Wound Assessment and Management Disclaimer: Please not that all photos within this presentation are the property of Rachael White, CNS, CDHB and permission for the purpose of teaching has been granted to her by the patients involved. In no circumstances are these to be reproduced without further permission.

Wound Assessment and Management

Rachael White CNS Wound Management OPHSS RCpN, PG Dip Health Sciences & Advanced Nursing, GC Wound Management

T.I.M.E

The Largest Organ Of the Body - The Skin • The largest organ of the body – cover approx 750sqcm

• Receives 1/3 blood supply

8 Primary Functions Of The Skin • Protection – physical barrier against infection and fluid loss • Thermoregulation – body temp regulated through vasoconstriction, vasodilatation and sweating • Excretion – certain waste products , electrolytes, and water are excreted through the skin • Storage – about 15% of water is retained in the skin

Skin Function Continued • Metabolism – synthesizes vitamin D, activates the metabolism of calcium and phosphate

• Absorption – Skin can absorb certain drugs and deliver them into the blood stream • Sensation – nerve ending in the skin allow us to feel pain, pressure, heat and cold • Body image – the skin plays cosmetic identification, and communication roles (Baranoski, 2001).

Skin Function and Ageing • Thinning of the epidermis

• Loss of elastin fibres (↓ ability for skin to “bounce back”) • Barrier function decreases risk for infection and bruising • Blood vessels become thinner and more fragile ↑ risk of haemorrhage

Skin Function and Ageing cont • Decrease in sebaceous glands and sweat gland activity (skin hydration) • Loss of normal barrier mechanism

• Decreased sensory perception • Dermal atrophy ( protective padding) • Decreased vascularity

Skin Tears •

Traumatic wound occurring principally on the extremities of older adults as a result of friction alone or shearing and friction forces which separate the

epidermis from the dermis (partial thickness wound) or which separate both the epidermis from the dermis from underlying structures (full thickness wound)

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Most frequently occur on the hands, arms and lower extremities (approx 80%)

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(Payne & Martin, 1993).

Wheelchair injuries (approx 25%)

Skin Tears Cont. • Impact with objects (approx 25%) (Baranoski and LeBlanc, 2009).

• Transfers (approx 18%)

• Accidentally bumping into objects (approx 25%) • Falls (approx 12.4%) (Christensen, Keast, LeBlanc & Orsted, 2008).

Skin Tear Prevention • Staff education(RN, EN, HA) on careful handling of elderly patients with frail skin

• Encourage correct positioning, turning, lifting, and transferring techniques to prevent friction and shear. Use a sliding sheet to move and turn patients • Provide padding to bedrails, wheelchair are and leg supports • Provide shear protectors • Avoid adherent dressings on very frail skin

Shear Protectors

Management Of Skin Tears • Management will depend on the category of the skin tear • When the injury is first seen

Management of Skin Tears cont • Control the bleeding • Clean the wound with 0.9% Normal Saline • Approximate the skin flap/tissue if present, as closely as possible • Draw an arrow of the direction of the skin flap

• If there is risk of a haematoma, prick the flap with a sterile needle

Skin Tear Management cont • Secure flap edge with minimal amounts of steri strips • For very frail skin think of alternatives such as silflex™, Mepitel™, Mepilex Border™, Allevyn Gentle Border ™ • Provide support to affected area • Wound mapping and wound measurements/photo with patient consent

• Bandages on lower limbs should ALWAYS be toe to knee

Skin Tear Management Continued • Consideration should be made for ABPI assessment on the lower limbs • Review the wound 48 hours post trauma • Consider co-morbidities, nutritional support, pain management, local wound conditions and optimal dressing selection • Consider Tetanus Shot!!

Ankle Brachial Pressure Index

Pedal Pulses • Palpation of pedal pulses

Doppler Assessment Doppler Assessment • Ankle Brachial Pressure index • Toe Brachial Pressure Index

ALWAYS TRY TO REALIGN!!!!! You Have Nothing To Lose BUT YOUR PATIENT DOES!!!!!

Pressure Injuries • 95% of Pressure Injuries Are Avoidable

Pressure Injury 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 and/or friction (National Pressure Ulcer Advisory Panel, 2009) • Pressure injuries kill patients. This is not reflected statistically in our hospitals and rest-homes. Features: • Painful • Complex • Expensive • Debilitating • Preventable

LOCAL CASE STUDY PRE SURGERY PRESSURE ULCER • 92 year female patient admitted to Christchurch Hospital 29/10/09 after a fall – fractured Neck of Femur. Skin integrity documented as intact on admission. • Prior to fall – patient living in independent residential unit – active, very social. • Co-morbidities – Atrial Fibrillation, Ischeamic Heart Disease, Hypertension, Osteoarthritis, Chronic Urinary Tract Infection

29/10/09

Admitted # NOF, skin integrity documented as intact on admission

1/11/09TIMELINE

OT - #NOF

4/11/09

Tx rehab with PI sacrum

19/11/09

Discharged home to district nursing

23/11/09

Tx CH for PI management

27/11/09

OT - debridement and rotation flap of PI under GA Post op – persistent faecal ooze

6/12/09

OT – loop colostomy due to ongoing faecal ooze contaminating sacral flap, further debridement of PI

16/12/09

Tx rehab and continuing PI management

3/2/10

Tx Plastics OPD at CH continuing faecal ooze Tx back to Rehab

15/2/10

TX to CH for OT- closure of loop colostomy Post op - continuing wound deterioration, decision no further OT, indefinite NPWT

8/3/10

Dx to hospital level residential care

26/4/10

Deceased

DEBRIDEMENT

Discharge Planning for End Of Life Care

Summary • 102 days hospitalisation, average length of stay for # NOF (rehab and acute) 27 days. • 3 operations related to Pressure Injury • Braden scale documented on admission, no documentation of reassessments

Costs provided by Decision Support Pathology/blood tests Doctor costs including Surgeon, ward, OP Radiology IV/ECG Nursing cost including ward, CNS and OP Inventory ie mattress and VAC rental Anaesthetic Operating Theatre Physio Pharmacy Social Work Dressings including ward/OP and VAC dressings Occupdational Therapy including mobility aid rental Total

1238.83 14388.21 365.75 782.01 21849.26 6902.4 4179.42 5303.25 1203.37 62.99 968.52 4788.25 273.28 62305.54

Actual costs from a Nursing perspective Pathology/blood tests

1238.83

Doctor costs including Surgeon, ward, OP

14,388.21

Radiology

365.75

IV/ECG

782.01

Nursing cost including ward, CNS and OP

21,849.26

Inventory i.e., mattress

6902.40

VAC rental

9951.65

Anaesthetic

4179.42

Operating Theatre

5303.25

Physio

1203.37

Pharmacy

62.99

Social Work

968.52

Dressings including ward/OP and VAC dressings

4788.25

Occupational Therapy including mobility aid rental

273.28

Total:

72,257.19

Clinical Board • Case study presented to Clinical Board 2010 • Clinical board endorsed proposal of raising awareness of Pressure Injuries and provide funding to perform prevalence studies across CDHB • First prevalence study performed 2011 • 38% of patients had a pressure injury • Only 17% were documented to be present on admission • Had to assume that 83% of pressure injuries developed in our care

Prevalence of Pressure Injuries in the Elderly • Patients over the age of 65 years are at greater risk (AWMA, 2012) • Elderly patients have an increased prevalence of comorbidities that predispose immobility or poor blood supply to vulnerable areas of the body (Tweed & Weatherall, 2006)

• Approximately 70% of pressure injuries occur in patients over the age of 70 years (Jual, 2010)

Increasing Ageing Population • Predicted by 2031 21% of NZ’s will be over 65 years old (

•

(Statistics NZ, 2012)

• NZ labour department predict that the demand on health and disability services in NZ will grow between 40 and 69% by 2021. (NZ Institute of Economic Research, 2004)

• Therefore it is likely that pressure injuries will increase as population continues to age

Mechanisms of Injury

Incontinence

Stage 1 Pressure Injury • • • •

Intact skin Non-blanchable redness Localized area Usually over bony prominence • Not as visual in dark pigmented people

Stage 1 Pressure Injury

Stage 2 Pressure Injury • Partial thickness loss of dermis • Presents as a shallow/superficial open ulcer • Pink wound bed • Without slough • May also be present as an intact or open/ruptured serum filled blister

Stage 3 Pressure Injury • Full thickness tissue loss • Subcutaneous fat may be visible • Bone, tendon or muscle NOT exposed • Slough may be present (but does not obscure depth • May include undermining and tunnelling

Stage 4 Pressure Injury • Full thickness tissue loss • Exposed bone, tendon or muscle is evident • Slough or eschar may be present • Undermining and tunnelling may be present

Unstageable Pressure Injury • Full thickness tissue loss • Base of ulcer covered with slough (yellow, tan, grey, green or brown) • And/or eschar (tan, brown or black) in wound bed • Slough and/or eschar needs debriding to expose base of wound (giving true depth)

Pedal Pulses • Palpation of pedal pulses

Doppler Assessment Doppler Assessment • Ankle Brachial Pressure index • Toe Brachial Pressure Index

? Deep Tissue Injury • Purple of maroon area of discoloured skin or blood filled blister • Tissue may be painful, firm, mushy, boggy, warmer or cooler compared to adjacent tissue

Management of pressure injury • Initially air mattress was provided • Turning regime and appropriate wound care, diet etc • Patient could not transfer from bed to wheelchair • Tried numerous alternating air mattresses unsuccessfully

• Trialled self adjusting technology mattress

Self Adjusting Technology • Foam encased Nonpowered chambers with interconnected in-let and out-let valves that automatically regulate body weight • Effective for prevention and management of PI’s (up to stage three) • Heel slope

One Month Later • After one month on the self adjusting mattress, PI had reduced significantly • Patient was able to transfer independently • Patient was discharged home with the same mattress • PI was healed in a further month

Prevention of Pressure Injuries in an Older Person Health Facility • Began purchasing self adjusting technology mattresses for OPHSS wards at The Princess Margaret Hospital 2010 • 2011 – 37% bed coverage of ATR wards • 2013 – 100% bed coverage of ATR wards

New Pressure Relieving Equipment Contract Roho Mattress and Cushion (DME 354 9239)

Quattro Plus and Cushion (DME 354 9239)

Pressure Relieving Equipment Cont Area Mattress Accurate Health Care 0800 80 75 74

Cirrus Mattress Accurate Health Care 0800 80 75 74

Maxcare Heel Protector (Susan Maxwell – Morton and Perry 021 248 3612, 0800 238 423, [email protected] )

ACC45 • Nurse can complete this form • Suggested to complete for a stage 1 to 2

ACC2125 • Nurses can complete this form • Dr’s must complete if patient requires time off work • Suggested to complete for a grade 3 to 4 • On going treatment will be required

Patient Label Older Persons Health & Rehabilitation

Braden Scale Pressure Injury Assessment Date Sensory Perception Completely Limited Very Limited Slightly Limited No Impairment Mobility Completely immobile Very limited Slightly limited No limitations Moisture Constantly Moist Very Moist Occasionally Moist Rarely Moist Nutrition Very Poor Probably Inadequate Adequate Excellent Activity Bed rest Bed Chair Walks Occasionally Walks Frequently Friction and Shear Significant Problem Problem Potential Problem No Apparent problem Total Score Name Signature

Assessment 1 1 2 3 4 Score 1 2 3 4 Score 1 2 3 4 Score 1 2 3 4 Score 1 2 3 4 Score 1 2 3 4



Assessment 3 1 2 3 4

Assessment 4 1 2 3 4

Assessment 5 1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

Score 9 or below

Score 10 - 12

Score 13 - 14

Score 15 - 24

VERY HIGH RISK Review weekly Or PRN if patient deteriorates or develops a pressure injury

HIGH Review weekly

MODERATE Review weekly

Or PRN if patient deteriorates or develops a pressure injury

Or PRN if patient deteriorates or develops a pressure injury

LOW Review weekly Or PRN if patient deteriorates or develops a pressure injury

Pressure Injury Assessment Tool Grade 2 Grade 3

Grade 1

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Assessment 2 1 2 3 4

Intact Skin Non-blancable redness

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Partial thickness Superficial Wound bed pink Intact or ruptured blister

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Full thickness Slough may be present Undermining and tunnelling

Grade 4

  



Full thickness Exposed bone, tendon or muscle Slough may be present Undermining and tunnelling

Strategies to Consider o o o o o

o o o o o

Appropriate mattress Change of position frequency Review bed / chair time Dietician referral Protect heels

Review of continence products Review appropriate pressure injury dressing Review foot wear / clothing for tightness Review safe handling equipment Check bedding for wrinkles

PRESSURE REDISTRIBUTING SUPPORT SURFACES GUIDELINES OPHSS

Owned

Atmosair

Low to moderate risk (24-13)

DME 03 354 9239

Roho Overlay and Cushion

-Self adjusting technology - Patient must be able to self re-position - Effective on grade 13 pressure injury

OPHSS

Owned

Quattro Plus (DME)

Hired - Moderate to High Risk (12-19) - Effective on grade 1-4 pressure injury - - ideal for patients who sit elevated - great for heel pressure injuries - NO WEIGHT RESTRICTIONS

Hired

03 354 9239 Moderate to High Risk ( 12-19) - alternating air pressure - effective on Grade 1-4 - ideal for patients who sit elevated - suitable for unstable fractures - Weight range 26kg – 250kg

- Moderate to high risk (12-19) - Effective on grade 1 3 - Good at providing pain relief - weight restriction 30 – 165kg

Cirrus (Accurate Health Care) 0800 80 75 74

Hired - Moderate to High risk (12-19) - Effective on grade 14 pressure injury - Very good at providing pain relief - suitable for palliative patients

Max care Heel Protector (Morton and Perry)

Purchase

Heel Lift Suspension Boot (DME)

- Prevention and Existing pressure injuries of the heel - elevates the heel from the surface of the bed - Protects against shear - appropriate to mobilise in - Single patient use

Draft Form for trial period over the month of May 2012

Purchase - Prevention and Existing Pressure injuries of the heel - Prevent friction and shear - Complete off load of pressure - Not suitable for mobilisation

Pressure Injury Alert Stickers

2 Hourly Turning Schedule

Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury, (2012). Retrieved from http://www.awma.com.au/publications/publications.php#pipm

“Only after examining the whole patient should we examine the ‘hole’ in the patient” Gary Sibbald MD Toronto 2002

Scenario One • Mrs B is a 78 yr old woman acutely admitted following a fall at home. She sustained a # R) neck of femur and has been waiting for surgery for 3 days. • She has limited bed mobility & poorly controlled pain • She has CHF & hypertension • She had been independent prior to her fall • This area was discovered during her morning wash.

Scenario Two

Scenario Two • Mrs D is a 67 yr old woman who is referred by her GP to a specialist wound clinic • She suffers from a chronic leg ulcer which has been deteriorating to the point where she is struggling to cope • She is obese at 103 kgs and smokes • She has also just found out her rent has been significantly increased

Venous Leg Ulcers • Caused by Chronic Venous Hypertension • The non-return valve in the vein is damaged, allowing back flow of blood

VENOUS AETIOLOGY • Venous efficiency in the lower legs relies on the calf muscle pump • The direction on the blood flow depends on the efficiency of the pumping mechanism and the competence of the valves inside the vein walls (which are designed to prevent backflow) • The most common reason for venous ulceration is damage to these valves, thus causing backflow which therefore brings higher than normal venous pressure - known as Venous Hypertension

CLINICAL SIGNS OF VENOUS HYPERTENSION

• Brown Staining known as Haemosiderin Deposits

Ankle Flare • Ankle Flare – dilation of venules

Atrophie Blanche • Atrophy Blanche – Smooth, ivorywhite plaques • Often associated with ulcerations and Chronic Venous Insufficiency

Lipodermatosclerosis • Lipodermatosclerosis – fibrosed woody tissue (Champagne bottle)

Oedema • Oedema – fluid within the interstitial spaces

Varicose Eczema • Varicose Eczema – Extravasation of irritating proteclytic enzymes & metabolic wastes within the dermis

Varicose Veins • Varicose Veins – engorged blood filled veins following damage to the deep or perforating veins

Patients who present with venous ulceration may have a history • DVT • Major limb trauma – eg fracture, crush injury or major laceration • Vein Surgery • Reduced Mobility • Obesity

VENOUS ULCERATION . Venous ulcers typically

. . . . . .

develop on the gaiter region Typically shallow Irregular Ruddy Granulating Well defined wound borders Surrounding skin may be oedematous, or indurated or hyper pigmented

COMPRESSION THERAPY • This is the corner stone of treatment for Venous ulcers The aim of venous ulcer management is to: • reduce the blood pressure in the superficial venous system • aid venous return • reduce oedema

PRIMARY PRODUCTS VENOUS • should provide a moist warm wound environment, yet absorb excessive exudate • Simple non-adherent dressings for shallow non exudating ulcers • Absorbent foam or alginate dressings should be used for exudating ulcers

Management of Venous Ulcers • While it may be debated as to the main plan of treatment, it is necessary to care for the ulcer primarily

• Use dressings to protect the ulcer from infection, control exudate, enhance autolytic debridement and reduce pain.

• This can be achieved by graduated compression therapy • ABPI must be within safe range (NZ Guidelines) • Compression should only ever be applied by a trained practitioner

ARTERIAL AETIOLOGY • Caused by insufficient arterial blood supply to the limb, resulting in ischaemia and necrosis

• Atherosclerosis (disease in which deposits of fat cause the artery wall to thicken) is the most common cause of arterial ulcers.

PREDICTORS OF PERIPHERAL ARTERIAL OBSTRUCTIVE DISEASE • Gender – Male • Age 60 – 80 • History of Intermittent Claudication (pain on ambulation) • History of Diabetes • History of Smoking • History of Increased Blood Pressure

Arterial Disease cont • As the disease progresses the patient may experience: • pain at rest, particularly when legs are elevated in bed • This is relieved by dependency and patients will commonly hang their feet out of bed, or sleep in an armchair • Claudication – pain on walking

CLINICAL SIGNS OF ARTERIAL INSUFFICIENCY • • • • • • • • • •

Cold, shiny, hairless skin Dystrophic nails Limb blanches white when elevated Nail deformities and fungal infections Poor capillary refill Muscle wasting Dependency oedema Decreased or absent pedal pulses Gangrene on foot or toes Pain, intermittent Claudication

ARTERIAL ULCERS • Typically develop on the lower leg or foot distal to the arterial narrowing or blockage • Peripheral pulses may be decreased or absent • The ulcer is usually pale, dry without granulation tissue • ‘punched out’ appearance

What are the differences between Venous and Arterial Ulcers? Arterial Ulcers Predisposing Factors  arteriosclerosis.  advanced age.  diabetes. Ulcer Location  between toes or at tip of toes.  over phalangeal heads.  on heel.  above lateral malleolus.  (for diabetic patient) over metatarsal heads, on side or sole of foot.

Venous Ulcers Predisposing Factors  Hx of DVT.  Hx of valvular incompetence in perforating veins. Ulcer Location  anteromedial malleolus.  pretibial area.

What are the differences between Venous and Arterial Ulcers cont Arterial Ulcers Associated Changes in Leg or Foot  Thin, shiny dry skin  Thickened nails  Absence of hair growth  Temperature variations  Pallor on elevation  Dependant rubor  Pain severe, worse on elevation, exercise or at night Ulcer Characteristics  Well demarcated edges  Black or necrotic tissue  Deep, pale base  Exceedingly painful

Venous Ulcers  Associated Changes in Leg or Foot  Firm ‘brawny’ oedema  Reddish brown discoloration  Evidence of healed ulcers  Dilated and tortuous superficial veins  Pain variable, exacerbated by cellulitis or oedema Ulcer Characteristics  Uneven edges  Ruddy granulation tissue  Superficial  Moderately painful

ASSESSMENT OF VENOUS OR ARTERIAL ULCERS • Assessment is necessary to accurately diagnose the aetiology of the ulcer, and therefore provide the best possible treatment. • A Doppler Ultrasound is necessary to calculate the Ankle Brachial Pressure Index (ABPI). • DOPPLER ASSESSMENT SHOULD ONLY EVER BE PERFORMED BY A TRAINED PRACTITIONER GUIDED BY THE NZ NATIONAL GUIDELINES!!!!

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