General Nursing Orientation: Wound and Skin Care
Transcript of General Nursing Orientation: Wound and Skin Care
July 2019
Patsy Maclean MSc(WHTR) RN IIWCC
Equipment and Product Standardization Nurse (Skin and Wound)
Supply Chain Management
General Nursing Orientation: Wound and Skin Care
Objectives
• Recognize importance of maintaining skin integrity
• Identify pressure injuries
• Describe risk factors for skin breakdown
Function of the skin
• Largest organ in the body
• Temperature regulation
• Sensation
• Elimination
• Communication
• It is our greatest protector!!
Pressure injury
“A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear“
National Pressure Ulcer Advisory Panel 2016
What do pressure and shear actually do? • Tissue deformation – Pressure and shear directly
deform cells → cell membranes and cytoskeleton are damaged → cells die. Cell death can start within minutes with high pressure and shear forces
• Ischemia – Blood vessels and lymph channels occluded → less oxygen to tissue → changes in metabolism → accumulation in waste products → pH decreases → cells die. Tends to occur with lower pressure and shear forces. Takes 6-8 hours for cell damage to occur
• Perfusion – reperfusion injury may also play a role in damaging cells
Stage 1
Stage 2
Stage 3
Stage 4
Unstageable Pressure Injury
Deep Tissue Pressure Injury
Risk factors/conditions
Look at the whole patient,
not just the hole in the patient!
Risk Assessment
Braden Q
Sensory perception
• Is the patient aware of pressure related discomfort? • Turning schedules are essential for bedfast patients
• Reposition regularly, even on a specialty surface
• Reposition chair bound patients at least every hour
• Even minor movements can make a difference
Moisture
All sources of moisture need to be identified.
• Wound exudate
• Excessive sweating
• Emesis
• Urine and feces
Friction
• Caused by skin rubbing across the bed or chair surface
• First indication may be a superficial abrasion of the skin
• Friction can accelerate the onset of ulceration
Shear
• Skin or internal tissues slide against a supporting structure
• Can be caused by repeated sliding down in bed/chair
• Adding shear force to pressure causes undermining into adjacent tissues.
Hips and knees even with the
bend of the bed (gatch)
Mobility and Activity
• Activity level is directly related to pressure on tissues and loss of skin integrity
• In older adults, decline in walking ability begins within 2 days of hospitalization
Nutrition
• Malnutrition and deficiencies are risk factors for skin breakdown
• Reduced nutritional intake and/or chronic losses from the wound can delay wound healing.
The interdisciplinary team
• You!
• The patient and their family
• Physiotherapists
• Occupational therapists
• Dieticians
• Ostomy and Wound Resource Team
• Physician, pharmacist, social worker etc
Points to ponder
• When health is compromised the skin is more vulnerable to injury
• Assess all patients for pressure injury risk
• Consider all risk factors
• Intervene and modify to reduce risk of skin breakdown
• Psychologically and economically, prevention is better than the treatment of lost skin integrity