Post on 14-Mar-2020
Team-CenteredWoundCare:MakingYourWoundCareSafe
andSimpleAgainOctober4th,2017
RyanP.DirksPA-CFounderandCEO
RoadtosuccessDetailedWoundAssessment/RiskAssessment
IndividualizedCarePlanning
Evidence-BasedTreatment
Documentation
Documentation
ExternalSupport
TOPICS
WOUNDASSESSMENT101
PRESSUREINJURYDOCUMENTATION
KENNEDYULCERS
MEDICALDEVICEPRESSUREINJURY
WoundAssessment
WashingtonandIdahoHealthCareAssociation
WoundAssessment• Location• Etiology• Size:Lengthxwidthxdepth• Woundbase• Woundmargins• Drainagecolor• Undermining• Tunneling/sinustracks
WoundMeasurement
• Measurethegreatestlength(headtotoe)
• Measurethegreatestwidth(sidetoside)
• Describethewoundasthefacetoaclock• Headin12o’clock• Feetare6o’clock• Sidetosideis3o’clockto9o’clock
WoundMeasurement
• Measuredepth– useacottontippedapplicatortomeasuretheverticaldistancetothedeepestareainthewoundbed.
• Tunneling=channelthatextendsinanydirection
• Undermining=tissuedestructionunderlyingintactskinalongwoundmargins
WoundAssessment
• Location• Etiology• Size:Lengthxwidthxdepth• Woundbase• Woundmargins• Drainagecolor• Undermining• Tunneling/sinustracks
WoundAssessment
• Woundbaseorwoundbed– identifycolor(s)• Granulatingtissue(red)• Slough(yellow)• Infectedtissue(green)• Necrotictissue(black)• Epithelializing(pink)
• Tissue• Hypergranulation• Muscle,Tendon,Fascia,Bone
WoundAssessment
•WoundEdges• Intact• Irregular•Welldefined• Calloused,fibrotic,firm•Macerated,soft• Epibole (”Epiboly”)– rolledunderedges
WoundAssessment
• Drainage• Serous,Sanguineousserosanguinous,purulent
• Amount• Odor
• Strong• Foul• Musty• Mild• Sweet
• Periwound• Erythema• Induration• Texture• Scartissue• Lesions/Rashes• Edema• Temperature• Color• Ecchymosis• Maceration
MostCommonChronicWoundEtiologies
• PressureInjury/Ulcer• VenousStasisUlcer• ArterialInsufficiencyUlcer• Diabetic-NeuropathicUlcer
PressureInjury
DefinitionofPressureInjury• Localizeddamagetotheskinand/orunderlyingsofttissueusuallyoverabonyprominenceorrelatedtoamedicalorotherdevice.Theinjurycanpresentasintactskinoranopenulcerandmaybepainful.Theinjuryoccursasaresultofintenseand/orprolongedpressureorpressureincombinationwithshear.Thetoleranceofsofttissueforpressureandshearmayalsobeaffectedbymicroclimate,nutrition,perfusion,co-morbiditiesandconditionofthesofttissue.
(NPUAP,2016)
HighRisk
• Elderlywithhipfractures
• Spinalcordinjuries
• Criticalcare
• >70yearsofage
PathogenesisofPressureInjury
•“Stuckbetweenarockandahardplace”•Capillaryclosingpressuregenerallyconsideredtobe32mmHg•Venous/lymphaticoutflowceases• Increasedhydrostaticpressurereducesarterialinflow
(Bryant,R.A.&Nix,D.P.,2007)
PathogenesisofPressureInjury
• Within2-9hoursofsustainedpressuretissueischemiacanoccur.
(Bryant,R.A.&Nix,D.P.,2007)
SitesforPressureInjuryDevelopment
PathogenesisofPressureInjury
• INTRINSICFACTORS• NutritionalDebilitation• AdvancedAge• LowBloodPressure• Stress• Smoking• ElevatedBodyTemperatures
• EXTRINSICFACTORS• SHEARING,FRICTION,MOISTURE
MoistureAssociatedSkinDamage
• NOTapressureinjury
• Topdownmechanismvs.bottomup
Howwouldyoustagethese?
Stage1PressureInjury
Stage1pressureInjury
• Intactskinwithalocalizedareaofnon-blanchable erythema,whichmayappeardifferentlyindarklypigmentedskin.Presenceofblanchable erythemaorchangesinsensation,temperature,orfirmnessmayprecedevisualchanges.Colorchangesdonotincludepurpleormaroondiscoloration;thesemayindicatedeeptissuepressureinjury.
(NPUAP2016)
Howwouldyoustagethese?
Stage2PressureInjury
STAGE2
Stage2PressureInjury
§ PartialThicknessSkinlosswithexposeddermis§ Woundbedisviable,pinkorred,moist,andmayalsopresentasanintact
orrupturedserum-filledblister.§ Adipose(fat)isnotvisibleanddeepertissuesarenotvisible.
Granulationtissue,sloughandeschararenotpresent.§ Theseinjuriescommonlyresultfromadversemicroclimateandshearin
theskinoverthepelvisandshearintheheel. Thisstageshouldnotbeusedtodescribemoistureassociatedskindamage(MASD)includingincontinenceassociateddermatitis(IAD),intertriginousdermatitis(ITD),medicaladhesiverelatedskininjury(MARSI),ortraumaticwounds(skintears,burns,abrasions).
(NPUAP2016)
Howwouldyoustagethis?
Stage3Pressureinjury
Stage3PressureInjury
§ FullThicknessSkinLoss§ Granulationtissueandadiposetissueoftenvisible§ Sloughand/orescharmaybevisible§ Depthofthetissuedamagevariesdependingonanatomicallocation(nostage3
onnoseandear)§ Underminingandtunnelingmayoccur§ Fascia,Muscleandtendonligaments,cartilage,andbonearenot exposed§ Ifsloughorescharobscurestheextentofthetissuelossthewoundbe
consideredUnstageable.
(NPUAP2016)
STAGE3
Stage4PressureInjury
Stage4PressureInjury
§ FullThicknessandTissueLossexposedWITHdirectlypalpablefascia,muscle,tendon,ligament,cartilageorboneintheulcer
§ Sloughand/orescharmaybevisible§ underminingand/ortunnelingoftenoccur§ Depthvariesbyanatomicallocation§ Ifsloughorescharobscures----STILLASTAGE4!
(NPUAP2016)
UnstageablePressureInjury§ Fullthicknessskinandtissuelossinwhichtheextentofthetissue
damagewithintheulcercannotbeconfirmedbecauseitisobscuredbysloughoreschar.
§ Ifsloughorescharisremoved,aStage3orStage4pressureinjurywillberevealed.
§ Stableeschar(i.e.dry,adherent,intactwithouterythemaorfluctuance)onanischemiclimbortheheel(s)shouldnotberemoved.
(NPUAP2016)
UnstagablePressureInjury
DeepTissuePressureInjury
DeepTissueInjury§ Persistentnon-blanchable deepred,maroonorpurplediscoloration§ Intactornon-intactskinorbloodfilledblister§ Painandtemperaturechangeoftencanprecedeaskincolorchange§ Discolorationmayappeardifferentlyindarklypigmentedskin§ DTPIresultsfromintenseand/orprolongedpressureandshearforcesatthebone-muscleinterfaces
§ Canevolverapidlytorevealtheactualextentoftissueinjury,ormayresolvewithouttissueloss.Ifnecrotictissue,subcutaneoustissue,granulationtissue,fascia,muscleorotherunderlyingstructuresarevisible,thisindicatesafullthicknesspressureinjury(Unstageable,Stage3orStage4)
(NPUAP2016)
DEEPTISSUEPRESSUREINJURY
Trials,TribulationsandInstitutionalRisk
• CentersforMedicare&Medicaidservicesrefusetoreimbursehospitalsforhospitalacquiredwoundsatastage3/4.(2007)• F-Tag314– Facilitymustensurearesidentdoesn’tdeveloppressureinjuriesunlesstheclinicalconditiondemonstratestheywereunavoidable.
• Thisplacesmoreemphasisondocumentationandensuringthatappropriateassessments,treatmentplansandwoundcareisreordered• Havinganadvancedprovidertoassessandorderwoundcaretreatmentsisamajorbenefit
WhatisaKennedyTerminalUlcer
• AKennedyTerminalUlcerisapressureulcersomepeopledevelopastheyaredying
Firstdescribed• NPUAP1989.• NamedafteraNPinFortWayneIndiana• Laterfoundtobedescribedin1877”DecubitusAcutus”byDr Jean-MartinCharcot.
• Controversy:isthisasymptomofdeathoracauseofdeath?• LawyerssaycategorizingKTUasunavoidableisirresponsible• 62%ofpatientsinhospicedeveloppressureulcersintheirfinal2weeksoflife
WhatdoesaKUlooklike
• Itusuallypresentsonthesacrumorbuttocks.• Itcanbeshapedlikeapear,butterflyorhorseshoe.• Itcanbered,yellow,blackorpurple.• Thebordersareusuallyirregular• Suddenonset• Commonstatements:“Ohmygoshthatwasnottheretheotherday”
KENNEDYULCER
HowdoesaKUprogress
• ItusuallystartsoutasablisteroraStageIIandcanrapidlyprogresstoaStageIIIorIV.• Mayinitiallylooklikeanabrasion.
Cause
• Moreresearchneeded• Skinutilizes25-30%ofthetotalcardiacoutputtomaintainperfusion.• Probablyendoflifeorganfailureofskin.• Usuallypartofmulti-organfailure• Itseemsthatskinoverbonyprominencesinparticularstartstoshoweffectsofpressureofamuchshortertimeframe
HowaretheydifferentfromotherPI
• TheystartourlargerthatotherPI’s,andmaybemoresuperficialinitially.
• Thendeveloprapidlyinsize,depth,andcolor.
BestTreatment
• TreatmentisthesameforotherPI.
• Whatyouseeiswhatyoutreat.
MEDICALDEVICEPRESSUREINJURY
DEFINITION
• “Pressureulcersthatresultfromtheuseofdevicesdesignedandappliedfordiagnosticortherapeuticpurposes.Theresultantpressureulcergenerallycloselyconformstothepatternorshapeofthedevice.”
EPUAP,NPUAP,andPanPacificPressureUlcerAlliance.“PreventionandTreatmentofPressureUlcers:ClinicalPracticeGuidelines.”SecondEdition2014,page119
MEDICALDEVICEPRESSUREINJURY
MEDICALDEVICEPRESSUREINJURY
INCREASEDRISKWITH:
• Impairedsensation• Moistureunderthedevice• Poorperfusion• Alteredtissuetolerance• Poornutritionalstatus• Edema
Commondevices
• Nasogastrictubes• Feedingtubes• Endotrachealtubes• Tracheostomytubes/collars/straps• Oxygendelivery–Mask• – Nasalcannula
• IV/PICCline/Centrallines• Anti-Embolicstockings• bedpans
UNAVOIDABLE?
• Whenitismedicallycontraindicatedtoadjust,relocate,orpadunderneathatherapeuticdevice
• Whenalifesustainingvascularaccessorothermedicaldeviceprecludesturningandpositioning
• Whenunderlyingedemaoruncontrollablemoistureunderdevicecompromisestissuetolerancetopressure/shearforces
STRATEGIESFORPREVENTION
• Properselectionandfittingofdevice• Communicatewithpatientifpossible• Closeobservation• Extensivecareplan• Education• Consistentreassessment/re-evaluation• Teaminvolvement(PT/OT)• Followmanufacturersspecifications• Securedeviceproperly
RoadtosuccessDetailedWoundAssessment/RiskAssessment
IndividualizedCarePlanning
Evidence-BasedTreatment
Documentation
Documentation
ExternalSupport
LearnMore!
• www.healu.firmwater.com
Kick-OffTo
Team-CenteredWoundCare
WhatMakesaWinningTeam?
– Focusingonpatientcare–Willingtodiscussideasandchallengeeachotherinapositivewaywhilealwaysmovingtoasolution.–Understandingthattogetherwearebetterthanifweworkedindependently:• Bringingdifferenttreatmentideastogethertofindthebesttreatment• Servingeachothertoprovidecarethatwouldbeextremelydifficultforoneperson(onepersontreats,onepositions,onecharts)• Dailycarecombinedwithweeklyconsultingwithanexpertcanproducefaster/morecompletehealing.
WinningComponentsofWeeklyWoundRounds• ConsistentTeammembers• OrganizedApproach• AccurateWoundAssessments• Evidence-BasedTreatments• InfectionPrevention• ConsistentDocumentation• Routine
WoundRoundsFlow
Huddle
Position
AssessWoundBedPrep
Dressing
Team-CenteredWoundCare
• 2cohortsofskilledpatientswithallmajortypesofchronicwounds• 311hadstandardnursingcare(internallyled)• 372hadmultidisciplinaryteamledbyanexternalwoundmanagementgroup• 10monthstudy• 3primaryoutcomes
• Daystoheal• Woundrelatedre-hospitalizations• Cost
DeZanzo etal.2011
Internallyvs.ExternallyLedWoundCare
• 115averagetreatmentdays
• 0.21%re-hospitalizations/dayduetowoundcomplications
• $354.26perresidentday(didnotincludeoutsidetransportation)
• 94averagetreatmentdays
• 0.08%/day
• $229.07perresidentday
• Internalgroupwoundcarecosts$40,678.63• Externallyledcosts$21,449.00
• Woundshealedfaster• Lesswoundrelatedcomplications/hospitalization
• Iwouldventurethatthequalityofcareinothernon-woundrelatedareasincreasedalthoughthiswasnotstudied.Simplybecauseoflesseffortandenergyspentonwoundmanagement.
• 50+SkilledNursingFacilities• King• Peirce• Skagit• Gray’sHarbor• Thurston
UnitedWoundHealingWashingtonDataWoundType FacilityAverage NationalAverage
ArterialUlcer 40 81Dermatologic/Rash 24 42DiabeticUlcer 40 83Other 32 57PressureUlcer 33 71SkinTear 15 30SurgicalWound 30 67VenousUlcer 53 69TotalAverageDaysToHeal 35 69TotalWoundsIncluded 1326 266222FacilitiesIncluded 84 803
IDTTeamMembersPresent• DNS/ADON• DietaryManager/RD• Therapist• SDC• CNA/NAC(newregs)• UnitManager/RCM’s• MDSnurse
IDTSkinReview
Mrs.Jones
• 86yof• Admittedafterrecenthospitalization• Hipfracturerequiringsurgicalintervention• ICUstay
Mrs.Jones
• What’snext?• AdmissiontoDischarge
Questions?LearnMore!
• www.healu.firmwater.com