Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Skin, Nails, Hair

No description
by

Dana Brackney

on 22 September 2014

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Skin, Nails, Hair

Function and Structure
What is Skin?
Lymph node names and location
Regional Lymphatics of the head and neck
Developmental Considerations (skin, nails, head, face, and neck)
Assessment of Face
Assessment of Nails
Assessment of Neck
Assessment of nails
Assessment of Skin
Assessment of hair
Abnormal Skin Color
Skin Color by Ethnic Groups
Skin Healthy Adult
Skin Structure
Abnormal Lymph Node Response
Health Promotion during Exam
Portfolio
Assessment of Head
Skin Color
Macule
Inspect and palpate hair
Color
Texture
Distribution
Lesions
Objective Data:
Physical Examination
Braden Scale
Assymmetry
Border
C
Diameter
E
ABCDE
Inspect and palpate skin (cont.)
Lesions:
if any are present note:
Color
Elevation
Pattern or shape
Size
Location and distribution on body
Any exudate: note color and odor
Objective Data:
Physical Examination
Inspect and palpate skin (cont.)
Texture
Thickness
Edema
Mobility and
turgor
Vascularity or bruising
Multiple bruises at different stages of healing and excessive bruises above knees or elbows should raise concern about physical abuse
Needle marks or tracks from intravenous injection of street drugs may be visible on antecubital fossae, forearms, or on any available vein
Objective Data:
Physical Examination
Inspect and palpate skin
Color
General pigmentation, freckles, moles, birthmarks
Widespread color change
Note color change over entire body skin, such as
pallor
(pale),
erythema
(red),
cyanosis
(blue), or
jaundice
(yellow)
Note if color change transient or due to pathology
Objective Data:
Portfolio: Physical Examination
Regional Examination
Individuals may seek health care for skin problems and assessment focused on skin alone
Assess skin as one entity; getting overall impression helps reveal distribution patterns
Inspect lesions carefully
With a rash, check all areas of body as you cannot rely on the history that rash is in only one location
Skills used are
inspection and palpation
because some skin changes have accompanying signs that can be felt
Objective Data:
Physical Examination
Preparation
Consciously attend to skin characteristics;
the danger is one of
omission
Equipment needed
Strong direct lighting, gloves, penlight, and small centimeter ruler
Objective Data:
Physical Examination
Additional history for adolescents
Skin problems such as pimples, blackheads?

Additional history for aging adults
What changes have you noticed in your skin in last few years?
Any delay in wound healing?
Any change in
feet
: toenails; bunions, wearing shoes?
Falling: bruises, trauma?
History of diabetes or peripheral vascular disease?
Subjective Data Adolescents/Older Adult
Additional history for children (cont.)
Has child been exposed to:
Contagious skin conditions: scabies, impetigo, lice?
Communicable diseases: measles, chicken pox, scarlet fever?
Toxic plants: poison ivy?
Does child have habits such as nailbiting or twisting hair?
What steps are taken to protect child from
sun exposure
?
Subjective Data Infants and Children
Additional history for infants and children
Does child have any birthmarks?
Any change in skin color as a newborn?
Physiologic
jaundice
?
Cyanosis?
Does child have any rash or sores?
Does child have
diaper rash
?
Does child have any burns or bruises?
Where?
How did it happen?
Subjective Data Infants/children
Health History Questions
Past history of skin disease, allergies, hives, psoriasis, or eczema?
Change in pigmentation or color?
Change in mole size, shape, color, tenderness?
Excessive dryness or moisture?
Pruritus or skin itching?
Excessive bruising?
Rash or lesions?
Medications:
prescription and over-the-counter?
Subjective Data
Skin is
waterproof, protective,
and
adaptive
Protection from environment
Prevents penetration
Perception
Temperature regulation
Identification
Communication
Wound repair
Absorption and excretion
Production of vitamin D
Structure and Function (cont.)
Structure of Nails
Epidermal appendages:
Structures formed by tubular invagination of epidermis down into underlying dermis
Hair
Sebaceous glands
Sweat glands: important for fluid balance and thermoregulation
Eccrine glands
Apocrine glands
Nails
Structure and Function (cont.)
Structure of Skin
Think of skin as body’s largest organ system
Covers 20 square feet of surface area in adults
Skin is sentry that guards body
Environmental stresses, e.g., trauma, pathogens, dirt
Adapts it to other environmental influences, e.g., heat, cold
Structure and Function

Chapter 12
Skin, Hair, and Nails
Slide 2
A. Cyanosis
B. Flushing
C. Rubor
D. Jaundice
1. The nurse is assessing a patient who has been admitted for liver failure. What finding would the nurse expect?
Inspect and palpate skin (cont.)
Temperature
Use
backs of hands
to palpate person
Skin should be warm, and temperature equal bilaterally;
warmth suggests normal circulatory status
Hands and feet may be slightly cooler in a cool environment
Hypothermia
Hyperthermia
Moisture
Diaphoresis
Dehydration
Objective Data:
Physical Examination
Complete Physical Examination
Skin assessment
integrated
throughout examination
Scrutinize the outer skin surface first before you concentrate on underlying structures
Separate
intertriginous areas (areas with
skinfolds
) such as under large breasts, obese abdomen, and groin and inspect them thoroughly
These areas are dark, warm, and moist and provide perfect conditions for irritation or infection
Always inspect
feet,
toenails, and between toes
Objective Data:
Physical Examination
Health History Questions (cont.)
Hair loss?
Change in nails’ shape, color, or brittleness?
Environmental or occupational hazards?
Self-care behaviors?
Subjective Data
Skin has two layers:
Epidermis: outer highly differentiated layer
Basal cell layer forms new skin cells
Outer horny cell layer of dead keratinized cells
Derivation of skin color
Dermis: inner supportive layer
Connective tissue or collagen
Elastic tissue
Beneath these layers is a subcutaneous layer of adipose tissue
Structure and Function (cont.)
Slide 3
A. grouped.
B. zosteriform.
C. polycyclic.
D. linear.
2. The lesions in the illustration are best described as:
Epidermal appendages:
Structures formed by tubular invagination of epidermis down into underlying dermis
Hair
Sebaceous glands
Sweat glands: important for fluid balance and thermoregulation
Eccrine glands
Apocrine glands
Nails
Structure and Function (cont.)
Structure of Skin
Skin has two layers:
Epidermis: outer highly differentiated layer
Basal cell layer forms new skin cells
Outer horny cell layer of dead keratinized cells
Derivation of skin color
Dermis: inner supportive layer
Connective tissue or collagen
Elastic tissue
Beneath these layers is a subcutaneous layer of adipose tissue
Structure and Function (cont.)
Think of skin as body’s largest organ system
Covers 20 square feet of surface area in adults
Skin is sentry that guards body
Environmental stresses, e.g., trauma, pathogens, dirt
Adapts it to other environmental influences, e.g., heat, cold
Structure and Function
Epidermal appendages:
Structures formed by tubular invagination of epidermis down into underlying dermis
Hair
Sebaceous
glands
Sweat
glands: important for
fluid balance
and
thermoregulation
Eccrine
glands (saline solution called sweat)
Apocrine
glands (musky scent called love)
Nails
Structure and Function (cont.)
Structure of Skin
Skin has two layers:
Epidermis
: outer highly differentiated layer
Basal cell layer forms new skin cells
Outer horny cell layer of dead keratinized cells
Derivation of skin color
Dermis
: inner supportive layer
Connective tissue or collagen
Elastic tissue
Beneath these layers is a subcutaneous layer of
adipose
tissue
Structure and Function (cont.)
Think of skin as body’s
largest organ
system
Covers 20 square feet of surface area in adults
Skin is sentry that
guards
body
Environmental stresses, e.g., trauma, pathogens, dirt
Adapts it to other environmental influences, e.g., heat, cold
Structure and Function
Subjective and Objective Data
Skin Assessment
Subjective Data
Objective Data
Not so “Basic” at either end of the age spectrum.
Basic Skin Care
Pressure Ulcer Staging
Weakening of epidermal-dermal attachment
leading to skin tears

Overall Changes:
Thin, dry, fragile skin
Decreased healing rate
Decreased nutritional stores
Susceptible to friction & shear forces
Easily sensitive to
soap & cleansers
Age-related Changes
Atrophy
Thinning of all layers
Wasting more in extremities
Decreased padding over boney areas
Degeneration of collagen & elastin fibers
Decrease of collagen by 1% per adult year
Increased risk for poor wound healing
Age-related Changes
Dressing
Adhesives and Tape
“Tape Burns”
Surgical patient “tape-tenting phenomena”
Not applying skin sealants prior to taping
Epidermal Stripping
For ambulatory patients - legs
For immobile patients - arms
High Risk Areas
Same patient

Different body parts
Importance of Sun Exposure
Future Skin Tear Patient
Stiffness & spasticity
Polypharmacy
Dependent for ADLs
Use of assistive devices
Adhesive removal
Applying & removing stockings
Transfers & falls
> 85 years
Female
Caucasian
Immobility
Inadequate nutritional intake
Long term sun exposure
History of skin tears
Long term steroid use
Cognitive impairment
Risk Factors For Skin Tears
Are caused by trauma or surgery such as:
Abrasions
Lacerations
Incisions
Hematoma
Skin tears
Epidermal stripping from adhesives
Perineal dermatitis
These usually heal within 2 weeks
Acute Wounds
Pressure ulcers
Neuropathic ulcers
Arterial ulcers
Skin tears
Perineal dermatitis
Burns
Post surgical wounds
Malignancies
Dermatologic Conditions
Abrasions
Road Rash
Lacerations
Avulsion
Degloving
Traumatic amputations
Penetrating wounds
(GSW, stabbing,
impalement)
Which wounds will you see
in your patient ???
Total collapse of bone structures
Creates pressure points
Starts with callous formation
Deep tissue destruction over time
Charcot Foot
Diabetic Ulcers

Peripheral neuropathy and impaired microcirculation leads to increased risk for wounds and poor wound healing
Lower Extremity Neuropathic Disease (LEND)
Total collapse of bone structures
Creates pressure points
Starts with callous formation
Deep tissue destruction over time
Charcot Foot
Diabetic Ulcers

Peripheral neuropathy and impaired microcirculation leads to increased risk for wounds and poor wound healing
Lower Extremity Neuropathic Disease (LEND)
Dressing
Adhesives and Tape
“Tape Burns”
Surgical patient “tape-tenting phenomena”
Not applying skin sealants prior to taping
Epidermal Stripping
Total collapse of bone structures
Creates pressure points
Starts with callous formation
Deep tissue destruction over time
Charcot Foot
Practice Guidelines:
Treatment of Pressure Ulcers
Biophysical Agents:

Acoustic (Ultrasound)
Hyperbaric Oxygen Therapy – poor research on pressure ulcers
Topical Oxygen Therapy - insufficient evidence
Practice Guidelines:
Treatment of Pressure Ulcers
Biophysical Agents:
Electrical Stimulation – for stage III/IV
Electromagnetic Agents (PEMF) – for stage III/IV – primarily on expert opinion
Phototherapy
Infrared Therapy – insufficient evidence
Laser - insufficient evidence
Ultraviolet Light – expert opinion only
Practice Guidelines:
Treatment of Pressure Ulcers
Major components:
Wound assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Topical Therapy
Surgical Intervention
Manage Pain
Educate patients and family
Practice Guidelines:
Treatment of Pressure Ulcers
Major components:
Wound assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Topical Therapy
Surgical Intervention
Manage Pain
Educate patients and family
Creative Dressing Solutions
Posterior Head
Surface swabs are of little value for determining infecting bacteria but are sometimes ordered
Never take a swab of drainage under an occlusive dressing (e.g. hydrocolloid, transparent film)
A tissue biopsy is the best way to determine infective agent
Culturing the Wound
Practice Guidelines:
Treatment of Pressure Ulcers
Major components:
Wound assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Topical Therapy
Surgical Intervention
Manage Pain
Educate patients and family
Wound Assessment
Practice Guidelines:
Prediction and Prevention of Pressure Ulcers

Major components:
Risk Assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Educate patients and family
Pressure redistribution
Static Air – prevention
Alternating Air – prevention, early treatment
Foam - > 4 inch = prevention

Be sure they are inflated
Watch for “bottoming out”
Mattress Overlay
Minimizes pressure under bony prominences
Provides stability
Allows ease of transfer
Allows weight shifting
Controls temperature & moisture of skin
Is lightweight & cost effective
Is durable & easy to clean
Meets infection control standards
The Ideal Support Surface…
Practice Guidelines:
Prediction and Prevention of Pressure Ulcers

Major components:
Risk Assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Educate patients and family
Screen all “at risk” patients for nutritional status
Consider providing a minimum of:
30 to 35 kcal/kg
1.25 to 1.5 g/kg/day protein
1 ml of fluid per kcal/day
Refer patients to registered dietician
Offer high protein oral or tube supplementation
Nutrition for Patients at Risk
First step for protection from urine and stool
Long lasting Zinc Oxide formula
Treats and prevents rash associated with incontinence by sealing out wetness
Contains moisturizers and skin conditioners
Protective Cream
Practice Guidelines:
Prediction and Prevention
of Pressure Ulcers

Major components:
Risk Assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Educate patients and family
Is an alert & oriented 75 year old male with Diabetes and peripheral neuropathy.
He is admitted now due to left foot infection and has been restricted to bed. He is otherwise mobile.
He is continent of urine & stool
He told admitting nurse that he had not been feeling well 4-5 days prior to admission with fever, chills, nausea and vomiting
Mr. Little
Is on general surgery unit s/p right BKA. He has DM and PVD. He eats 50% of his meals but will take nutritional supplements b/w meals.
He is alert and confused. He has a sitter in the room because he has attempted to get out of bed twice. He refuses to stay turned on his side.
He is occasionally incontinent of urine and stool (2 times a shift).
Mr. Isaac
Is an 44 year old male on the step down unit - 5 days s/p small bowel resection and ileostomy due to Crohns disease.
He is alert and oriented. He has not advanced with his diet re no bowel sounds.
He refuses out of bed orders due to ongoing abdominal pain though he will turn when reminded.
Last night he spiked a temperature and has been very diaphoretic.
Mr. Black
One of the most important principles of prevention includes:

Identifying Those At Risk

Which scale to use?
Who completes the scale?
How often to perform risk assessment?
What level of risk = which interventions?
Practice Guidelines:
Prediction and Prevention of Pressure Ulcers

Major components:
Risk Assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Educate patients and family
Pressure Ulcer
Prevention
Usually occurs over bony prominences (but not always)
Shear, Friction, and moisture contribute
Time verses pressure relationship
It may take days or weeks to see full extent of damage
It may appear to worsen despite intervention
Pressure Ulcer Etiology
Conclusion
The intensity of pressure between the patient’s bony prominence & support surface (bed or chair)
Amount of pressure to close capillaries
Varies with age and blood pressure
Can not be directly measured
Tissue Interface Pressure
Pressure Ulcer
Etiology
Evidenced-based Practice
Questions & Discussion
Pain Management
Use pain scale to assess pain associated with ulcer and treatment
Prevent pain by:
Repositioning off ulcer
Handling wound with care
Utilize moist wound dressings
Practice Guidelines
Proteins that are used by many different types of cells for intercellular communication & wound healing
Platelet Derived Growth Factor is most recognized
Becaplermin gel (Regranex) is a PDGF for use in diabetic ulcers
Platelet Rich Plasma - autologous platelet preparation
TIME – Advanced Therapies
Growth Factors
Dermagraft & Apligraf - tissue engineered products from neonatal foreskin
Apligraf - bilayered skin product - fibroblasts from foreskin grown in a collagen matrix make dermal layer topped by epidermal layer grown from neonatal keratinocytes
Dermagraft - dermal substitute - fibroblasts from foreskin
Both approved for Diabetic ulcers, Apligraf also approved for venous ulcers
TIME – Advanced Therapies
Tissue Engineered Skin Substitutes
Unclear how this therapy works
TIME – topical agents
Distorts cells causing increased granulation tissue growth (effect directly on cells & release of biochemicals)
Stimulates new blood vessel growth
Reduces tissue edema
Removes fluid and bacteria from wound
Fill dead space = negative pressure wound therapy
TIME – topical agents
Amorphous - Usually changed daily
To fill dead space, saturate a gauze with the gel and pack into the wound
Sheet - used on partial thickness skin loss - skin tears and abrasions - usually changed every other day to Q 3 days
Minimally exudative to dry = Hydrogel
Excess moisture = calcium alginate


Used on moderate to heavily exudative wounds
Usually changed daily – silver alginate can be changed every 3-5 days
Can be used with necrotic tissue
Will be mushy when removed from the wound
Used to fill dead space
TIME – topical agent
Silver - many forms
Has antimicrobial properties

Contact Layer - used with minimally to moderate exudative wound
Silver Alginate - used with moderate to heavily exudative wounds – can be used to fill dead space
Silver Foam- used with moderate to heavily exudative wounds
Silver Wound Gel- used with minimally exudative wounds
Powder – can be used under negative pressure wound therapy
TIME – topical options
Iodine (Not betadine) formulations

Iodoflex ™ – paste is used with exudative wounds
Iodosorb ™– gel is used with less exudative wounds

Usually changed every 2-3 days
TIME – topical options
Enzymes: Santyl™

Can be used with gauze packing
Dressing changed daily
Breaks denatured protein bonds to remove necrotic tissue
Will NOT hurt healthy tissue
Chemical Debriding Agents
T = tissue – viable or deficient

I = infection/inflammation

M = moisture imbalance

E = edge of wound
Wound Bed Preparation:
The TIME approach
This is not a new concept

Decreased infection (Mertz Hutchinson, 1989; Buchan, Andrews & Lang, 1981)
Faster Healing (Winter, 1962; Barnett, Berkowitz Nemeth, Eaglstein Madden, Nolan Vogt, et al., 1995)
Decreased Scar Tissue (Linsky, Rovee & Dow, 1981)
Brem, H & Lyder, C (2004) Protocol for the successful treatment of pressure ulcers. The American Journal of Surgery, 188 (Suppl July, 2004) 9S-17S
Moist Wound Healing
Closure of the wound (Will wound heal? Cancer in the wound? Underlying osteomyelitis?)
Prevention of infection (Location of the wound?)
Reduction of pain (Does dressing change hurt? Is there pre medication?)
Decreased length of hospital stay (engage discharge planner early!!!)
Goals of Wound Management
Glucose metabolism
Oxygen consumption
Inflammatory cell infiltrates
Macrophages & Fibroblast function
Capillary growth
Collagen remodeling
Contraction & reepithelialization rate
Impact of Age on Healing
Nutritional Status
Protein Deficiency - affects all aspects of healing
Carbohydrates & Fats - leads to use of amino acids as energy source causing protein deficiency
Factors That Affect Wound Healing
Wound Care
Topical Therapy
Documentation:
Site – Sacrum
Stage – DTI
Appearance – 70% purple skin; 30% pink
Size – 16cm x 10cm
Odor – none
Drainage – small serous
Documentation:
Site – left heel
Stage – Unstageable
Appearance – 100% slough/tan
Size – 2.5cm x 2.5cm
Odor – none
Drainage – small yellow
Documentation:
Site – Sacrum
Stage – SDTI
Appearance – pink & purple intact skin
Size – 6 cm x 6 cm
Odor – none
Drainage – none
Sacrum
Documentation:
Site – Left heel
Stage – II
Appearance – intact serous blister
Size – 2cm x 2cm
Odor – none
Drainage – none
Forearm
Documentation:
Site – Sacrum
Stage – IV
Appearance – 10% bone; 90% pink
Size – 10 cm x 10 cm
Odor – none
Drainage – moderate sang
Documentation:
Site – lateral edge of right foot
Stage – III
Appearance – 100 % pink
Size – 3 cm x 1.5 cm
Odor – none
Drainage – small serous
Documentation:
Site – Bilateral Buttocks
Stage – II
Appearance – 100 % pink
Size – 8 cm x 15 cm
Odor – none
Drainage – small serous
Bilateral Buttocks
Bilateral Buttocks
Documentation:
Site – Sacrum
Stage – IV
Appearance – 70% slough/yellow; 30% pink
Size – 8cm x 12cm
Odor – moderate
Drainage – small yellow
Perirectal
Area
Sacrum
Buttocks
Pretibial
Area
Buttocks
& Posterior
Thighs
Buttock
Documentation:
Site – Sacrum/Coccyx
Stage – Stage IV
Appearance – 30% slough/yellow; 60% pink; 20% bone
Size – 4cm x 4cm; 4.5 cm x 4.5 cm
Odor – none
Drainage – small yellow
Documentation:
Site – Posterior Head
Stage – Unstageable
Appearance –100% eschar
Size – 5cm x 3cm
Odor – none
Drainage – none
Documentation:
Site – Sacrum
Stage – III
Appearance – 90% pink; 10% slough
Size – 1.5 cm x 1.5 cm
Odor – none
Drainage – small serous
Sacrum
Sacrum
Let’s Test Your Knowledge
More than 27 different bacterial species found in normal healing wounds


Presence of bacteria does not equal wound infection
Sepsis
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.

Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or
fluctuance) eschar on the heels serves as “the body’s natural (biological) cover” and should not be removed..
Unstageable
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers.
Bone/tendon is not visible or directly palpable .
Stage III
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.
Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.

Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage I may
be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (a heralding sign of risk).
Stage I
Identifies tissue involvement
Not documentation of healing
No reverse staging also called backstaging
Once a stage IV it remains a stage IV until completely healed
Staging
Only pressure ulcers are staged with this system
Stage

Describes the depth into the skin that the pressure ulcer extends

Based on system developed by
the National Pressure Ulcer Advisory Panel
For patient – comprehensive record of physical and mental status during stay
For hospital – reflects quality and quantity of care provided
For health care team – provides a multidisciplinary record of physical and mental status of patient and guides treatment re patient response to care
For legal system – serves as evidence of status of the patient and care provided
The Medical Record
The resident developed a pressure ulcer and the facility did not do one or more of the following:
a. Evaluate resident’s clinical condition and pressure ulcer risk factors;
b. Define and implement interventions that are consistent with resident needs, resident goals, and recognized standards of practice;
c. Monitor and evaluate the impact of the interventions;
d. Revise interventions as appropriate.
CMS definition of
Avoidable Pressure Ulcer
Note it says MOST but not ALL.


When the medical record reflects that all preventive measures have been provided and patient develops a pressure ulcer – this would be considered an Unavoidable pressure ulcer
Most pressure ulcers are preventable
Assume patient or family knows nothing about skin care & pressure ulcer prevention
Teach patient to turn every 2 hrs – and reasons to turn
Teach family to turn every 2 hrs at home
Engage family to assist with turning while in hospital – great training opportunity.
Patient and Family
Education
If Nothing Else….
Does it float the heels? If not…..
Gives a false sense of security
May actually be harmful
Heel Relief Devices?
Which One to Choose???
Reduce external pressure to heel:
Place a pillow under calf
Some mattresses provide a heel section
Place heel relief/reduction product
Prevention Modalities
High interface pressures to small area
Minimal padding (adipose tissue)
Bed rest creates shear forces (digging)
Physiologically: area with poorest blood flow
Why the Heels?
Provides pressure redistribution and higher air flow (microclimate)
For treatment of pressure ulcers
For treatment of severely eroded perineal dermatitis (diaper rash)

Remember
Always use air flow pads with this surface
Air Fluidized Therapy
Provides pressure redistribution as well as increased air flow (microclimate)
For prevention and treatment of pressure ulcers
For treatment of moderate perineal dermatitis (diaper rash)

Remember
Always use air flow pads with this surface
Low Air Loss Therapy

Know YOUR support surface weight limit Not the frame weight limit
First data point to determine appropriate bed is patient’s weight.
Support surface to sleep on

Pressure redistribution surface for:
prevention of pressure ulcers
treatment of pressure ulcer
treatment of perineal dermatitis

Therapy for prevention of pulmonary complications
Aid in providing care
Sized appropriately for bariatric patients
More than something to sleep on!
Mechanical Loading & Support Surface
Use pressure redistribution surfaces for at risk patients
Which bed surface is best?
Which chair cushion is best?
Use lifting devices (draw sheets)
Place cushion between knees and feet
Avoid trochanter positioning
Keep HOB as low as possible
Practice Guidelines
Teach patient/caregiver about importance of eating (protein intake)
Encourage family to bring in food from home (if consistent with medical plan of care)
Encourage family to feed patient – great time to teach about safest way to feed patient
Patient Education
Practice Guidelines:
Prediction and Prevention of Pressure Ulcers

Major components:
Risk Assessment
Skin Care and Managing Incontinence
Nutrition
Tissue Load Management
Educate patients and family
Long lasting formula (often with higher % zinc oxide)
Provides a high level of protection for patients with severe diarrhea
Will not wash away after repeated exposure to urine and feces
Contains karaya to absorb moisture and adhere to weepy, macerated skin
Non-sensitizing
Example Criticaid Paste, Extra Protective Cream
Protective Paste
Next (or first) step for treatment of perineal dermatitis
Long lasting petrolatum ointment or Dimethicone
Treats and prevents rash associated with incontinence by sealing out wetness
Contains moisturizers and skin conditioners
Protective Ointment
Soap free, pH balanced
No-rinse formula
Helps maintain skin’s natural acid mantle
Gentle, non-sensitizing formula which effectively cleanses and removes incontinent waste
No Rinse Incontinence Cleanser

Use Incontinence Cleanser after each incontinent episode

Use a protective cream or ointment after each episode of incontinence
Patient Incontinent Bladder/Bowel
Wilson, JR et al (2005) A toxicity index of skin and wound cleansers used on in vitro fibroblasts & keratinocytes. Advances in Skin & Wound Care, September, 373-78.
Toxicity level of body washes on skin (keratinocytes):
Dial antibacterial soap 1000
Dove body wash 1000
Ivory liqui-gel 1000
Must be diluted 1:1000 to not damage
the skin!
To Soap or not to Soap?
Dry skin
Cracked & fissured skin
Skin tears
Perineal dermatitis
Pressure ulcers
Damage to skin leads to…
SKIN
Periodic inspection
Skin cleansing
Care of dry skin
Use of moisture barriers
Implement a plan to address incontinence
The plan of care should include…
Sensory Perception 4 alert
Moisture 2 linens changed twice/shift
Activity 2 chair fast (non-amb re new BKA)
Mobility 4 able to get OOB & fall
Nutrition 2 50% meal & takes supplement
Friction/Shear 3 can turn self onto back
Total 17 low risk
Braden Score
Sensory Perception 4 alert & oriented
Moisture 3 diaphoretic
Activity 1 refuses amb
Mobility 4 able to turn w/o help
Nutrition 1 5 days not eating
Friction/Shear 3 able to move self
Total 16 low risk
Braden Score
Sensory Perception 1 unresponsive
Moisture 4 cath. & no stools
Activity 1 bedfast
Mobility 1 immobile
Nutrition 2 feedings on hold
Friction/Shear 1 250 lbs & immobile
Total 10 high risk
Braden Score
Is a 250 lb female admitted from a nursing home with aspiration pneumonia.
She is unresponsive & immobile re CVA.
She has a urinary catheter, PEG tube and tracheostomy Her tube feedings are on hold due to PEG tube clogged.
You are to administer a SMOG enema due to no BM in 5 days.
Ms. Allen
Braden Scale
6 subscales
Significant research
Norton Scale:
5 parameters – score range 5 to 20
Performance Palliation Scale
5 subscales
Focus on hospice patients
Needs more research
Adult Risk Assessment Scales
Moisture - macerates the epidermis & makes skin at increased risk

Sources of moisture
Urinary incontinence
Fecal incontinence
Draining wounds
Diaphoresis
Moisture
Layers of skin slide across one another
Tearing or blood vessels
Increases when HOB elevated
Shear Forces
Certain co-morbidities increase risk of pressure ulcer development:
Diabetes Alzheimer’s disease
Arteriosclerosis Spinal cord injury

66% elderly admitted with femur fracture

33% patients in ICU

60% prevalence rate with quadriplegia
Co-Morbidities
Objects found in two patient’s bed!
Acute Limb Ischemia (ALI) – sudden onset; needs urgent attention for limb salvage
Critical Limb Ischemia (CLI) – most common presentation = rest pain.
1 year mortality rate > 20%
40% need amputation within 6 months
LEAD
Includes:
peripheral vascular disease (PVD)
peripheral arterial occlusive disease (PAOD)
peripheral arterial disease (PAD)
Disorder affecting the leg arteries
ABI < 0.9 independently associated with increased risk for cardiovascular death
Twice as likely to have cardiovascular event within 5 years (Collins et al., 2006)
Lower Extremity Arterial Disease (LEAD)
Off Loading is Key to Healing
Posterior Head
Laceration
Hematoma
Main function of this layer is to act as a barrier to outside world.
Avascular
Keratinocytes - produces keratin
(waterproofing substance)
Melanocytes - produces melanin
(provides skin color)
Langerhans Cells - macrophages -ingests foreign substances. (Garbage disposals)
New epidermis every 4 to 6 weeks (regenerates)
Epidermis
Skin is made of 2 layers: Epidermis and Dermis.

They rest on subcutaneous adipose tissue

Protect muscle, tendon and bone

To accurately assess depth of a wound, these structures need to be identified.
Anatomy of Skin
Skin 101
Wound Healing at the Cellular Level
Hinman & Maibach (1963) showed similar effect in humans
Removing dry bandages:
Causes secondary trauma
Removes cells attributed with healing (epithelial cells & fibroblasts)
Modern Wound Healing
Wound Healing at the Cellular Level
Winter (1962) animal models showed:
Occluded wounds healed faster (moist wound environment)
Increased epithelialization
Wounds exposed to air healed slower
Modern Wound Healing
AHRQ (formerly AHCPR) guidelines are outdated and archived
WOCN Society published guidelines for pressure ulcers in 2010
AMDA published revised and updated guidelines in 2008
NPUAP and EPUAP published their first international guidelines in 2010
Guidelines for Care
www.guideline.gov

10 guidelines listed
Registered Nurses’ Association of Ontario
American Society of Plastic Surgeons
Smith and Nephew
Institute for Clinical Systems Improvement
Paralyzed Veterans of America
National Stroke Foundation
American Medical Directors Association
John A. Hartford Foundation –Institute for Geriatric Nursing
Wound Ostomy and Continence Nurses Society (not listed)
AHRQ Pressure Ulcer Prevention and Treatment (not listed)
“Pressure Ulcer” Guidelines
The Curriculum Developer warrants that he/she owns all copyrights and other rights to reproduce and distribute any associated handout materials, or that the he/she is authorized by the owner to reproduce and distribute such materials for this workshop. The Curriculum Developer further warrants that all materials contributed herein are
not libelous or unlawful, will not cause harm or injury, and do not infringe on any
copyright or other proprietary, personal, or contractual rights of any other party
whether statutory or non-statutory, of any third parties.
NOTE:
Some of the pictures and images in the PowerPoint presentation were not included in this handout.

Please use the white areas/back of page to include any references for images not printed.
Calcium Alginate
Silver Contact Layer
Hydrocolloid
Sacral shaped foam
Sacrum
What topical therapy would you use?
Transparent Film
ECM
Wet to Dry Dressing
Sacral shaped foam
Lateral Edge of Foot
What topical therapy would
you use?
Barrier Ointment
Interdry AG
Heel Pressure Relief Device
NPWT
Buttocks
What topical therapy would you use?
Transparent Film
Hydrocolloid
Barrier Paste
Santyl Ointment and gauze
Sacrum
What topical therapy would you use?
Pressure Relieving Cushion
Silver Contact Layer
Cadexomer Iodine
Santyl Ointment
Posterior Head
What topical therapy would you use?
Acticoat
ECM AG
NPWT
Normal saline or DABS moist to moist dressing
Buttocks & perianal area
What topical therapy would you use?
Santyl
None
Silver Wound Gel
Silver Contact Layer
Sacrum
What topical therapy would you use?
Nothing
NPWT
Cadexomer Iodine
Hydrocolloid
Posterior Head
What topical therapy would
you use?
Silicone Foam
Wound Gel
ECM
Barrier Paste
Perineal/buttocks
What topical therapy
would you use?
Silver Foam
Silicone Foam
Santyl Ointment with hydrotherapy
Nothing, this is fine!
Sacrum
What topical therapy
would you use?
Calcium Alginate
Silver Foam
Antifungal Cream and Barrier Paste
Wound Gel
Buttocks
What topical therapy
would you use?
Wet to dry dressing
Cadexomer Iodine
Calcium Alginate
Santyl and gauze
Sacrum
What topical therapy
would you use?
TIME – topical agents
Encourages deposition & organization of new collagen fibers & granulation tissue in the wound.
Extra cellular matrix also decreases proinflammatory cells in wound bed.

Changed every 1-3 days
Slow proliferation (filling in the dead space) = Collagen, Extra Cellular Matrix
TIME – topical agents
Can be very cost effective
Changed every 5-7 days & when wound fluid leaks
Can not be used on ulcers with a cavity
Supports autolytic debridement
Use this when surrounding skin is intact and healthy
Minimal moisture = Hydrocolloid
Mepilex Border
TIME – topical agents

Used on moderate to heavily exudative ulcers
Changed every 3-7 days depending on amount of drainage
Good for hypergranulation tissue
Excellent around tubes & tracheostomy
There is a silicone adhesive foam – good for use on skin tears
Excessive moisture = Foam
Bedside hydrotherapy – pulsed lavage or ultrasonic debridement

Use normal saline

PSI of 12-15 – loosen necrotic tissue but not hurt healthy tissue

Adjunct for mechanical debridement

Performed by Physical Therapy
Pulsed Lavage
Facilitate discharge (What is the post discharge location? What can they provide?)
Cost (Is there insurance? Can they afford the dressings? )
Ease of procedure (Who will do the dressing?)
Goals of Wound Management
Nutritional status assessed
Correct Extrinsic Factors:
Pressure relief
Moisture management
Shear/friction addressed
Before You Dress!
Or
How to make the best of a bad situation
Chronic Wound Management
Impaired oxygenation
Cigarette smoking – each cigarette causes vasoconstriction of the blood vessels
Endocrine disorders - Diabetes
Coagulation disorders - thrombocytopenia
Immunologic disorders - decreases ability to clear infection
Psychological factors – depression, stress and pain
Factors That Affect Wound Healing
Malfunction in normal wound healing cascade

Chronic wound fluid has:
elevated protease activity
diminished growth factor activity
elevated levels of proinflammatory cytokines

The wound gets stuck in inflammatory and proliferative stages and doesn’t move on to complete closure
Chronic Wound Healing
Buttock
Heel
Note speckled base = hair follicles
Documentation:
Site – Left buttock
Stage – II
Appearance – 100% pink
Size – 3 cm x 3 cm
Odor – none
Drainage – small serous
Left Buttock/
Sacrum
Melanoma
Documentation:
Site – Lateral right calf
Stage – no stage – not a pressure ulcer
Appearance – 50% yellow; 20% black; 30% pink
Size – 10 cm x 10 cm
Odor – foul
Drainage – moderate yellow & sang
Lateral Calf
Documentation:
Site – Forearm
Stage – No stage – not a pressure ulcer
Appearance – 100% pink
Size – 5cm x 3cm
Odor – none
Drainage – small serosang
Posterior/Lateral Lower Thigh
Lateral edge
of foot
Muscle
Sacrum
Documentation:
Site – Posterior Head
Stage – I
Appearance – pink intact skin
Size – 4 cm x 1 cm
Odor – none
Drainage – none
Posterior Head
Pressure damage from a urinary catheter
Documentation:
Site – Left Buttock
Stage – III
Appearance – 100% pink
Size – 4cm x .7cm
Odor – none
Drainage – small serous
Posterior Head
This is slough covered area from pressure damage
Documentation:
Site – Sacrum
Stage – Unstageable
Appearance – 100% slough/yellow;
Eroded to 5 cm out
Size – 3cm x 3cm
Odor – none
Drainage – small yellow & serosang.
Slough
Tissue
Sacrum
Clean wound with saline
Use culture swab and roll over no more than 1 cm area of pink tissue
Press hard enough to express fluid from tissue bed
Use the Levine Method when obtaining a surface culture of the wound that has been ordered by the physician
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.

Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar.
Suspected Deep Tissue Injury (DTI)
Stage IV
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling.

Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable..
Stage IV
Stage III
Stage II
Linear measurements - longest length & widest width & greatest depth
Size
Linear pressure ulcer on posterior upper calf related to TED hose
Pressure ulcer can occur in any location when pressure is related to a medical device such as NG tubes, cervical collars, and other care items.
Wound Assessment
Pressure Ulcers physical assessment
Location Undermining
Stage Sinus tracts
Wound bed Tunneling
Surrounding skin Odor
Wound edges Exudate
Size
Reassess for ulcer healing at least weekly
Adjust treatment plan if no progress in 2 weeks
Practice Guidelines
Policies and procedures
Skin care products
Specialty beds
Documentation forms
Consultative services (Wound, Nutrition, OT/PT)
Linen and lifts
You can have tools for preventing avoidable pressure ulcers
Give your defense expert something to defend you with
DOCUMENT YOUR CARE
Medical record
Any photographs
Depositions from care providers and family
National and local standards
What does the Medical Legal Expert use to determine care meeting the national standards???
Pressure ulcer litigation is still a major occurrence that seems to be spreading nationally and internationally
Effecting long term care and acute care
CMS definition of
Unavoidable Pressure Ulcer
The pressure ulcer developed even though the facility had:
Evaluated the resident’s clinical condition and pressure ulcer risk factors;
Defined and implemented interventions that are consistent with resident needs, goals, and recognized standards of practice;
Monitored and evaluated the impact of the interventions;
Revised approaches as appropriate.
Co-morbidities
Peripheral vascular disease
Diabetes
Congestive heart failure
Peripheral neuropathy
Contractures of knees &/or hips
Venous insufficiency = edema
Why the Heels?
Mechanical Loading & Support Surface
For the Critically Ill patient:
Upgrade surface for high risk patient
Even small shifts are beneficial for pressure ulcer prevention
Monitor patients for shear injury when continuous lateral rotation therapy is used
For Bariatric patient
Ensure surface weight limit
Ensure adequate width
Strongly consider air flow surfaces for moisture
Practice Guidelines
Mechanical Loading & Support Surface
Reposition all at risk patients
Use pressure redistribution surfaces
Chair bound shift weight Q 15 minutes
Use lifting devices (draw sheets)
Place cushion between knees and feet
Avoid trochanter positioning
Keep HOB as low as possible
Practice Guidelines
NPO, nauseated, missed meals re tests, change in taste re medications, cultural differences, food quality, medical condition (swallowing dysfunction), fatigue, isolation ..

Eating is a social event
Nutrition and the
Hospitalized Patient
Linear pressure ulcers from diapers
They Do Cost too Much!
No diaper
One pad
. . . Open Air System Is Best
No diapers
Why????
Diaperless units drop their nosocomial infection rate
Avoid Pitfall Practices
So we DON’T see these
Restores moisture, conditions and soothes dry skin
Use for all over body moisturizing
Lotion will NOT provide adequate moisturizing

Many examples: Eucerin, Secura, Remedy etc – no research to support one over another
Moisturizing Cream
No Rinse Incontinence Cleanser
No Rinse Bath additive
What should be avoided ?
What should be used…
Remember . . .
Avoid use of bar soap, liquid soap, or baby shampoo during bed bathing
Use gentle no rinse body wash for full body washing
Containing no detergents known to dry skin
Provides an emollient to help prevent dry skin
Routine Skin Care
Sensory Perception 4 alert & oriented
Moisture 4 continent of bowel & bladder
Activity 1 Bedfast
Mobility 4 mobile in bed
Nutrition 1 poor PO intake prior to admission
Friction/Shear 3 moves self in bed
Total 17 low risk
Braden Score
Braden Q
Studied on acutely ill children
7 subscales
Neonatal Skin Risk Assessment
Based on Braden Q
Researched on Neonatal population
Neonatal Skin Condition Scale
Low birth weight
Starkid Skin Scale
Based on Braden Q
Researched on general pediatrics – not neonatal
Pediatric Risk Assessment Scales
“Ounce of Prevention…
equals a Pound of cure”
Cheaper than treatment
Medicare and most insurance companies do not pay for prevention
Pressure Ulcer Prevention
$11 billion per year
$2,000 to $40,000 per pressure ulcer
$25,000 in reconstruction costs
Not included:
Amputations
Legal awards
Human suffering
Prosthesis
Lost wages
Cost of the Problem
Tissue
Friction
Persistent rubbing of skin
Damaging epidermis
Tremors or casts
Friction
Shear
Friction
Pressure
Moisture
Major Extrinsic Forces
Pressure Ulcers
Caused by What?
www.NPUAP.org
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 and/or friction.
A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated.
Pressure Ulcer Definition
Compression Therapy
Duke Boot (Unna Boot)
Malformation of valves in venous system or regurgitation
Malfunctioned valves in veins
Chronic edema
Stasis ulcers in calf region
Venous Ulcers
Side of Calf
Avulsion – patient “bumped” her wheelchair
Abrasion Due to a Fall
Are caused by trauma or surgery such as:
Abrasions
Lacerations
Incisions
Hematoma
Skin tears
Epidermal stripping from adhesives
Perineal dermatitis
These usually heal within 2 weeks
Acute Wounds
Made of connective & adipose tissue
Nutritional reserve during starvation & illness
Mechanical shock absorber
Heat insulator
Vascular (major blood vessels)
Lymphatics structures
Nerves receptors
Subcutaneous Tissue
Provides support & nutrition to epidermis
Fibroblasts –
Important role in wound repair
Produces collagen & elastic fibers
Macrophages (Garbage disposals)
Rich vascular supply
Nerve receptors
Lymphatic
Dermis
Largest organ of body
Protects other organ systems
Regulates body temperature
Absorption and excretion
Provides major sensory function of touch and pain (tactile sensation)
Importance of Healthy Skin
WOCN Society published guidelines for
Arterial Leg Ulcer – 2008
Venous Leg Ulcer - 2005
Neuropathic Ulcer – 2004
DPM – Neuropathic Foot Ulcers – 2006
CDC – Surgical Site Infection – 1999
American Society of Plastic Surgeons – Leg Ulcers - 2007
Guidelines for Care

Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) (National Patient Safety Goals)
Center for Medicare & Medicaid Services
Magnet Hospital (National Database of Nursing Quality Indicators)
Standards from Subspecialty Organizations (ONS, AACN, NPUAP, WOCN, AAWC)
Division of Facility Services
Nursing, Medical, PT, OT Schools
Guidelines for Clinical Practice
Hospital Nursing Process Standards (Pressure Ulcer Prevention Protocol, Specialty Bed Protocol, Advanced Skin Care Protocol, Dressing Change Procedures)
Hospital Structure Standards (Staffing Policy)
North Carolina Board of Nursing, Physical Therapy, Medicine, Occupational Therapy…..
North Carolina Statutes (Nurse Practice Act)
National Discipline Organizations (American Nurses Association, American Medical Association)
Agency for HealthCare Research and Quality
Wound Research
Guidelines for Clinical Practice
Created by:
Penny Jones RN, MN, CWS, CWCN
Wound Care:
Evidenced-based Practices
Pain Management
Administer appropriate pain medication
Utilize diversion interventions for pain management
Music
Guided imagery
Therapeutic touch
Practice Guidelines
Surgical Intervention
Optimize nutrition
Smoking cessation 1 month before and a minimum of 1 month after surgery
Determine presence of osteomyelitis
Obtain appropriate post op surface
Post operative care
HOB as low as possible
Continue pressure ulcer prevention efforts
Plan for continuum of care – supportive care
Practice Guidelines
Iodine solution
Silver Contact Layer
Hydrocolloid
Sacral shaped foam
What topical therapy would you use?
Santyl
Silver Alginate
Transparent film
Hydrocolloid
Plantar Aspect of Foot
What topical therapy would you use?
Calcium Alginate
Hydrocolloid
Barrier Paste
NPWT
Pretibial area
What topical therapy would you use?
Hydrocolloid
Calcium Alginate
NPWT
Looks good to me. I wouldn’t put anything on these.
What topical therapy would
you use?
Wet to Dry Dressing
Foam and Compression Wrap
Transparent Film
NPWT
Pretibial Area
What topical therapy would
you use?
Hydrocolloid
Crushed Metronidazole & Xeroform/Vaseline Gauze
Transparent Film
NPWT
Chest Wall
What topical therapy would you use?
Silver Wound Gel
Barrier Paste or Barrier Ointment
Transparent Film
NPWT
Buttock
What topical therapy would you use?
Usually changed 2-3 times weekly
Can be painful – be sure to pre-medicate
Consult with discharge planner early – requires significant discharge planning
Obtain wound measurements
Contraindications:
wounds with cancer cells
untreated osteomyelitis
> 30% necrotic tissue
Unexplored fistulas
TIME – topical agents
Indications:
Diabetic & stasis ulcers
Dehisced surgical wounds
Grafts & flaps
Pressure ulcers
This wound has more obvious signs of infection – red, swollen surrounding skin
Usual signs of infection often missing in chronic wounds
TIME
Infection
Friable, absent or abnormal granulation tissue
Pus
Odor
Delayed healing
Pain/tenderness
Increased exudate
Change in color of wound base
Look for:
Usual signs of infection often missing
TIME – Bioburden Management
Use Normal Saline or DABS solution
Be sure to moisten before removal from the wound
Contrast with Wet to Dry which is a form of non-selective debridement
TIME - Moist to Moist Dressings
“self-cleaning”
Wound exudate is rich in proteolytic enzymes that liquefy necrotic tissue and create a moist environment
Most conservative form of debridement
Examples of dressings – hydrocolloid, wound gel
Autolytic Debridement
Necrotic tissue must be removed for the wound to heal. Wounds without adequate arterial supply may not be debrided.

There are 4 ways to debride the wound.
Sharp - scissors or scalpel
Chemical - Collagenase
Autolytic - moist wound environment
Mechanical - wet to dry dressings, hydrotherapy
TIME - Tissue
Inhibits Wound Healing
Glucocorticsteriods
Antineoplastic drugs
Anticoagulants
Stimulates Wound Healing
Growth hormone
Vitamin A Vitamin C
Copper Zinc
Effect of Medications
Very mature scar tissue > 1 year old
Replacement of Collagen type II with Collagen type I
Decreased surface capillaries related to decreased needs
Starts at 6 weeks and continues for 2 years
Reaches tensile strength of 80%
Differentiation Phase
Blister
Heel
Documentation:
Site – Post thigh
Stage – Stage I
Appearance – 100% intact pink skin
Size – 1cm x 5cm
Odor – none
Drainage – none
Posterior/Lateral Lower Thigh
Bone
Sacrum
Squamous cell cancer
Note lesion on non-pressure point areas
Documentation:
Site – Buttock & perineal
Stage – No stage – not a pressure ulcer
Appearance – 100% pink
Size – 15cm x 8 cm
Odor – mild
Drainage – small serosang
This is what happens when hydrocolloid is applied to fragile, eroded skin
Documentation:
Site – Sacrum
Stage – Unstageable
Appearance – 40% slough/yellow; 60% pink; eroded perirectal area
Size – 4cm x 4cm
Odor – none
Drainage – small serous
Pressure ulcer in this area would be linear with more regular edges
Documentation:
Site – Right Calf
Stage – No stage – not a pressure ulcer
Appearance – 100% slough
Size – 8cm x 4cm
Odor – mild
Drainage – small yellow
Herpes Simplex Virus lesions
Documentation:
Site – Posterior thighs & buttocks
Stage – Not a pressure ulcer – do not stage
Appearance – 100% pink
Size – 5cm x4cm;
with several smaller lesions
on buttocks
Odor – none
Drainage – small serous
Bone
Sacrum
Slough tissue covering this area
Documentation:
Site – Sacrum
Stage – Unstageable
Appearance – 20% slough/yellow; 80% pink
Size – 5cm x 4cm
Odor – none
Drainage – small yellow
Use gloved finger to measure undermining whenever possible
Location - use clock position with head being 12 o’clock and feet being 6 o’clock (e.g. 4 cm at 12 o’clock)


Use extreme caution when using cotton tipped swab – especially into area where other vital organs or larger blood vessels are located
Sinus Tracts & Undermining
Note the red, edematous surrounding skin. Very reliable sign of wound infection.
Signs & Symptoms of Infection
extensive erythema
pus
edema
pain
elevated body temperature
change in drainage or odor
elevated WBC
Wound Infection
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 blister.

Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising.*
This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation.
*Bruising indicates suspected deep tissue injury .
Stage II
Stage I
Most common location for adults is sacrum and then heels
Most common location for pediatrics is posterior head
Medial &
Lateral Malleolus
Knee
Trochanter
tuberosities
Shoulder
Ear
Inspection of the pressure ulcer involves several key areas.
Anatomical location
Size & shape
Sepsis
Exudate
Surrounding skin
Sinus tracts & undermining
Maceration
Epithelialization
Necrotic tissue
Tenderness & Tissue bed
Assessment of the pressure ulcer
2nd most common site (Adult & Pediatric)
Consistent increased prevalence nationally
Occurs in all care settings
10% -18% hospital pressure ulcers
Scope of Problem
Mechanical Loading & Support Surface
Provide heel protective devices that completely suspend heels
Is a pillow under calves adequate?
What about sheep skin or bunny boots?
Avoid use of ring pressure reduction devices
Avoid positioning on medical devices
Practice Guidelines
Keep food warm; re-warm before serving
Offer hand washing before meals
Position in high fowlers or sitting
Feed patients if they can’t feed themselves
Offer nutritional supplements – on ice
What Can You Do?
Diapers Do Cost too Much!
Plastic chux pads
Multiple “layers” under patient
Non-Airflow pads on air flow surfaces
Avoid Pitfall Practices
Not so “Basic” at either end of the age spectrum.
Basic Skin Care
Total collapse of bone structures
Creates pressure points
Starts with callous formation
Deep tissue destruction over time
Charcot Foot
For ambulatory patients - legs
For immobile patients - arms
High Risk Areas
Within first couple of weeks these are considered
Acute wounds

After a few weeks these
are considered Chronic wounds
Perineal Dermatitis
Skin Tear
Calf
Chronic:
Takes longer to heal (>2 weeks)
Pressure ulcers
Venous stasis ulcers
Neuropathic Ulcer
Arterial ulcers
Malignancy wounds
Skin diseases (Pyoderma gangrenosum, connective tissue diseases, calciphalyxis)
Treatment related wounds (IV infitrates)
Type of Wounds
Practice standards have been out for the past decade.
Why do some hospitals continue to struggle with wound management?

We have the knowledge to impact policy, but come up short with practice!
Wound Care Today
Barrier Paste
Wound Gel
Santyl Ointment
NPWT
Coccyx/Sacrum
What topical therapy
would you use?
Note removal of necrotic tissue and increased amounts of healthy pink tissue
Same wound after sharp surgical debridement and moist dressings
This wound is dry and necrotic
Use pulsed lavage, ultrasonic debridement or irrigate with 30 ml syringe and 18 gauge IV catheter
Use saline to clean initially and with each dressing change

Avoid use of cytotoxic agents (hydrogen peroxide, acetic acid, Dakin’s solution, Betadine)
It all starts with cleaning the wound bed
Note the diaper
Documentation:
Site – Buttocks
Stage – No stage – not a pressure ulcer
Appearance – eroded rash
Size – entire perineal & inner buttocks
Odor – none
Drainage – small serous
Note odor of exudate/wound
None
Mild
Moderate
Foul
Note color of wound drainage
Serous
Serosanguinous
Bloody
Yellow/purulent
Green
Tan
Note amount of wound drainage
Scant
Small
Moderate
Large
Copious
Exudate
Medical Records are Legal Documents!
The record and ulcer are all that are left behind
REMEMBER
In real time
Document ALL events
Not like this!!!!
Only
Use airflow pads on low air loss and air fluidized surfaces

Turn patient every 2 hours Patients need turning for pulmonary toilet in addition to skin issues.
Specialty Bed Protocol
CLRT therapy is indicated for a maximum of 7 days after a pulmonary insult
Continuous Lateral
Rotation Therapy
ICU Patient with 2 of the following:
Intubated
Immobile/ineffective mobility
Receiving neuromuscular blockage
Hemodynamically unstable with manual turning
Yes
The next decision point for non-bariatric patient is pulmonary status

Protein Deficiency - effects all aspects of healing
Carbohydrates & Fats - leads to use of amino acids as energy source causing protein deficiency
Nutrition and Pressure Ulcers
14
9
12
21
18
Completed on admission and periodically
A score of 18 or less equates to risk
Helps guide overall prevention strategies
Prevention/treatment are focused
on patients at risk
Interventions based on subscales
Braden Pressure Ulcer
Risk Assessment Scale
SHEAR
PRESSURE
Tissue
Time and magnitude relationship
Two type of tissue damage:
Superficial (dermal layers)
Deep tissue (subcutaneous and muscle)
Blood Vessels feeding skin flow horizontal and vertical
Shear alters vertical flow
Pressure alters horizontal flow
Muscle tissue more susceptible to mechanical forces than skin
Tissue Biomechanics
Diabetic Ulcers

Peripheral neuropathy and impaired microcirculation leads to increased risk for wounds and poor wound healing
Lower Extremity Neuropathic Disease (LEND)
Same patient

Different body parts
Importance of Sun Exposure
Lateral Thigh
Burns
Superficial (1st degree)
Partial Thickness (2nd degree)
Full Thickness (3rd degree)
Type of Wounds
Technology
Standards
Practice
Policy
Dressings
The Wound Care Dilemma
Hypergranulation
Epiboli
Healthy advancing margins
Problems = hyperkeratotic, undermining, epiboli, hypergranulation wound base
TIME – Edge of Wound
Too moist
Too dry
Balance between extremes
Moisture facilitates epidermal migration
Excessive chronic wound fluid = ongoing inflammation
TIME
Moisture Balance
Hematoma formation

Oxygenation

Pressure - Capillary closure pressure - 20 to 40 mmhg

Shear & Friction forces

Radiation
Microorganisms - S. aureus, group A. strep, P. aeruginosa, e. coli

Foreign bodies - gauze pieces

Necrotic tissue

Dehydrated wound base
Factors That Affect
Wound Healing
This wound has severely eroded surrounding skin which will affect which dressing can be used.
Unstageable sacral pressure ulcer
Provides clues about status of the wound & effect of treatment
Color
Intact
Edema
Induration
Maceration
Surrounding Skin
POD # 40
POD # 11
POD # 5
DTI Evolution
POD #3
POD #17
Initial small discoloration 4-7 days post-op
Tissue off loading (specialty beds) does not reverse process
Speculate the damage occurred prior to observable signs
DTI Assessment
* Most common areas for pressure ulcer development in adults
Spinous Process
Ulcers can occur on any bony prominence
Scapulae
Elbow
Head
Ischial
tuberosities
Heels*
Sacrum *
Most commonly occur in these areas
Posterior Head
Heels
Sacrum
Pressure Ulcers
Are caused by an underlying impaired arterial flow such as with the pathology of peripheral vascular disease

Can also occur as a result of an emboli or as a consequence of vasoactive therapy
Arterial Ulcers
Dressing
Adhesives and Tape
“Tape Burns”
Surgical patient “tape-tenting phenomena”
Not applying skin sealants prior to taping
Epidermal Stripping
Future Skin Tear Patient
Stiffness & spasticity
Polypharmacy
Dependent for ADLs
Use of assistive devices
Adhesive removal
Applying & removing stockings
Transfers & falls
> 85 years
Female
Caucasian
Immobility
Inadequate nutritional intake
Long term sun exposure
History of skin tears
Long term steroid use
Cognitive impairment
Risk Factors For Skin Tears
Abdomen
Lateral Thigh
Chronic
Acute
Post Surgical Wound
Arm
Knee
Buttocks
Abrasion
“Road Rash”
No
Skin and Wound Issues are next decision points
Yes
Yes
Routine Support
Surface
Air Fluidized Therapy
Low Airloss Therapy
Has 2 or more following criteria:
Immobile  22 hours daily
Truncal stage II pressure ulcers on 2 or more turning surfaces
Moderate moisture issues
Pressure ulcer on only 1 surface and at very high risk for further pressure ulcer development (Braden < 9 or Braden Q <16)
Has 2 or more following criteria:
Immobile  22 hours daily
Truncal stage III or IV pressure ulcers on 2 or more turning surfaces
Post op posterior flap/graft
Severe issue with moisture
The goal is to avoid seeing these
Your patient may be predisposed to developing a pressure ulcer because of these intrinsic factors
Poor Nutrition
Age
Infection
Disease
Body Type
Sensory Loss
Immobility
Pressure Ulcer
From knee immobilizer
Eschar is hard leathery necrotic tissue
Slough is stringy gray to whitish necrotic tissue
“Wound healing cannot take place until necrotic tissue is removed.”(Maklebust & Sieggreen, 1996)

Hard stable eschar on the heels is an exception. That would not be debrided.
Necrotic Tissue
Chin
Forehead
Toes
Patella
Pubis
Shoulder
Ear
Prone Positioning
Some potential consequences of Avoidable Pressure Ulcers
Internet Reporting
www.medicare.gov/nhcompare/
http://www.nchospitalquality.org/index.lasso
Civil Penalties
Citations
Higher Cost of Care
Each category has a score of 1 to 4 except friction & shear.
Lowest total score is 6
Highest total score is 23
Friction & Shear
Nutrition
Mobility
Activity
Moisture
Sensory Perception
There are 6
subscales
PRESSURE
PRESSURE ULCER
YEAST
FUNGUS
SHEAR
FRICTION
ERODED SKIN
PERINEAL DERMATITIS
PERSPIRATION
MACERATED SKIN
(OVER-HYDRATED)
URINE
FECES
INTACT SKIN

A Pressure Ulcer Develops
The eroded skin is now open to microbial invasion and can then be made worse by friction and shear
CANDIDA ALBICANS
SHEAR
FRICTION
ERODED SKIN
PERINEAL DERMATITIS
PERSPIRATION
MACERATED SKIN
(OVER-HYDRATED)
URINE
FECES
INTACT SKIN
The Result Is . . .
Your patient may be placed at increased risk related to increased extrinsic factors from their environment.
Incontinence
Heat
Posture
Moisture
Impact Injury
Friction/ Shear
Pressure
Pressure Ulcer
Reavy, K & Tavernier S (2008) Nurses Reclaiming Ownership of Their Practice: Implementation of an Evidence-Based Practice Model and Process. Journal of Cont Ed in Nursing; 39(4):166-172.
Communication
Ideas/Questions
Ideas/Questions
Staff Nurse
(Clinical Expert)
Uses findings in practice,
Contributes ideas for research,
Asks questions.
Nurse Researcher/
Best Research Evidence
Patient
Recipient of care,
values
POD # 42
POD # 32
POD # 10
POD # 16
DTI Evolution
Phases of Normal Wound Healing
100
Differentiation
30
Proliferative
10
Time (Days)
3
1
Inflammatory
Acute wounds follow a normal cascade
when healing.
Kinair IV
Continuous Lateral Rotation
SpOrt
Advanced 3000
Total Care
Crib
BariMaxx
Size Wise Big Turn 2
Magnum II
Clinitron Rite Hite
Clinitron
Envision
Bariatric
Zoneaire
Foam
Air Fluidized
Low Air Loss
The Bottom Line: The blood loss is stopped and wound is cleaned up
Inflammatory Phase
Garbage disposals for wound
Wound Macrophage
Remove foreign bodies, bacteria, non-functional host cells & damaged matrix components
Enhances Fibroblast &
Smooth muscle cell chemotaxis
Brings in chemicals to help wound heal
Macrophages
Attracts WBCs, macrophages, smooth muscle cells, fibroblasts
TGF-β
PDGF
Platelets
Hemostasis
Injury
The Bottom Line: Wound is filled in and covered with scar tissue
Proliferative Phase
Epithelialization
Epidermal growth factor (EGF)
Transforming growth factor alpha (TGFa)
Keratinocytes
Platelets
Wound macrophage
Stimulates protease inhibitor (TIMP)
Decrease secretion of proteases
Create granulation tissue
Fibroblasts
TGF-β
T lymphocytes
Macrophages
Platelets
Skin Deteriorates
Extra Protective Cream (EPC)
Moisturizing Cleanser
Braden > 18
Braden Q > 23
Consult Wound Management
Skin Deteriorates
Mar 2008
Protective Ointment
NO
YES
Protective Cream
Skin Intact?
Implement Pressure Ulcer
Prevention Protocol
Duke University Health System
Advanced Skin Care Algorithm
Bedside Lotion PRN
Moisturizing Cream
Incontinent Bowel/Bladder
Braden < 18
Braden Q < 23
Braden /Braden Q Score
ATI Video
Abnormal Head Shapes
Vestigial Claws
Nails
Head and Neck
Abnormalities in head size and contour
Hydrocephalus
Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head
Increasing pressure also produces dilated scalp veins, frontal bossing, and downcast or
“setting sun” eyes
(sclera visible above iris)
Cranial bones thin, sutures separate, and percussion yields a “cracked pot” sound
Abnormal Findings
Lymphatics: lymph nodes

Preauricular
, in front of ear
Posterior auricular
(mastoid), superficial to mastoid process
Occipital
, at base of skull
Submental,
midline, behind tip of mandible
Submandibular
, halfway between angle and tip of mandible
Jugulodigastric
, under angle of mandible
Structure and Function (cont.)
Lymphatics
Lymphatic system: an extensive vessel system, is major part of
immune
system, which detects and eliminates foreign substances from body
Vessels allow flow of clear, watery fluid from tissue spaces
into circulation
Nodes
are small, oval clusters of lymphatic tissue that filter lymph and engulf pathogens, preventing potentially harmful substances from entering the circulation
Greatest supply is in head and neck
You should be familiar with direction of drainage patterns of lymph nodes
Structure and Function (cont.)
Head (cont.)
Two pairs of
salivary glands
are accessible to examination on the face
Parotid
glands are in cheeks over mandible, anterior to and below ear; the largest of salivary glands they are not normally palpable
Submandibular
glands beneath mandible at angle of jaw
Third pair, sublingual glands, lie in floor of mouth
Temporal artery
lies superior to temporalis muscle, and pulsation is palpable anterior to ear
Structure and Function
Palpable
Swellings of head and neck (cont.)
Parotid gland enlargement
Rapid painful inflammation of parotid occurs with mumps
Parotid swelling also occurs with blockage of duct, abscess, or tumor; note swelling anterior to lower ear lobe
Stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergic
Abnormal Findings (cont.)
Swellings of head and neck (cont.)
Thyroid, single nodule
Most solitary nodules are benign; solitary nodule poses a greater risk of malignancy
Suspect any painless, rapidly growing nodule, especially the appearance of a single nodule in a young person
Cancerous nodules tend to be hard and are fixed to surrounding structures
Pilar cyst
(wen)
Smooth, firm, fluctuant swelling on scalp; pressure of contents causes overlying skin to be shiny and taut
Benign growth
Abnormal Findings (cont.)
Swellings of head and neck
Torticollis (wryneck)
Hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side
Thyroid, multiple nodules
Multiple nodules usually indicate inflammation or multinodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule
Abnormal Findings (cont.)
Abnormalities in head size and contour (cont.)
Paget’s disease of bone (osteitis deformans):
Localized bone disease of unknown etiology that softens, thickens, and deforms bone
Affects 3% of adults over age 40 years and 10% over age 80 years and occurs more often in males
Acromegaly
Excessive secretion of growth hormone from pituitary after puberty creates an enlarged skull and thickened cranial bones
Note elongated head, massive face, prominent nose and lower jaw, heavy eyebrow ridge, and coarse facial features
Abnormal Findings (cont.)
Aging adult
Temporal
arteries
may look
twisted
and prominent
In some aging adults, a mild rhythmic tremor of head may be normal
Senile tremors are benign and include head nodding and tongue protrusion
If some teeth have been lost, lower
face
looks unusually
small
, with mouth sunken in
Neck may show
concave curve
when head and jaw are extended forward to compensate for kyphosis of spine
Objective Data:
Physical Examination (cont.)
Pregnant female
During second trimester, chloasma may show on face; a blotchy, hyperpigmented area over cheeks and forehead that fades after delivery
Thyroid gland may be palpable normally during pregnancy
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Special procedures: transillumination
Use if you suspect an abnormal head size or intracranial lesion
Hold a rubber-collared flashlight firmly against infant’s skull
Explore all regions of head: frontal, both sides, occiput
A small ring of light around flashlight is normal
Should not see larger halo around rubber collar
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Special procedures: percussion
With an infant, you may directly percuss with your plexor finger against head surface; this yields a resonant or “cracked pot” sound, which is normal before closure of fontanels
Auscultation
Bruits are common in skull of children under 4 or 5 years of age or children with anemia
Systolic or continuous; heard over temporal area
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Special procedures: palpation
Craniotabes is softening of skull’s outer layer
In newborn pressure along suture of parietal and occipital bones above ear produces snapping sensation because of pliable skull bone
Do not attempt palpation unless craniotabes is suspected because of other abnormal findings; even then avoid excessive pressure
Craniotabes may be normal, especially with premature infants
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Neck (cont.)
During infancy, cervical lymph nodes are not palpable normally; but child’s lymph nodes are palpable
Palpable nodes less than 3 mm are normal
Children have a higher incidence of infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in neck
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Neck
An infant’s neck looks short
; it lengthens during the first 3 to 4 years
Assess muscle development with gentle passive ROM
Cradle infant’s head with your hands and turn it side to side and test forward flexion, extension, and rotation
Note resistance to movement, especially flexion
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Face
Check facial features for symmetry, appearance, and swelling
Note symmetry of wrinkling when infant cries or smiles, e.g., both sides of lips rise and both sides of forehead wrinkle
Normally, no swelling is evident
Parotid gland enlargement best seen when child looks up; swelling appears below angle of jaw
Objective Data:
Physical Examination Face
Infants and children (cont.)
Skull (cont.)
Note infant’s head posture and head control; infant can turn the head side to side by 2 weeks; shows tonic neck reflex when head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg); reflex disappears between 3 and 4 months, and then head is maintained midline
Head control achieved by 4 months, when baby can hold head erect and steady
Objective Data:
Physical Examination (cont.)
Infants and children (cont.)
Skull (cont.)
Two common variations in newborn cause shape of skull to look markedly asymmetric:
Caput succedaneum
: edematous swelling and ecchymosis of presenting part of head caused by birth trauma; gradually resolves during first few days of life and needs no treatment
Cephalhematoma
: subperiosteal hemorrhage, a result of birth trauma appears several hours after birth and
gradually increases in size;
will be reabsorbed during first few weeks of life without treatment
Objective Data:
Physical Examination
Infants and children
Skull
Measure infant’s head
at each visit up to age 2 years; and yearly up to age 6 years
Note infant’s head posture and head control; infant can turn head side to side by 2 weeks
Shows tonic neck reflex when supine and head turned to one side (extension of same arm and leg, flexion of opposite arm and leg); reflex disappears at 3 to 4 months
Objective Data:
Physical Examination
Inspect and palpate neck (cont.)
Trachea
Normally, trachea is midline; palpate for any tracheal shift
Space should be symmetric on both sides
Note any deviation from midline
Thyroid gland
Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules
If enlarged, auscultate thyroid for presence of bruit, which occurs with accelerated or turbulent blood flow, indicating hyperplasia of thyroid (e.g., hyperthyroidism)
Objective Data:
Physical Examination (cont.)
Inspect and palpate neck (cont.)
Lymph nodes
Normal nodes feel movable, discrete, soft, and nontender
If any nodes are palpable,
note location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness
If nodes enlarged or tender,
check area they drain for source of the problem;
they often relate to inflammation or neoplasm in head and neck
Follow up on or refer your findings; an enlarged lymph node, particularly when you cannot find the source of problem, deserves prompt attention
Objective Data:
Physical Examination (cont.)
Inspect and palpate neck (cont.)
ROM (cont.)
Look for swelling below angle of jaw; note thyroid gland enlargement though normally none is present
Note any obvious pulsations; carotid artery creates brisk localized pulsation just below angle of the jaw
Normally, there are no other pulsations while person is in sitting position
Objective Data:
Physical Examination Neck
Inspect and palpate neck (cont.)
Symmetry
Head position is centered in midline, and accessory neck muscles should be symmetrical
Head should be held erect and still
Range of Motion (ROM)
Note any limitation of movement during active motion
When neck is supple, motion is smooth and controlled
Test muscle strength and status of cranial nerve XI by trying to resist person’s movements with your hands as person shrugs shoulders and turns head to each side
Objective Data:
Physical Examination (cont.)
Inspect face
Note facial expression and appropriateness to behavior or reported mood
Facial structures always should be symmetric
Note symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of mouth
Note any abnormal facial structures (coarse facial features, exophthalmos, changes in skin color or pigmentation), or abnormal swellings
Note any involuntary movements (tics) in facial muscles; normally none occur
Objective Data:
Physical Examination
Inspect
Inspect and palpate skull (cont.)
Palpate
temporal artery
above zygomatic (cheek) bone between eye and top of ear
Palpate
temporomandibular joint
as the person opens the mouth, and note normally smooth movement with no limitation or tenderness
Objective Data:
Physical Examination
Palpate
Inspect and palpate skull
Note general size and shape
Assess shape: place fingers in person’s hair and palpate scalp
Skull normally feels symmetric and smooth
Cranial bones that have normal protrusions are: forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear
There is no tenderness to palpation
Objective Data:
Physical Examination
Additional history for infants and children
Maternal alcohol or drug use?
Type of delivery? Vaginal or by cesarean section? Any difficulty? Use of forceps?
Growth pattern? Was it on schedule?
Additional history for aging adult
Dizziness? How does it affect your daily activities?
Neck pain? How does it affect your daily activities? Are you able to drive, perform at work, do housework, sleep, and look down when using stairs?
Subjective Data:
Health History Questions
Infants and Aging
Headache (cont.)
Head injury or blow to your head?
Dizziness?
Neck pain or limitation of neck motion?
Lumps or swelling?
History of head or neck surgery?
Subjective Data:
Health History Questions
Headache
Headache (cont.)
Do you have other illness or take any medications?
Pattern: Any family history of headache?
Frequency: Once a week?
For females: When do they occur in relation to your menstrual periods?
What seems to help: sleep, medications?
Coping strategies: How have headaches affected self-care, ability to work, home, and social ability?
Subjective Data:
Health History Questions
Headache
Headache (cont.)
Course and duration: When do headaches occur? Do they awaken you from sleep?
How long do they last? Hours or days?
Precipitating factors: What brings it on: activity, exercise, work environment, emotional upset, anxiety, alcohol? Note signs of depression
Associated factors: any relation to other symptoms
Nausea, vomiting, vision changes, pain with bright lights, neck pain or stiffness, fever, weakness, moodiness, stomach problems?
Subjective Data:
Health History Questions
Headache
Headache
Onset: When did this kind of headache start?
Gradual, over hours, or a day?
Suddenly over minutes, or less than 1 hour
Ever had this kind of headache before?
Location: Where do you feel it: frontal, temporal, behind your eyes, in sinus area, or in occipital area?
Is pain localized on one side, or all over?
Character: throbbing, aching, mild, moderate, or severe?
Subjective Data:
Health History Questions
Headache
Developmental care (cont.)
Pregnant female
Thyroid gland enlarges
slightly during pregnancy as a result of hyperplasia of tissue and increased vascularity
Aging adult
Facial
bones
and orbits appear more
prominent,
facial skin sags resulting from decreased elasticity, decreased subcutaneous fat, and decreased moisture in skin
Lower face may look smaller if teeth have been lost
Structure and Function
Pregnant and Aging
Developmental care (cont.)
Infants and children
During infancy, trunk growth predominates so that head size changes in proportion to body height
Facial bones grow at varying rates; in toddler mandible and maxilla are small and nasal bridge is low
Lymphoid tissue is well developed at birth and grows to adult size when the child is 6 years old
Facial hair also appears on boys at adolescence: first on upper lip, then on cheeks and lower lip, and last on the chin. A noticeable enlargement of the thyroid cartilage occurs, and with it, the voice deepens
Structure and Function
Growth
Developmental care
Infants and children
Bones of neonatal skull are separated by
sutures and fontanels
, spaces where the sutures intersect
These membrane-covered
“soft spots”
allow growth of brain during 1st year; gradually ossify
Triangle-shaped
posterior fontanel closes by 1 to 2 months
, and diamond-shaped
anterior fontanel closes between 9 months and 2 years
During fetal period, head growth predominates;
head size is greater than chest circumference at birth and reaches 90% of final size at 6 years old
Head Structure
Infants
Locations of Lymph Nodes
Lymphatics: lymph nodes (cont.)
Superficial cervical
, overlying sternomastoid muscle
Deep cervical
, deep under sternomastoid muscle
Posterior cervical
, in posterior triangle along edge of trapezius muscle
Supraclavicular,
just above and behind clavicle, at sternomastoid muscle
Structure and Function (cont.)
Drainage Patterns of Lymph Nodes
Structures of Neck
Neck (cont.)
Thyroid gland
an important endocrine gland straddles trachea in middle of the neck
Synthesizes and secretes
thyroxine (T4)
and
triiodothyronine (T3)
, which are hormones that stimulate rate of
cellular metabolism
The gland has two lobes, connected in middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring
Thyroid cartilage above that, with small palpable notch in upper edge, the “Adam’s apple” in males
Structure and Function
Thyroid
Neck (cont.)
Major neck muscles
sternomastoid
and
trapezius
are innervated by
cranial nerve XI
Sternomastoid enables head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles
Two trapezius muscles move shoulders and extend and turn head
Structure and Function (cont.)
Neck
Neck delimited by base of skull and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below
Think of neck as
conduit
of many structures
Vessels, muscles, nerves, lymphatics, and viscera of respiratory and digestive systems
Internal carotid branches off common carotid and runs inward and upward to supply brain
External carotid supplies face, salivary glands, and superficial temporal area
Structure and Function
Head
Skull is rigid box that protects brain and is supported by cervical vertebra
Cranial bones
Frontal
Parietal
Occipital
Temporal
Facial expressions formed facial muscles which are mediated by
cranial nerve VII,
the
facial nerve
Structure and Function
Pediatric facial abnormalities
Fetal alcohol syndrome
Congenital hypothyroidism
Down syndrome
Atopic (allergic) facies
Allergic salute and crease
Abnormal Findings (cont.)
Aging adult (cont.)
During examination, direct aging person to perform ROM slowly; they may experience dizziness with side movements
Aging person may have prolapse of submandibular glands, which may be mistaken for a tumor; but drooping submandibular glands will feel soft and be present bilaterally
Objective Data:
Physical Examination
Using a gentle circular motion of fingerpads, palpate lymph nodes
Beginning with preauricular lymph nodes in front of ear, palpate the 10 groups of lymph nodes in routine order
Many nodes are closely packed, so you must be systematic and thorough in your examination
Do not vary sequence or you may miss some small nodes
Objective Data:
Physical Examination (cont.)
Inspect and palpate neck
Symmetry
Range of motion
Lymph nodes
Trachea
Thyroid gland
Posterior approach
Anterior approach
Auscultate thyroid for bruit, if enlarged
Objective Data:
Physical Examination
Head
Cranial bones
Sutures
Facial bones
Facial muscles
Salivary glands
Structure and Function (cont.)
Bell’s palsy
Brain attack or cerebrovascular accident
Cachectic appearance
Scleroderma
Parkinson syndrome
Cushing syndrome
Graves’ disease
Hyperthyroidism
Myxedema (hypothyroidism)
Abnormal facial appearances with chronic illnesses
Abnormal Findings (cont.)
Sun protection
Ph neutral cleansers for the young and old
ABCDE for moles
Self skin exam
Nails Short
Fungal prevention
Acne care
A survey of skin wounds across the lifespan
Acute and Chronic Wounds
http://www.atitesting.com/ati_next_gen/LegacyContent/Launch.aspx?ID=16&AttemptId=39679095&TutorialID=
ATI Video Skin Assessment
Clubbing
Fungal Nails
http://www.atitesting.com/ati_next_gen/LegacyContent/Launch.aspx?ID=2&AttemptId=39678769&TutorialID=
Portfolio: Numbers

1. Kyphosis of the spine is common with aging. To compensate, older adults will:

A. increase their center of gravity.
B. extend their heads and jaws forward.
C. stiffen their gait.
D. shuffle.











2. Most facial bones articulate at a suture. Which facial bone articulates at a joint

A. Nasal bone
B. Mandible
C. Zygomatic bone
D. Maxilla



3. A severe deficiency of thyroid hormone leading to nonpitting edema, coarse facial features, dry skin,
and dry coarse hair is known as:

A. congenital hypothyroidism.
B. scleroderma.
C. myxedema.
D. Hashimoto thyroiditis.







4. Which of the following statements describing a headache would warrant an immediate referral?

A. "This is the worst migraine of my life."
B. "This is the worst headache I've had since puberty."
C. "I have never had a headache like this before; it is so bad I can't function."
D. "I have had daily headaches for years."




5. What disease is characterized by a flat, expressionless, or mask-like face, a staring gaze, oily skin, and elevated eyebrows?

A. Acromegaly
B. Scleroderma
C. Cushing syndrome
D. Parkinson disease


The nurse suspects that a patient has hyperthyroidism. Which of the following findings would the nurse most likely find on examination?
A, Increased heart rate, weight loss
B. Decreased heart rate, weight gain
C. Increased heart rate, weight gain
C. Decreased heart rate, weight loss

Color
Temperature
Moisture
Texture
Thickness
Edema
Mobility and Turgor
Vascularity Bruising
Lesions
Full transcript