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WELCOME
SKINtelligence
SKINtelligence
Protecting our birthday suit
(or looking after our skin)
Skin
Skin (an organ)
• Protects • Temperature
• Impact and pressure
• Microorganisms
Skin
• Regulates
– Body temperature
– Fluid balance (sweating etc)
– Reservoir for synthesis of Vitamin D
Skin
• Network of nerve cells to aid sensation of touch, pressure temperature or pain
Lots of challenges with skin…
• Skin conditions and inflammatory disorders
• Including non infective conditions such as:
Eczema
Psoriasis
And infective disorders
• Viral: – Human papilloma virus (HPV) causing warts and
veruccas
– Herpes Virus – chickenpox and shingles
• Bacterial: – Impetigo – highly infectious
– Cellulitis
• Fungal – Ringworm and tinea pedis (athlete’s foot)
Viral Infections
• HPV • Herpes
– Shingles on stomach
Bacterial infections
• Impetigo
• Cellulitis
Fungal infections
• Ringworm • Tinea pedis (athlete’s foot)
Further challenges…
• Skin becomes thinner as it ages
• Blood supply to skin decreases
• Other compromises to skin:
– Dehydration
– Pyrexia
– Malnourishment
– Immobility
– Certain Medications (especially corticosteroids)
Venous Eczema
Not to be confused
with cellulitis!
End of life skin changes
• Recent SCALE document
• The skin is an organ, and can fail at the end of life
• Certain changes unavoidable
• Consider if healing is possible…it could be a palliative wound, consider patient preference etc
Prevention is the name of the game!
Prevent the unknown?
How do we know who is at risk?
• Tools – risk assessment, Walsall etc
• Awareness of clients ‘baseline’
• Be aware of the risks e.g. ‘what is the relation between healing and nutrition’
• But Mrs Smith doesn’t want to change her position! Does she understand the importance?
• Etc……….
What assessment tools do you have and use?
What are they for?
Are they effective?
Are they ALWAYS used …. and more importantly are they acted
upon?
Malnutrition Universal Screening Tool (MUST) Record Sheet
Date:
Date: Date: Date:
STEP 1
Height (m)
Weight (kg)
BMI (kg/m2) (see chart)
BMI Score (circle)
(A)
0 1 2 0 1 2 0 1 2 0 1 2
STEP 2
% unplanned weight loss
(work out using MUST chart)
% unplanned weight loss score (circle)
(B)
0 1 2 0 1 2 0 1 2 0 1 2
STEP 3
Acute disease or no nutritional intake for >5
days score (circle)
(C)
0 2 0 2 0 2 0 2
STEP 4
MUST score =
(A + B + C)
For use when the patient scores 2 or more (or scores 1 and then shows no
improvement)
Nutritional Intervention
Date Comments
Maintain food record charts
Establish patient likes and dislikes
Encourage with energy dense meals and puddings from the menu,
including those which are fortified
Encourage with small frequent snacks between meals such as cakes and
biscuits
Encourage with milky drinks made with full cream milk such as Hot
Chocolate and Horlicks
Trial nutritional supplements such as Build Up soups, Build Up
milkshakes, Ensure Plus and Enlive
Ensure Plus and Enlive must be prescribed by the
GP on a named patient basis and recorded on the
drug chart. Aim 2 per day
Continue to follow the above steps and monitor intake. Repeat MUST
score weekly.
If no improvement seen within 3 weeks, contact dietician for advice
regarding further supplementation or artificial feeding
Walsall (or pressure damage risk assessment tool)
RISK CATEGORIES
SCORE
ASSESSMENT DATES
LEVEL OF
CONSCIOUSNESS
ALERT 0
LETHARGIC/CONFUSED 3
SEMI-COMATOSE 3
COMATOSE 3
MOBILITY
AMBULATION
MOVES WITHOUT ASSISTANCE 0
MOVES WITH LIMITED ASSISTANCE 3
MOVES ONLY WITH ASSISTANCE 8
CHAIRFAST (8HRS PLUS) 8
BEDFAST (12HRS PLUS) 8
SKIN CONDITION
HEALTHY 0
RASHES/DRYNESS 2
INCREASED TURGOR/FRAGILE 4
REDNESS 4
NUTRITIONAL STATUS
WELL BALANCED DIET/STABLE WEIGHT 0
POORAPPETITE/WEIGHT LOSS 4
VERY POOR/FLUIDS ONLY/NIL NY MOUTY 4
SUB TOTAL RISK SCORE (A)
RISK CATEGORIES Score
ASSESSMENT DATES
BLADDER
NONE 0
INCONTINENCE OCCASIONAL (<2/24 HRS OR
CATHTERISED 0
USUALLY >2/24 HRS) 1
TOTAL (NO CONTROL 4
BOWEL NONE 0
INCONTINENCE OCCASIONAL (<2/24 HRS OR
CATHTERISED 4
TOTAL (NO CONTROL) 6
CARER INPUT NO CARER REQUIRED 0
ACTIVE CARERS (24HRS) 0
INTERMITTENT CARER (8 HRS
PLUS) 2
LIMITED CARER (3-8 HOURS 2
OCCASIONAL CARER (0-3 HRS) 2
SUBTOTAL RISK SCORE
SUBTOTAL RISK SCORE (A)
TOTAL RISK SCORE
TICK IF PATIENT HAS PRESSURE ULCER
ASSESSOR'S SIGNATURE
Name…………………… DOB……………NHS number……………..
ADAPTED WALSALL COMMUNITY PRESSURE ULCER RISK CALCULATOR
The Walsall Community Pressure Ulcer Risk Calculator assists in the identification of the main contributing factors in the development of pressure ulcers. It has been validated for use in the Community/domiciliary environment. ¹ It should be used in conjunction with clinician’s professional’s judgement and as part of an overall patient/client Care Plan. 1. RISK ASSESSMENT
The columns allow for regular assessment, either at intervals indicated by the patient’s level of risk, or should the patient’s condition change.
2. RISK CATEGORIES
Score the patient in one area only in each risk category. Record the score in the appropriate column and total the end. From the total risk score, determine the category as:
<4 not at risk
4 - 9 low risk
10 - 14 medium risk
15 + high risk
3. PRESSURE ULCER GRADING SCALE²
CATEGORY 1 – Intact skin with non-blanchable redness of a localized area .Area may be painful, firmer or softer, and warmer or cooler compared with adjacent tissue. CATEGORY 2 – Partial thickness loss of dermis presenting as a shallow ulcer with no slough .Can present as a blister. CATEGORY 3 – Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon and muscle cannot be seen. CATEGORY 4 – .Full thickness Tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.
4. EQUIPMENT GUIDE
This risk calculator and equipment guide are guidelines only. The equipment guide includes a range of equipment within each section. Selection should be based on comprehensive patient assessment, including physical, social, psychological and environmental factors in conjunction with clinician’s professional judgement. These guidelines should be used along side Pressure Damage prevention Guidance and Guidance on prescribing equipment. If you are unsure please contact the equipment nurse on 01235 205497.
Risk Category
Mattress Selection
Cushion Selection
Low Foam Base( premier super glide) or Propad
topper to own bed/mattress Foam( carefree)
Foam with Gel( transflo)
Medium (Prevention) Foam overlay (Propad)if own mattress
Foam replacement ( premier super glide) Static air overlay ( Repose)
Foam Foam with Gel(Transflo)
Static air (Repose)
High (Prevention) Foam Replacement( premier super glide)
Static air overlay (Repose) Alternating Replacement
Foam and Gel (transflo) Alternating(serenade)
Static air (Roho ,Starlock)
High Alternating Replacement ( Nimbus, Autologic
,qautro, essentials) Alternating Nimbus, (Autologic ,qautro,
essentials)
What about skin tears?
• Lots of risk factors! – Increased age
– Female
– Caucasian
– History of skin tears
– Compromised nutrition
– Dehydration
– Impaired sensory perception
– Medication (esp corticosteroids)
– Etc!
Skin tears
• In compromised patients these can become chronic
• Skin tears on lower limb (especially with patients with oedema and/or venous/arterial disease will often become a leg ulcer
• Many could be prevented by careful risk assessment and excellent skin care
• ALL STAFF CAN PLAY A ROLE
Skin tear risk assessment
Group one
(1 or more)
Tick if appropriate
Skin tear in the last 90 days
A current skin tear
Total ticks
Group two
(4 or more)
Tick if appropriate
Decision-making skills impaired
Visual impairment
Extensive assistance/total dependence for ADL’s
Wheelchair assistance required
Loss of balance
Confined to bed or chair
Unsteady gait
Bruises
Total ticks
Group three
(5 or more)
Tick if appropriate
Physically abusive
Resists ADL care
Agitation
Hearing impaired
Decreased tactile stimulation
Wheels self in wheelchair
Manually/mechanically lifted
Contracture of arm, legs, shoulders or hands
Hemiplegia/hemiparesis
Trunk – total or partial inability to balance to turn body
Pitting oedema of legs
Open lesions of extremities
3-4 senile purpuras on extremities
Dry/scaly skin
Total ticks
Prevention of skin tears
Practical tips:
• Wash with soap substitutes which are less drying and more pH neutral
• Moisturise skin daily
Moisture can cause more risks
• Are you using the most absorbent pads and changing in a timely way?
• Use barrier creams on vulnerable skin
Try to avoid adhesives on skin
• Alternative to adhesive dressing: – Non-adhesive contact
layer, pad and tubular bandage
• Tubular bandage clinifast applied to exposed skin to help protect against skin tears
Weapons of mass destruction to vulnerable skin
(staff and clients!!!)
Nutrition & Hydration
Extra protein in the diet is needed if there is a wound, to help the wound to heal
Example…..
• Offer 1.25 to 1.5 grams protein/kg body weight daily for an individual with a pressure ulcer when compatible with goals of care, and reassess as condition changes
• Eg. patient weighing 8 stone = approx 50kg would require 62.5grams protein (small tin of tuna is only 27grams!)
• Assess renal function to ensure that
high levels of protein are appropriate
for the individual
Safe environment
• Appropriate lighting
• No trip hazards
Leg Ulcers • Do you know who is at
risk?
• Currently no risk assessment tool …… you
need to know what to look out for
Usually in two categories Can be ‘mixed’
• Venous
• Arterial
Risk factors for leg ulcers
• Venous: approx 75%
– Obesity – Immobility – Personal or family
history of varicose veins – Previous DVT – Arteriovenous fistula – Increasing age – History of leg fracture or
trauma – History of venous leg
ulcer
• Arterial or mixed – arterio/atherosclerosis – Hypercholesterolemia – Hypertriglyceridemia – Hypertension – History of angina, MI or CVA – Diabetes – Connective tissue disorders – Rheumatoid arthritis – Blood disorder – History of smoking – Excessive alcohol intake – Raynaud’s phenomenon – History of arterial/mixed
ulcer
Risk assessment for leg ulceration
Risk Factor tick
Previous DVT
History of venous leg ulcer
Obesity
Personal or family history of varicose veins
Immobility
History of leg fracture or trauma
Chronic oedema
Increasing age
Arteriovenous fistula
Venous (makes up approx 75%) of leg ulcerations
Arterial/mixed aetiology Risk Factor tick
Arterio/atherosclerosis
Hypercholesterolemia
Hypertriglyceridemia
Hypertension
History of angina, MI or CVA
Diabetes
Connective tissue disorders
Rheumatoid arthritis
Blood disorder
History or current smoker
Excessive alcohol
Raynaud’s phenomenon
History of arterial disease
1 tick or more indicates significant risk, and a baseline ABPI (ankle brachial pressure index, i.e. Doppler assessment) reading would be recommended.
Greater number of ticks = greater risk
Reduce risk!
Regular exercise, even short walks (walk to the dining room instead of wheelchair, plan for extra time)
Balanced diet and healthy weight
Examine feet and legs regularly
Regularly moisturise legs
Remember to use downward strokes and not apply between toes
Stop smoking improve circulation to limbs
If compression hosiery is advised it should be worn every day
Elevate legs
Carry out regular leg exercises – can be done seated and/or passively if unable
to do independently
Stimulates calf pump muscle to pump blood back up towards the heart
PRESSURE!
Pressure Ulcer
• 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.
EPUAP 2012
Pressure Damage and PREVENTION
Pressure Damage • 3 causes
– Direct pressure
– Shear -usually skin moves in one direction and bone moves in the opposite direction
– Friction – usually skin rubs
over a surface, such as sheet,
duvet, foot plates
Sit on your hands experiment!
How do we stop pressure damage?
• A=Know what causes it!
• B=Know the patient and their risk factors
• (use assessment tools accurately and ACT upon them!)
• A+B= avoidable pressure damage prevention
Preventing damage
• Use adapted techniques for moving and handling safely (eg slide sheets, careful use of hoists, especially when removing)
• Keep clients moving, even mobile patients can get pressure damage, especially when seated
• Ensure moisture levels are well managed. Incontinence and even perspiration can start to compromise skin integrity.
• The correct absorbency of pad changed regularly and washing with a soap substitute and the use of barrier creams/sprays will help
Consider positioning…what about the 30o tilt?
Bed mattress
Pillows can be used to lift the mattress, The patient stays in contact with the powered mattress, relieving pressure,
but the tilted mattress means that the patient’s weight is more spread over
a wider area.
Know how to categorise ….
• We use the EPUAP categorising (used to be called ‘grades 1-4’ now categories)
• European Pressure Ulcer Advisory Panel
• You can go up in categories, but never down!
• i.e. a cat 3 can become a cat 4, but a 4 can never become a cat 3, even if it improves!
• It just becomes a healing cat 4!
Category/Stage I: Non-blanchable redness of intact skin
• Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.
EPUAP 2014
Category/Stage II: Partial thickness skin loss or blister
• Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.
EPUAP 2014
Category/Stage III: Full thickness skin loss (fat visible)
• Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling.
• Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.
EPUAP 2014
Category/Stage IV: Full thickness tissue loss (muscle/bone visible)
• Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.
EPUAP 2014
Where are bony prominences
EPUAP 2014
Which areas are at risk?
and here?
What’s this?
Moisture lesions
• Also known as incontinence dermatitis
• Compromises skin, creating greater risk of breakdown
• Often confused with pressure damage
• Treatment – manage moisture in first instance
?step up absorbency of pad/increase changes/urinary catheter for a while
Treatment of moisture lesions
• Manage moisture (if diarrhoea, treat approriately ?referral to bladder and bowel service)
• Better pads/frequency of change • Wash in soap substitute eg Hydromol ointment
‘melted’ in warm water. (Using soap causes catastrophic changes to pH levels of skin, increasing risk even further)
• Apply moisturiser (Hydromol ointment) rubbed between palm of hands and applied thinly to buttocks. If skin is already damaged you may need to step up to a barrier cream or spray. Start with Derma-S and step up again to ProShield if needed.
IN MOST CASES DRESSINGS WILL SIMPLY AGGRAVATE
THE SITUATION!
Question:
WHAT DO WE PUT ON A PRESSURE
ULCER?
Answer:
ANYTHING BUT THE PATIENT!!!!
No pressure ulcer will ever heal until the pressure is removed!
Special Caution - HEELS • DO NOT DEBRIDE WITHOUT A DOPPLER
ASSESSMENT TO CHECK ARTERIAL FLOW
• If a wound like this is debrided and the patient has compromised arterial flow, they will have an open wound and not enough oxygenated blood flow to heal. It will become infected, and will stay in a cycle of infection leading to possible sepsis.
Pressure relieving equipment • Whole selection available!
• Try to familiarise yourself with what your home use, and check with manufacturers (usually quick on line check) re: maximum patient weight, level of pressure damage, regular maintenance checks etc
• Sometimes simple and cheap is just as effective
• Think of equipment as medication – know what it’s for, who it’s for, why it’s ‘prescribed’, how long for and when it needs reviewing