Respiratory Therapy/Nursing

MAPS: Managing Airways & Protecting Skin

Rene Graham RN, CWSClinical Specialist

Covenant Health Systems Lubbock, TX

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Objectives1. Identify how care of

the lungs and care of the skin most often enhance each other.

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Respiratory Therapy/Nursing

Objectives2. Identify techniques

and devices used to protect skin while securing an airway

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Objectives3. Recognize how continuous

lateral rotation and progressive upward mobility may be initiated to promote restorative care and promote improved outcomes.

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Objectives1. Describe how care of the

lungs and care of the skin most often enhance each other

Objectives2. Refer to conditions that

may impact both skin and lungs

Objectives2. Refer to conditions that

may impact both skin and lungs

3. Describe how mucosal and nose and ear ulcers differ from other pressure ulcers

Objectives4. List techniques and devices

used to protect skin while securing an airway

Objectives5. Describe how continuous

lateral rotation and progressive upward mobility may be initiated in an intensive care setting…

Objectives5. …as a measure to promote

restorative care and promote improved outcomes

IntroductionThe Deficit Reduction Act

(DRA) of 2005 was passed through legislation and enacted in 2006 as a means to curb the national deficit

IntroductionAlong with other measures,

one of the goals of the DRA was to cut back runaway Medicare spending that was not showing signs of improved quality of care

IntroductionThe National Quality Forum

researched and developed a list of conditions occurring in hospitals that could be considered adverse events, referred to as “never events”

IntroductionPer the DRA, the Centers

for Medicare and Medicaid Services (CMS) formalized the list of hospital-acquired conditions (HAC) that were considered:

Introduction1. Reasonably preventable

2. Non-reimbursable for the care and treatment of the injury

Stage III and IV facility- acquired pressure ulcers (FA PrU) are on that listMost experts feel that not

all pressure ulcers are avoidable

Although facility- acquired injuries to the skin at the ears, nose, mouth, face, and neck are seldom severe,…

…healthcare professionals are taking the high road by trying to prevent all injuries to the skin

*The newborn and neonate may be the exception because what would be a minor injury to an adult patient may become a more serious or disfiguring injury to our smallest patients

Example: nasal septum tissue necrosis after nasal continuous positive airway pressure (N CPAP)

It is recognized that:The condition of the skin

may represent the quality of care the patient is receiving to some families

It is recognized that:The skin is the largest

organ of the body and a major shield to infection- causing bacteria invading the body

Simultaneously, healthcare professionals must be mindful of the threat of infection via the airway

There is a greater mortality rate related to ventilator- associated pneumonia (VAP) than all infections related to central lines, sepsis, and respiratory tract infections in the non-intubated patients

The challenge before us:

1. Managing and protecting the airway

2. Protecting the skin from injury which could lead to portal of entry for infection

The challenge before us:

3. Bridging the two priorities in a plan that works to compliment the protection of both

Special ConsiderationAge, presence of co-

morbidities, nutritional status, and length/severity of illness may all play a part in risk of skin (or lung) complications

Other injuries may occur around/in the mouth, nose, ears, neck, and face:Skin tears Moisture-related

breakdown/chafing [tracheostomy (trach) site]

Other injuries may occur around/in the mouth, nose, ears, neck, and face:Aphthous ulcers (aphtha =

“ulcer”)◦canker sore (inside

mouth); cold sore (outside)

Other injuries may occur around/in the mouth, nose, ears, neck, and face:Aphthous ulcers (aphtha =

“ulcer”)◦aphthous stomatitis

(recurrent)

Other injuries may occur around/in the mouth, nose, ears, neck, and face:Aphthous ulcers (aphtha = “ulcer”)◦Sutton’s disease (major, multiple,

recurring)

“Kerr’s Cocktail”Hydrocortisone (60mg) 30 ml

Benadryl (75 mg) 30 ml

Nystatin Suspension 30 ml

Tetracycline 30 ml

“Kerr’s Cocktail”Magic Mouthwash, Pink

WashViscous Lidocaine, Mylanta

Special ConsiderationThe bridge of the nose and

the ears do not have a subcutaneous layer of fat

“Deep” PrU to these areas look different than on other areas of the body

The National Pressure Ulcer Advisory Panel (NPUAP) Position Statement: “The staging system for PrU of the skin cannot be used for staging mucosal pressure ulcers (MPrU).”

The National Pressure Ulcer Advisory Panel (NPUAP) Position Statement: “MPrU are PrU…with a history of a medical device in use at the site of injury.”

Mucosal tissue has a very thin non-keratinized epithelium over a vascular connective tissue layer◦often cannot visualize

“non-blanching erythema” (Stage I)

Mucosal tissue has a very thin non-keratinized epithelium over a vascular connective tissue layer◦probably cannot see

definable margins (Stage III)

Mucosal tissue has a very thin non-keratinized epithelium over a vascular connective tissue layer◦soft coagulum (pale clot)

may resemble slough (III, IV, unstageable PrU)

Do classify MPrU as pressure ulcers

Don’t stageDo be aware that medical

device placement can be blamed for the MPrU

Don’t list anything that is not a PrU (e.g., skin tears) as a PrU

Devices that may cause injury:Endotracheal tube (ETT) or

intranasal intubation tubeNon-invasive ventilation

(NIV) – CPAPNasal cannulas

Devices that may cause injury:Face masks (elastic straps)Tracheotomy tubes and

umbilical tapesTape

Devices that may cause injury:Nasogastric tubes,

although not related to airway, may also cause mucosal and/or skin damage

PreventionKnow and follow clinical

practice guidelines:

a. NPUAP Clinical Practice Guidelines

Preventionb.Pressure Ulcers in Adults:

Prediction and Prevention. Clinical Practice Guideline No. 3. AHCPR (Agency for Healthcare Policy and Research) Pub. No. 92-0047 (purple book)

Preventionc.Neonatal Skin Care (2nd

Edition), Carolyn Lund, RN, MS, FAAN

Prevention◦ *AHWONN (Association of

Women’s Health, Obstetrics and Neonatal Nurses) Clinical Guideline for Neonatal/Newborn Skin Care

Assess and DocumentSkin and mucosal

membranes before placement of oxygen delivery device – not always possible in emergent situation (providing patent airway is always first)

Assess and DocumentRemember CMS rules for

documentation for POA (present on admission)

Reposition TubesEvery shift (as safety

allows, maintaining airway)

Reposition TubesReassess at this time and

documentGood time to provide oral

care (one of the key components of the Ventilator Bundle to decrease VAP)

Reposition TubesNasal cannula over ears

over bridge of nose or top of head

Change neonatal CPAP mask prongs

Limit Tape UseUse tape cautiously in the

elderly (thin, frail skin; slower healing)

When tape is required, use tape remover to remove it

Limit Tape UseLimit the use of tape,

especially in the neonatal unit

DO NOT use adhesive tape remover on neonates – it is toxic and can be absorbed through the skin

Limit Tape UseDale® trach tube and ETT

holdersNeobars©

Pad and ProtectSkin barrier prepHydrocolloid or silicone

dressing (T-shape at newborn nasal septum)

Pad and ProtectHydrogelHydrofoam Nasal cannula wraps (Salter

Labs® EZ Wraps™, TLCannulas™)

Manage MoistureCheck humidified linesSkin barrier prep (at ears to

prevent chafing)PRN (as needed) trach careManage moisture

(Coloplast Interdry™ AG)

Ventilator Bundle ProtocolsRecommended by the

Institute for Healthcare Improvement (IHI)

Ventilator Bundle ProtocolsPeptic ulcer and deep vein

thrombosis prophylaxis, head of bed (HOB) >30°, oral care

Ventilator Bundle ProtocolsDaily "sedation vacations"

and assessment of readiness to extubate

Plan restorative care

Restorative Care

Airway first!

Lungs Skin

HOB >30˚To tape

HOB <30˚Or Not To Tape

MAPS: Managing Airways & Protecting Skin

If you have any questions about the program you have just watched, you may call us at: (800) 424-4888 or fax (806) 743-2233.Direct your inquiries to Customer Service.Be sure to include the program number, title and speaker.

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04/30/2013

The accreditation for this program is valid through:

Release Date:

05/01/2011

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The Continuing Respiratory Care Education (CRCE) system of the American Association for Respiratory Care (AARC) approves the following course for 1 hour of continuing education (1 contact hour). Certificate of completion will indicate “LIVE” if evaluation occurs on the first Tuesday of each month. For instructor-directed questions call 1-800-424-4888. Certificate of completion will indicate “Self-Study” if evaluation occurs any other day of each month.

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Provider approved by California Board of Registered Nursing, Provider #CEP11800, for the designated number of contact hours for each program. Provider approved by Florida Department of Health Board of Nursing, Provider #FBN2060. Provider approved by West Virginia Board of Examiners for Registered Professional Nurses, Provider #WV1998-0262RN. Iowa Board of Nursing approved provider #325. Accepted by the North Carolina Board of Nursing. Reminder to all PARTICIPANTS, certificates should be retained for a period of four (4) years.Health.edu reports Florida Continuing Education (Contact Hours) to CE Broker. This activity provides 1.5 contact hours.

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This activity is presented for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of nursing. The content of the presentations is provided solely by presenters who have been selected for presentations because of recognized expertise in their field.

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DISCLOSURE TO PARTICIPANTS

Requirements of successful course completion:

•Complete the program via video presentation, PowerPoint slides, audio presentation, and/or manuscript.

•Complete the course evaluation.

•Complete the posttest with a score of 80% or greater.

•Complete the time utilized in course completion including the posttest.

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Conflicts of Interest:

Rene Graham RN, CWS has disclosed that no financial interests, arrangements or affiliations with organization/s that could be perceived as a real or apparent conflict of interest in employment, leadership positions, research funding, paid consultants or member of an advisory board or review panel, speaker’s bureau, major stock or investment holder, or other remuneration.

Commercial Support:There is no commercial support and/or relevant financial relationships related to this educational activity. Commercial support is defined as financial (or in-kind) contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. Relevant financial relationships are defined as financial relationships of any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest.

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Non-endorsement of Products:

Rene Graham RN, CWS has disclosed that no significant relationships with commercial companies whose products or services are discussed in educational presentations. For speakers, significant relationships include receiving from a commercial company research grants, consultancies, honoraria and travel, or other benefits or having a self-managed equity interest in a company. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.

Off-label Use:

Rene Graham RN, CWS has disclosed that no products with off-label or unapproved uses are discussed within this activity.

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