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Twin Cities District Dietetic Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

Twin Cities District Dietetic Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE Mary Murphy, RN, MA, CWOCN. Objectives. Identify anatomy and physiology of skin Describe prevention strategies to reduce incidence of pressure ulcers

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Twin Cities District Dietetic Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE

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  1. Twin Cities District Dietetic Association Meeting November 9, 2010 Kim Bihm, RD, LD, CDE Mary Murphy, RN, MA, CWOCN

  2. Objectives • Identify anatomy and physiology of skin • Describe prevention strategies to reduce incidence of pressure ulcers • Describe an interdisciplinary approach to prevention and treatment of pressure ulcers • Define nutritional treatment modalities for wound healing.

  3. Why should we care? • Complications to patients • Lead to pressure ulcers • Painful • Infection • Quality of Life

  4. Why should we care? • Cost • Hospitalizations • Health care workers • Skin Care Products • Reduction in payment from regulatory bodies

  5. Incidence of Pressure Ulcers (PU)Data from the NPUAP • Volume: 1-3 million people in US develop PU/year • Mortality: 60,000 people die from PU complications/year • Quality of Life: PU reduce quality of life due to pain, treatments, increased length of institutional stay, etc. • Finances: Cost of treating PU ranges from 5-8.5 billion dollars/year • Legal: 87% of verdicts from NH cases goes to Plaintiff • Average award is $13.5 million • Highest award is $312 million in one case!

  6. Clinical Practice Guidelines by NPUAP/EPUAP: • Evidenced-Based Practice • Best scientific research available • Systemic review of literature • Provides tools for best judgment • Allows decision-making on more than “expert opinion” alone. • DOES NOT dictate practice or replace clinical reasoning or judgment – it ENHANCES these! • These are guidelines • Policies are absolute

  7. An interdisciplinary approach to prevention and treatment of pressure ulcers • Hospital skin team • Registered Dietitian • Wound, Ostomy, Continence nursing • Occupational Therapy/Physical Therapy • Physicians – primary/specialty • Plastic surgery • RN staff • Respiratory Therapy • Education staff • Nursing Manager • Pharmacist

  8. Interdisciplinary Approach All disciplines need to assess for risk and put prevention interventions into place: • Occupational Therapy • Cognitive screening • Assistive Technology • Speech Therapy • Memory assessment • Cognition • Communication • Assistive Technology • Physician • C-collar inspection orders • Nursing • Pressure Ulcer Protocol • Nutrition • High protein, high calorie diet with snacks and supplements • Physical Therapy • Wheelchair cushion pressure mapping • Avoiding shear during transfers

  9. Prevention: Risk Assessment Co-morbidities Previous PU Smoking hx Long OR time Long ED stays Critically ill – ICU= 4x more Wheelchairs Obese/thin

  10. Guidelines to Preventing Pressure Ulcers • Combination of Risk Assessment + Skin Inspection + Clinical Judgment • Reassess RISK • Upon admission • At regular frequency • Change in condition • Skin Inspections • Head to toe inspection regularly • Individualized plan of care • Use Interdisciplinary Approach • MD, Nutrition, PT/OT, Speech Therapy

  11. Anatomy and Physiology of Skin • Largest organ of the body • Weight: up to 15% of body weight – about 6 pounds • Size: Average adult – 3000 square inches • Receives 1/3 of body’s circulating blood volume • Constantly exposed to changing environments • Has capability to self-regenerate

  12. Skin Layers: Epidermis • Outermost layer made of epidermal cells • Thin and avascular • Regenerates every 4-6 weeks • Melanocytes reside in epidermis • Melanin is pigment responsible for color of skin

  13. Skin Layers • Dermis • Thicker layer • Contains: • blood vessels • hair follicles • lymphatic vessels • sebaceous glands • sweat and scent glands • nerve endings

  14. Skin Layer: Dermis • Collagen: • Major structural protein • Gives skin strength • Anchors dermis to hypodermis layer • Elastin: • Responsible for skin recoil and resiliency • Allows skin to stretch

  15. Skin Layers: Hypodermis • Subcutaneous Tissue • Composed of adipose and connective tissue • Filled with major blood vessels, nerves and lymphatic vessels • Attaches dermis to underlying structures • Provides insulation and cushioning to body • Acts as a ready reserve of energy

  16. Functions of Skin • Body Image • Maintenance of body form • Appearance, attributes and expression • Sensation • Abundant nerve receptors in skin • Touch • Heat/Cold • Pain • Pressure • Moisture

  17. Functions of Skin • Regulation of body temperature • 98.6 F / 37 C • Thermoregulatory mechanisms: • Circulation • Blood vessels dilate to dissipate heat • Blood vessels constrict to shunt heat to body organs • Sweating • 2-5 million sweat glands

  18. Functions of Skin • Protection • Safety against sunburn • Melanin in the epidermal cells protects against ultraviolet light • Metabolism • Vitamin D formation • Presence of sunlight • This activates the metabolism of calcium and phosphate and minerals (important in bone formation)

  19. Functions of Skin • Protection • Barrier to germs and poisons • Normal floral = • Staph Aureus • Diphtheroids • Gram neg bacilli • NOT Candida – That comes from GI tract • Chemical defenses • Sweat, oils, wax from skin glands contain lactic acid and fatty acid • These acids make skin pH acidic to kill bacteria and fungi

  20. Functions of Skin • Maintenance of water balance • Prevents loss of water through evaporation • <10% moisture – cells shrink = increase invasion of bacteria • >30-40% moisture level = maceration • Increased permeability • Increased risk of injury from friction

  21. Theory of pH • pH refers to management of acid or base levels • Acidic is 0-6 • Neutral is 7 • Basic is 8-14 • Rain is 5.6 • Seawater is >7 • Milk is <7 • Gastric juices are acidic • Saliva and blood are neutral

  22. Skin pH • Skin pH is 4-6.8 with mean of 5.5 • Depends on area of body • Urine, stool, soap and frequent cleansing will increase pH to more basic levels • Pooled urine changes pH to 7.1 – or alkaline shift = this contributes to overgrowth of bacteria • Patients with fecal incontinence are 22x more likely to develop pressure ulcers

  23. Skin Changes • Age-Related changes: • Functions decline • Epidermal/dermal junction flattens • Decreases skin strength • Increases risk for tearing • Melanocytes shrink (decrease in volume) • Increases sensitivity to sun

  24. Skin Changes • Age-Related changes: • Decreased sweat production • Leads to increased dryness and flaking • Nutrition changes • Medications

  25. Guidelines to Preventing Pressure Ulcers • Skin Inspections • Checking all bony prominences • Check under skin folds • Check under medical devices • Check where there is limited sensation • Educate professional staff on skin conditions for early identification • Technique for blanching response • How to assess warmth, edema, and induration • Set time frame for on-going inspections

  26. What are Pressure Ulcers? • Pressure ulcer definition: • A pressure ulcer is 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. • Different from: Neuropathic ulcers Arterial ulcers Venous ulcers Trauma injuries

  27. Stage I Pressure Ulcers • Intact skin with non-blanchable redness of a localized area- usually over a bony prominence.

  28. Stage II Pressure Ulcers • Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. • May also present as an intact or ruptured serum-filled blister.

  29. Stage III Pressure Ulcers • Full thickness tissue loss. Subcutaneous fat may be visible but not bone, tendon, muscle. • Slough may be present, but does not obscure the depth of tissue loss. • May include undermining and tunneling

  30. Stage IV Pressure Ulcers • Full thickness tissue loss with exposed bone, tendon or muscle. • Slough/eschar may be present. • Often includes undermining/tunneling.

  31. Unstageable Pressure Ulcers • Full thickness tissue loss in which actual depth of ulcer is completely obscured by slough and/or eschar.

  32. Suspected Deep Tissue Injury • Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure/ shear.

  33. Iatrogenic Damage:Pressure Injury from Medical Devices

  34. Assess for Risk by RN • Braden Risk Assessment (by Barbara Braden) • Reliable research based risk assessment tool • Sensory • Mobility • Activity • Friction/Shear • Nutrition • Moisture

  35. Risk due to Sensory Impairment • Can they feel? • Prevention: • If they can’t feel – someone must look at skin!! • Check under devices • Check for proper fitting shoes and socks • Need redistribution mattress

  36. Risk due to Mobility Impairment • Can they move themselves? • Prevention: • Must be turned every 2 hours • Must be trained in proper pressure relief • Must have pillows elevated

  37. Risk due to Activity • Can they walk? • Are they bedfast? Chair fast? • Prevention: • Do they have a PT/OT consult? • Do they have a proper fitting wheelchair cushion? • Must have training in pressure relief

  38. Risk due to Friction and Shear • Are they sliding in bed or wheelchair? • Prevention: • Watch transfers from w/c to bed • If concerned, get PT/OT consult • Manage spasticity • Report concerns to MD • Keep knee gatch up in bed to prevent sliding in bed

  39. SKIN INSPECTIONS: Bony Prominences To Check

  40. Support Surfaces • How to make sense of the confusion????

  41. What Do We Know- Evidence • Pressure = Force/Area • Pressure is caused by perpendicular force = • Treatment = pressure redistribution • Pressure redistribution = depth of pressure without bottoming out • Shear is parallel force = • Treatment = prevent sliding

  42. Features of Support Surfaces • Air Fluidized • A feature that provides pressure redistribution via a fluid-like medium created by forcing air through beads as characterized by immersion and envelopment

  43. Features of Support Surfaces • Low Air Loss • A feature that provides a flow of air to assist in managing the heat and humidity (microclimate) of the skin.

  44. Features of Support Surfaces • Foam • Elastic foam or Visco-elastic foam

  45. Features of Support Surfaces • Gel • A feature that is a solid, jelly-like material that can have properties ranging from soft and weak to hard and tough. It is a soft molding layer that contours around the shapes and bumps of the human body. Consider gel products for zone redistribution

  46. Features of Support Surfaces • Alternating Pressure • A feature that provides pressure redistribution via cyclic changes in loading and unloading as characterized by frequency, duration, amplitude and rate of change parameters.

  47. Repositioning – Evidence A • Relieve/redistribute pressure • 30 degree side lying is important • Alternate positions • Avoid shear • Avoid lying on medical devices • Avoid slouching in w/c – use footplates • Avoid HOB elevation: HOB = shear/pressure • Elevate heels • Consider “zone” positioning changes • Consider: Every layer on top of surface changes the surface support • Think of chux/linen/briefs = change in performance of bed

  48. Wheelchair cushions • Check w/cushion – pressure mapping • Check chair position • Back tilt w/ legs up • Upright w/ foot rests • Limit sitting time

  49. Risk due to Moisture • Is their skin too moist? • Prevention: • Avoid plastic diapers • Avoid extra pads that retain heat • Skin barrier protection is critical

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