Tissue Viability. Alison Johnstone Clinical Nurse Specialist Tissue Viability

Transcription

1 Tissue Viability Alison Johnstone Clinical Nurse Specialist Tissue Viability

2 Who is T/V? Alison Johnstone Heather Hodgson Tel Tel 0138 Matrons Flat, 34, Shelley court 6 th Floor Med block GGH GRI.

3 What is tissue viability about? Tissue Viability is about the maintenance of skin integrity. Also the management of patients with acute and chronic wounds, prevention and management of pressure damage. It is not a substitute of holistic assessment of patients at risk and with wounds.

4 The Skin Epidermis Dermis Hypodermis Nerves Hair follicle Fat cells Sweat glands Blood vessels Deep fascia Muscle layer

5 Epidermis Avascular Very thin 5 layers Stratum corneum / outer layer Stratum basale / inner layer Ph:

6 Dermi s Collagen and elastin capillaries Sensory nerve endings Sebaceous glands Sweat glands Hair follicles

7 Epidermal/Dermal Junction Between epidermis and dermis Separates and attaches the epadermis and dermis The junction flattens with age Site where skin tears usually occur

8 Blister s Fluid trapped between the epidermis and the dermis.

9 Urinary incontinent skin damage

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12 Skin Excoriation Tool for Incontinent Patients (NATVNS Scotland)

13 NATVNS (SCOTLAND) SKIN EXCORIATION TOOL FOR INCONTINENT PATIENTS 0 = HEALTHY SKIN Clean skin with skin cleanser Healthy, intact skin. No erythema (redness). 1 = MILD EXCORIATION Clean skin with skin cleanser Use durable barrier cream Erythema (redness) of skin only. No broken areas present. 2 = MODERATE EXCORIATION Clean skin with skin cleanser Use barrier film spray Erythema (redness), with less than 50% broken skin. Oozing and/or bleeding may be present. 3 = SEVERE EXCORIATION Seek advice from Tissue Viability Nurse where available for local guidelines/guidance Erythema (redness), with more than 50% broken skin. Oozing and/or bleeding may be present. Origination: Lydia Jack, TVN IRH, & Anne Wilson TVN RAH Design: Colin Blain, Med Photo, Inverclyde Royal, Greenock References: NMC The Code Standards of conduct, performance and ethics for nurses. (May 2008) Best Practice Statement for the Prevention of Pressure Ulcers (2005) NHS Quality Improvement Scotland. Cooper P, Gray D, (2001) Comparison of two skin care regimes for incontinence. British Journal of Nursing,10 (6), P6-20 Journal of Wound Care, Evans SJ, Stephen-Haynes J, 2004, Identification of superficial pressure ulcers Vol16, No2, 54-56

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15 moisture

16 Tissue breakdown as result of moisture lesion Moisture as a result of incontinence, sweat or wound exudates can macerate the skin This will lead to the increased likelihood of frictional damage occurring The skin becomes waterlogged in the dermis and becomes soft and fragile Correct management of incontinence is important, as frequent washing with soap and water can destroy the protective sebum layer increasing the likelihood of bacterial contamination Healthy skin should be clean and well hydrated.

17 What Problem? 1 in 10 patients across Europe have a pressure ulcer 50% of those are grade 3 and 4 - EPUAP 50% of patients who develop a severe ulcer will die within 4 months - Bliss Costs NHS 2 2 Billion per year 90% of grade 1s are reversible with adequate nursing intervention - Bader

18 Pressure Ulcers & QoL lack of privacy changes in body image loss of control and independence increased pain social exclusion malodour growing limitations on activity and mobility

19 Pressure Ulcers.. are areas of localised damage to skin caused by pressure, shear and friction and usually occur over bony prominence. NHS Centre for Reviews and Dissemination and Nuffield Institute for Health 1995

20 Pressure Ulcer Development causes: PressurePressure a a perpendicular load or force being exerted on a unit of area. ShearShear a a mechanical stress that is parallel to a plane of interest FrictionFriction the force related to two surfaces moving across one another

21 Combined effects of pressure, shear and friction

22 Immobile clients can be at risk from Pressure Ulcer development in less than 25 minutes

23 Shear Effect of Raising The Head of The Bed

24 Mechanisms contributing to tissue breakdown Local ischaemia - as a result of capillary occlusion. Endothelial damage to microcirculation - cells lining blood & lymphatic vessels become damaged, e.g.by shear. Reperfusion injury (when blood flow is abruptly restored following a period of ischaemia) Prolonged deformation or pressure on cells will result in cell death

25 Factors affecting PU development External pressure - inadequate support surface, invasive lines spigots, unrelieved Shearing Forces -profiling beds footstools,chair Friction -maybe a result of, skin moisture rubbing, M&H Waiting times A&E, Theatre, Chair nursing X-ray External temperature 1% rise in patient temp may increase metabolic demand by 13% Extrinsic FACTORS Intrinsic Anxiety - respite care, hospital admission, recent stress Immobility as a result of illness/trauma anaes/seda Advancing Age reduction in collagen & tissue stiffness Illness- infec, Spinal CV/PV disease,diab MS, Park, Anaem Alz,fluid loss, Neuro Internal pressure ie, bony promin, inadequate nursing care Skin maceration - sweat,urine, faeces Malnutritionpoor tissue, lack of fatty & muscle tissue

26 Scottish Adapted EPUAP Grading Tool (NATVNS Scotland)

27 European Pressure Ulcer Advisory Panel (EPUAP) Grading Tool GRADE 1 Non blanchable erythema of intact skin. Discolouration of the skin, warmth, oedema, induration or hardness may also be used as indicators, particularly on individuals with darker skin 1 GRADE 2 Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister. 1 GRADE 3 Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia. 1 GRADE 4 Bone Bone Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss. 1 Tendo n Origination: Lydia Jack, Tissue Viability Nurse Specialist Design: Colin Blain, Med Photo, Inverclyde Royal, Greenock POINTS TO CONSIDER Grade 3 pressure ulcers may have undermining present. Recognise and work within the limits of your competence. 2 Make a referral to another practitioner when it is in the interests of someone in your care. 2 1 European Pressure Ulcer Advisory Panel (1999). Guidelines on treatment of Pressure Ulcers. EPUAP Review, 1(2); NMC- The Code. Standards of conduct, performance and ethics for nurses and midwives (May 2008)

28 Classification Systems Promotes accurate communication Aids in the decision process of care Provides a reflection of wound appearance indicating improvements/deterioration Risk calculators & classification systems are open to user error.

29 Preventative Strategies

30 Risk Assessment Essential when planning pressure ulcer and wound care. Determines the most suitable treatment required to prevent deterioration of wound and skin.

31 Waterlow Risk Assessment tool

32 moving and handling techniques

33 The 30 degree tilt Recumbent position

34 Advantages of the 30 tilt The patients weight is spread over a larger area, this will reduce the risk of pressure damage over the hot spots The patient lies on a 30 tilt so they have a better view of their surroundings and may find it easier to eat and drink. Reduces risk of tissue damage from shear and friction (usually occurs when a patient slips down the bed) As this position only involves tilting (not lifting) carers will find it easier to perform and greatly reduces the risk of back injuries

35 SOFTFORM

36 Support surface when seated

37 Specialised support

38 Within 6 hours of admission assess patient using Waterlow. Intact skin or Grade 1 or 2 damage (Scottish adapted EPUAP Grading Tool) up to Grade 3 damage (EPUAP) (Scottish adapted EPUAP Grading Tool) up to Grade 4 damage (EPUAP) (Scottish adapted EPUAP Grading Tool) Greater Glasgow Product Selection Guide No No Yes Yes Yes Utilise electric profiling bed & 30 tilt Careplan should include: Nutrition assessment Skin care Wound chart - if needed Equipment used Turning/ repositioning regime Re-Assess as required Re-evaluation date Utilise Pressure Redistribution products, eg, heel protectors Utilise electric profiling bed & 30 tilt PRIMO Mattress +/- cushion TVN review Careplan should include: Nutrition assessment Skin care Wound Chart Equipment used Turning/ repositioning regime Re-Assess as required /Re-evaluation date Utilise electric profiling bed &30 tilt DUO/DUO2 Mattress +/- cushion TVN review Careplan should include: Nutrition assessment Skin care Wound chart Equipment used Turning/ repositioning regime Re-assess as required Re-evaluation date Visco- Elastic mattress PRIMO MR Cont.Low Pressure Max weight: 150kg No Min weight limit Duo / Duo 2 MR Cont. Low Pressure/ Alt. Low Pressure Max weight:150kg Min Weight: 35kg These guidelines are to assist in the selection of appropriate Hill-Rom therapy mattresses further guidance can be obtained from your Hill-Rom Clinical Advisor on ( or TVN)

39 Management

40 Best Practice Statement BPS Pressure Ulcer Prevention (updated 2005) BPS Treatment & Management Pressure Ulcers (2005) Reviewed & Amalgamated Available as part of the practice development toolkit Available from QIS web site

41 Any questions??????