WOUNDS: WHAT CAN WE DO?
PRESENTED BY: HEATHER THOMPSON RN
RNAO LTC BEST PRACTICE CO-COORDINATOR
LHIN 13 NORTH EAST REGION
Objectives





Define a pressure ulcer
Identify risk factors or warning signs
Discuss Best Practices related to wound prevention
and treatment plans
Discuss the “Team” and your role in wound care
Hand on exercise: “Tender touch”
“Your are tearing me apart”
“ Orange you glad we did this”
Key Terms
 Friction- mechanical force exerted on the skin
 Shearing- skin remains stationary and underlying






tissue moves, tears and stretches
BPG- (Best Practice Guideline)
Team- client, family, care giver, nurse, Doctor,
Occupational and Physical therapist, Dietician and more
Braden Scale - useful assessment tool to determine risk
of skin breakdown
Moisture- due to incontinence or perspiration
Sensory – ability to feel and understand
Nutrition – protein to assist in healing
Wound Definition

“an area of localized damage to the skin and
underlying tissue caused by pressure, shear, friction
and/or a combination of these” European Pressure Ulcer Advisory
Panel EPUAP (2003)
Typically found over bony areas and can occur
anywhere
 The tissue does not receive adequate nutrition and
becomes necrotic and dies
 Wounds are staged based on degree of tissue
damage.

What do we know?
Preventing the development of pressure ulcers is a
huge challenge
 Data (1990-2003) shows 29% incidence in Canada
 Further challenged by limited resources
 Costs, knowledge and time to name a few

Myths and Truth
Myth
 Pressure Ulcers are
prevented by nurses
 Sheepskin prevent Pressure
Ulcers
 Pressure redistribution
surface prevents Pressure
Ulcer alone
Truth
 It takes team work: Client,
Family, Care giver, Nurse,
Doctor, Physical and
Occupational therapist,
Dietitian
 Made of wool and
polyester, reduce friction at
start but material
deteriorates quickly
 They help but client still
needs repositioning
What can we do?
 Knowledge
 Prevention
 Protection
 Assessment
 Communication
 Teamwork
Best Practice Guideline
Assessment &
Management
of Stage I – IV
Pressure Ulcers
And
Risk Assessment &
Prevention of Pressure
Ulcers
Free download at
http://ltctoolkit.rnao.ca
Evidence-Based Practice
Evidence-based practice is the integration of best research
evidence with clinical expertise and patient values to
facilitate clinical decision making.
DiCenso et al., 2005
What the Wound BPG can do?

To demonstrate that the implementation of a
standardized skin and wound care program,
partnered with an ongoing educational program
has a result in the reduction of internally acquired
pressure ulcers.
Function of the skin
 Protects to keeps harmful substances out; keeps





water and electrolytes in
Supports internal structures and organs
Assists in production of vitamin D
Performs excretory function
Performs sensory role
Assists in regulating body temperature
Skin
 Largest organ
 Two layers:
Epidermis
Dermis
 Subcutaneous
tissue
So how do pressure ulcers form
 Greatest damage over bony prominence
 Ulcer already started by the time you see the redness
 Can increase in severity in just one day if not
addressed
 Pressure over area will significantly decrease the
blood flow and delivery of nutrients to an area,
causing eventual death of cells
Staging of Wounds
 Stage 1 −
discolouration of the
skin, warmth, swelling
or hardness
 Stage 2− partial
thickness skin loss
involving epidermis or
dermis, or both. May
look like an abrasion
or blister
Staging of Wounds
 Stage 3– full thickness
skin loss involving
damage to or cell death of
underlying tissue, may
extend down to, but not
through, fibrous tissue
beneath the skin
 Stage 4 – extensive tissue
cell death, or damage to
muscle, bone or
supporting structures with
or without full thickness
skin loss
Risk Factors
Uncontrolled
Controlled
 Age and gender
 Positioning
 Body size
 Shearing and Friction
 Medication
 Medical condition
 Nutritional and
hydration status
 Mobility
 Environment
 moisture
 Surface areas
 Mobility
 Environment
 Nutritional and
hydration status
 moisture
Watch for Warning Signs
 Incontinent
 Excessive perspiration
 Cannot change position on own, limited mobility
 Weight loss, dehydration
 Discoloured, swollen skin over bony areas or skin
tear areas
 Poor circulation, history of pressure ulcers
 Decrease in senses
 Pain
Action to Protection
 Assessment of risks weekly performed by client,





caregiver, nurse. Use of effective tool (Braden Scale)
Communicate results
Improved nutrition: Dietician assessment ongoing,
act on dietician suggestions
Communicate results
Physical Therapist assessment to maintain or
improve mobility, Occupational Therapist
assessment
Communicate results
Action to Protection
 Manage Moisture: Moisture increases the risk for




pressure ulcers. Two sources of moisture are urine and
sweat.
Manage Nutrition & Hydration: Nutrition and
Hydration are important in keeping skin healthy
Manage Friction, Sheer and Pressure: Reducing friction,
sheer and pressure helps to prevent pressure ulcers.
Manage Repositioning: Repositioning helps prevent
pressure ulcers.
Manage Sensory/Perception: If a patient is unable to
feel pain or pressure normally, they can be injured without
knowing it.
Pain Management
http://ltctoolkit.rnao.ca/sites/ltc/files/resources/pressure_ulcer/AssessmentTools/Painmangementflowre
cord.pdf
 Severity of pain pre-treated
 Location of pain
 Quality of pain
 Regular pain medication
time
 Non-pharmacological
treatment
 Severity of pain post
treatment
What to Report
 Pressure, shearing, friction
 level of mobility
 sensory impairment
 continence
 level of consciousness
 Exacerbation of acute, chronic and terminal illness
What to Report
 Posture
 Cognition, psychological status
 Previous pressure damage
 Nutrition and hydration status
 Moisture to the skin
Pressure Relief Devices
 Heel and elbow protectors
 Bed cradle and foot board
 Air flow mattress
 Alternating pressure bed
 Special cushions for chair
Other Actions
 Nutritional support
 Skin barriers
 Positioning techniques
 Incontinence management program (Best Practice
Guidelines: Promoting Continence using Prompted
Voiding and Prevention of Constipation in the older
Adult Population)
 Education
 Communication
Summary of Wound management
 History, physical assessment, motivation for
treatment
 Involve the client, family, dietary, OT, PT, nurses,
dietician and care giver
 Ongoing assessment or at least every 3 months
and when there is a change in condition
 Contributing factors: mattress, surface supports,
transfer type, mobility, nutrition and knowledge
 Look at the whole person
Team Roles





Resident – prevention, treatment plan,
communication
PSW and Care Giver – prevention, skin screening,
treatment evaluation, communication
Nurse –prevention, pain control, assessment,
treatment, evaluation, communication
OT and PT –prevention, physical assessments,
treatment, evaluation, communication
Family – prevention, care routines,
communication
Knowledge can be Fun
 Exercise “Tender Touch”
 Exercise “ You are tearing me apart”
 Exercise “Orange you glad we did this”
Questions and Discussion
References






RNAO. (2007, March). Assessment & Management of Stage I-IV Pressure
Ulcers.
RNAO. (2005, March). Risk Assessment & Prevention of Pressure Ulcers.
Potter & Perry. (2006). Canadian Fundamentals of Nursing 3rd ed. Chapt. 43
Potter & Perry. (2006). Clinical Nursing Skills & Techniques 6th ed. Chapt. 13
Website resource: http://ltctoolkit.rnao.ca
Janet Evans BScN MN BPG Coordinator LHIN 11