Wounds: What can we do? Presented by: Heather Thompson RN RNAO LTC Best Practice Co-coordinator LHIN 13 N orth East R

1. Wounds: What can we do?Presented by: Heather Thompson RNRNAO LTC Best Practice Co-coordinatorLHIN 13 North East Region

2. Objectives • Define a pressure ulcer • Identify risk factors or warning signs • Discuss Best Practices related to wound prevention and treatment plans • Discuss the “Team” and your role in wound care • Hand on exercise: “Tender touch” “Your are tearing me apart” “ Orange you glad we did this”

3. Key Terms • Friction- mechanical force exerted on the skin • Shearing- skin remains stationary and underlying tissue moves, tears and stretches • BPG- (Best Practice Guideline) • Team- client, family, care giver, nurse, Doctor, Occupational and Physical therapist, Dietician and more • Braden Scale - useful assessment tool to determine risk of skin breakdown • Moisture- due to incontinence or perspiration • Sensory – ability to feel and understand • Nutrition – protein to assist in healing

4. Wound Definition • “an area of localized damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these”European Pressure Ulcer Advisory Panel EPUAP (2003) • Typically found over bony areas and can occur anywhere • The tissue does not receive adequate nutrition and becomes necrotic and dies • Wounds are staged based on degree of tissue damage.

5. What do we know? • Preventing the development of pressure ulcers is a huge challenge • Data (1990-2003) shows 29% incidence in Canada • Further challenged by limited resources • Costs, knowledge and time to name a few

6. Myths and Truth Myth Truth • Pressure Ulcers are prevented by nurses • Sheepskin prevent Pressure Ulcers • Pressure redistribution surface prevents Pressure Ulcer alone • It takes team work: Client, Family, Care giver, Nurse, Doctor, Physical and Occupational therapist, Dietitian • Made of wool and polyester, reduce friction at start but material deteriorates quickly • They help but client still needs repositioning

7. What can we do? • Knowledge • Prevention • Protection • Assessment • Communication • Teamwork

8. Best Practice Guideline Assessment & Management of Stage I – IV Pressure Ulcers And Risk Assessment & Prevention of Pressure Ulcers Free download at http://ltctoolkit.rnao.ca

9. Evidence-Based Practice Evidence-based practice is the integration of best research evidence with clinical expertise and patient values to facilitate clinical decision making. DiCenso et al., 2005

10. What the Wound BPG can do? • To demonstrate that the implementation of a standardized skin and wound care program, partnered with an ongoing educational program has a result in the reduction of internally acquired pressure ulcers.

11. Function of the skin • Protects to keeps harmful substances out; keeps water and electrolytes in • Supports internal structures and organs • Assists in production of vitamin D • Performs excretory function • Performs sensory role • Assists in regulating body temperature

12. Skin • Largest organ • Two layers: Epidermis Dermis • Subcutaneous tissue

13. So how do pressure ulcers form • Greatest damage over bony prominence • Ulcer already started by the time you see the redness • Can increase in severity in just one day if not addressed • Pressure over area will significantly decrease the blood flow and delivery of nutrients to an area, causing eventual death of cells

15. Staging of Wounds • Stage 1 − discolouration of the skin, warmth, swelling or hardness • Stage 2− partial thickness skin loss involving epidermis or dermis, or both. May look like an abrasion or blister

16. Staging of Wounds • Stage 3– full thickness skin loss involving damage to or cell death of underlying tissue, may extend down to, but not through, fibrous tissue beneath the skin • Stage 4 – extensive tissue cell death, or damage to muscle, bone or supporting structures with or without full thickness skin loss

17. Risk Factors Uncontrolled Controlled • Age and gender • Body size • Medication • Medical condition • Nutritional and hydration status • Mobility • Environment • moisture • Positioning • Shearing and Friction • Surface areas • Mobility • Environment • Nutritional and hydration status • moisture

18. Watch for Warning Signs • Incontinent • Excessive perspiration • Cannot change position on own, limited mobility • Weight loss, dehydration • Discoloured, swollen skin over bony areas or skin tear areas • Poor circulation, history of pressure ulcers • Decrease in senses • Pain

19. Action to Protection • Assessment of risks weekly performed by client, caregiver, nurse. Use of effective tool (Braden Scale) • Communicate results • Improved nutrition: Dietician assessment ongoing, act on dietician suggestions • Communicate results • Physical Therapist assessment to maintain or improve mobility, Occupational Therapist assessment • Communicate results

21. Action to Protection • Manage Moisture: Moisture increases the risk for pressure ulcers. Two sources of moisture are urine and sweat. • Manage Nutrition & Hydration: Nutrition and Hydration are important in keeping skin healthy • Manage Friction, Sheer and Pressure: Reducing friction, sheer and pressure helps to prevent pressure ulcers. • Manage Repositioning: Repositioning helps prevent pressure ulcers. • Manage Sensory/Perception: If a patient is unable to feel pain or pressure normally, they can be injured without knowing it.

22. Pain Management http://ltctoolkit.rnao.ca/sites/ltc/files/resources/pressure_ulcer/AssessmentTools/Painmangementflowrecord.pdf • Severity of pain pre-treated • Location of pain • Quality of pain • Regular pain medication time • Non-pharmacological treatment • Severity of pain post treatment

23. What to Report • Pressure, shearing, friction • level of mobility • sensory impairment • continence • level of consciousness • Exacerbation of acute, chronic and terminal illness

24. What to Report • Posture • Cognition, psychological status • Previous pressure damage • Nutrition and hydration status • Moisture to the skin

25. Pressure Relief Devices • Heel and elbow protectors • Bed cradle and foot board • Air flow mattress • Alternating pressure bed • Special cushions for chair

26. Other Actions • Nutritional support • Skin barriers • Positioning techniques • Incontinence management program (Best Practice Guidelines: Promoting Continence using Prompted Voiding and Prevention of Constipation in the older Adult Population) • Education • Communication

27. Summary of Wound management • History, physical assessment, motivation for treatment • Involve the client, family, dietary, OT, PT, nurses, dietician and care giver • Ongoing assessment or at least every 3 months and when there is a change in condition • Contributing factors: mattress, surface supports, transfer type, mobility, nutrition and knowledge • Look at the whole person

28. Team Roles • Resident – prevention, treatment plan, communication • PSW and Care Giver – prevention, skin screening, treatment evaluation, communication • Nurse –prevention, pain control, assessment, treatment, evaluation, communication • OT and PT –prevention, physical assessments, treatment, evaluation, communication • Family – prevention, care routines, communication

29. Knowledge can be Fun • Exercise “Tender Touch” • Exercise “ You are tearing me apart” • Exercise “Orange you glad we did this”

30. Questions and Discussion

31. References • RNAO. (2007, March). Assessment & Management of Stage I-IV Pressure Ulcers. • RNAO. (2005, March). Risk Assessment & Prevention of Pressure Ulcers. • Potter & Perry. (2006). Canadian Fundamentals of Nursing 3rd ed. Chapt. 43 • Potter & Perry. (2006). Clinical Nursing Skills & Techniques 6th ed. Chapt. 13 • Website resource: http://ltctoolkit.rnao.ca • Janet Evans BScN MN BPG Coordinator LHIN 11