Nursing Home Care

1. Nursing Home Care John E. Morley Debbie Tolson Joseph G. Ouslander Bruno Vellas

2. Chapter 20Skin Disorders and Pressure Ulcers

3. Skin Disorders and Pressure Ulcers With aging there is a decrease in epidermal and dermal cell turnover leading to a thinner skin, with less production of oils and a decrease in subcutaneous adipose tissue. This makes the skin more vulnerable to a variety of pathogens and irritants. The skin is also more vulnerable to damage from shear forces. For these reasons topical skin care assumes a major role in the care of nursing home residents.

4. Skin Care • A variety of skin care lotions have been developed for use in nursing home residents. • Unfortunately, there are minimal studies demonstrating their effectiveness. • The use of disposable absorbent underpants to protect against incontinence has the best evidence of efficacy. • However, they need to be changed on a regular basis to be effective. • A combination of urine and stool can be especially damaging to skin. Thus, it is especially important to frequently check and change residents with double (both urine and stool) incontinence. • Decreasing skin dryness and pressure sores is best done by using no-rinse cleansers. • A mixture of zinc oxide, hydrous wool fat, benzyl benzoate and benzyl alcohol appears to be capable to reducing skin redness.

5. Screening for Skin Disorders • Skin conditions represent one of the most common sets of disorders facing the health professional in the nursing home. • Many skin lesions are complex and their diagnosis and skin care in general is a major challenge. • The lack of expertise on skin conditions in older persons among the average physician has led to rapid growth of teledermatology programs. • Most of these programs utilize a screening for skin lesions by nurses who then request a consult from the dermatologist for diagnosis and management. • With the consult the dermatologist receives a copy of the screening form, a photograph of the skin lesion, and a medication list. • The dermatologist can then either make a diagnosis or request a “live” consult by “skype” or other telemedicine technique.

6. Skin Screening Form for Nurses • Name:___________________________ Date of Birth:_________ Location:_________ • Skin tears: Y/N Location:______________________________________ • Rashes: Y/N Location:______________________________________ • Bruises: Y/N Location:______________________________________ • Pressure ulcer: Y/N Location:______________________________________ • Tumor (growths) Y/N Location:______________________________________ • Bullae: Y/N Location:______________________________________ • Dry skin: Y/N Location:______________________________________ • Reddened areas: Y/N Location:______________________________________ • Abscess: Y/N Location:______________________________________ • Red area: Y/N Location:______________________________________ • Skin flaking: Y/N Location:______________________________________ • NOTE: A picture of the lesion should be submitted with this report to the dermatologist

7. Normal features of aged skin • fine and coarse wrinkles • purpura • dry skin • lentigines • telangieclasia • sebaceous hyperplasia • elastic skin • pigment changes • giant comedones • blotchiness • photoagingleads to actinic keratosis.

8. Local Causes of Pruritus • Xerosis • Herpes zoster • Dermatitis • Scabies • Pediculosis corpora • Dermatitis herpetiformis • Bullous pemphigoid • Mycosis fungoides • Urticaria

9. Systemic Causes of Pruritus • Diabetes mellitus • Uremia • Neurodermatitis (psychogenic) • Carcinoid • Systemic mastocytosis • Cholestasis • Lymphoma • Polycythemia • Infections, e.g., HIV, ascariasis, filariasis • Medications: Aspirin Opiates Vancomycin Antibiotic hypersensitivity

10. Causes of Flushing • Medication side effects, e.g., niacin • Spicy foods • Carcinoid • Systemic Mastocytosis • Medullary carcinoma of thyroid • Renal cell carcinoma • Bee sting • Anaphylaxis

11. Common Skin Disorders Seen in the Nursing Home

12. Common Skin Disorders Seen in the Nursing Home

13. Diagnostic Approach to Skin Tumors

14. TineaVersicolor

15. Psoriasis

16. Bullous pemphigoid

17. Pemphigus

18. Skin Tears“A wound caused by shear, friction and/or blunt force resulting in separation of skin layers. A skin tear can be partial-thickness (separation of epidermis from dermis) or full thickness (separation of both the epidermis and the dermis from the underlying structures).”

19. Skin Tears • The incidence of skin tears is about 0.9 per resident per year. • A few residents can have multiple skin tears over the year. • Both intrinsic and extrinsic factors lead to skin tears • Skin tear prevention programs have been demonstrated to markedly decrease skin tears in nursing homes.

20. Risk Factors for Development of Skin Tears Intrinsic • Senile purpura • Ecchymosis • Edema • Poor nutritional state • Neuropathy • Vascular disease • Advanced age (>90 years) • Hematoma • Previously healed skin tears Extrinsic • Trauma • Corticosteroid use • Skin cleansers • Tape removal • Transfers • Excess bathing

21. Elements of a Skin Tear Prevention Program • Assess all residents on admission for skin tear risk factors • At risk individuals should protect skin: wear sleeves, long pants and long socks • Shin guards for persons who have skin tears • Apply moisturizers (emollients) twice a day • Educate staff on appropriate transfer strategies to avoid skin tears • Identify environmental causes and cover with protective devices • Avoid daily bathing and non-emollient soaps • Lotions containing humectants and barrier ingredients can be used judiciously

22. Management of Skin Tears • Assess wound using STAR or Payne-Martin classification • Clean wound with saline applied from a syringe • Remove blood clots/slough/foreign bodies • Use adhesive strips to obtain juxtaposition of epidermis in category I and II tears • Apply a moist wound dressing • Do not remove dressing for 2 to 3 days to allow healing • Consider tetanus prophylaxis

24. Skin Cancer • Skin cancer is the most common type of cancer. • The three common types of skin cancer are basal cell cancer, squamous cell cancer and melanoma. • Nonmelanoma skin cancer rarely leads to death. • Melanomas account for three quarters of skin cancer deaths.

25. Basal Cell carcinoma

26. Squamous Cell Cancer

27. Melanoma

28. Characteristics Suggestive of a Melanoma • Multiple colors – tan, blue, black, red, brown • Evolving in size, shape or color • Local growth • Asymmetry • New spot (metastases) • Outline irregular • Mole is itchy or bleeding • Area: >6mm in diameter

29. Treatment for Skin cancer • Basal Cell Carcinoma: Mohs’ surgery or complete circumferential peripheral and deep margin assessment. External radiation may be an alternative. In frail persons watchful waiting may be the best approach. • Squamous Cell Cancer: Topical chemotherapy with imiquimod or 5-fluoruracil can control disease. Cryotherapy or radiation are alternatives. In most cases curative therapy requires surgery.

30. Treatment of melanoma • Stage O (melanoma in situ) requires surgery with a wide margin excision. • Stage I is surgery of tumor, possibly with lymph node removal. • Stage II is surgery and lymph node mapping with removal is cancer is present. • Stage III is surgery followed by interferon. • Stage IV treatment is ipilimumab or vemurafenib with biological therapy with interleukin-2. Outcomes are poor and all persons should be offered the opportunity to enter a clinical trial.

31. Pressure Ulcers International advisory groups (European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel 2009) define pressure ulcers as: localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.

32. Pressure Ulcers • Pressure ulcers cause pain and distress, wound healing may be prolonged which and if poorly managed can have serious complications that can lead to life-threatening infections. • It is important that nurses and nursing aides are aware of the risk factors for pressure ulceration and know how to minimize risk for individual residents. • Nurses are also educators and as such need to make sure that residents and visitors are aware of these and of the importance of prevention. For example if the family are taking a resident for an outing that involves prolonged sitting in a wheel chair the nursing team should advise on the use of an appropriate gel pad or other device.

33. Pressure Ulcers • About one in ten residents in a nursing home have a pressure ulcer, though incidence rates as high as 39% have been reported from Brazil. • Nearly two-thirds of these pressure ulcers have their origin in acute care facilities. • Pressure ulcers have a large cost burden – In the United States this is $11 billion and in the United Kingdom ₤2.4 billion.

34. Factors that Predispose to Pressure Ulcers • Intrinsic FactorsExtrinsic Factors • Limited mobility Pressure • Chronic diseases Shear forces • Poor nutrition Friction forces • Thinning of skin Urine incontinence • Bony prominences Fecal Incontinence Corticosteroid use

35. Pressure Scales • Common pressure ulcer scales the Norton, Braden and Waterlow • All the scales include mobility and moisture exposure. • The Norton and Braden scales include a measure of physical activity, while the Waterlow and Norton have a measure of general activity. • The Braden and Waterlow scale examine nutrition or appetite respectively. • The Braden estimates function/shear forces and sensory perception. • There is little evidence that using these scales results in fewer pressure ulcers than good nursing practices and increase preventive measures when a stage I pressure ulcer develops.

36. Pressure Ulcer Staging/Category • Stage/CategoryClinical Features • Suspected Deep Tissue Injury Purple discoloration or a blood filled blister due to underlying tissue damage • I Intact skin with non-blanchable redness • II Partial-thickness loss of dermis with red/pink wound bed and no slough • III Full thickness tissue loss without exposure of bone, muscles or tendon. Slough can be present. Tunneling can be present • IV Full-thickness tissue loss with exposed bone, tendon or muscle. Do not remove eschar on heels • Unstageable Full-thickness tissue loss with base covered with slough or eschar in the wound bed

37. The MEASURE Mnemonic to Describe Pressure Ulcers • Measure size accurately using ruler or computer assisted techniques • Exudate volume • Anatomic location • Suffering including pain, odor and effect of drainage on clothes • Undermining along wound edges • Re-evaluation on a regular basis • Edge is or is not macerated

38. Differential Diagnosis of Ulcers • Ulcer TypeDistinguishing Feature • Pressure ulcer Occurs over a bony prominence • Venous ulcers Located medially above or below the malleolus. • Presence of varicosities • Arterial ulcers Punched out, dry ulcer on a cool, shiny leg with little hair. Pain relieved when leg is dependent • Diabetic foot wounds Occur in areas of pressure associated with peripheral neuropathy • Malignant ulcers A single nodular ulcer that heals poorly

39. Prevention of Pressure Ulcers • The basic strategies to prevent pressure ulcers are to turn the resident regularly and prevent excessive wetness of the skin. • Most programs turn residents every 2 hours, but this is an empirical approach with no data to support it. • Healthy older persons will develop skin redness after 90 minutes of lying in one position. • All persons in the nursing home should be encouraged to move every 15 minutes.

40. Pressure Reducing Devices • Pressure reducing devices need to reduce pressure to less than 32 mmHg which is capillary closing pressure. • The Australian medical sheep skin has been shown to successfully prevent sacral pressure ulcers. • Other pressure reducing devices include static, e.g., foam mattresses or devices filled with water, and dynamic, e.g., alternative pressure devices or air fluidized beds. • All of these devices reduce pressure ulcers by half compared to standard hospital beds. • There appears to be little advantage of the static over the dynamic pressure relieving devices, making the choice of the device to be driven by cost and ease of use. • None of these devices can adequately reduce pressure over heels and the trochanter. • When pressure relieving devices are used in conjunction with turning, it appears the optimum turning time is 4 hours.

41. Avoid Bacterial Cultures • Superficial bacterial cultures from pressure ulcers are valueless, can be misleading, and result iun unnecessary health care costs. • Clinical leadership should not allow them to be done in their facilities. • The Levine technique where a swab is pressed against the ulcer floor expressing fluid and then rotated 360° may have more value, but this remains questionable. • In general, an antibiotic should only be used when there are clear signs of systemic infection.

42. Management of Pressure Ulcers • Pressure reduction • Low air-loss bed • Frequent turning (90 min to 4 hours) • Other static pressure relieving devices • Occlusive dressings (see Box 20.5) • Debridement • Surgical sharp • Wet to dry gauze dressings removed when dry (not recommended) • Enzyme debridement: Papain (no longer on U.S. Market) better than collagenase • Topical growth factors (minimal effect) • Nutritional support • 1.2-1.5g/kg/day protein • Zinc in zinc deficient • Bacterial management • Topical silver compounds • Topical cadexomer iodide • Antibiotics for signs of systemic infection

43. Box 20.17: Comparison of Wound Dressings Available to Treat Pressure Ulcers (+Yes, -No) Wet Saline Polymer GauzeHydrocolloidsFilmsHydrogelsAlginates Water permeable + -+++ Easy to apply ++-++ Bacterial resistant - +--+ Damage epithelial cells +/- -+ - - Pain relief + ++++ Maceration of skin +/- -+/---

45. Foot Ulcers in Diabetics • One in four diabetics is likely to have a foot ulcer in their lifetime). • The cost of managing a diabetic foot ulcer is approximately $6000 (₤ 19,000). • They occur because of the combined effects of neuropathy and peripheral vascular disease (ischemia). • Total contact casting, but not other forms, enhances healing. • Hydrogel treatment is more effective than surgical debridement. • Maggots can reduce MRSA in diabetic foot ulcers. • Vacuum assisted closure (.125mmHg negative pressure) has not been shown to be more effective at wound healing. • Topical recombinant human platelet derived growth factor beta-(beta homodimer) increased time to wound healing and the probability of complete wound healing. • There is some evidence suggesting that hyperbaric oxygen may reduce the requirement for amputation in diabetic foot ulcers. • Ampicillin-salbactamintravenously or oral amoxicillin-clavulanate produced equivalent wound healing to linezolid. • There are no controlled trials demonstrating usefulness of antibiotics in most diabetic foot ulcers. • Diabetic shoes with customized insoles have a role in preventing diabetic foot ulcers. • All residents with severe diabetic foot ulcers should have vascular studies to determine the degree of peripheral vascular disease. In the United Kingdom it is recommended that all persons with a diabetic foot ulcer should have a referral to a diabetic foot clinic within 24 hours of the development of the ulcer.

46. Foot Ulcer

47. Approaches to Managing Diabetic Foot Ulcers • Utilize an appropriate dressing • Relieve pressure off the wound area • Debridement where appropriate (evidence is poor and to be avoided if tissue hypoxia) • Negative pressure wound therapy (limited positive data) • Hyperbaric oxygen can be used in those with low transcutaneous (partial) oxygen pressure • Oral or intravenous antibiotics if wound is infected • Epidermal growth factor (expensive/small effect) • Stem cell application most probably helps • Bioengineered fibroblast/keratinocyte co-culture • Revascularization surgery

48. Vascular Ulcers • Vascular ulcers can be either arterial or venous. • These ulcers need to be differentiated from pressure ulcers and their cause documented. • Ischemic (arterial insufficiency) ulcers are due to poor blood flow through the capillary beds of the legs. • They classically occur on the lateral surface of the ankle or the distal digits. These ulcers have a “punched out” appearance with small, round borders. • They are associated with a cold hairless limb and a lack of peripheral pulses. • The limbs tend to be red when dangling and paler when elevated. • The ulcers are painful, especially when the limb is exercised. • Treatment of arterial ulcers includes keeping the wound dry. • Cadexomeriodine can absorb fluid draining from the ulcer. • Occlusive dressings should be used. • Topical antibiotics need to be avoided. • The resident should not smoke. • Treatment of pain is critical. • Improving circulation can be done medically or by surgical revascularization. • Pumps that increase perfusion to the limb can be considered

49. Differential Diagnosis of Arterial Leg Disease Calciphylaxis Spider bite Pyodermagangrenosum Pressure ulcers Venous ulcers Eosinophilicvasculitis Traumatic Scleroderma

50. Varicose leg ulcers • Varicose leg ulcers occur on the lower leg. • They are associated with skin varicosities and red-brown skin discoloration. • About three quarters of venous ulcers are healed at 16 weeks. • Wound dressings and wound compression (>25mmHg) are the cornerstones of treatment. • No dressing has been shown to be superior.