General Nursing Orientation: Wound and Skin Care

July 2019

Patsy Maclean MSc(WHTR) RN IIWCC

Equipment and Product Standardization Nurse (Skin and Wound)

Supply Chain Management

General Nursing Orientation: Wound and Skin Care

Objectives

• Recognize importance of maintaining skin integrity

• Identify pressure injuries

• Describe risk factors for skin breakdown

Function of the skin

• Largest organ in the body

• Temperature regulation

• Sensation

• Elimination

• Communication

• It is our greatest protector!!

Pressure injury

“A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear“

National Pressure Ulcer Advisory Panel 2016

What do pressure and shear actually do? • Tissue deformation – Pressure and shear directly

deform cells → cell membranes and cytoskeleton are damaged → cells die. Cell death can start within minutes with high pressure and shear forces

• Ischemia – Blood vessels and lymph channels occluded → less oxygen to tissue → changes in metabolism → accumulation in waste products → pH decreases → cells die. Tends to occur with lower pressure and shear forces. Takes 6-8 hours for cell damage to occur

• Perfusion – reperfusion injury may also play a role in damaging cells

Stage 1

Stage 2

Stage 3

Stage 4

Unstageable Pressure Injury

Deep Tissue Pressure Injury

Risk factors/conditions

Look at the whole patient,

not just the hole in the patient!

Risk Assessment

Braden Q

Sensory perception

• Is the patient aware of pressure related discomfort? • Turning schedules are essential for bedfast patients

• Reposition regularly, even on a specialty surface

• Reposition chair bound patients at least every hour

• Even minor movements can make a difference

Moisture

All sources of moisture need to be identified.

• Wound exudate

• Excessive sweating

• Emesis

• Urine and feces

Friction

• Caused by skin rubbing across the bed or chair surface

• First indication may be a superficial abrasion of the skin

• Friction can accelerate the onset of ulceration

Shear

• Skin or internal tissues slide against a supporting structure

• Can be caused by repeated sliding down in bed/chair

• Adding shear force to pressure causes undermining into adjacent tissues.

Hips and knees even with the

bend of the bed (gatch)

Mobility and Activity

• Activity level is directly related to pressure on tissues and loss of skin integrity

• In older adults, decline in walking ability begins within 2 days of hospitalization

Nutrition

• Malnutrition and deficiencies are risk factors for skin breakdown

• Reduced nutritional intake and/or chronic losses from the wound can delay wound healing.

The interdisciplinary team

• You!

• The patient and their family

• Physiotherapists

• Occupational therapists

• Dieticians

• Ostomy and Wound Resource Team

• Physician, pharmacist, social worker etc

Points to ponder

• When health is compromised the skin is more vulnerable to injury

• Assess all patients for pressure injury risk

• Consider all risk factors

• Intervene and modify to reduce risk of skin breakdown

• Psychologically and economically, prevention is better than the treatment of lost skin integrity