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SKIN CARE AND WOUND PREVENTION
By: Karen C. Lyon, PhD, APRN, ACNS, NEAPresented by: Wanda Butaud RN, BSN, WOCN
Spring 2015
Differentiate categories of chronic wounds in terms of predisposing factors, anatomic location and wound characteristics
Describe assessment parameters for venous ulcers, diabetic leg/foot ulcers and pressure ulcers
Describe wound care management strategies including appropriate primary and secondary dressings, compression, offloading, biologic dressings and bed surfaces
http://guidelines.gov/content.aspx?id=24492
Student Learning Outcomes
Chronic Wound Prevalence in US
Over 6.5 million patients with chronic wounds in US
One half of these are pressure sores80% of patients with pressure sores are over
65 years of age85% of paraplegics will develop a pressure
sore63% of pressure sores are present at hospital
admission
Over $25 billion spent annually on treatment
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2810192/
http://www.justice.gov/opa/pr/2003/June/03_civ_386.htm
A wound is a disruption of normal anatomic structure and function that is usually inclusive
of the skin.
◦Anatomic continuity◦Function
Wound healing should result in restoration of…
ACUTE
VS.CHRONIC
Shear is caused by tissue layers sliding against each other. This results in disruption or angulation of blood vessels, usually at the fascia level
Purple areas on sacrum and heels Ulcers start deep and work outward Irregularly shaped Undermined
Shear
Excessive moisture causes maceration which acts as a factor in skin breakdown
Incontinence Wound drainage Excessive sweating
Moisture
Altered skin integrity Delayed wound healing Decreased resistance to infection Nutritional supplements Feeding tubes Anabolic steroids
Nutritional Compromise
Activity and mobility Loss of sensation Age Disease states Previous ulcers Medications
Contributing Factors
KEY Cells Macrophages Fibroblasts Endothelial Cells
KEY Elements Macrophage derived
- PDGF- TGF-- FGF-2 (bFGF)
MMPs- Cell migration
Granulation Tissue Formation
Reference: Monaco JL, Lawrence TL. Acute wound healing; an overview. Clinics in Plastic Surgery 30 (2003): 1-12.
Reepithelialization
Keratinocyte Proliferation
Keratinocyte Migration
Relevant Growth Factors
Keratins
Chronic wounds have failed to proceed through an orderly and
timely process to produce anatomic and functional integrity, or proceeded
through the repair process without establishing a sustained anatomic
and functional result.Lazarus GS et al. Arch Dermatol 1994.
It is not as much an issue of time as it is condition of the wound
What we are really talking about is wound healing failure which may be identifiable almost at the time of injury
Chronic is actually a misnomer:
Ischemia Infection Edema Scarring Radiation injury
Topical steroids Local toxins Trauma, pressure Foreign bodies Local malignancy
Local factors affecting wound healing:
Diabetes mellitus Tobacco use Renal failure Nutritional
deficiencies Hereditary disorders Alcohol use Distant malignancy Systemic infections
Connective tissue disease
Immunological disorders
Chemotherapeutic agents
Extremes of age Systemic steroids Hepatic failure
Systemic factors affecting wound healing:
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
10000
11000
Num
ber
of C
ells
0 1 2 3 4 5 6 7 8 9 10 11 12 13
Day
OA
YA
NB
(Buras and Buras, Harvard Medical School, MGH, Boston)
Age associated differences in cellular proliferation…
5
10
15
20
25
30
35
# C
ells
X 1
04
1 2 3 4 5 6 7 8 9
Non-Diabetic
Diabetic
Days
(Buras and Buras, Harvard Medical School, MGH, Boston)
Decreased cellular proliferation with diabetes…
A PRESSURE ULCER IS:Any lesion caused by unrelieved pressureResults in damage to underlying tissueLocated over bony prominences
PRESSURE ULCER DEFINITION
Pressure Ulcers
• External pressure impedes local blood flow to skin (20mmHg), muscle• Muscle and subcutaneous tissue more susceptible to injury than skin• Necrosis generally over bony
prominence• Loss of skin moisture
Pathophysiology
Stage 1
Stage 2
Stage 3Stage 4
Posterior Calf
Heel 8%
Sacrum 23%
Elbow 3% Spinous
processes 1%
Scapula 5%
Back of head 1%
Dorsum of foot and ankle
Knee 6%
Thigh Iliac crest 4%
Anterior Chest
Acromion process
Cheek and ear
Points of PressureLateral Position
Malleolus 7% Medial and lateral condyles
Greater trochanter 15%
Ribs Ear
Points of PressureSitting Position
Plantar surface of foot
Scapula
Sacrum & coccyxIschial tuberosity 24%
Heel
Popliteal
http://education.woundcarestrategies.com/coloplast/resources/BradenScale.pdf
Braden Scale
Venous Leg Ulcers
• Prolonged venous hypertension• Valvular incompetence, DVT, calf muscle dysfunction• Enlarged dermal capillaries, reduced capillary number, microvascular thrombosis, increased permeability of microlymphatics• WBC sequestration,
ischemic/reperfusion injury
Pathophysiology
Diabetic Wounds/Amputations
Pathophysiology • Sensory, motor, autonomic neuropathy • Low resistance to infection with attenuated inflammatory response impaired chemotaxis, inefficient bacterial killing• Perivascular localization of
albumin• Large vessel arterial occlusive disease• Peripheral A-V shunting
http://www.medicalcriteria.com/site/index.php?option=com_content&view=article&id=114%3Adbtfoot&catid=49%3Adiabetes&Itemid=80&lang=en
Wagner Diabetic Wound Grading Scale
Table 1. Suggested Technique for the Management of Chronic Wounds
Intervention Handwashing Gloves
Supplies (Includes solutions and dressing supplies) Instruments
Wound cleansing Yes Clean
Normal saline solution or commercially prepared wound cleanser - sterile; maintain as clean per care setting policy*
Irrigation with sterile device; maintain as clean per care setting policy
Routine dressing change without debridement Yes Clean
Sterile; maintain as clean per care setting policy*
Sterile; maintain as clean per care setting policy
Dressing change with mechanical, chemical, or enzymatic debridement Yes Clean
Sterile; maintain as clean per care setting policy*
Sterile; maintain as clean per care setting policy
Dressing change with sharp, conservative bedside debridement Yes Sterile Sterile Sterile
* "Maintain clean as per care setting policy" means that each care setting must address the parameters for maintenance,
such as expiration dates for supplies, consideration of cost, and correct interpretation of the manufacturer's recommendations.
Farrow Wraps
Skin careRisk assessment
Pressure relief/reduction
Nutritional
Support
Early
Treatment
Education
Outcomes
Tracking
Documentation
NURSING IMPLICATIONS