Concepts of care for patients with skin conditions Exam 2

Pressure injuries

• Loss of tissue integrity cause when skin and underlying soft tissue are compressed between a bony prominence and external surface

• Results in reduced perfusion

Pressure inuries

Risk factors

• Excessive interaction with moisture

• Undernourishment

• Aging skin

• Mental impairment

• Impaired nerves

Pressure injuries

Higher risk areas

• Back of head and ears

• Shoulder

• Elbow

• Lower back and buttocks

• Inner knees

• Heel

Shearing force

• stationary and tissues below the skin moves

Friction

• Surface rubs the skin and tears the epithelial tissue

Surface

• Make sure your patients have the right support

Skin inspection

• Early inspection means early detection

• Show patients and carers what to look for

Nutrition/Hydration

• Help patients have the right diet and plenty of fluids

Braden Scale

• Predicting pressure ulcers

• <18 needs to a turn patient (we turn them every 2 hrs)

Contributing factors to pressure ulcers

• Immobility

• Incontinence

• Decreased sensory perception

• Malnutrition

• Cognitive problems

Contributing factors to pressure ulcers

• Weight loss

• Skin folds

• Decreased level of consciousness

• Impaired nutrition

Physical assessment for pressure ulcers

• Inspect : esp bony prominences, BMI, skin, hair and nails

• Mobility: loss of any

• Wound assessment

  • Location

  • Size

  • Color

  • Extent of tissue involvement

  • Wound base

  • Exudate

  • Surrounding tissue

Epithelial & granulation

• New tissue/scar tissue

Eschar

• Necrotic tissue

Slough tissue

• Will need to treat infection to see wound

Extra precautions of surrounding tissue

• Check for foreign body to see if external factor is causing wound

Assessing patients with dark pigmented skin

• Look for changes in skin color such as areas darker than surrounding skin

• Use natural light to access color

• Asses skin temp and edema

• Ask about pain

Early sign of pressure related complications

• Bacterial infection of skin and soft tissue

Cellulitis

• Bacterial infection of skin and soft tissue

Undermining

• Separation of skin layers around the wound margin

Stage 1 Pressure Injury

• Intact skin with localized area of non-blanchable erythema

• Changes in sensation, temp, or firmness

• Color changes are not purple or maroon just pink

• For darker skin loo faro darker areas and ask about pain

Stage 1 Pressure Injury

Stage 2 Pressure Injury

Stage 2 Pressure Injury

• Partial-thickness loss of skin and exposed dermis

• Wound bed is viable, pink or red and moist

• May look like intact or ruptured serum-filled blister

Stage 3 Pressure Inury

Stage 3 Pressure Injury

• Full thickness skin loss with adipose (fat) visible in the ulcer

• Granulation tissue and rolled wound edges are often present

• Underlining, slough and sometimes eschar tissue present

Stage 4 Pressure Injury

Stage 4 Pressure Injury

• Full thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage or bone

• Slough or eschar may be present

• Undermining, rolled edges, tunneling often occur

• High risk for infection

Osteomyelitis

• High risk for this infection in stage 4 pressure injury

Unstageable injuries

• Extent of damage cannot be confirmed because it is covered by eschar and slough

Unstageable injury

Suspected deep tissue injury

• Purple or maroon localized area of discolored intact skin or blood-filled blister

Suspected deep tissue injury

Psychosocial assessment of pressure injury

• Body image

• SDOH

Laboratory assessment

• Blood tests

• Potential cultures

Diagnostic tests for pressure injuries

• Arterial blood flow : if you don’t know the cause

  • Ex: not a nerve or turning issue

• Duplex ultrasound : venous issue

Non surgical management: Dressings

• Help remove debris off surface

• Help protect healthy tissue

• Make barrier from infection

Nonsurgical management: Debridement

• Removing dead tissue

Debridement: Mechanical

• Intrap and detach dead tissue

• Wet or dry dressing put it on take it off and add new

Debridement: Topical

• Type of debridement: Chemical

• Use enzyme preparation (loosens UTO necrotic tissue)

Debridement: Surgical

• Prior to starting dressing debridement and wound interventions

• Surgical removal of dead tissue

Antibiotics

• Drug therapy for wounds and pressure ulcers

• Only to be used if patient has infection because can cause resistance

Nutrition therapy for wounds/pressure ulcers

• Emphasize protein

• Fats also necessary

• Supplements/Alternatives for those who can’t eat

Adjuvant therapies

• To be used only IN ADDITION to other interventions

Electrical stimulation

• Low voltage to increase granulation

Hyperbaric oxygen

• Enhances WBC to reduce swelling and kill bacteria

• 100 % oxygen tube

• For life threatening wounds

  • Ex: burns

Topical growth factors

• Something that’s naturally occurring and put artificially to enhance granulation

Ultrasound assured wound therapy

• To cleanse and debread necrotic tissue

Negative pressure wound

• Intermittent pressure helping to remove fluid bs promotes healing

Prevention infection

• Monitor for signs and symptoms of infection

• Report changes to primary healthcare provider

• Maintain safe environment

• CLEAN AND DRY

Home care management for wounds/pressure ulcers

• Outpatient wound healthcare clinic

• Home health care referral

• Wedge that reduces pressure

Self management education for wounds/pressure ulcers

• Well balanced diet

  • Increase fluids and protein

• Self care and cleaning

• Absorbent pads and barrier creams

Debridement: Natural

• Let body self digest tissue