Skin Wound Ostomy

SkinWound Ostomy

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Travel the world and explore all things pressure Injury assessment and prevention. Collect the numbers to open the safe and complete your adventure!

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Facts and Figures

1. Patient care cost per injury
2. Overall pressure injury cost
3. # Lawsuits related to PI
4. Patients per year who develop PI
5. Patients per year who die as a result of PI

CMS Classifies pressure injuries as "never events", however, no other preventable event occurs as frequently as pressure injuries.

The 5 Elements of Pressure Injury Assessment

Click each to learn more about the element

Risk Assessment

Nutrition & Fluids

Skin Assessment

Reposition

Support

Braden Scale

The Braden score should reflect your patient's CURRENT condition.

Sensory Perception

Mobility

Nutrition

Moisture

Activity

Friction & Shear

CHOOSE YOUR DESTINATION

1. Mrs. Jones

2. Assessment & Documentation

4. Types of Pressure Injuries

5. Jan

3. Mr. Smith

Mrs. Jones

• 82 y/o female admitted with SBO and c/o nausea, vomiting, and diarrhea-sometimes having leaking from colostomy
• 5'7", 138 lbs
• Alert & Oriented x 4
• Hx of colon and lung cancer
• Abdomen distended
• Transfers with 1-2 assist
• Spends most of the day in the chair
• Admission orders:
• NPO
• IV Fluids
• NGT to suction
• Bedrest, up to a chair as tolerated
• O2 via NC PRN

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Mrs. Jones's Chart

What is Mrs. Jones Braden Score?

14

20

Braden Scale

A total Braden Scale score ≤ 18 in an adult is predictive of pressure injury development unless preventative measures are taken.

• 9 or less = Very high risk
• 10-12 = High risk
• 13-14= Moderate risk
• 15-18 = Mild risk
• 19-23= Generally not at risk

How often should we do a skin assessment?

Nursing Interventions

What are Mrs. Jones risk factors?

Hx of cancer, moisture from colostomy, diarrhea, mobility, activity, nutrition

Obesity, chronic pain, constipation, level of conciousness

Family hx of htn, use of glasses, excessive exercise, frequent urination

What is the most common site for a pressure injury to occur?

Knee

Sacrum

Heel

CONGRATULATIONS

The first number is:

Back to map

Assessment & DOcumentation

If a wound is not documented on admission, the hospital could end up owning it.

START

The National Pressure Injury Advisory Panel describes a pressure injury as localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. It can be present under intact skin or as an open area.

What are some signs that you look for when assessing the skin?

Special Considerations:

• Different skin tones
• Obese or thin
• Devices or objects
• Age
• Recent illness causing immobility or bed rest

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2 RN/ 4-Eye Skin Assessment

A Dual or 4-Eye Skin Assessment is conducted when 2 RNs assess the patient's skin at the same time from head to toe and front to back. Skin assessments should be performed and documented on:

• Admission
• LOS (every 7 days)
• Post-op/procedure (when returned to home unit)
• Transfer

Document Pressure Injuries in EHR. All other injuries may be listed in a nursing note. CPRS should be updated with known injuries.

When should the wound care nurse be consulted? Click the bandaids below.

Mr. John has been in the hospital for 2 days. Since yesterday, he has declined to get out of bed. After completing a bed bath the Carepartner reports to you that Mr. John has a red area on his sacrum.

Mr. John is now being prepped for discharge. What are some discharge considerations to think about?

CONGRATULATIONS

The second number is:

Back to map

Mr. Smith

78 y/o male with a history of hypertension, peripheral artery disease, and uncontrolled Type II diabetes. He was admitted yesterday for an infected open area on his right foot. He complains of numbness in his right leg.

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What risk factors probably contributed to Mr. Smith's wound and poor wound healing?

What care/orders do you anticipate Mr. Smith would need?

What is an essential component of patient education for Mr. Smith?

Proper foot care and regular inspection for new wounds

Avoiding all physical activity until the wound heals

Using tight shoes to protect feet

CONGRATULATIONS

The third number is:

Back to map

Be aware of but consult WCN for staging

Blanchable Erythema

If there is an area of erythema over a bony prominence, check for blanching.

Place finger over area with pressure and release. If the skin color changes to white/yellow, that is considered to be “blanchable erythema”

Unstageable Pressure Injury

Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar.

If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed

Stable Eschar

• Serves as “the body’s natural (biological) cover”

• Dry, adherent intact without erythema or fluctuance

• Monitor daily for pain, drainage, odor, induration, and redness. If none present, leave eschar intact.

• May obtain physician order to apply Betadine daily to stable eschar for antimicrobial effect

Unstable Eschar

• Wet, draining, loose, boggy, edematous, red

• Eschar with pain, drainage, odor, induration or redness.

• If present, notify physician for orders. Expect debridement.

Medical Device Related Pressure Injury

Medical device related pressure injuries result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.

Mucosal Membrane Pressure Injury

Mucosal membrane pressure injuries are found on mucous membranes with a history of medical devices in use at the location of the injury. Due to the anatomy of the tissue, these ulcers cannot be staged.

CONGRATULATIONS

The fourth number is:

Back to map

Jan

20 y/o female college student who recently suffered a severe bout with Crohn's disease while home on break. She was admitted to your unit following ostomy surgery.

START

What are your nursing priorities when assessing Jan post-operatively?

Healthy Stoma vs. Complications

Jan is now 4 days post-op colostomy without complications, and you are preparing her and her family for discharge. What key elements of education will you include?

CONGRATULATIONS

The last number is:

Back to map

TRY AGAIN?

This adventure is not over yet. What is the secret code 🔑?

Collect the 5 digit code on your journey

Ability to respond meaningfully to pressure-related discomfort

Healthy Stoma

This is a normal appering stoma. Beefy, red, and moist are all good things we want to see.

Full thickness skin loss, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location. Undermining and tunneling may occur.

• Skin Health, bathing/showering, travel

• Diet/fluids/activity

• Ostomy management – odor, gas, meds, irrigation

• Psychosocial – clothing, emotions, intimacy

• Assessment, position, mobility
• X-ray/ CT to rule out osteomyelitis
• Wound Consult
• Nutrition Consult
• Diabetes Management: Diet, blood sugar
• Labs:
• Wound C&S-identify infecting organism
• Serum Protein-often decreased
• Albumin- decreased may indicate severe skin disease or severe malnutrition
• Pre-albumin- good indicator of nutritional status
• WBC-may be elevated; especially if fever is present
• ESR-may be elevated; especially if osteomyelitis is present

• Purple/bluish discoloration

• Localized edema/swelling due to the inflammatory response

• Temperature change- initial warmth due to the inflammatory response which will become cooler as tissue death occurs

• Pain and discomfort- sometimes manifest as itching

• Alteration in sensation- in response to either inflammation or ischemia

• Change in tissue consistency in relation to surrounding tissue- induration (hardness) due to excessive inflammation and necrosis. May also become soft and boggy

Nutrition & Fluid

• Usual food intake pattern

(NPO, diabetic, poor appetite)

• Albumin & pre-albumin levels

Necrotic Stoma

Insufficient blood supply in the digestive organs. This lack of blood can be caused by too much tension on the mesentery or too much trimming of the mesentery tissue. Ischemia occurs in 1-10% of colostomies and 1-5% of ileostomies.

Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury.

• Stage 3, 4, deep tissue, and unstageable pressure injuries

• Complex wounds

• Facility aquired wounds

• Pressure injury/wound worsening or not showing improvement

• New/established ostomy patients

• Negative pressure wound therapy (VAC)

Remember: Wound care will stage pressure injury, as a nurse you can describe the wound.

Next

Ability to change or control body position. Immobility is the primary risk factor for developing a pressure inury.

Degree of physical activity

• Support at home- does patient need home heatlh, has case management/discharge planner seen patient, does patient need rehab facility

• Nutrition- high protein, increase fluid intake, access to meals (meals on wheels, delivery services)

• Follow up- have follow up appointments been made, does patient have access to transportationt to and from

• Repositioning- instruct to stay off area as much as possible, change position q 2 hr, preventative dressing

Next

• Uncontrolled Type II Diabetes
• Hx of Htn
• Hx of PAD
• Decreased sensation in lower extemity

At WNCVAHCS, assessments are completed:

• Upon admission- Within 4 hours of admission along with ordering and implementing prevention measures

• Required to complete every shift

• With a change in patient condition- fall, surgery, deterioration in condition, transfer to another unit

• When a patient has a total Braden Score of 18, staff are to initiate the Braden order sets.

• Vital signs- All vitals within normal limits.

• Stoma assessment – Should be beefy and red (any variation in color to brown, black, or purple should be reported immediately) and moist. The stoma will be swollen.

• Surrounding skin - Digestive enzymes make the output from the stoma very corrosive, so protecting the skin around the stoma is extremely important

• Abdomen- Assess for distention, surgical incision bleeding or dehiscing, etc.

• Stool assessment - The stool from a colostomy can vary. It typically starts out as liquid, and then becomes more formed as the patient resumes a regular diet.

• Drain assessment

• I&O – at risk for dehydration and electrolyte imbalance

Degree to which skin is exposed to moisture. Perspiration, fever, tube leakage, incontinence of urine or feces, both greatly increases the risk.

Friction: The resistance that one surface or object encounters when moving over another (ex. sliding your feet back and forth) Shear: Strain in a structure when layers are laterally shifted in relation to each other (ex. how the body shifts with position change- laying to sitting in bed)

Risk Assessment

• Braden Score
• Risk Factors

Skin Assessment

• Common sites for pressure injury

• Dual Skin Assessment

(4-eyes, 2 nurses)

Reposition

• HOB
• Heels
• Back
• Buttocks
• Proning

Support

• Pillows
• Cushions
• Braces
• Preventative Dressings

Prolapsed Stoma

Internal orgrans protrude farther out of the stoma than expected. They are often seen in overweight patients or patients with weak abdominal muscles. Treatment for a prolapsed stoma is to use a flat and flexible pouching system; this will prevent trauma to the stoma when pouching.

Mucocutaneous Seperation

Seperation of the sutured junction between the stoma and the skin. This is seen in a patient who has compromised healing.

Assesses typical dietary intake pattern. Pay close attention to protein intake, calories, & hydration.

Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel.

Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole, undermining, and/or tunneling often occur. Depth varies by anatomical location. Stage 4 ulcers can extend into muscle and/or supporting structures (e.g. fasica, tendon, or joint capsule) making osteomyelitis possible.

Braden Scale Assessment

Use the table to score Mrs. Jones risk for imparied skin.