tissue viability - nhsggc

Tissue Viability

Alison JohnstoneAlison JohnstoneClinical Nurse SpecialistClinical Nurse Specialist

Tissue ViabilityTissue Viability

Who is T/V?

Alison Johnstone Heather Hodgson Alison Johnstone Heather Hodgson Tel 24193 Tel 0138 Tel 24193 Tel 0138

Matrons Flat, 34, Shelley court Matrons Flat, 34, Shelley court 66thth Floor Med block GGH Floor Med block GGH

GRI.GRI.

What is tissue viability about?

Tissue Viability is about the maintenance of Tissue Viability is about the maintenance of skin integrity. Also the management of skin integrity. Also the management of patients with acute and chronic wounds, patients with acute and chronic wounds, prevention and management of pressure prevention and management of pressure damage.damage.

It is not a substitute of holistic assessment It is not a substitute of holistic assessment of patients at risk and with wounds.of patients at risk and with wounds.

The Skin

Epidermis

Dermis

Hypodermis

Deep fascia

Muscle layer

Blood vessels

Sweat glands

Fat cells

Hair follicle

Nerves

Presenter

Presentation Notes

The skin is the largest organ of the body. Structurally, the skin can be divided into two parts: the epidermis and dermis. One often divides it in 3 layers though. The subcutaneous tissue/hypodermis (sub-cutis), composed of fatty and loose connective tissue, lies below the dermis and is sometimes considered to be a part of the skin. It provides a cushioning effect for the skin, stores calories and is a heat insulator. It attaches the skin to the bone and muscle. Deeper tissue layers consist of fascia which is a thin fibrous covering over the muscle, muscle and bone. Note: The yellow vessels are a part of the lymphatic system. The lymphatic system has three main functions; maintenance of fluid balance in the tissues. Transport of fats and other substances from the digestive tract to the circulation Immunity- the lymphatic system filters micro-organisms out of the blood and the lymph contains immune cells, such as lymphocytes, which destroy foreign material.

Epidermis

•• AvascularAvascular•• Very thinVery thin•• 5 layers5 layers•• Stratum corneum / Stratum corneum / outer layerouter layer

•• Stratum basale / Stratum basale / inner layerinner layer

•• Ph: 4.5 Ph: 4.5 –– 5.55.5

Presenter

Presentation Notes

The Epidermis is the protective outer layer of the skin that is separated from the dermis by a basement membrane. Avascular (no blood supply of its own). Very thin (about the thickness of a peach skin); 5 layers make up the epidermis. The outer layer is called the (stratum corneum/epidermal layer) and in constantly shedding. These cells = keratinocytes (composed primarily of the protein keratin). The pH generally ranges from 4.5 to 5.5. It is slightly acidic. Cells form at the innermost layer (stratum basale/basal layer) and differentiate as they migrate to the outer surface. Process usually takes 28 days but may take longer in the elderly. This layer has an irregular surface and is attached to the dermis by the basement membrane. As they move towards the skin surface, epithelial cells change shape and become keratinized and die. The dead cells in the protective stratum corneum are surrounded and coated with lipids which waterproofs them and prevents water-soluble substances from entering the body.

Dermi s

•• Collagen and Collagen and elastin elastin capillariescapillaries

•• Sensory nerve Sensory nerve endingsendings

•• Sebaceous Sebaceous glandsglands

•• Sweat glandsSweat glands•• Hair folliclesHair follicles

Presenter

Presentation Notes

The Dermis is a layer of fibrous and elastic tissue that lies between the hypodermis and the outer dermis. The components which are contained within the dermis include: collagen (for strength) and elastin (for recoil and stretch ability) fibroblasts and macrophages. (Cells essential for wound healing) capillaries sensory nerve endings (wounds with the dermis exposed are usually very painful) sebaceous glands (may be referred to as ’fat’ or ’oil’ glands); decreased production as a person ages sweat glands hair follicles Vascular network assists with thermoregulation and provides nutrients and oxygen to the epidermis.

Epidermal/Dermal Junction

•• Between epidermis and Between epidermis and dermisdermis

•• Separates and attaches Separates and attaches the epadermis and the epadermis and dermisdermis

•• The junction flattens The junction flattens with agewith age

•• Site where skin tears Site where skin tears usually occurusually occur

Presenter

Presentation Notes

Basement membrane: The area between the epidermis and dermis. Separates and attaches the epidermis and dermis. Since the epidermis has no blood supply of its own, this dermal-epidermal junction allows for perfusion to occur from the dermis to the epidermis. As a person ages, this junction often flattens, which allows the epidermis to slide across the dermis This places the older individuals at high risk for ’skin tears’. This area is where skin tears are most likely to occur.

Blister s

Fluid trapped between the epidermis and Fluid trapped between the epidermis and the dermis.the dermis.

Presenter

Presentation Notes

When blisters occur, fluid is trapped between the epidermis and dermis. May be caused by friction or burn injuries.

Urinary incontinent skin damage

Skin Excoriation Tool for Incontinent Patients

(NATVNS –Scotland)

NATVNS (SCOTLAND) SKIN EXCORIATION TOOL

0 = HEALTHY SKIN

Healthy, intact skin. No erythema (redness).

1 = MILD EXCORIATION

Erythema (redness) of skin only. No broken areas present.

2 = MODERATE EXCORIATION

Erythema (redness), with less than 50% broken skin.Oozing and/or bleeding may be present.

3 = SEVERE EXCORIATION

Erythema (redness), with more than 50% broken skin.Oozing and/or bleeding may be present.

FOR INCONTINENT PATIENTS

Clean skin with skin cleanser

Clean skin with skin cleanser Use durable barrier cream

Clean skin with skin cleanserUse barrier film spray

Seek advice from Tissue Viability Nurse where available for local guidelines/guidance

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, 54-56Origination: Lydia Jack, TVN IRH, & Anne Wilson TVN RAH

Design: Colin Blain, Med Photo, Inverclyde Royal, Greenock

moisture

Presenter

Presentation Notes

Moisture as a result of incontinence, sweat or wound exudate can macerate the skin leading 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. The maintenance of a good skin condition can greatly minimise the likelihood of tissue breakdown. Healthy skin should be clean and well hydrated. Principles of skin care include: Cleaning and protecting broken area, and minimising moisture. Regular skin inspection with particular attention to bony areas (at least once a day or as often as condition indicates). Washing with warm water and mild cleansing agent only, and using a barrier cream where appropriate to minimise dryness. Barrier creams should be kept to a minimum and must be cleaned away prior to reapplication. Correct moving and handling techniques, as previously mentioned, can help reduce friction and shear. Plastic draw sheets, and layers of incontinence padding should be avoided, and leaking dressings should be changed as soon as possible, to minimise the effects of friction. Avoid massaging or rubbing skin, as this will exacerbate friction and could cause deep tissue damage (Ek et al 1985, Dyson 1978, EPUAP 1998b).

Tissue breakdown as result of moisture lesion

Moisture as a result of incontinence, sweat or Moisture as a result of incontinence, sweat or wound exudates can macerate the skinwound exudates can macerate the skinThis will lead to the increased likelihood of This will lead to the increased likelihood of frictional damage occurring frictional damage occurring The skin becomes The skin becomes ‘‘waterloggedwaterlogged’’ in the dermis and in the dermis and becomes soft and fragilebecomes soft and fragileCorrect management of incontinence is important, Correct management of incontinence is important, as frequent washing with soap and water can as frequent washing with soap and water can destroy the protective sebum layer increasing the destroy the protective sebum layer increasing the likelihood of bacterial contaminationlikelihood of bacterial contaminationHealthy skin should be clean and well hydrated.Healthy skin should be clean and well hydrated.

What Problem?1 in 10 patients across Europe have a pressure ulcer1 in 10 patients across Europe have a pressure ulcer

50% of those are grade 3 and 4 50% of those are grade 3 and 4 -- EPUAPEPUAP

50% of patients who develop a severe ulcer will die within 50% of patients who develop a severe ulcer will die within 4 months 4 months -- BlissBliss

Costs NHS Costs NHS ££2 Billion per year2 Billion per year

90% of grade 1s are reversible with adequate nursing 90% of grade 1s are reversible with adequate nursing intervention intervention -- BaderBader

Pressure Ulcers & QoLlack of privacylack of privacy

changes in body imagechanges in body image

loss of control and independenceloss of control and independence

increased painincreased pain

social exclusionsocial exclusion

malodourmalodour

growing limitations on activity and mobilitygrowing limitations on activity and mobility

Pressure Ulcers

……....””are areas of localised damage to skin are areas of localised damage to skin caused by pressure, shear and friction and caused by pressure, shear and friction and usually occur over bony prominenceusually occur over bony prominence””..

NHS Centre for Reviews and Dissemination and Nuffield Institute NHS Centre for Reviews and Dissemination and Nuffield Institute for Health 1995for Health 1995

Pressure Ulcer Development causes:

PressurePressure…”…”a perpendicular load or force being exerted on a perpendicular load or force being exerted on

a unit of areaa unit of area””. . ShearShear

…”…”a mechanical stress that is parallel to a plane a mechanical stress that is parallel to a plane of interestof interest””FrictionFriction

…”…”the force related to two surfaces moving the force related to two surfaces moving across one anotheracross one another””

Combined effects of pressure, shear and friction

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

Shear Effect of Raising The Head of The Bed

Mechanisms contributing to tissue breakdown

Local ischaemia Local ischaemia -- as a result of capillary occlusion.as a result of capillary occlusion.

Endothelial damage to microcirculation Endothelial damage to microcirculation -- cells lining blood cells lining blood & lymphatic vessels become damaged, e.g.by shear.& lymphatic vessels become damaged, e.g.by shear.

Reperfusion injury (when blood flow is abruptly restored Reperfusion injury (when blood flow is abruptly restored following a period of ischaemiafollowing a period of ischaemia))

Prolonged deformation or pressure on cells will result in Prolonged deformation or pressure on cells will result in cell deathcell death

Factors affecting PU development

External pressure- inadequate support

surface, invasive linesspigots, unrelieved

ShearingForces

-profiling bedsfootstools,chair

Anxiety- respite care,

hospital admission,recent stress

Immobilityas a result ofillness/trauma

anaes/seda

Advancing Agereduction incollagen &

tissue stiffness

Illness- infec, SpinalCV/PV disease,Diab

MS, Park, AnaemAlz,fluid loss, Neuro

Internal pressureie, bony promin,

inadequatenursing care

Skin maceration- sweat,urine,

faeces

Malnutrition-poor tissue,

lack of fatty &muscle tissue

Intrinsic

FACTORS

Extrinsic

Friction-maybe a result

of, skin moisturerubbing, M&H

Waiting timesA&E, Theatre,Chair nursing

X-ray

External temperature1% rise in patient

temp may increasemetabolic demand by 13%

Scottish Adapted EPUAP Grading Tool

(NATVNS –Scotland)

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 skin1

Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion or blister.1

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia.1

Extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures with or without full thickness skin loss.1

1 European Pressure Ulcer Advisory Panel (1999). Guidelines on treatment of Pressure Ulcers. EPUAP Review, 1(2); 31-33.

European Pressure Ulcer Advisory Panel (EPUAP) Grading Tool

GRADE 1

GRADE 2

GRADE 3

GRADE 4

Bone

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

2 NMC- The Code. Standards of conduct, performance and ethics for nurses and midwives (May 2008)

Tendo n

Bone

Origination: Lydia Jack, Tissue Viability Nurse Specialist

Design: Colin Blain, Med Photo, Inverclyde Royal, Greenock

Classification Systems

Promotes accurate communicationPromotes accurate communication

Aids in the decision process of careAids in the decision process of care

Provides a reflection of wound appearanceProvides a reflection of wound appearanceindicating improvements/deteriorationindicating improvements/deterioration

Risk calculators & classification systems are open Risk calculators & classification systems are open to user error.to user error.

Preventative Strategies

Risk Assessment

Essential when planning pressure ulcer and Essential when planning pressure ulcer and wound care.wound care.

Determines the most suitable treatment Determines the most suitable treatment required to prevent deterioration of wound required to prevent deterioration of wound and skin.and skin.

Waterlow Risk Assessment tool

moving and handling techniques

Presenter

Presentation Notes

It is important that patients are correctly moved and positioned to prevent skin injury to the patient, and back injury to the nurse / carer. “Dragging” the patient up the bed can cause deep shearing forces as well as frictional abrasion. Devices to assist moving and handling should be used during transfer and positioning of patients to minimise shear forces for those patients who require assistance in movement in accordance with EU moving and handling regulations. (EPUAP 1998)

The 30 degree tilt Recumbent position

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

SOFTFORM

Support surface when seated

Specialised support

Intact skin orGrade 1 or 2 damage(Scottish adapted EPUAP Grading Tool)

up to Grade 4damage (EPUAP)

(Scottish adapted EPUAP Grading Tool)

up to Grade 3 damage (EPUAP)

(Scottish adapted EPUAP Grading Tool)

Utilise electric profiling bed &30° tilt DUO/DUO2 Mattress +/- cushionTVN reviewCareplan 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 PRIMO Mattress +/- cushionTVN reviewCareplan 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° tiltCareplan 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

Within 6 hours of admission assess patient using Waterlow.

These guidelines are to assist in the selection of appropriate Hill-Rom therapy mattresses further guidance can beobtained from your Hill-Rom Clinical Advisor on 01530 411000 ( or TVN)

Yes

Yes

Yes

No

No

Greater Glasgow Product Selection Guide

Duo / Duo 2 MRCont. Low Pressure/ Alt. Low Pressure

Max weight:150kg

Min Weight: 35kg

PRIMO MRCont.Low Pressure

Max weight: 150kg

No Min weight limit

Visco-Elasticmattress

Management

Best Practice Statement

BPS BPS –– Pressure Ulcer Prevention (updated Pressure Ulcer Prevention (updated 2005)2005)BPS BPS –– Treatment & Management Pressure Treatment & Management Pressure Ulcers (2005)Ulcers (2005)Reviewed & AmalgamatedReviewed & AmalgamatedAvailable as part of the practice Available as part of the practice development toolkit development toolkit

Available from QIS web site

Any questions??????

tissue viability - nhsggc

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