Skin Pressure Injuries PDF

Skin / Pressure Injuries Based on the comprehensive Assessment of a resident, the facility must ensure that— A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable. A resident...

Skin / Pressure Injuries Based on the comprehensive Assessment of a resident, the facility must ensure that— A resident who enters the facility without pressure sores does not develop pressure sores unless the individual’s clinical condition demonstrates that they were unavoidable. A resident that has pressure sores receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. F686 Failure To Prevent Pressure Injuries Types of Skin Issues  Skin Tears  Pressure Ulcers  Arterial Ulcers  Venous Ulcers  Diabetic Ulcers Skin Tears  Caused by mechanical trauma.  The risk of skin tears are higher in elderly people with impaired mobility. This is because they may require more assistance with activities of daily living.  The use of equipment, particularly wheelchairs, can also increase the risk of skin tears. This is due to poor handling or blunt trauma. Types of Skin Tears Arterial Ulcers  A painful, deep sore or wound in the skin of the lower leg or foot.  Caused by a lack of arterial blood flow (ischemia, PVD, PAD)  Punched-out look usually round in shape with well defined margins. Venous Stasis Ulcer  Open sores that often occur on the lower legs.  Irregular shaped opened areas.  Caused by blood backing up in the veins and not pushed back to the heart.  Caused by obstruction, leaky or damaged valves in the veins, or an ineffective calve pump.  Characteristics include edema, dark discoloration , and hardened skin. Diabetic Ulcers  An open sore or wound that occurs on the foot in approximately 15 percent of patients with diabetes.  Poor circulation and nerve damage caused by elevated blood sugars over a period of time.  Vascular disease can impede healing and cause infection. Pressure Injuries  Localized skin damage as well as underlying soft tissue damage, usually occurring over a bony prominence or related to medical devices. Risk Factors  Poor nutrition  Decreased skin integrity  Decrease mobility (can’t shift their own weight)  Neuro issues (decreased LOC, or spinal injury)  Decrease tissue perfusion  Incontinence  Activities that cause friction and shear  Other comorbidities Friction  The rubbing of skin against a hard object, such as the bed. This rubbing causes heat, which can remove the top layer of skin and often results in skin damage. Shearing  Occurs when tissue layers move over the top of each other, causing blood vessels to stretch and break as they pass through the subcutaneous tissue.  Example: when a patient slides down in bed, the outer layer of skin remains immobile because it remains attached to the sheets due to friction. Shearing Common Areas of Pressure Injuries Common Areas Root Cause Stage I : Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Color may appear differently in darker skin. Stage II: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. Stage III: Full-thickness skin loss Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location. Undermining and tunneling may occur. May see rolled edges. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is Unstageable.. Stage IV: Full-thickness skin and tissue loss  Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible.  Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location.  If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Un-stageable: Obscured full-thickness skin and tissue loss  Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.  If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed.  Stable eschar on the heel or ischemic limb should not be softened or removed. Deep Tissue Injury: Persistent non-blanchable deep red, maroon or purple discoloration  Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister.  Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. Medical Device Related Pressure Injury Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. Mucosal Membrane Pressure Injury Mucosal membrane pressure injury is found on mucous membranes with a history of a medical device in use at the location of the injury. Due to the anatomy of the tissue, these ulcers cannot be staged. Prevention – All steps should be taken to prevent pressure ulcers from developing or worsening.  Turning and repositioning – while in bed and wheel/geri-chair  Proper Incontinent Care – while in bed and wheel/geri-chair  Wheel/Geri-chair cushions  Floating Heels with pillows – Creative Solutions does not approve of “Heel Protector” use.  Bed Cradle Prevention – continued  Air Mattress – for Stage 3 or 4, or unstageable or DTI that could possibly be equivalent to a Stage 3 or 4 wound on the core or trunk of the body  Prevent skin to skin contact  Maintain the head of the bed as low as possible for bed-fast residents  Resident nutrition and hydration  Staff education  Resident Education  Administrative Nurse rounds Prevention – continued  “Peggy Baker Program” – Place a credit card sized, laminated, colorful card with “Bring to DON” written on it under a resident while in the bed or chair. The card was placed and then she noted what time it was returned. Prevention – continued  Certain heel protectors are not recognized as a pressure reducing device. Bad Types of Heel Protectors Good Types of Heel Protectors – the heel floats Assessments  Initial Skin Assessment – completed on admission and readmission within 4hrs  Weekly Skin Assessment – completed each week for each resident  Braden Scale  completed weekly x4 for new admissions  completed x1 for readmissions Assessments  Weekly Ulcer Assessment – completed weekly for any pressure, arterial, venous, or diabetic ulcer.  1 assessment for each ulcer  If a resident has 5 ulcers, then they require 5 Weekly Ulcer Assessments each week Wound Report  Located in Data IQ  Information is pulled from the weekly ulcer assessment. Treatments  Resources for dressing supplies include:  Impact Medical (Part B)  Medline Supplies  Vohra Wound Photos Demo  PCC  Initial and Weekly Skin Assessment  Braden Scale  Weekly Ulcer Assessment and care plan  Monitoring Skin Changes  Residents at Risk  Weekly Wound Report Thank You!