Skin and Wound Care - 1 Nursing CE

Author: Kristi Hudson RN MSN CCRN

Written: January 17, 2005

Updated: September 28, 2009

 

Course Objectives

• Upon completion of this course the student will be able to:
• Describe how pressure ulcers occur
• Differentiate between the four stages of skin breakdown
• Explain 3 measures to prevent pressure ulcers
• List the steps of properly applying the Wound Vac to a wound or pressure ulcer

Statistics:

• Two thirds of pressure ulcers occur in patients older than 70 years
• The prevalence rate in nursing homes is estimated to be 17-28%.
• Among patients who are neurologically impaired, pressure sores occur with an annual incidence of 5-8%, with lifetime risk estimated to be 25-85%
• Pressure ulcers are listed as the direct cause of death in 7-8% of all paraplegics
• Patients hospitalized with acute illness have an incidence rate of pressure sores of 3-11%
• Even with medical and surgical therapies, patients who achieve a healed wound have recurrence rates as high as 90%

How pressure ulcers occur:

• On a cellular level, ischemia occurs to tissue when too much pressure is applied to one area for a prolonged period of time. This pressure is usually from a bony prominence on one side and a hard surface on the other side. The soft tissue between these two surfaces is subjected to abnormal pressure. The ischemia produced leads to tissue necrosis
• The tissue closest to the bone is typically the first tissue to undergo necrosis
• It has been demonstrated that the capillary pressure on the arterial side is around 30-32 mmHg and around 12 mmHg on the venous side. Sustained pressures at values higher than these may result in circulatory compromise and tissue necrosis.
• Frictional and shearing forces also play roles in tissue necrosis and must be reduced or eliminated.
• General health, skin texture, mobility, nutritional status and body weight all play a key role in pressure ulcers.

Patients at greatest risk for pressure ulcers include:

• Patients with advanced age
• Patients who are chairfast or bedfast
• Patients with impaired ability to reposition themselves 
• Patients with involuntary muscle movements that cause rubbing against sheets
• Patients who have decreased sensory perception (i.e., loss of feeling in certain part of body, a patient who is comatose).
• Patients with decreased nutritional intake
• Patients with excessive exposure to moisture (i.e., incontinence)
• Patients who score less then 16 on a Braden Scale

The four stages of pressure ulcers are described as:

• Stage 1: A non-blanchable (does not turn white when pressed) reddened area. In individuals with darker skin, discoloration of skin, warmth, edema, induration, or hardness may also be indicators.
• Stage 2: Partial thickness skin loss that blisters and presents with an open area, there is redness and irritation at or around the site.
• Stage 3: Full thickness skin breakdown now takes on a “crater” look and the tissue below the surface is damaged.
• Stage 4: The pressure ulcer has become so deep that there is now muscle and possibly bone damage.

Nursing assessment and documentation of pressure ulcers includes:

• Is the dressing intact? (wet, dry, loose, clean dirty)
• Is there drainage on the outside of the dressing (this is called “strikethrough”)
• Location of the wound (foot, leg, thigh, sacrum, buttox,elbow, shoulder)
• Use defining terms for location (anterior, posterior, medial, lateral)
• Size (length, width, depth), compare to previous measurements
• Stage (1-4), compare to previous measurements
• Is undermining present ( is there skin that overhangs the wounds edges?)
• Drainage (serous, purulent, bloody, green, yellow, clear, thick)
• Odor (this indicates infection)
• Necrotic tissue (percentage)
• Infection (red or streaking redness, hot, swollen)
• Other clinical data (labs, fever, vital signs, pain)
• Treatment plan (which products, type of dressing)
• Nursing interventions include:
• Turn patient minimally Q 2 hours
• Relieve the pressure on that area. (use pillows, special foam cushions, and sheepskin)
• Treat the pressure ulcers based on the stage of the ulcer. 
• Avoid further trauma or friction.
• Improve nutrition and other underlying problems that may affect the healing process
• Keep the area clean and free of dead tissue
• Do NOT massage the area of the ulcer. Massage can damage tissue under the skin
• Donut-shaped or ring-shaped cushions are NOT recommended. They interfere with blood flow to that area and cause complications
• The head of the bed should be raised as little and for as short a time as possible if consistent with medical conditions and other restrictions
• Avoid placing patient directly on bony prominences; try to distribute weight evenly

Treatment of pressure ulcers with a Wound VAC (Vacuum Assisted Closure) system:

The Wound Vac works by using negative pressure applied through the open cell foam functions to "pull" the wound edges toward the center of the wound. The suction also drains any excess fluid from the wound site into the collection canister. The combination of the drainage and suction force is thought to have a positive effect on wound healing.

Vacuum assisted closure devices (Wound Vac), are modalities that are being used to effectively (and inexpensively) manage both acute and chronic open wounds. The Wound Vac works by using negative pressure applied through the open cell foam functions to "pull" the wound edges toward the center of the wound. The suction also drains any excess fluid from the wound site into the collection canister. The combination of the drainage and suction force is thought to have a positive effect on wound healing.

Advantages of a Wound VAC system include:

• Increased blood perfusion by removing excess fluid
• Increased nutrient delivery by increasing blood flow
• Increased granulation and cellular formation
• Decreased bacterial levels
• Increased neoangioenesis (regeneration of blood vessels)

Disadvantages of a Wound VAC system include:

• The machine itself is bulky
• Can cause limitation to mobility
• Depending on size and shape of wound adhering good suction is sometimes difficult
• Method of use includes:
• Cut open cell foam to fit size of wound
• Place tubing on the open cell foam
• Cover the entire system with an adhesive drape
• Connect exposed tubing to the collection canister
• Start the computerized machine (most systems have a default setting pressure)
• Set pressurized setting as ordered

Care and management of the Wound VAC system includes:

• The pressure should be adjusted for patient comfort normally around 125mmHg (range 50 - 200mmHg). The program will normally be "continuous" for at least the first 48 hours but exceptions occur.
• The canister should be changed when half full. The dressing should be changed every 48 hours, unless the wound is infected (twice daily) or is a meshed graft (never), or other clinical reasons dictate otherwise.

References

Shrestha, B,. M., Nathan V., C., & Delbridge M., S. et al. Vacuum assisted closure (VAC) therapy in the management of wound infection following renal transplant. Sheffield Kidney Institute, Northern General Hospital, Sheffield UK. Kathmandu University Medical Journal. (2007). Vol. 5, No. 1, Issue 17, pg 4-7/SPAN>