BASIC HUMAN NEEDS ALTERATIONS IN SKIN INTEGRITY PRESSURE ULCERS Donna M Penn RN MSN CNE

BASIC HUMAN BASIC HUMAN NEEDSNEEDS

ALTERATIONS IN ALTERATIONS IN SKIN INTEGRITYSKIN INTEGRITY

PRESSURE PRESSURE ULCERSULCERS

Donna M Penn RN MSN CNEDonna M Penn RN MSN CNE

Skin IntegritySkin Integrity

Skin/Integumentary system is the Skin/Integumentary system is the body’s largest organ, 1/6body’s largest organ, 1/6thth of TBW of TBW

Protects against disease causing Protects against disease causing organismsorganisms

Sensory organ for temp, pain, touchSensory organ for temp, pain, touch Synthesizes Vitamin DSynthesizes Vitamin D Injury to skin poses a risk to safety Injury to skin poses a risk to safety

and triggers a complex healing and triggers a complex healing processprocess

Normal IntegumentNormal Integument

2 principle layers in relation to 2 principle layers in relation to wound healingwound healing

EpidermisEpidermis DermisDermis Separated by basement membraneSeparated by basement membrane

EpidermisEpidermis

Outer layer has several layers within Outer layer has several layers within itit

Stratum CorneumStratum Corneum Stratum LucidemStratum Lucidem Stratum GranulosumStratum Granulosum Stratum SpinosumStratum Spinosum Basal cell layerBasal cell layer

DermisDermis

Inner layer of skinInner layer of skin Provides tensile strength & Provides tensile strength &

mechanical support & protection to mechanical support & protection to underlying muscle, bones, and organsunderlying muscle, bones, and organs

Contains mostly connective tissueContains mostly connective tissue Also includes blood vessels, nerves, Also includes blood vessels, nerves,

sensory nerve cells, lymphatics, sensory nerve cells, lymphatics, collagencollagen

Skin FunctionsSkin Functions

Epidermis-functions to re-surface Epidermis-functions to re-surface wounds & restore the barrier wounds & restore the barrier against bacteriaagainst bacteria

Dermis-functions to restore Dermis-functions to restore structural integrity-collagen& structural integrity-collagen& physical properties of skinphysical properties of skin

Pressure UlcersPressure Ulcers

New NPUAP terminology (2007)New NPUAP terminology (2007)

A pressure ulcer is a localized injury to A pressure ulcer is a localized injury to the skin and/or underlying tissue the skin and/or underlying tissue usually over a bony prominence, as a usually over a bony prominence, as a result of pressure, or pressure in result of pressure, or pressure in combination with shear and/or friction.combination with shear and/or friction.

A number of contributing factors are A number of contributing factors are also associated with pressure ulcersalso associated with pressure ulcers

Pressure UlcersPressure Ulcers

Tissues receive oxygen and nutrients Tissues receive oxygen and nutrients and eliminates metabolic wastes via the and eliminates metabolic wastes via the bloodblood

Any factor that interferes with this Any factor that interferes with this affects cellular metabolism and cell lifeaffects cellular metabolism and cell life

Pressure affects cellular metabolism by Pressure affects cellular metabolism by decreasing or stopping tissue decreasing or stopping tissue circulation resulting in tissue ischemiacirculation resulting in tissue ischemia

Causes of Pressure Causes of Pressure UlcersUlcers

Pressure > ischemia > edema > Pressure > ischemia > edema > inflammation > small vessel inflammation > small vessel thrombosis > cell deaththrombosis > cell death

Shear – trauma caused by tissue Shear – trauma caused by tissue layers sliding across each other, layers sliding across each other, results in disruption or angulation of results in disruption or angulation of blood vesselsblood vessels

Pressure Ulcer Pressure Ulcer Contributing FactorsContributing Factors

FrictionFriction Poor NutritionPoor Nutrition IncontinenceIncontinence MoistureMoisture Co-existing Medical ConditionsCo-existing Medical Conditions

PressurePressure

Tissue damage occurs when Tissue damage occurs when pressure exerted on the capillaries is pressure exerted on the capillaries is high enough to close the capillarieshigh enough to close the capillaries

Capillary closing pressure is the Capillary closing pressure is the pressure needed to close the pressure needed to close the capillary > 32 mmHgcapillary > 32 mmHg

After a period of ischemia light After a period of ischemia light toned skin undergoes 2 hyperemic toned skin undergoes 2 hyperemic changeschanges

HyperemiaHyperemia

Normal Reactive Hyperemia-visible Normal Reactive Hyperemia-visible effect of localized vasodilatation effect of localized vasodilatation (REDNESS) area will blanch with (REDNESS) area will blanch with fingertip pressure and redness lasts less fingertip pressure and redness lasts less than 1 hourthan 1 hour

Abnormal Reactive Hyperemia-Abnormal Reactive Hyperemia-excessive vasodilatation and induration excessive vasodilatation and induration (edema) in response to pressure. Skin (edema) in response to pressure. Skin appears bright pink-red. Lasts 1 hour to appears bright pink-red. Lasts 1 hour to 2 weeks2 weeks

Risk Factors for Pressure Risk Factors for Pressure Ulcer DevelopmentUlcer Development

Impaired Sensory InputImpaired Sensory Input

Impaired Motor FunctionImpaired Motor Function

Altered Level of ConsciousnessAltered Level of Consciousness

Orthopedic DevicesOrthopedic Devices

Pathogenesis of Pressure Pathogenesis of Pressure UlcersUlcers

Intensity of pressure and capillary Intensity of pressure and capillary closing pressureclosing pressure

Duration and sustenance of pressureDuration and sustenance of pressure

Tissue ToleranceTissue Tolerance


Bony prominences are most at risk Bony prominences are most at risk (sacrum, heels, elbows, lateral (sacrum, heels, elbows, lateral malleoli, greater trochanter, ischial malleoli, greater trochanter, ischial tuberositiestuberosities

Pressure ulcer forms as a result of Pressure ulcer forms as a result of time/pressure relationshiptime/pressure relationship

Greater the pressure and duration of Greater the pressure and duration of pressure, the greater the incidence pressure, the greater the incidence of ulcer formationof ulcer formation


Skin and subcutaneous tissue can Skin and subcutaneous tissue can withstand some pressurewithstand some pressure

Tissue will over time become Tissue will over time become hypoxic and ischemic injury will hypoxic and ischemic injury will occuroccur

If the pressure is above 32mmHg If the pressure is above 32mmHg and remains unrelieved to the point and remains unrelieved to the point of tissue hypoxia, the vessel will of tissue hypoxia, the vessel will collapse and thrombosecollapse and thrombose


If circulation is restored before this If circulation is restored before this critical point, circulation to tissue is critical point, circulation to tissue is restored (Reactive Hyperemia)restored (Reactive Hyperemia)

Skin has a greater ability to tolerate Skin has a greater ability to tolerate ischemia than does muscle, hence ischemia than does muscle, hence true pressure ulcers begin at bone true pressure ulcers begin at bone with pressure related to muscle with pressure related to muscle ischemia eventually coming through ischemia eventually coming through to epidermis (Shear injury) Sacrum to epidermis (Shear injury) Sacrum and heels most susceptibleand heels most susceptible

Pressure Ulcer StagingPressure Ulcer Staging

Depth of destroyed tissueDepth of destroyed tissue Does not indicate healingDoes not indicate healing Ulcer covered by necrotic tissue or Ulcer covered by necrotic tissue or

eschar cannot be staged until eschar cannot be staged until debrideddebrided

NPUAP system used most clinicallyNPUAP system used most clinically Other staging systems existOther staging systems exist

Stage 1 Pressure UlcerStage 1 Pressure Ulcer

Intact skin with non-blanchable redness of Intact skin with non-blanchable redness of a localized area usually over a bony a localized area usually over a bony prominence.prominence.

Darkly pigmented skin may not have Darkly pigmented skin may not have blanching: its color may differ from the blanching: its color may differ from the surrounding areasurrounding area

The area may be painful, firm, soft, warmer The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue.or cooler as compared to adjacent tissue.

Stage I may be difficult to detect in Stage I may be difficult to detect in individuals with darker skin tonesindividuals with darker skin tones

Stage I TreatmentStage I Treatment

Off-load pressureOff-load pressure

Transparent film dressingTransparent film dressing

Hydrocolloid dressingHydrocolloid dressing

Moisture barrierMoisture barrier

Stage 2 Pressure UlcerStage 2 Pressure Ulcer

Partial thickness skin loss involving the Partial thickness skin loss involving the epidermis and/or dermis. epidermis and/or dermis.

The ulcer is superficial and presents The ulcer is superficial and presents clinically as an abrasion, blister, or clinically as an abrasion, blister, or shallow open ulcershallow open ulcer

Presents as shiny or shallow ulcer Presents as shiny or shallow ulcer (red/pink wound bed) without slough or (red/pink wound bed) without slough or bruising. This stage should not be used to bruising. This stage should not be used to describe skin tears, tape burns, perineal describe skin tears, tape burns, perineal dermatitis, maceration or excoriationdermatitis, maceration or excoriation

Stage II TreatmentStage II Treatment

Hydrocolloid dressing: dressing of Hydrocolloid dressing: dressing of choice in minimally draining stage 2 choice in minimally draining stage 2 ulcerulcer

Absorptive dressings (Foam) Absorptive dressings (Foam) draining woundsdraining wounds

Hydrogel: Healing woundsHydrogel: Healing wounds Off-load pressureOff-load pressure

Stage IIIStage III

Full thickness skin loss involving damage Full thickness skin loss involving damage or necrosis to subcutaneous tissue that or necrosis to subcutaneous tissue that may extend down to, but not through may extend down to, but not through underlying fasciaunderlying fascia

Ulcer presents as a deep crater with or Ulcer presents as a deep crater with or without undermining or tunneling of without undermining or tunneling of adjacent tissueadjacent tissue

Slough tissue may be present but does Slough tissue may be present but does not obscure the depth of tissue lossnot obscure the depth of tissue loss

Depth varies by anatomical locationDepth varies by anatomical location

Stage III TreatmentStage III Treatment

Requires physician order for Stage III Requires physician order for Stage III or IVor IV

Draining vs. Non-drainingDraining vs. Non-draining Necrotic vs. GranulatingNecrotic vs. Granulating Draining wounds-Absorptive dressingsDraining wounds-Absorptive dressings Granulating wounds-HydrogelGranulating wounds-Hydrogel Necrotic wounds-Require debridement Necrotic wounds-Require debridement

(Chemical. Mechanical, Autolytic, (Chemical. Mechanical, Autolytic, Sharp)Sharp)

Stage IVStage IV

Full thickness skin loss with extensive Full thickness skin loss with extensive destruction, tissue necrosis or damage to destruction, tissue necrosis or damage to muscle, bone , or supporting structures muscle, bone , or supporting structures (tendons, joint)(tendons, joint)

Undermining and tunneling are often Undermining and tunneling are often associated with Stage IV ulcersassociated with Stage IV ulcers

Slough or eschar may be present in some on Slough or eschar may be present in some on some parts of the wound bedsome parts of the wound bed

Depth of wound varies by anatomical locationDepth of wound varies by anatomical location Exposed bone or tendon is visible or directly Exposed bone or tendon is visible or directly

palpablepalpable

Unstagable WoundsUnstagable Wounds

Full thickness tissue loss in which the base Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar tan, gray, green or brown) and/or eschar (tan, brown, black) in the wound bed(tan, brown, black) in the wound bed

The true depth of the wound cannot be The true depth of the wound cannot be determined until slough or eschar is determined until slough or eschar is removed, therefore stage cannot be removed, therefore stage cannot be determined.determined.

Stable eschars serve as the body’s natural Stable eschars serve as the body’s natural biological cover and should not be biological cover and should not be removedremoved

Deep Tissue InjuryDeep Tissue Injury Purple or maroon localized area of Purple or maroon localized area of

discolored intact or blood filled blister due discolored intact or blood filled blister due to the damage of underlying soft tissue to the damage of underlying soft tissue from pressure or shear.from pressure or shear.

The area may be preceded by tissue that is The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissuecooler as compared to adjacent tissue

May be difficult to detect with darker skin May be difficult to detect with darker skin tonestones

Evolution may include a thin blister over a Evolution may include a thin blister over a dark wound beddark wound bed

Staging by ColorStaging by Color

BlackBlack

YellowYellow

Pink/RedPink/Red

Mixture of colorsMixture of colors

Process of Wound Process of Wound HealingHealing

Primary IntentionPrimary Intention

Secondary IntentionSecondary Intention

Healing by Primary Healing by Primary IntentionIntention

Inflammatory (Reaction)Inflammatory (Reaction)

Proliferative (Regeneration)Proliferative (Regeneration)

Maturation (Re-modeling)Maturation (Re-modeling)

Healing by Secondary Healing by Secondary IntentionIntention

Healing takes longerHealing takes longer Wounds drain more fluidsWounds drain more fluids Inflammation phase is prolonged, Inflammation phase is prolonged,

chronicchronic Wound becomes filled with fragile Wound becomes filled with fragile

granulation tissue rather than collagengranulation tissue rather than collagen Wound Contraction takes placeWound Contraction takes place More susceptible to infectionMore susceptible to infection

Complications of Wound Complications of Wound HealingHealing

HemorrhageHemorrhage Infection (Nosocomial)Infection (Nosocomial) DehiscenceDehiscence EviscerationEvisceration Fistula FormationFistula Formation

Risk Assessment for Risk Assessment for Pressure UlcersPressure Ulcers

Identify at risk populationIdentify at risk population Norton ScaleNorton Scale Gosnell Scale Gosnell Scale Braden Scale- most uses clinically, includes Braden Scale- most uses clinically, includes

6 subscales (sensory perception, moisture, 6 subscales (sensory perception, moisture, activity, mobility, nutrition, friction & shearactivity, mobility, nutrition, friction & shear

6-23 score, <18 at risk in hospitalized 6-23 score, <18 at risk in hospitalized patientspatients

Refer to P&P pg. 1496-1497 for Braden Refer to P&P pg. 1496-1497 for Braden ScaleScale

Factors Affecting Pressure Factors Affecting Pressure Ulcer FormationUlcer Formation

Shearing forceShearing force FrictionFriction MoistureMoisture Tissue Tolerance FactorsTissue Tolerance Factors NutritionNutrition InfectionInfection Impaired Peripheral CirculationImpaired Peripheral Circulation AgeAge

Factors that Impair Wound Factors that Impair Wound HealingHealing

AgeAge MalnutritionMalnutrition ObesityObesity Impaired oxygenationImpaired oxygenation SmokingSmoking Diabetes (blood glucose level)Diabetes (blood glucose level) DrugsDrugs RadiationRadiation Wound StressWound Stress

Nursing ProcessNursing ProcessAssessmentAssessment

Predictive measures-Risk assessment Predictive measures-Risk assessment toolstools

Skin assessment- any areas susceptible Skin assessment- any areas susceptible to pressure sources, (NG, oxygen tubes, to pressure sources, (NG, oxygen tubes, casts, bony prominences)casts, bony prominences)

Tactile Assessment-Blanching red areasTactile Assessment-Blanching red areas Assess mobilityAssess mobility Assess nutritional statusAssess nutritional status

Wound AssessmentWound Assessment

Location, Size, StageLocation, Size, Stage Wound drainageWound drainage Wound bed, tissue typeWound bed, tissue type Wound edgesWound edges Periwound skinPeriwound skin Presence of undermining, tunnelingPresence of undermining, tunneling


Anatomical locationAnatomical location Stage-NPUAP stagingStage-NPUAP staging Staging is for pressure ulcers only, Staging is for pressure ulcers only,

other wounds are classified as other wounds are classified as partial or full thicknesspartial or full thickness

Size- Measure length, width, depth Size- Measure length, width, depth in centimetersin centimeters


DrainageDrainage Amount, color, consistency, odorAmount, color, consistency, odor Scant, moderate, largeScant, moderate, large Serous, serosanguinous, purulent, Serous, serosanguinous, purulent,

yellow, brown, green, clearyellow, brown, green, clear Odor to wound may be indicative of Odor to wound may be indicative of

infectioninfection

Wound AssessmentWound AssessmentTissue TypeTissue Type

When describing wound bed include % of When describing wound bed include % of each tissue type (50% slough, 50% each tissue type (50% slough, 50% granulation)granulation)

Necrotic tissue-nonviableNecrotic tissue-nonviable Eschar- dry, leathery, black or brownEschar- dry, leathery, black or brown Slough- stringy, cheesy, loose, yellow, tanSlough- stringy, cheesy, loose, yellow, tan Granulation- healthy, viable pink to beefy Granulation- healthy, viable pink to beefy

redred Epithelialization-occurs along wound edges Epithelialization-occurs along wound edges

or as islands inside wound bed, pale pink or as islands inside wound bed, pale pink resurfacing of woundresurfacing of wound

Wound AssessmentWound AssessmentPeriwound AreaPeriwound Area

Erythema-may mean infectionErythema-may mean infection

Maceration-Whitish, wrinkled Maceration-Whitish, wrinkled appearanceappearance

Indicates presence of excessive Indicates presence of excessive moisturemoisture

Rash- Macular or papular, may indicate Rash- Macular or papular, may indicate fungal infectionfungal infection

Wound AssessmentWound AssessmentPresence of Presence of

Undermining/TunnelingUndermining/Tunneling Document location and depthDocument location and depth Use hands of clock as descriptorUse hands of clock as descriptor Measure with cotton tipped Measure with cotton tipped

applicatorapplicator

Staging LimitationsStaging Limitations

Difficult to identify stage I in dark Difficult to identify stage I in dark skinned patientsskinned patients

Unable to stage when obscured by Unable to stage when obscured by eschareschar

Reverse Staging/DownstagingReverse Staging/Downstaging

Nursing ProcessNursing ProcessDiagnosisDiagnosis

You tell me!!!!!You tell me!!!!!

Nursing ProcessNursing ProcessPlanningPlanning

Preventing pressure ulcers-early Preventing pressure ulcers-early identification of those at risk (Braden, identification of those at risk (Braden, Norton, Gosnell scales)Norton, Gosnell scales)

Prevention protocols by hospitalPrevention protocols by hospital PositioningPositioning Hygiene and skin care (incontinence care)Hygiene and skin care (incontinence care) Support surfacesSupport surfaces Nutritional supportNutritional support Prevent friction and shearPrevent friction and shear EducationEducation

Nursing ProcessNursing ProcessAcute Care ImplementationAcute Care Implementation

Management of Pressure UlcersManagement of Pressure Ulcers Culturing woundCulturing wound Cleansing woundCleansing wound Debridment of woundDebridment of wound Moist Wound HealingMoist Wound Healing Dressing selectionDressing selection Nutritional supportNutritional support Off-load pressureOff-load pressure

Wound Dressing Wound Dressing SelectionSelection

Goal: Promote moist wound healingGoal: Promote moist wound healing Transparent dressingTransparent dressing HydrocolloidHydrocolloid HydrogelHydrogel Calcium alginateCalcium alginate Foam dressingFoam dressing Silver/AntimicrobialSilver/Antimicrobial Collagen dressingCollagen dressing Biological dressing (Regranex)Biological dressing (Regranex) Negative pressure wound therapy (VAC)Negative pressure wound therapy (VAC)

Practice ScenarioPractice Scenario The nurse is assessing a bedridden client The nurse is assessing a bedridden client

when a large erythemic area is noted on when a large erythemic area is noted on the client’s sacrum. In addition, the the client’s sacrum. In addition, the center of the injury looks like an center of the injury looks like an abrasion with a shallow center. The abrasion with a shallow center. The nurse would classify this ulcer as:nurse would classify this ulcer as:

How will the nurse treat this type of How will the nurse treat this type of pressure ulcer?pressure ulcer?

What risk factors could have contributed What risk factors could have contributed to this patient developing a pressure to this patient developing a pressure ulcer?ulcer?

Practice QuestionPractice Question

A nurse is working in a geriatric A nurse is working in a geriatric screening clinic. The nurse would expect screening clinic. The nurse would expect that the skin of the normal elderly client that the skin of the normal elderly client will demonstrate which of the following will demonstrate which of the following characteristics?characteristics?

A. Dehydration causing skin to swell.A. Dehydration causing skin to swell. B. Moist skin turgor.B. Moist skin turgor. C. Skin turgor showing a loss of elasticityC. Skin turgor showing a loss of elasticity D. Overhydration causing skin to wrinkle.D. Overhydration causing skin to wrinkle.

Practice QuestionPractice Question

The nurse decides to treat a Stage II The nurse decides to treat a Stage II pressure ulcer with a hydrocolloid pressure ulcer with a hydrocolloid dressing. The nurse recognizes that dressing. The nurse recognizes that the dressing will promote which type the dressing will promote which type of wound debridement?of wound debridement?

A. Sharp A. Sharp B. Autolytic B. Autolytic C. ChemicalC. Chemical D. MechanicalD. Mechanical

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BASIC HUMAN NEEDS ALTERATIONS IN SKIN INTEGRITY PRESSURE ULCERS Donna M Penn RN MSN CNE