There is a high incidence of wounds in the Long Term Care (LTC) setting and according to the literature over 6.5 million people are affected by chronic wounds and an estimated $25 billion is spent annually in the United States for treatment. Therefore prevention of wounds is of the utmost importance.
There are various types of ulcers: Pressure ulcers,
Venous ulcers, Arterial ulcers and Diabetic/Neuropathic ulcers. LTC residents may also acquire a fungal dermatitis. This is a superficial skin infection, which, if left untreated can progress into ulceration or bacterial cellulitis Wounds may also be the result of operative procedures that has delayed healing.
Skin tears result from shearing or friction that causes separation of the skin layers. These occur most frequently in the upper extremities and can mostly be prevented with careful handling and the use of protective sleeves.
In this blog I will concentrate on pressure ulcers and their staging, treatment and prevention. Pressure ulcers are lesions resulting from unrelieved pressure which causes damage to underlying tissue. These most commonly occur over bony prominences such as in the hips, buttocks, back, ankles, heels and elbows.
In bygone days pressure ulcers were considered to be the result of poor nursing care. A billboard on a Florida highway had the following advertisement “If you have concerns about a loved one’s care in a nursing home call 1 800 bed sore”. Greater knowledge and better equipment have removed most of that burden from nurses.
Several factors other than pressure contribute to ulcers including friction, moisture, sensory loss, immobility and underlying medical conditions. If there is a severe loss of mobility, it may be appropriate to involve the physical therapy department. Seemingly healthy and ambulatory residents may be at risk for pressure ulcers and other wounds. It is very important to schedule frequent “skin check” when doing rounds.
Moisture weakens the resilience of the epidermis resulting in maceration, which results in softening and resultant breakdown of the skin. Residents’ should receive care after each incontinent episode. Friction can be avoided by providing skincare that is gentle with no aggressive rubbing or scrubbing. A resident’s position should be changed by careful lifting not dragging.
The ASPECTS of pressure ulcer prevention.
I found these in some literature many years ago and memorized them for future use.
A: Assessment of the risk for pressure ulcers. We need to consider underlying medical conditions such as diabetes, obesity, arterial disease, anemia, hypoxemia and a previous history of pressure ulcers. Review the paitent’s medication profile. Use a validated risk scale like
Braden or Norton. Be sure to check skin turgor.
S: Skin assessment should be done daily on compromised residents. Integrity, turgor, temperature, color and moisture status should be assessed and documented.
P: Patient concerns and pain: Keep the resident informed of progress and remind them of the goals set for prevention. Ask the resident if they are in pain and the location of the pain. Use a validated, cognitive appropriate pain scale. Provide pain medication prior to a dressing change.
E: Eating and drinking: evaluate eating, drinking, swallowing and weight. Have the dietician assess the resident for nutritional needs and adequate hydration.
C: Continence and moisture management: Assess for urinary and fecal incontinence. Clean and protect the skin with barrier creams after each episode. Moisturize dry skin.
T: teach the resident, family and caregivers the importance of prevention and observation.
S: Support surfaces, repositioning and turning the resident. There are many pressure relieving and redistributing products, such as foam, memory foam, low air loss and alternating pressure mattresses available for at-risk residents but they only work if they are used. Turning and repositioning limbs must be done at individualized time-intervals based on need. Both bed and chair bound residents should be repositioned at least every 2 hours.
Stages of Pressure Ulcers:
Stage 1 ulcers are areas of non blanchable erythema.These can be difficult to identify in people with dark pigmentation. The resident may complain of pain but the skin is intact.
Stage 2 ulcers are artificial skin breaks in the dermis layer only or may appear as a clear blister.
Stage 3 is a full thickness skin break involving the subcutaneous tissue. It may have undermining or slough present but you can always visualize the depth of tissue lost.
Stage 4 ulcer goes all the way through muscle until there is bone showing. Slough or eschar may be present in parts of the wound bed and tunneling and undermining may also be present. Tunnelling is channeling that may pass through subcutaneous tissue and muscle and may result in dead space and abscess formation.
Undermining is tissue destruction underlying the intact skin along the wound margins indicating the wound margins have separated from the wound.
Unstageable ulcers are so called because there is so much necrotic tissue (eschar) present that the base of the wound cannot be visualized.
SDTI (Suspected Deep Tissue Injury) may present on the the surface as a purple discolored firm warm area. It is pressure related and is injury to the subcutaneous tissue under intact skin. It can present as a deep bruise but can quickly become a stage 3 or 4 ulcer even with the best care.
Pressure ulcers do not heal in a reverse sequence. The body does not replace lost tissue, so as the ulcer heals, it would be referred to as a healing stage 4 or healing stage 3 ulcer.
Nurses should be aware of the changes that occur in aging skin which makes it more susceptible to injury. These changes also slow healing. The area between the epidermis and the dermis flattens causing increased fragility. Elasticity diminishes and surface moisture decreases. There is also decrease in subcutaneous fat and loss of nerve structure. These are just some of the anatomic and physiologic changes that occur and when those are added to comorbidities, it should be realised that prevention is the mainstay of care. Smoking, alcohol and illicit drug use can impair tissue perfusion and delay wound healing.
Assessment: Location, size, shape and depth and if more than Stage 2, the condition of the edges should be documented. The length and width should be measured in centimetres and documented. Up to 4 centimetres from the edge of the wound should be assessed. The depth of the ulcer can be obtained by inserting a sterile cotton tipped applicator into the wound bed and marking it at skin level. The applicator is then measured using a metric ruler. In the same way the tunnel depth should be measured using a sterile cotton swab and recorded. Its direction should be documented by using the clock method (5cm at 3 o’clock).
Circumferential redness of up to 2 inches is indicative of cellulitis and induration is an indication of infection. Good assessment and documentation is of the utmost importance. Wound exudate should be described as to amount and as clear, bloody, serosanguineous, thick yellow or greenish. Describe eschar, tunneling or undermining. Indicate the presence of odors.
Treatment: Treatment plans are based on the findings from the assessment and its most major use is to prevent undirected and inappropriate care. Adequate wound cleaning is very important as well as debridement. Bacterial growth is promoted by necrotic tissue and wound healing is impaired until eschar is removed. Warming solutions and ointments before they come in contact with the skin is not only soothing for the resident but also speeds healing.
LTC facilities must develop and implement a wound care program with a systematic approach to prevention and treatment protocols as well as diligent staff education. Utilizing the use of a wound care physician or a certified wound care nurse is an option used by many facilities. Wound care rounds should be done weekly. This includes measurements, observations of the healing process and results of the current treatments. With this option there is also less disruption of the residents’ day and lower costs from transportation back and forth from the wound clinic.
I will not attempt to discuss treatment as they are so varied and each facility has its own protocol. I firmly believe in consistency in care and good observations are paramount to improvement. Some European hospitals are finding excellent results from Manuka honey. Decrease in wound measurement is indicative of healing and if a wound covered with epithelium without drainage it is considered healed.
The resident’s and family’s perception of wound care need to be considered. The nurse should not give unrealistic expectations, especially for residents with grossly compromised medical status whose wounds may never heal.
Weekly assessment and documentation are an essential component of wound care. Many LTC facilities use photographs of wound progress as It can visually monitor wound healing (or failure to heal). It is an adjunct to assessment documentation. It can clarify what is often not easy to describe. “A picture is worth a thousand words”. It is part of the medical record and can be beneficial in protecting against liability.
Informed consent must be obtained prior to photography. The photographs should be titled and dated and become part of the medical record. They should not be left lying in the open. HIPAA (Health Insurance Portability and Accountability Act) regulations must be maintained.
