WELCOME

SKINtelligence

SKINtelligence

Protecting our birthday suit

(or looking after our skin)

Skin

Skin (an organ)

• Protects • Temperature

• Impact and pressure

• Microorganisms

Skin

• Regulates

– Body temperature

– Fluid balance (sweating etc)

– Reservoir for synthesis of Vitamin D

Skin

• Network of nerve cells to aid sensation of touch, pressure temperature or pain

Lots of challenges with skin…

• Skin conditions and inflammatory disorders

• Including non infective conditions such as:

Eczema

Psoriasis

And infective disorders

• Viral: – Human papilloma virus (HPV) causing warts and

veruccas

– Herpes Virus – chickenpox and shingles

• Bacterial: – Impetigo – highly infectious

– Cellulitis

• Fungal – Ringworm and tinea pedis (athlete’s foot)

Viral Infections

• HPV • Herpes

– Shingles on stomach

Bacterial infections

• Impetigo

• Cellulitis

Fungal infections

• Ringworm • Tinea pedis (athlete’s foot)

Further challenges…

• Skin becomes thinner as it ages

• Blood supply to skin decreases

• Other compromises to skin:

– Dehydration

– Pyrexia

– Malnourishment

– Immobility

– Certain Medications (especially corticosteroids)

Venous Eczema

Not to be confused

with cellulitis!

End of life skin changes

• Recent SCALE document

• The skin is an organ, and can fail at the end of life

• Certain changes unavoidable

• Consider if healing is possible…it could be a palliative wound, consider patient preference etc

Prevention is the name of the game!

Prevent the unknown?

How do we know who is at risk?

• Tools – risk assessment, Walsall etc

• Awareness of clients ‘baseline’

• Be aware of the risks e.g. ‘what is the relation between healing and nutrition’

• But Mrs Smith doesn’t want to change her position! Does she understand the importance?

• Etc……….

What assessment tools do you have and use?

What are they for?

Are they effective?

Are they ALWAYS used …. and more importantly are they acted

upon?

Malnutrition Universal Screening Tool (MUST) Record Sheet

Date:

Date: Date: Date:

STEP 1

Height (m)

Weight (kg)

BMI (kg/m2) (see chart)

BMI Score (circle)

(A)

0 1 2 0 1 2 0 1 2 0 1 2

STEP 2

% unplanned weight loss

(work out using MUST chart)

% unplanned weight loss score (circle)

(B)

0 1 2 0 1 2 0 1 2 0 1 2

STEP 3

Acute disease or no nutritional intake for >5

days score (circle)

(C)

0 2 0 2 0 2 0 2

STEP 4

MUST score =

(A + B + C)

For use when the patient scores 2 or more (or scores 1 and then shows no

improvement)

Nutritional Intervention

Date Comments

Maintain food record charts

Establish patient likes and dislikes

Encourage with energy dense meals and puddings from the menu,

including those which are fortified

Encourage with small frequent snacks between meals such as cakes and

biscuits

Encourage with milky drinks made with full cream milk such as Hot

Chocolate and Horlicks

Trial nutritional supplements such as Build Up soups, Build Up

milkshakes, Ensure Plus and Enlive

Ensure Plus and Enlive must be prescribed by the

GP on a named patient basis and recorded on the

drug chart. Aim 2 per day

Continue to follow the above steps and monitor intake. Repeat MUST

score weekly.

If no improvement seen within 3 weeks, contact dietician for advice

regarding further supplementation or artificial feeding

Walsall (or pressure damage risk assessment tool)

RISK CATEGORIES

SCORE

ASSESSMENT DATES

LEVEL OF

CONSCIOUSNESS

ALERT 0

LETHARGIC/CONFUSED 3

SEMI-COMATOSE 3

COMATOSE 3

MOBILITY

AMBULATION

MOVES WITHOUT ASSISTANCE 0

MOVES WITH LIMITED ASSISTANCE 3

MOVES ONLY WITH ASSISTANCE 8

CHAIRFAST (8HRS PLUS) 8

BEDFAST (12HRS PLUS) 8

SKIN CONDITION

HEALTHY 0

RASHES/DRYNESS 2

INCREASED TURGOR/FRAGILE 4

REDNESS 4

NUTRITIONAL STATUS

WELL BALANCED DIET/STABLE WEIGHT 0

POORAPPETITE/WEIGHT LOSS 4

VERY POOR/FLUIDS ONLY/NIL NY MOUTY 4

SUB TOTAL RISK SCORE (A)

RISK CATEGORIES Score

ASSESSMENT DATES

BLADDER

NONE 0

INCONTINENCE OCCASIONAL (<2/24 HRS OR

CATHTERISED 0

USUALLY >2/24 HRS) 1

TOTAL (NO CONTROL 4

BOWEL NONE 0

INCONTINENCE OCCASIONAL (<2/24 HRS OR

CATHTERISED 4

TOTAL (NO CONTROL) 6

CARER INPUT NO CARER REQUIRED 0

ACTIVE CARERS (24HRS) 0

INTERMITTENT CARER (8 HRS

PLUS) 2

LIMITED CARER (3-8 HOURS 2

OCCASIONAL CARER (0-3 HRS) 2

SUBTOTAL RISK SCORE

SUBTOTAL RISK SCORE (A)

TOTAL RISK SCORE

TICK IF PATIENT HAS PRESSURE ULCER

ASSESSOR'S SIGNATURE

Name…………………… DOB……………NHS number……………..

ADAPTED WALSALL COMMUNITY PRESSURE ULCER RISK CALCULATOR

The Walsall Community Pressure Ulcer Risk Calculator assists in the identification of the main contributing factors in the development of pressure ulcers. It has been validated for use in the Community/domiciliary environment. ¹ It should be used in conjunction with clinician’s professional’s judgement and as part of an overall patient/client Care Plan. 1. RISK ASSESSMENT

The columns allow for regular assessment, either at intervals indicated by the patient’s level of risk, or should the patient’s condition change.

2. RISK CATEGORIES

Score the patient in one area only in each risk category. Record the score in the appropriate column and total the end. From the total risk score, determine the category as:

<4 not at risk

4 - 9 low risk

10 - 14 medium risk

15 + high risk

3. PRESSURE ULCER GRADING SCALE²

CATEGORY 1 – Intact skin with non-blanchable redness of a localized area .Area may be painful, firmer or softer, and warmer or cooler compared with adjacent tissue. CATEGORY 2 – Partial thickness loss of dermis presenting as a shallow ulcer with no slough .Can present as a blister. CATEGORY 3 – Full thickness tissue loss, subcutaneous fat may be visible but bone, tendon and muscle cannot be seen. CATEGORY 4 – .Full thickness Tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present.

4. EQUIPMENT GUIDE

This risk calculator and equipment guide are guidelines only. The equipment guide includes a range of equipment within each section. Selection should be based on comprehensive patient assessment, including physical, social, psychological and environmental factors in conjunction with clinician’s professional judgement. These guidelines should be used along side Pressure Damage prevention Guidance and Guidance on prescribing equipment. If you are unsure please contact the equipment nurse on 01235 205497.

Risk Category

Mattress Selection

Cushion Selection

Low Foam Base( premier super glide) or Propad

topper to own bed/mattress Foam( carefree)

Foam with Gel( transflo)

Medium (Prevention) Foam overlay (Propad)if own mattress

Foam replacement ( premier super glide) Static air overlay ( Repose)

Foam Foam with Gel(Transflo)

Static air (Repose)

High (Prevention) Foam Replacement( premier super glide)

Static air overlay (Repose) Alternating Replacement

Foam and Gel (transflo) Alternating(serenade)

Static air (Roho ,Starlock)

High Alternating Replacement ( Nimbus, Autologic

,qautro, essentials) Alternating Nimbus, (Autologic ,qautro,

essentials)

What about skin tears?

• Lots of risk factors! – Increased age

– Female

– Caucasian

– History of skin tears

– Compromised nutrition

– Dehydration

– Impaired sensory perception

– Medication (esp corticosteroids)

– Etc!

Skin tears

• In compromised patients these can become chronic

• Skin tears on lower limb (especially with patients with oedema and/or venous/arterial disease will often become a leg ulcer

• Many could be prevented by careful risk assessment and excellent skin care

• ALL STAFF CAN PLAY A ROLE

Skin tear risk assessment

Group one

(1 or more)

Tick if appropriate

Skin tear in the last 90 days

A current skin tear

Total ticks

Group two

(4 or more)

Tick if appropriate

Decision-making skills impaired

Visual impairment

Extensive assistance/total dependence for ADL’s

Wheelchair assistance required

Loss of balance

Confined to bed or chair

Unsteady gait

Bruises

Total ticks

Group three

(5 or more)

Tick if appropriate

Physically abusive

Resists ADL care

Agitation

Hearing impaired

Decreased tactile stimulation

Wheels self in wheelchair

Manually/mechanically lifted

Contracture of arm, legs, shoulders or hands

Hemiplegia/hemiparesis

Trunk – total or partial inability to balance to turn body

Pitting oedema of legs

Open lesions of extremities

3-4 senile purpuras on extremities

Dry/scaly skin

Total ticks

Prevention of skin tears

Practical tips:

• Wash with soap substitutes which are less drying and more pH neutral

• Moisturise skin daily

Moisture can cause more risks

• Are you using the most absorbent pads and changing in a timely way?

• Use barrier creams on vulnerable skin

Try to avoid adhesives on skin

• Alternative to adhesive dressing: – Non-adhesive contact

layer, pad and tubular bandage

• Tubular bandage clinifast applied to exposed skin to help protect against skin tears

Weapons of mass destruction to vulnerable skin

(staff and clients!!!)

Nutrition & Hydration

Extra protein in the diet is needed if there is a wound, to help the wound to heal

Example…..

• Offer 1.25 to 1.5 grams protein/kg body weight daily for an individual with a pressure ulcer when compatible with goals of care, and reassess as condition changes

• Eg. patient weighing 8 stone = approx 50kg would require 62.5grams protein (small tin of tuna is only 27grams!)

• Assess renal function to ensure that

high levels of protein are appropriate

for the individual

Safe environment

• Appropriate lighting

• No trip hazards

Leg Ulcers • Do you know who is at

risk?

• Currently no risk assessment tool …… you

need to know what to look out for

Usually in two categories Can be ‘mixed’

• Venous

• Arterial

Risk factors for leg ulcers

• Venous: approx 75%

– Obesity – Immobility – Personal or family

history of varicose veins – Previous DVT – Arteriovenous fistula – Increasing age – History of leg fracture or

trauma – History of venous leg

ulcer

• Arterial or mixed – arterio/atherosclerosis – Hypercholesterolemia – Hypertriglyceridemia – Hypertension – History of angina, MI or CVA – Diabetes – Connective tissue disorders – Rheumatoid arthritis – Blood disorder – History of smoking – Excessive alcohol intake – Raynaud’s phenomenon – History of arterial/mixed

ulcer

Risk assessment for leg ulceration

Risk Factor tick

Previous DVT

History of venous leg ulcer

Obesity

Personal or family history of varicose veins

Immobility

History of leg fracture or trauma

Chronic oedema

Increasing age

Arteriovenous fistula

Venous (makes up approx 75%) of leg ulcerations

Arterial/mixed aetiology Risk Factor tick

Arterio/atherosclerosis

Hypercholesterolemia

Hypertriglyceridemia

Hypertension

History of angina, MI or CVA

Diabetes

Connective tissue disorders

Rheumatoid arthritis

Blood disorder

History or current smoker

Excessive alcohol

Raynaud’s phenomenon

History of arterial disease

1 tick or more indicates significant risk, and a baseline ABPI (ankle brachial pressure index, i.e. Doppler assessment) reading would be recommended.

Greater number of ticks = greater risk

Reduce risk!

Regular exercise, even short walks (walk to the dining room instead of wheelchair, plan for extra time)

Balanced diet and healthy weight

Examine feet and legs regularly

Regularly moisturise legs

Remember to use downward strokes and not apply between toes

Stop smoking improve circulation to limbs

If compression hosiery is advised it should be worn every day

Elevate legs

Carry out regular leg exercises – can be done seated and/or passively if unable

to do independently

Stimulates calf pump muscle to pump blood back up towards the heart

PRESSURE!

Pressure Ulcer

• A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear.

EPUAP 2012

Pressure Damage and PREVENTION

Pressure Damage • 3 causes

– Direct pressure

– Shear -usually skin moves in one direction and bone moves in the opposite direction

– Friction – usually skin rubs

over a surface, such as sheet,

duvet, foot plates

Sit on your hands experiment!

How do we stop pressure damage?

• A=Know what causes it!

• B=Know the patient and their risk factors

• (use assessment tools accurately and ACT upon them!)

• A+B= avoidable pressure damage prevention

Preventing damage

• Use adapted techniques for moving and handling safely (eg slide sheets, careful use of hoists, especially when removing)

• Keep clients moving, even mobile patients can get pressure damage, especially when seated

• Ensure moisture levels are well managed. Incontinence and even perspiration can start to compromise skin integrity.

• The correct absorbency of pad changed regularly and washing with a soap substitute and the use of barrier creams/sprays will help

Consider positioning…what about the 30o tilt?

Bed mattress

Pillows can be used to lift the mattress, The patient stays in contact with the powered mattress, relieving pressure,

but the tilted mattress means that the patient’s weight is more spread over

a wider area.

Know how to categorise ….

• We use the EPUAP categorising (used to be called ‘grades 1-4’ now categories)

• European Pressure Ulcer Advisory Panel

• You can go up in categories, but never down!

• i.e. a cat 3 can become a cat 4, but a 4 can never become a cat 3, even if it improves!

• It just becomes a healing cat 4!

Category/Stage I: Non-blanchable redness of intact skin

• Intact skin with non-blanchable erythema of a localized area usually over a bony prominence. Discoloration of the skin, warmth, oedema, hardness or pain may also be present. Darkly pigmented skin may not have visible blanching. Further description: The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons.

EPUAP 2014

Category/Stage II: Partial thickness skin loss or blister

• Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister. Further description: Presents as a shiny or dry shallow ulcer without slough or bruising. This category/stage should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

EPUAP 2014

Category/Stage III: Full thickness skin loss (fat visible)

• Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Some slough may be present. May include undermining and tunneling.

• Further description: The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

EPUAP 2014

Category/Stage IV: Full thickness tissue loss (muscle/bone visible)

• Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often include undermining and tunneling. Further description: The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

EPUAP 2014

Where are bony prominences

EPUAP 2014

Which areas are at risk?

and here?

What’s this?

Moisture lesions

• Also known as incontinence dermatitis

• Compromises skin, creating greater risk of breakdown

• Often confused with pressure damage

• Treatment – manage moisture in first instance

?step up absorbency of pad/increase changes/urinary catheter for a while

Treatment of moisture lesions

• Manage moisture (if diarrhoea, treat approriately ?referral to bladder and bowel service)

• Better pads/frequency of change • Wash in soap substitute eg Hydromol ointment

‘melted’ in warm water. (Using soap causes catastrophic changes to pH levels of skin, increasing risk even further)

• Apply moisturiser (Hydromol ointment) rubbed between palm of hands and applied thinly to buttocks. If skin is already damaged you may need to step up to a barrier cream or spray. Start with Derma-S and step up again to ProShield if needed.

IN MOST CASES DRESSINGS WILL SIMPLY AGGRAVATE

THE SITUATION!

Question:

WHAT DO WE PUT ON A PRESSURE

ULCER?

Answer:

ANYTHING BUT THE PATIENT!!!!

No pressure ulcer will ever heal until the pressure is removed!

Special Caution - HEELS • DO NOT DEBRIDE WITHOUT A DOPPLER

ASSESSMENT TO CHECK ARTERIAL FLOW

• If a wound like this is debrided and the patient has compromised arterial flow, they will have an open wound and not enough oxygenated blood flow to heal. It will become infected, and will stay in a cycle of infection leading to possible sepsis.

Pressure relieving equipment • Whole selection available!

• Try to familiarise yourself with what your home use, and check with manufacturers (usually quick on line check) re: maximum patient weight, level of pressure damage, regular maintenance checks etc

• Sometimes simple and cheap is just as effective

• Think of equipment as medication – know what it’s for, who it’s for, why it’s ‘prescribed’, how long for and when it needs reviewing