Transcript An Ounce of Prevention Beats A Pound of Cure

*
Misty Bailey Edwards, BSN, RN, CWOCN
Princeton Baptist Medical Center
* Skin: A Brief Overview
* Skin Assessment
* Risk Factors for Skin Breakdown
* Prevention of Skin Breakdown
* Moisture Associated Skin Damage
* Documentation
* Conclusion
*
* Medicare Reimbursement
* Legal Aspects
* Appropriate and Prompt Treatment of any Skin
Issues
*
* Epidermis: Outermost layer
* Basement Membrane:
Anchors the epidermis to
the dermis
* Dermis: The thickest layer
that forms “true skin”;
Contains capillaries, nerve
endings, sweat glands, hair
follicles, and other
structures
*
* Protection: The body’s LARGEST organ
* Physical barrier from the outside environment
* Protection from physical abrasion, bacterial invasion,
dehydration, and UV radiation
* Regulation
* Sweat glands and capillaries contained in the dermis
* Uses sweating and changes in blood flow to regulate
temperature when exposed to extreme highs or lows
* Sensation
* Contains abundant nerve endings and receptors
* Detects stimuli related to temperature, touch,
pressure, and pain
*
*
* Should be performed at least upon admission, every
shift, and with every change of caregiver (and per
facility’s policy otherwise)
* Important for the prevention of pressure ulcers and
moisture associated skin damage
* Should include assessment of:
* Skin Temperature
* Edema
* Change in skin consistency with surrounding tissue
* Localized pain
*
* Consider:
* Texture
* Dryness/Flakiness
* Erythema
* Lesions
* Maceration/Denudation
* Color Changes
* Blanching/Non Blanching
* Patient’s Positioning (Contractures, Mobility, etc)
* Any Medical Devices in Use
*
* Use natural light/halogen (Fluorescent gives illusion
of bluish tint)
* May be unable to assess blanching vs. non blanching
* Look for areas that are darker than the surrounding
skin
* Warmer temperature to an area than the
surrounding skin
* Indurated, shiny, or taut areas
*
* Increased dryness
* Loss of Elasticity
* Sun Exposure
* Rhytides or “Wrinkles”
* Tan/Brown Macules/Patches
*
*
* Braden Scale
* Sensory Perception: Ability to respond meaningfully to
pressure-related discomfort
* Moisture: Degree to which the skin is exposed to moisture
* Activity: Degree of physical activity
* Mobility: Ability to change/control body position
* Nutrition: Usual food intake pattern
* Friction/Shear: Depends on the level of assistance patient
requires with moving and the level of muscle strength
*
*
© Barbara Braden and Nancy Bergstrom, 1998 All rights reserved
* Low Risk
* 23 to 20
* Medium Risk
* 19 to 16
* High Risk
* 15 to 11
* Very High Risk
* 10 to 6
* * A Braden Score of 18 or below indicates an
INCREASED RISK for pressure ulcers
*
* Age
* Bed Bound Patients
* Sun Exposure
* Immobility
* Dehydration
* Multiple Co-Morbidities (i.e.
* Soaps
Diabetes, ESRD)
* Infection
* Nutrition
* Decreased Oxygen/Ventilator
* Medications
* Drug/Alcohol/Tobacco Use
*
Dependent
* Incontinence to Urine and/or
Stool
*
* Avoid positioning on an area of erythema
* Keep the skin clean and dry
* Do not massage/vigorously rub an area that is at risk
for pressure ulcers
* Protect the skin from excessive moisture
* Keep the skin moisturized and hydrated appropriately
to prevent skin damage
*
* Air Overlays for Mattress
* Low Air Loss/Alternating
Pressure Mattress
* Foam Wedges for
Turning/Offloading
* Heel Suspension
Devices/Boot
*
* Black, et al. listed several recommendations for the
use of wound dressings in pressure ulcer prevention
put together by a group of experts in the field from
Australia, Portugal, the UK, and the USA
* These recommendations included considering the use
of a five-layer silicone bordered foam dressing to
enhance, but not replace, pressure ulcer strategies for
the sacrum, buttocks, and heel
* * Note there are several types/brands of foam
dressings available which are being used for
prevention
*
* Routine turning every 2 hours
* Support bony prominences
* Suspend heels off of the bed
* Gatch knees to decrease
shearing/friction
* Use draw sheet for repositioning
* Keep the head of bed at 30
degrees or below if possible
*
* Research with pressure
mapping studies have shown
that the number of layers of
linen directly correlates with
pressure ulcer risk
* More Layers of Linen = More
Risk for Pressure Ulcers
* Tips:
* Assess for a “Moisture
Management Plan” to
determine the linen needed
* Communicate this with any
staff working with you (i.e.
Nursing Assistants, Techs,
LPNs, etc)
*
*
* Skin breakdown related to incontinence to
stool and/or urine
* Prolonged/repetitive exposure to urine/stool
* May begin as redness or tenderness
* If untreated, skin can become macerated and
even progress to skin loss
*
*
* A consistently applied, defined, or structured skin
care regimen (Doughty, et al. JWOCN 2012)
* Product Selection
* Selected based on consideration of individual
ingredients and broad product categories such as
cleanser, moisturizer, or skin protectant
* Skin Care Regimen Should Include:
* Timing, Cleansing, Moisturizing, and Protecting
*
*
* Timing: Cleansing should
occur as soon as possible
following an incontinent
episode
* Cleanse with a pH balanced
cleanser (mimic the pH of the
skin, 4-5.5) using a soft cloth
to decrease friction with the
skin
* Routine moisturizer to
replace lipids in the skin and
restore the barrier function
of the skin
* A variety of moisture-barrier
skin protectant products
available that vary in ability
to protect the skin from
irritants, macerations, and
maintain skin health
* Dimethicone Based
* Emollient properties soften and moisturize the skin
* Forms a protective, water resistant cover to lock in moisture, and
provide a barrier between the skin and urine/stool
* Works well for prevention of breakdown in intact skin
* Petrolatum Based
* Provides a moisture barrier to the skin
* Locks out moisture from urine/stool
* Works well for prevention of breakdown in intact skin
* Zinc Oxide Based
* Typically thicker barrier
* Works well in prevention for heavily incontinent patients
* Works well in treatment of denuded skin
*Several brands available; Some products may be a combination of the above ingredients
* Some products include an antifungal component to treat IAD
*
* Occurs within skin folds
* Most often a result of trapped moisture due to
sweating
* May appear as a fissure or linear cut in the skin fold
* Commonly seen under breasts or within abdominal
folds
* May often hear a patient state that she has “yeast” in
this area; However, ITD can be caused by various types
of bacteria and may not be strict
*
* Daily cleansing to these
areas
* Daily cleansing to the
affected areas
* Dry these areas thoroughly
* Dry thoroughly
* May use cloth to “wick
* Use cloth to “wick away”
following bath
away” moisture from these
areas
* Powder to help absorb
moisture
*
moisture; A silver
impregnated cloth is
available that treats ITD
well
* Minimize the time between
an incontinent episode and
the time of cleaning/changing
* Use absorptive products
appropriately (diapers/under
pads)
* Diaper checks with turning
* Do NOT use additional
diapers, under pads, or
towels tucked into the
patient’s diaper
* Appropriate use of skin
barriers, along with a skin
care regiment in incontinent
patients
*
*
* Head to toe skin
assessments should be
documented upon
admission, every shift,
and with every change of
caregiver
* Any skin breakdown
should be noted within
your documentation and
pictures should be taken
per your facility’s policy
*
* Be as specific as your facility’s electronic medical
record (EMR) or other documentation system allows
* It never hurts to add an additional note if the EMR
allows it to further document your findings
* Be sure to note wound or skin breakdown was present
on admission
* If you suspect that it is a pressure ulcer, make sure that
you know your facility’s policy on staging and follow it
* You can never document too much!
*
* Document any changes or deterioration of wounds or
skin breakdown during the hospital stay
* Make sure that the WOC nurse or wound care staff has
been notified if there are any wounds/skin breakdown
and document that they have been consulted
* If you did not assess (“lay eyes”) on a wound, do NOT
document that you did
* Communication Helps Consistency
* Communicate any wounds/skin breakdown noted during
report to the next shift
* Communicate what the wound/skin looked like when you
assessed it
*
* Routine turning/repositioning
should be documented
* Any preventative measures in
place should be documented
(i.e. Mattresses/Overlays,
devices, preventative
dressings, etc)
* Diaper changes/checks should
be documented if possible
* Document any education
provided to the patient
and/or family
* If you don’t document, it
didn’t happen!
*
* Assessment, Prevention,
and Documentation
together makes up a
process that is critical to
bedside nursing
Assess
* If just ONE of the
components is missing,
nursing care is incomplete
or appears to be
incomplete
* Ensuring that all three
steps are followed through
will ensure that patients
are receiving the highest
quality of care possible!
*
Document
Prevent
* Black, J., Clark, M., Dealey, C., Brindle, C., Alves, P., &
Santamaria, N. (2014). Dressings as an adjunct to pressure
ulcer prevention: Consensus panel recommendations.
International Wound Journal, 12(4), 484-488.
* http://www.npuap.org/wp-content/uploads/2015/02/2.Preventive-Skin-Care-M-Goldberg.pdf
* Slachta, P. (2013). Assessing risk of pressure- and moisturerelated problems in long-term care patients. Wound Care
Advisor, 2(3).
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