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Comprehensive skin assessment

By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS

Each issue, Apple Bites brings you a tool you can apply in your daily practice. Here’s an overview of performing a comprehensive skin assessment.

In the healthcare setting, a comprehensive skin assessment is a process in which the entire skin of a patient is examined for abnormalities. It requires looking at and touching the skin from head to toe, with a particular emphasis on bony prominences and skin folds. Comprehensive skin assessment is repeated on a regular basis to determine whether changes in the skin’s condition have occurred. The goal of a skin assessment is to identify problem areas promptly for treatment and prevention. (more…)

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What is a comprehensive risk assessment?

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

Prevention of pressure ulcers and skin breakdown begins with a comprehensive risk assessment. Most providers use a skin risk assessment tool, such as the Braden or Norton scale. While these tools have been validated to predict pressure ulcer development, their use alone isn’t considered a comprehensive assessment, and frequently the individual risk factors they identify aren’t carried through to the plan of care. (more…)

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Assessing risk of pressure and moisture-related problems in long-term care patients

By Patricia A. Slachta, PhD, RN, ACNS-BC, CWOCN

Assessing moisture and pressure risk in elderly patients continues to be a focus for clinicians in all settings, particularly long-term care. Ongoing research challenges our ideas about and practices for cleansing and protecting damaged skin. Until recently, most wound care clinicians have cleansed long-term care patients’ skin with mild soap and water. But several studies have shown pH-balanced cleansers are more efficient than soap and water for cleansing the skin of incontinent patients.

Various terms are used to describe skin breakdown related to moisture—incontinence-associated dermatitis, perineal dermatitis, diaper rash, intertriginal dermatitis, intertrigo, moisture-related skin damage, moisture-associated skin damage, and even periwound dermatitis. This article uses moisture-associated skin damage (MASD) because it encompasses many causes of skin breakdown related to moisture. Regardless of what we call the condition, we must do everything possible to prevent this painful and costly problem.

Skin assessment

Start with an overall assessment of the patient’s skin. Consider the texture and note dryness, flaking, redness, lesions, macerated areas, excoriation, denudement, and other color changes. (See Identifying pressure and moisture characteristics by clicking the PDF icon above.)

Assessing MASD risk

A patient’s risk of MASD can be assessed in several ways. Two of the most widely used pressure-ulcer risk scales, the Norton and Braden scales, address moisture risk. The Norton and Braden subscales should drive your plan for preventing skin breakdown related to moisture or pressure. The cause of breakdown (moisture, pressure, or shear/friction) must be identified, because treatment varies with the cause.

Both the Norton and Braden scales capture activity, mobility, and moisture scores. The Braden scale addresses sensory perception, whereas the Norton scale identifies mental condition. (See Subscales identifying pressure, shear, and moisture risk by clicking the PDF icon above.) Also, be aware that two scales have been published for perineal risk, but neither has been used widely.

You must differentiate pressure- and moisture-related conditions to determine correct treatment. Patients who are repositioned by caregivers are at risk for friction or shear. Also, know that agencies report pressure-ulcer prevalence. Care providers no longer classify mucous-membrane pressure areas in skin prevalence surveys; mucous membranes aren’t skin and don’t have the same tissue layers. Furthermore, don’t report skin denudement from moisture (unless pressure is present) in prevalence surveys.

When moisture causes skin breakdown

Skin has two major layers—epidermis and dermis. The epidermis itself has five layers: The outermost is the stratum corneum; it contains flattened, keratin protein–containing cells, which aid water absorption. These cells contain water-soluble compounds called natural moisturizing factor (NMF), which are surrounded by a lipid layer to keep NMF within the cell. When skin is exposed to moisture, its temperature decreases, the barrier function weakens, and skin is more susceptible to pressure and friction/shear injury. Also, when urea in urine breaks down into ammonia, an alkaline pH results, which may reactivate proteolytic and lipolytic enzymes in the stool. (See Picturing moisture and pressure effects by clicking the PDF icon above.)

Caring for moisture-related skin breakdown

The standard of care for moisture-related skin breakdown includes four major components: cleanse, moisturize, protect, and contain. Specific products used for each component vary with the facility’s product formulary.

Cleanse

Gently wash the area using a no-rinse cleanser with a pH below 7.0. Don’t rub the skin. Pat dry.

Moisturize

Use creams containing emollients or humectants. Humectants attract water to skin cells and help hold water in the cells; don’t use these products if the skin is overhydrated. Emollients slow water loss from skin and replace intracellular lipids.

Protect

Options for skin protectants include:
• liquid film-forming acrylate sprays or wipes
• ointments with a petroleum, zinc oxide, or dimethicone base
• skin pastes. Don’t remove these products totally at each cleansing, but do remove stool, urine, or drainage from the surface and apply additional paste afterward. Every other day, remove the paste down to the bare skin using a no-rinse cleanser or mineral oil.

Be sure to separate skinfolds and use products that wick moisture rather than trap it. These may include:
• commercial moisture-wicking products
• a light dusting with powder containing refined cornstarch or zinc oxide—not cornstarch from the kitchen or powder with talc as the only active ingredient
• abdominal pads.

Contain

To keep moisture away from skin, use absorbent underpads with wicking properties, condom catheters (for males), fecal incontinence collectors, fecal tubes (which require a healthcare provider order), or adult briefs with wicking or gel properties. Call a certified ostomy or wound care nurse for tips on applying and increasing wear time for fecal incontinence collectors.

If 4″ × 4″ gauze pads or ABD pads are saturated more frequently than every 2 hours, consider applying an ostomy or specially designed wound pouch to the area. Collecting drainage allows measurement and protects skin from the constant wetness of a saturated pad.

Don’t neglect the basics, for example, know that wet skin is more susceptible to breakdown. Turn the patient and change his or her position on schedule. Change linens and underpads when damp, and consider using a low-air-loss mattress or bed or mattress with microclimate technology.

Also, be aware that fungal rashes should be treated with appropriate medications. If the patient’s skin isn’t too moist, consider creams that absorb into the skin; a skin-protecting agent can be used as a barrier over the cream. Besides reviewing and using the standards of care, you may refer to the Incontinence-Associated Dermatitis Intervention Tool, which has categories related to skin damage. See the “Incontinence-Associated Dermatitis Intervention Tool” (IADIT).

Bottom line on skin breakdown

To help prevent skin breakdown related to moisture, assess patients’ skin appropriately, determine treatment using evidence-based guidelines, and implement an appropriate plan of care.

Selected references
Black JM, Gray M, Bliss DZ, et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis: a consensus. J Wound Ostomy Continence Nurs. 2011;38(4):359-70.

Borchert K, Bliss DZ, Savik K, Radosevich DM. The incontinence-associated dermatitis and its severity instrument: development and validation. J Wound Ostomy Continence Nurs. 2010;37(5):527-35.

Doughty D. Differential assessment of trunk wounds: pressure ulceration versus incontinence-associated dermatitis versus intertriginous dermatitis. Ostomy Wound Manage. 2012;58(4):20-2.

Doughty D, Junkin J, Kurz P, et al. Incontinence-associated dermatitis: consensus statements, evidence-based guidelines for prevention and treatment, and current challenges. J Wound Ostomy Continence Nurs. 2012;39(3):303-15.

Gray M, Beeckman D, Bliss DZ, et al. Incontinence-associated dermatitis: a comprehensive review and update. J Wound Ostomy Continence Nurs. 2012;
39(1):61-74.

Gray M, Black JM, Baharestani MM, et al. Moisture-associated skin damage: overview and pathophysiology. J Wound Ostomy Continence Nurs. 2011;38(3):233-41.

Langemo D, Hanson D, Hunter S, Thompson P, Oh IE. Incontinence and incontinence-associated dermatitis. Adv Skin Wound Care. 2011;24(3):126-40.

National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: clinical practice guideline.Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Sibbald RG, Krasner DL, Woo KY. Pressure ulcer staging revisited: superficial skin changes & Deep Pressure Ulcer Framework©. Adv Skin Wound Care. 2011;24(12):571-80.

Wound, Ostomy and Continence Nurses Society. Guideline for Prevention and Management of Pressure Ulcers. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2010.

Wound, Ostomy and Continence Nurses Society. Incontinence-Associated Dermatitis: Best Practice for Clinicians. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses Society; 2011.

Zulkowski K. Diagnosing and treating moisture-associated skin damage. Adv Skin Wound Care. 2012;25(5):231-6.

Patricia A. Slachta is an instructor at the Technical College of the Lowcountry in Beaufort, South Carolina.

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Control your claims: Pressure ulcer/wound care management

Diabetic Foot Ulcers

One of many dreaded tags from a Centers for Medicare & Medicaid Survey is F-Tag 314 — Pressure ulcers.

CMS writes, “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.” (more…)

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2014 Journal: May – June Vol. 3 No. 3

Wound Care Advisor Journal 2014 Vol3 No3

Understanding therapeutic support surfaces

Pressure-ulcer prevention and management guidelines recommend support-surface therapy to help prevent and treat pressure ulcers. Support surfaces include pads, mattresses, and cushions that redistribute pressure. Full cushions and cushion pads are considered therapeutic support surfaces if used to redistribute a patient’s pressure in a chair or wheelchair.

The National Pressure Ulcer Advisory Panel (NPUAP) defines support surfaces as “specialized devices for pressure redistribution designed for the management of tissue loads, microclimate, and/or other therapeutic functions.” These surfaces address the mechanical forces associated with skin and tissue injury, such as pressure, shear, friction, and excess moisture and heat. (See Clearing up the confusion.)

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Clinical Notes: Pressure Injury Prevention, Diabetes, LIV

Incidence density best measure of pressure-ulcer prevention program According to the National Pressure Ulcer Advisory Panel (NPUAP), incidence density is the best quality measure of pressure-ulcer prevention programs. Pressure-ulcer incidence density is calculated by dividing the number of inpatients who develop a new pressure ulcer by 1,000 patient days. Using the larger denominator of patient days allows fair comparisons between institutions…

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Clinician Resources: Patient Safety, Ostomy, Wound Management

This issue’s resources include patient tools and new guidelines. Improving patient safety Research suggests that adverse events affect patients with limited English proficiency (LEP) more frequently, are commonly caused by communication problems, and are more likely to result in serious harm compared to adverse events affecting English-speaking patients. Your hospital can take steps to reduce risks of adverse events for…

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Eating better to help manage chronic stress

By Debra Rose Wilson, PhD, MSN, RN, IBCLC, AHN-BC, and Dana Marie Dillard, MS, HSMI Like many clinicians, you may experience stress frequently, both on and off the job. Chronic stress can alter your equilibrium (homeostasis), activating physiologic reactive pathways that cause your body to shift its priorities. Physiologic effects of stress may include: slowed digestion delay in reproductive and…

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Hidden complications: A case study in peripheral arterial disease

By Pamela Anderson, MS, RN, APN-BC, CCRN, and Terri Townsend, MA, RN, CCRN-CMC, CVRN-BC Jan Smith, age 59, is admitted to the coronary intensive care unit with an acute inferior myocardial infarction (MI). Recently diagnosed with hypertension and hyperlipidemia, she smokes a pack and a half of cigarettes daily. She reports she has always been healthy and can’t believe she…

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I’m going to conference!

By: Donna Sardina, RN, MHA, WCC, CWCMS, DWC, OMS Years ago, when I first started out in the wound care specialty, the only way to learn about new products and what was going on in the field was to “go to conference” (wound care conference). All year long, planning and excitement continued to build for our big trip. Not going…

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Successful documentation of wound care

By Cheryl Ericson, MS, RN, CCDS, CDIP Providers are often surprised at how pages upon pages of documentation in a patient’s health record can result in few reportable diagnosis and/or procedure codes, which often fail to capture the complexity of the patient’s condition. However, providers need to be aware of the implications of coding. As healthcare data become increasingly digital…

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The DIME approach to peristomal skin care

By Catherine R. Ratliff, PhD, APRN-BC, CWOCN, CFCN It’s estimated that about 70% of the 1 million ostomates in the United States and Canada will experience or have experienced stomal or peristomal complications. Peristomal complications are more common, although stomal complications (for example, retraction, stenosis, and mucocutaneous separation) can often contribute to peristomal problems by making it difficult to obtain…

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Understanding the crusting procedure

By Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS Each issue, Apple Bites brings you a tool you can apply in your daily practice. The crusting procedure produces a dry surface and absorbs moisture from broken skin through an artificial scab that’s created by using skin barrier powder (stoma powder) and liquid polymer skin barrier. The crusting procedure is…

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Understanding therapeutic support surfaces

By Rosalyn S. Jordan, BSN, RN, MSc, CWOCN, WCC, and Sandra Phipps, BSN, RN, MBA, WCC Pressure-ulcer prevention and management guidelines recommend support-surface therapy to help prevent and treat pressure ulcers. Support surfaces include pads, mattresses, and cushions that redistribute pressure. Full cushions and cushion pads are considered therapeutic support surfaces if used to redistribute a patient’s pressure in a…

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What is a comprehensive risk assessment?

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN Prevention of pressure ulcers and skin breakdown begins with a comprehensive risk assessment. Most providers use a skin risk assessment tool, such as the Braden or Norton scale. While these tools have been validated to predict pressure ulcer development, their use alone isn’t considered a comprehensive assessment, and frequently the individual risk…

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Wound Care Advisor Journal 2014 may-june-vol3_no3

Click here to access the digital edition

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Preventing pressure ulcers starts on admission

By Jeri Lundgren, BSN, RN, PHN, CWS, CWCN

The first 24 hours after a patient’s admission are critical in preventing pressure ulcer development or preventing an existing ulcer from worsening. A skin inspection, risk assessment, and temporary care plan should all be implemented during this time frame. Essentially, it’s the burden of the care setting to prove to insurers, regulators, and attorneys the pressure ulcer was present on admission and interventions were put into place to avoid worsening of the condition. Of course, patients also benefit from having their condition identified and treated promptly. (more…)

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Scientists Seek People with Primary Progressive MS and Other Forms of MS to Study Gut Bacteria

Volunteers are being sought for a major study to help determine how the gut microbiome can be used to treat multiple sclerosis, lupus, and other diseases.

Investigators at the University of California in San Francisco are recruiting people with MS for an international study of the gut microbiome – the population of bacteria in the gut – in MS. They are seeking people with primary progressive MS nationwide (there is no need for onsite visits), as well as people with any other type of MS who can make a one-time visit to San Francisco, New York, Boston or Pittsburgh. The overall purpose of these studies is to investigate the potential role of gut bacteria in MS.

Scientists Focus on Gut Flora for Future Treatments of Autoimmune Diseases

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AlloFuse® Select CM Supports Your Patient’s Healing

ALLOFUSE® CORTICAL FIBERS & ALLOFUSE® FIBER BOAT

AlloFuse® Select CM – clinically proven to activate and support bone formation and can be used in a variety of spinal, neurologic, and orthopedic procedures.

AlloSource, one of the nation’s largest providers of cartilage, bone, skin, soft-tissue, and cellular allografts to advance patient healing in surgical procedures and wound care, today announced the release of AlloFuse® Select CM, a premium addition to AlloSource’s AlloFuse portfolio. (more…)

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Wound care treatment explained at Rotary

Wound Care Solutions at Community Hospitals and Wellness Centers-Bryan

When treating people for wounds, the care team preforms both a comprehensive diagnosis and comprehensive treatment, Kathy Khandaker, director of wound care at Community Hospitals and Wellness Centers-Bryan, told the Bryan Rotary Club at its Friday meeting.

The wound care clinic opened at CHWC in 2006, added ostomy care in 2007, continence care in 2010 and added a full-time physician in 2015. The care team includes a wound care nurse, a hyperbaric oxygen therapy technician and a receptionist in addition to the physician. (more…)

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Managing chronic venous leg ulcers — what’s the latest evidence?

Managing chronic venous leg ulcers — what’s the latest evidence?

Chronic venous leg ulcers (CVLUs) affect nearly 2.2 million Americans annually, including an estimated 3.6% of people over the age of 65. Given that CVLU risk increases with age, the global incidence is predicted to escalate dramatically because of the growing population of older adults. Annual CVLU treatment-related costs to the U.S. healthcare system alone are upwards of $3.5 billion, which are directly related to long healing times and recurrence rates of over 50%.

CVLUs are not only challenging and costly to treat, but the associated morbidity significantly reduces quality of life. That makes it critical for clinicians to choose evidence-based treatment strategies to achieve maximum healing outcomes and minimize recurrence rates of these common debilitating conditions. These strategies, which include compression therapy, specialized dressings, topical and oral medications, and surgery, are used to reduce edema, facilitate healing, and avert recurrence. (more…)

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Wound Photography – How it Benefits Clinical Documentation

wound photography

Accurate assessment and documentation of wounds is essential for developing a comprehensive plan of care. Photography now plays a key role in wound care. The use of digital photography has enhanced the reliability and accuracy of wound documentation. Though a wound assessment in patient files includes details such as location, depth, odor, condition of surrounding tissue and other details, a visual record can be worth even more.

Digital photography is becoming a more prevalent documentation tool. According to an article published in McKnight’s, forensic nursing experts recommend using photographs to document injury. The photos show both how an injury occurred and how it is healing.

The National Pressure Ulcer Advisory Panel (NPUAP) also supports photography as a more accurate means for assessment of wound dimensions and wound base over time.

A visual confirmation to the written record, these images:

  • Facilitate better diagnosis
  • Enhance clinical documentation
  • Help to monitor the progress of wound healing
  • Help prevent litigation in wound management
  • Allow inter-disciplinary communication among the wound care team

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2016 Journal: March – April Vol. 5 No. 2

2016 Journal: March – April Vol. 5 No. 2

No more skin tears

Imagine watching your skin tear, bleed, and turn purple. Imagine, too, the pain and disfigurement you’d feel.

What if you had to live through this experience repeatedly? That’s what many elderly people go through, suffering with skin tears through no fault of their own. Some go on to develop complications.

A skin tear is a traumatic wound caused by shear, friction, or blunt-force trauma that results in a partial

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Buzz Report: Latest trends, part 2

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Caution: Checklists may lead to inaccurate documentation

Using a checklist form to document wound care can make the task easier and faster—and help ensure that you’ve captured all pertinent data needed for assessment, reimbursement, and legal support. But the form itself may not be comprehensive; some important fields may be missing. Recently, we at Wound Care Advisor received a question from a clinician who was having trouble deciding how to code a patient’s wound in her hospital’s…

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Clinical Notes: ostomy, pressure ulcer, burn treatment

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Clinician Resources: human trafficking, npuap, caregiver, ostomy, HIV

Check out the following resources, all designed to help you in your clinical practice. Human trafficking resources Victims of human trafficking often suffer tremendous physical and psychological damage. Clinicians play an important role in identifying potential victims so they can obtain help. Here are some resources to learn more about human trafficking. • “Addressing human trafficking in the health care setting” is an online course that includes a…

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Comprehensive turning programs can avoid a pain in the back

Turning programs are essential to prevent and promote healing of pressure ulcers and to prevent the many negative effects of immobility, ranging from constipation to respiratory infections. However, turning a patient often puts a caregiver’s body in an awkward position, which can lead to musculoskeletal damage, especially back injuries. According to the U.S. Bureau of Labor Statistics, healthcare workers suffer…

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Exercise your right to be fit!

Nearly all clinicians know exercise is good for our physical and mental health. But incorporating it into our busy lives can be a challenge. The only types of exercise some clinicians have time for are working long shifts, juggling life’s demands, balancing the books, jumping on the bandwagon, climbing the ladder of success, and skipping meals. Clinicians are in a…

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FAQs about support surfaces

Support surfaces are consistently recommended for the prevention and treatment of pressure ulcers. So patients can derive optimal benefits from support surfaces, clinicians must understand how to use them effectively. This article answers several questions about these useful tools.

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How to apply silver nitrate

Topical application of silver nitrate is often used in wound care to help remove and debride hypergranulation tissue or calloused rolled edges in wounds or ulcerations. It’s also an effective agent to cauterize bleeding in wounds. Silver nitrate is a highly caustic material, so it must be used with caution to prevent damage to healthy tissues.

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No more skin tears

Imagine watching your skin tear, bleed, and turn purple. Imagine, too, the pain and disfigurement you’d feel. What if you had to live through this experience repeatedly? That’s what many elderly people go through, suffering with skin tears through no fault of their own. Some go on to develop complications. A skin tear is a traumatic wound caused by shear, friction, or blunt-force trauma that results in a partial-…

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Nutritional considerations in patients with pressure ulcers

Optimizing nutritional status is a key strategy both in preventing and managing pressure ulcers. In patients across all care settings, compromised nutrition— as from poor intake, undesired weight loss, and malnutrition—increases the risk of pressure ulcers. It contributes to altered immune function, impaired collagen synthesis, and decreased tensile strength. In many cases, malnutrition also contributes to wound chronicity and increases the risk for delayed and impaired wound healing. In patients with chronic…

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2016 Journal: March – April Vol. 5 No. 2

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