42. Malnourished ?

43. Category 5: Nutrition • Usual food intake pattern: • 1. Very poor: Never eats complete meal or rarely > 1/3 of offered foods. Poor fluid intake, no supplements, NPO or clear liquids >5/days • 2. Probably inadequate: Rarely eats complete meal, generally eats only about ½ of what is offered. Occasionally will take dietary supplement. Protein intake is only 3 servings of meat or dairy/day.

44. Nutrition (cont. • 3. Adequate nutrition: Eats over half of most meals and has 4 servings of protein or dairy foods. Occasionally refuses meals but will take supplements if offered. OF is on TPN or tube feeding which meets most nutritional needs. • 4. Excellent nutrition: Eats most of every meal without refusing. Usually eats a total of 4 or more servings of protein. Occasionally eats between meals and does not require supplements.

45. Nutrition (cont.) • Observe the patients patterns of eating. • Protein, fluid and supplement intake • Stress and smoking can lower protein stores • Wounds require increased protein intake to promote healing

46. Friction / Shear • Population at risk: • Elderly, malnourished, immobile • Population on long term steroids • Impact on skin: • Compromised blood supple creates ischemia • Ischemia leads to cellular death and tissue necrosis. • Prevention Strategies • 30 degree or < for head of bed • Trapeze when indicated • Protect elbows, heels, sacrum, and back of head. • Draw sheets • Special wraps, devices protective covers.

47. Friction without shear but not shear without friction Friction shear • Examples: • Abrasions • Superficial friction rubs • Blisters • The resistance to motion in a parallel direction. • Results when two surfaces move across one another • Examples: • Skin tears • Tape striping • Undermining in pressure ulcers • Mechanical force that acts on an area of skin in a direction parallel to the body’s surface.

48. Category 6: Friction/Shear • 1. Problem: Requires moderate/max assist in moving. Complete lift without sliding against sheet not possible. Frequently slides down in bed or chair. • 2. Potential problem: Moves feebly or requires minimal assist. Skin probably slides against sheet during moves. Maintains posture but slides down sometimes. • 3. No apparent problem: Moves independently, maintains good position in bed or chair

49. Adding it UP? • Each subset contains a range of number 1-4 • Risk score = total of numeric rating from each of the subsets. • 6 is the lowest possible score and 23 is the highest. • Scale scores • 15-18= patent is at risk • 13-14= patient is at moderate risk • 10-12=patient is at high risk: less than 9 = very high risk

50. What do we face???