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Pressure Ulcers for Physicians

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					 Wound Care for Physicians
Assessment, Documentation
      and Treatment



Rebecca Roberts RN MSN CWOCN
Gayle Moore-Lisa RN MSN CWOCN
Garth Ireland RN MSN MPA CWOCN
               Objectives

   By the end of the presentation the
    participant will be able to
    – accurately assess and document patient
      wounds
    – list basic wound care principles
    – identify wound care products available at
      UHCMS
   Assessment
Wound Measurement

         Length: head to foot
         Width: perpendicular
         to length
         Depth
         Undermining:Clock
         face
         Tunnel: tract in the
         wound
Assessment
Wound measurement
             Wound drawing




               Photography
Wound Assessment
   Wound bed:
    – Color: red, black (eschar), yellow (slough)
   Exudate:
    – Color
    – Odor
    – Quantity
   Periwound skin
    – Erythma, Maceration, denuded
    – Palpate for induration, warmth, fluctuation
    Wound Types
   Pressure Ulcers
    – Tissue damage due to pressure
    – Staged 1 to 4 based on depth of tissue involved
          Only staged if wound bed visible otherwise “unstageable”
           or deep tissue injury
    – Usually over pressure points
          Occiput
          Elbow
          Scapula
          Sacrum
          Ischium
          Malleolus
          Hip
          Braces, casts or tubing
    Pressure Ulcer Definition

 A pressure ulcer is a localized injury to
skin and/or underlying tissue usually over
a bony prominence a result of pressure, or
pressure in combination with shear and/or
                 friction.
Pressure Ulcer Staging

 The National Pressure Ulcer Advisory
 Panel has divided pressure ulcers into
  4 stages based on anatomical tissue
  loss and has included two additional
   categories of suspected deep tissue
    injury and unstageable pressure
                  ulcers.
 UHCMC Focus


University Hospital Case Medical Center is
     committed to the prevention of all
  nosocomial pressure ulcers. The goal is
 zero incidence of pressure ulcers acquired
           during hospitalization.
Physician Role

   CMS is asking that a pressure ulcer be
    properly documented by the physician
      upon admission. A pressure ulcer
    documented by the physician after the
        admission will be counted as a
      nosocomial pressure ulcer. This is
           even if there is admission
     documentation in the chart by other
      services such as nursing or dietary
             that the ulcer existed.
     Physician Role
   For the admission assessment the
    physician must view the patient from head
    to toe. Dressings must be removed, if
    possible, and the patient turned to view
    pressure points such as the heels, sacrum,
    occiput , elbows and scapula
   Pressure ulcers present on admission need
    to be documented as such and properly
    staged in the record.
     Why at This Time?
   The Center for Medicare and Medicaid
    Service (CMS) has stated that effective
    October 1, 2008, hospitals will not be paid
    for the care of nosocomial pressure ulcers.
   Since many private insurances follow
    Medicare guidelines, these private plans
    may also institute similar restrictions.
Current Hospital
Initiatives
   Recent replacement of all patient beds
    with pressure reduction surfaces on
    Medical surgical floors.
   Evaluation of replacement beds for
    intensive care units and operating
    suites.
   Extensive nursing in-service on
    assessment, prevention and treatment
    of pressure related skin problems.
      Stage I

    Intact skin with non-
    blanchable redness of a
    localized area usually over a
    bony prominence.
    Pigmented skin may not
    have visable blanching. Its
    color may be different from
    the surrounding area.
    The area may be painful,
    firm, soft, warmer or cooler
    than adjacent tissue.
Stage I
Stage I
Stage II

   Partial thickness loss of dermis presenting
    as a shallow open ulcer with a red or pink
    wound bed. May also present as an intact
    or open/ruptured serum-filled blister.
   A shiny or dry shallow ulcer without slough
    or bruising (indicative of suspected deep
    tissue injury).
   Does not include: skin tears, tape burns,
    perineal dermatitis, maceration or
    excoriation.
Stage II Pressure Ulcers
Stage II Pressure Ulcers
Stage II Pressure Ulcers
Stage III

   Full thickness tissue loss.
    Subcutaneous fat may be visible but
    not bone, tendon or muscle are not
    exposed.
   The depth of a stage III pressure
    varies by anatomical location. The
    bridge of the nose, occiput and
    malleolus do not have subcutaneous
    tissue and stage III ulcer can be
Stage III Pressure Ulcer
Stage IV

   Full thickness tissue loss with exposed
    bone, tendon and/or muscle.
   Slough or eschar may be present in
    some parts of the wound.
   Often includes undermining or
    tunneling.
Stage IV Pressure Ulcer
     Unstageable Pressure
            Ulcer
   Full thickness tissue loss in which the base
    of the ulcer is covered by slough (yellow,
    tan, brown) and/or eschar (tan, brown or
    black) in the wound bed.
   Until enough slough and/or eschar is
    removed to expose the base of the wound,
    the true depth and therefore stage can not
    be determined.
   Stable (dry, adherent, intact without
    erythema or fluctuance) eschar on the heels
    serves as the bodys natural cover and
    should not be removed.
Unstageable Pressure
       Ulcer
Unstageable Pressure
Ulcer
Unstageable Pressure
Ulcer
Suspected Deep Tissue
Injury
   Purple or maroon localized area
    discolored intact skin or blood-filled
    blister due to damage of underlying
    soft tissue from pressure and/or shear
   The area may be preceded by tissue
    that is firm, mushy, boggy, warmer or
    cooler as compared to adjacent tissue.
   The area may evolve rapidly to expose
    additional layers of tissue injury.
Suspected Deep Tissue
       Injury
Pressure vs. Vascular

   It is important to distinguish between
    pressure and possible vascular causes
    of tissue injury.
   Pressure related injuries occur over
    bony prominences or areas of
    shearing. Pressure injury can also be
    related to equipment such as braces,
    casts and tubing.
Venous Ulcers
               Medial lower leg
               Champagne Glass
                leg
               Dependent edema
               Hemosiderin
                staining
               Weeping wound
                with irregular
                borders
Venous Ulcers
Arterial Ulcers
   Cold, hairless leg
   Lack of pulse
   Pain on elevation
   Relief on dependent
    position
   Wound with punched
    out appearance and
    pale or necrotic
    wound bed
Arterial Ulcers
    Neuropathic/Diabetic
    Ulcer
   Plantar surface of the foot
   Round wound surrounded by callas
   Lack of sensation
   Foot deformity: Charcot foot.
Surgical Wounds

   Dehiscence
   Infection
   Fistula
   Necrosis
   Altered wound healing
Principles of Wound
Healing
 Protectwound and provide
 a moist wound
 environment
 – Cover wound
 – Fill in wound cavity
 – Moisten dry wounds
 – Control excessive moisture
Protect and Manage
Moisture
   Wet to Moist NOT Wet to Dry
    – New post operative wounds to monitor
      bleeding
    – Twice a day dressing changes that
      increase risk of contamination
    – Can reduce frequency of dressing change
      by adding moisture (Duoderm Hydrogel)
    – Painful
Protect and Manage
Moisture
   Mepilex Border Dressings
    – Silicone dressing of various sizes
    – Non occlusive to allow for air flow
    – Reduces pain and further trauma when
      removed
    – Change every 3 to 5 days
    – For stage I and II PU, skin tears or for
      cover dressings.
Protect and Manage
Moisture
   Xenaderm Ointment
    – Protective barrier to skin
    – Perineal Dermatitis
    – Skin Tears
    – Radiation Dermatitis
    – Requires MD order
    – Apply once to twice a day and after
      incontinence
Protect and Manage
Moisture
   Hydrocolloid (Duoderm)
    – Wound cover and protection
    – Occlusive for minimal exudate
    – Change 2 to 3 times per week
    – Used in home care to reduce visits
    – Can cause trauma to area when removed
Protect and Manage
Moisture
   Mepilex Transfer Dressing
    – For heavily draining wounds such as
      weeping venous wound or bullous lesions
    – Silicone foam dressing
    – Easy to remove with little trauma to
      tissue
    – Wicks drainage. Requires absorbent
      cover dressing
    – Change when saturated
Principles of Wound
Healing
 Fill   wound cavity
  – Hydrofiber (Aquacel)
      For moist and draining wounds
      Easy to apply. Comes in rope and sheets

      Change based on amount of drainage. Daily
       to every 3 days.
      Turns to gel. Easy and less painful to remove
       and apply.
Principles of Wound
Healing
   Negative Pressure Therapy
   KCI Wound VAC (Vacuum Assisted Closure)
    – Wound filled with sterile foam. Covered with
      occlusive drape and attached to negative
      pressure pump.
    – Removes exudate from wound
    – Promotes angiogenesis and wound contraction
    – Changed 3 times per week
    – Reduces exposure to contamination and pain
    – Expensive.
    – Can be used at home with insurance approval.
      Not covered at home by Medicaid
Principles of Wound
Healing
   Promote a clean wound base free
    from infection
    – Irrigate wound with each dressing change with
      normal saline or wound cleaner to reduce
      bioburden
    – Antimicrobial dressings
          Aquacel AG
          Mesalt (Hypertonic saline)
          Wound VAC Silver Dressing
    – Appropriate antibiotic therapy
Anti infective Agents

   Antibacterial fluids can be added to
    wet gauze dressings:
    – Sulfamylon (mafenide)
    – Dakins Solution (for short period for
      infected, odorous wounds)
    – Same concerns as previously noted for
      wet to moist dressings
Principles of Wound
Healing
   Remove nonviable tissue from the
    wound to promote new growth
    and reduce medium for infection
    – Debridement
         Surgical:Sharps: immediate
           – ”Excisional Debridement” removal of tissue and not
             just loose tissue fragments.
         Enzymatic: Collagenase/Santyl oint.
           –   Apply once or twice a day.
           –   Cover with dry dressing
           –   Necrotic Tissue needs to be scored with scalpel
           –   Can be slow process
Principles of Wound
Healing
   Investigate and resolve underlying causes
    – Pressure Ulcers
          Pressure relief
          Reduce risk of shear
          Incontinence care
    – Venous Insufficiency
          Compression if arterial involvement ruled out
    – Arterial Ischemia
          Revascularization
    – Neuopathic/Diabetic Ulcers
          Glucose Control
          Off loading footwear
Principles of Wound
Healing
   Collaboration
    – Physician: Plastics, Vascular, Dermatology,
      Infectious Disease
    – Nursing, WOCN
    – Dietitian
    – Diabetic Educator
    – Physical Therapy
    – Social Service
    – Home Care
Thank You