Archive for the ‘Wound and Skin Management’ Category

Wound Detective Series: When Wounds Won’t Heal

Friday, August 12th, 2016

Here’s how wound care detectives can solve the mystery of chronic wounds that fail to heal.

 

Epibole

 

Ready for some serious detective work? In this case, our focus is on those chronic wounds that just won’t heal, including epibole (which happens in full thickness wounds). And as we know, this rolled wound edge inhibits healing. But why does this happen with some wounds and not others?

Put on your Wound Detective hat, get out your magnifying glass, and look for the signs and symptoms in your patient’s wound bed, including color, tissue type and odor.

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Maceration and Hydrogels? Just Say Whoa

Thursday, July 21st, 2016

How do you use hydrogel dressings to keep wounds moist without causing maceration? Very carefully.  

 

Maceration and Hydrogels? Just Say Whoa

 

If you’ve ever taken a long bath or spent an afternoon in a swimming pool, you’re familiar with what happens to your hands and feet: they become soft, white, and wrinkled up like prunes. This is a classic case of maceration, which occurs when skin tissue is exposed to excessive moisture over a period of time.

As clinicians, we regularly treat patients with wounds (which need to be kept moist) that are surrounded by tissue that needs to be kept dry. So knowing how to properly treat the wound without causing maceration makes all the difference in the healing process.
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Oh Mercy, We Have MARSI!

Monday, June 13th, 2016

If you practice wound care, here’s what you need to know in order to avoid Medical Adhesive Related Skin Injury – also known as MARSI.

Oh Mercy, We Have MARSI!

 

Here’s a quiz for all of you in wound care: how many medical adhesive injuries are reported each year in the United States? The answer is 1.5 million. That’s a lot of skin tears and other painful dermal injuries that might have been prevented.

The good news is that with continued education, we can all help decrease Medical Adhesive Related Skin Injury (MARSI). This new descriptor in skin injury is definitely something you need to know.

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Telemedicine, Wound Care and . . . Dracula?

Friday, May 6th, 2016

Find out how telemedicine continues to change wound care (and what you can learn from your favorite cartoon characters).

Telemedicine, Wound Care and ... Dracula

 

What do Dracula, Wile E. Coyote and telemedicine have in common? It’s an intriguing question for sure, and you’ll be able to find out the answer at the Wild on Wounds (WOW) National Conference, to be held Aug. 31 – Sept. 3 in Las Vegas.

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Pressure Injuries? (Don’t) Say It Ain’t So!

Tuesday, April 19th, 2016

Mounting pressure to call pressure injuries (aka pressure ulcers) something else has caused a stir – and clinicians in wound care are feeling the heat. Find out why.

Pressury Injuries - Don't Say It Ain't So

One of the most basic principles of healing a wound is to determine the cause – and then remove it. It sounds so simple, doesn’t it? But this is easier said than done, as many wounds have similar characteristics, and we don’t always have all the facts at our disposal in order to pinpoint the cause.

Unfortunately, this process has become further – and unnecessarily – complicated, thanks to increasing pressure (no pun intended) on wound clinicians to name a pressure injury something else. See? We told you it was complicated. Here’s what you need to know.

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Pressure Injury (Ulcer) Staging: More Real-World Answers

Friday, April 15th, 2016

More real-world wound care questions and answers relating to pressure injury staging, including slough, debridement and skin breakdown.

More Real-World Pressure Injuries

 

Can’t get enough of pressure injury staging? Neither can we. That’s why we’re excited to present even more questions and answers about this topic, based on what wound clinicians experience out in the field (versus what we might learn from textbooks or in a classroom).

In our first such post – packed with some awesome pressure injury staging questions from the field – we discussed slough, levels of destruction and debridement. Here, you’ll find out more about pressure injury staging as it relates to abrasions, surgical flaps, skin breakdown due to clothing, and more. So here they are – five more tips for staging pressure injuries, based on real questions from clinicians.

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Moisture Associated Skin Damage: Know Your Type

Friday, March 4th, 2016

Know how to correctly identify these four common types of Moisture Associated Skin Damage (MASD) for best wound care practices.

MASD Categories

 

It might sound reasonable to assume that Moisture Associated Skin Damage (MASD) is the result of, well … moisture. The fact is that it takes more than just moisture to cause MASD, which is the inflammation and erosion of the skin that’s caused by prolonged exposure to various sources of moisture, including, urine, stool, perspiration, wound exudate, mucous, or saliva.  Skin does not break down in water alone.  However, when moisture on the skin is combined with friction, chemical irritants or bacterial/microbial factors, that’s when the real damage occurs.

For effective wound care, clinicians must be able to properly assess MASD from the onset – even if at first the diagnosis isn’t obvious. It all begins with good clue gathering, and knowing the characteristics of each of the four common types.

Identifying MASD

Because moisture on the skin increases skin permeability (which alters pH and cools the tissue), it compromises the barrier function of the skin’s protective acid mantle. This, in turn, makes the skin more susceptible to friction and shearing forces.

Correct MASD identification is critical for treatment, and should begin as soon as initial signs appear. The first step is to conduct a complete skin assessment. Don’t ever assume that you know what’s going on at first glance. Follow the general rule of thumb for any wound expert, and keep looking! Take your time, be methodical, and note the location, texture, moisture level, maceration, denuding and changes in skin color.

Know your type

Incontinence-Associated Dermatitis (IAD)

One of the most common forms of MASD is incontinence-associated dermatitis (IAD), which is the inflammation of the skin from extended exposure to urine or stool.  You may also know it as perineal dermatitis, irritant dermatitis or diaper rash (in children). The highest-risk patients are those that have both fecal and urinary incontinence.

As mentioned earlier, moisture requires an additional irritant in order to produce MASD. Urine contains ammonia, which increases the skin’s pH and destroys the protective acid mantle.  Adding to the problem, frequent skin cleansing in response to urinary or fecal incontinence can increase the risk of breakdown. Even incontinent briefs can contribute to IAD by causing perspiration in the affected area. Although the briefs pull the actual fluids away, the microclimate remains moist and warm.

So how do you know if it’s IAD? Here are typical characteristics:

  • Found over fatty tissue of the buttocks, perineum, inner thigh and groin (though they can occur over bony prominences).
  • Distributed in a consolidated or patchy formation.
  • Covers diffuse areas, shaped like a mirror image in the skin fold or linear area in the anal cleft.
  • Is superficial or partial thickness in depth. Note: if there’s tissue destruction into the subcutaneous tissue or deeper, it must be staged as a pressure ulcer (for more information, see the WCEI blog “Will the Real Pressure Ulcer Please Stand Up?”)
  • Presents with non-uniform redness in the wound bed, maceration in the surrounding skin and peri-anal redness. No necrosis.
  • Has diffuse and irregular wound margins.

Intertriginous Dermatitis (ITD)

Intertriginous dermatitis, also called intertrigo, is an inflammatory condition of opposing skin surfaces caused by moisture.  You’ll find it in skin folds, such as under the breasts, in the axillary (armpit) area, or inguinal (groin) region. It’s particularly common in obese patients.

Moisture can become trapped in the skin fold, where there is a lack of air circulation.  The excess moisture causes the dead cells in the uppermost layer of the skin (the stratum corneum) to become saturated and then puff up. The result is rough textures (which means they won’t glide very well), and the result is skin-on-skin friction.

Characteristics of ITD:

  • Found in the skin folds.
  • Distributed in a linear, mirror image on each side of the fold
  • Always partial thickness.
  • Presents as mild erythema (redness) that can quickly progress to erosion, oozing, maceration or crusting.
  • Surrounding skin is often macerated and prone to bacterial and fungal infections such as candidiasis.
  • Can be painful, itchy and may produce odor.

It’s important to realize that a patient can suffer from both IAD and ITD at the same time, coexisting side-by-side.

Periwound Moisture-Associated Dermatitis

Periwound moisture-associated dermatitis occurs when the skin adjacent to a chronic wound becomes exposed to exudate or toxins from bacteria in the wound bed, causing inflammation and erosion. This is a result of too much exudate that hasn’t been properly managed. Left untreated, the periwound will eventually break down and the wound will enlarge.

Infected wounds are especially prone to periwound moisture-associated dermatitis because they produce more exudate.  The condition is more common in the elderly and immunocompromised, but our clinical practices can contribute as well. This can be due to a number of risk factors, including improper dressing selection, infrequent dressing changes, and aggressive tape removal.

Peristomal Moisture-Associated Dermatitis

The final common type of MASD is peristomal moisture-associated dermatitis.  This form of inflammation and skin erosion occurs only in ostomy patients.  It begins at the stoma/skin junction, and can extend outward as much as 4 inches in any direction.  As many as 50% of patients with a stoma experience this condition, which can be extremely detrimental to their quality of life.

Peristomal moisture-assisted dermatitis can happen around any stoma, including tracheostomies, gastrostomies, urostomies, and colostomies.  However, ileostomy patients – those with stomas at the small intestine – have the highest risk since the effluent (output from the stoma) is watery and caustic.  When the pouching system leaks due to improper sizing, an uneven peristomal plane or incorrect wear time, the effluent causes skin irritation and potential breakdown.

Pay close attention to the area around the stoma, keeping a close eye out for potential problems, including well-defined erythema, edema, and loss of the epidermis. You may also see papules, vesicles, itching, crusting and oozing. As with other forms of MASD, it’s important to address the problem early.

Do you know your MASD types?

What types of MASD have you encountered the most in your facility, and have you ever had trouble identifying them? Do you have any tips for MASD identification, and has early identification made a difference in patient outcome? Please tell us about your experiences by leaving your comments below.

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Wound Assessment: Skin of Many Colors

Thursday, February 25th, 2016

Understanding the structural differences between light and dark skin is crucial for clinicians, and this free Wild on Wounds webinar will help – plus you’ll get awesome tips for assessing skin of color.

Wound Assessment: Skin of Many Colors

 

Chances are that when you studied skin and wound assessment in US textbooks, most of the case studies or photos involved patients with lighter skin tones – common to people of European decent.  Historically (and unfortunately), there’s been a lack of research, guidelines and consistency in treating skin of color.

This lack of diversity in educational resources can be downright dangerous. For example, without exposure to proper techniques, you might not recognize a Stage 1 pressure injury in a darker-skinned patient, because non-blanchable erythema (redness) is harder to see.

With the diverse US patient population, it is critical that clinicians understand how skin differs among people of various races and ethnicities. Knowing these differences is  essential for skin and wound assessment.

Learning starts here

Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS, WCEI Co-founder/ Clinical Instructor

Nancy Morgan, RN, BSN, MBA, WOC, WCC, DWC, OMS, WCEI Co-founder/ Clinical Instructor

Most of us have learned whatever we can about treating skin of color from our own experiences in the field. To remedy this, WCEI Co-founder and Clinical Instructor Nancy Morgan addressed this topic in her Wild on Wounds (WOW) national conference presentation, “How to: Skin of Color.”

Now offered as an on-demand webinar, Morgan discusses the specific characteristics of skin of color. She explains clinical conditions present differently in highly pigmented (versus lighter) skin. You can hear her entire presentation – and view it for free – with a special coupon code (listed below).

What makes skin darker?

Skin color is the result of melanin – a brown pigment. The purpose of melanin is to protect the skin by absorbing harmful ultraviolet (UV) radiation from the sun.  As we encounter UV rays, special cells called melanocytes produce additional melanin.

You may be surprised to learn that there’s no difference in the number of melanocytes between skin types. The palest and the darkest person will, on average, have the same number of these cells in their skin. However, the production and concentration of melanin in the epidermis (top layer of skin) is double in darker skin.

Does skin tone matter?

There are many skin tone classification scales used in the field, created mostly by and for dermatologists.  As Morgan states in her presentation, these scales aren’t helpful when it comes to wound care. “We have to do a very thorough visual inspection of the skin, and we have to talk to the patient about his or her baseline skin color.”

More webinar highlights

Besides exploring the basics of skin color and tone, you’ll find out more from Morgan’s webinar, including:

  • Skin conditions more common in darker skin, such as hyperpigmentation, keloid scarring, and xerosis.
  • Useful tips for performing a holistic assessment of a patient with dark skin.
  • Why some clinical conditions – such as sDTI, erythema or cyanosis – can be much more difficult to pick up in skin of color.
  • How other conditions, such as hemosiderin staining, may appear very different than they would in a patient with lighter skin.

Get your free webinarFree Webinar - Skin of Color

Are you ready to learn more about this topic and better address the wound care needs of your patients with dark skin?  Click here and use the code BLOG to access this 60-minute recording, which qualifies for an education credit.

More thoughts?

We’d love to know about your clinical experiences with skin of color. Did you receive any official training regarding this topic, or have you mostly learned from your own personal experiences? Is your facility proactive in making sure clinicians are knowledgeable in how skin tone and color effect proper wound assessment? Tell us about your observations and experiences by leaving your comments below.

 

Wild on Wounds℠ (WOW) is the national wound conference designed for healthcare professionals that are interested in enhancing their knowledge in skin and wound management. Clinicians come from all over the US to see, touch and participate in our hands-on workshops. They also learn about all the new and advanced wound care treatments and technologies to better help care for their patients.  For more information visit www.woundseminar.com

 

Is it Really a Bruise? Get The Bigger Picture on Skin Lesions

Thursday, February 18th, 2016

In the world of wound care, clinicians define skin lesions precisely. So what might look like a bruise at first glance could really be a suspected deep tissue injury, purpura . . . or something else. Do you know the difference?

Bruise sDTI or Purpura?

If a picture is worth a thousand words, then in the world of wound care, the same can be said about the appearance of a lesion – where the blood has escaped the vessels and entered the skin. By paying close attention to the color and texture, you can determine if it is more than a simple bruise.

Knowing what to look for – and getting the bigger picture – helps us conduct better assessments. What appears at first glance to be a standard bruise could actually be anything from purpura or petechiae, to an ecchymosis or hematoma. Or wait . . . is it a suspected deep tissue injury (sDTI)?

These terms are often used interchangeably, but within wound care, clinicians define them more precisely.  Confused? Don’t worry, we’re here to help!

Bruise

A bruise (also known as a contusion), is a leakage of blood from the vessels into tissues, and is always the result of blunt force trauma.  Keep in mind that “blunt force” doesn’t necessarily mean your patient has been in a fist fight or hit with a baseball bat. The bruise can be the result of something as simple as bumping into furniture.

So is it a bruise? Here’s how to tell:

  • Bruises typically resolve within two weeks.
  • They are initially a dark maroon or reddish color (because the blood is oxygenated).
  • As the bruise ages, it progresses through the colors of a ripening banana – from green to yellow and then brown – before fading away. Note: these colors will be less obvious with darker skin, so as you make your assessment, compare the site with a symmetrical area, if possible.
  • The skin is always intact.
  • The damage can be superficial, it can be deep, or it can be a combination of the two.
  • The tissues may be painful and swollen, and there may be a localized temperature increase due to the inflammation.

Hematoma

A subdermal hematoma is a collection of blood in the skin, often clotted, bulging or mass-like.  It may be in just the epidermis and dermis, or down into the subcutaneous tissue.   A hematoma is not the same as a bruise, though you may find a hematoma within a bruise. The most common cause of a hematoma is injury or trauma to the blood vessels.

Purpura/Petechiae/Ecchymosis

Purpura consists of red or purple lesions that are similar to bruises, in that they are blood added to the skin tissues.  However, purpura spots are not the result of blunt force trauma. Instead, they are caused by either an inflammatory skin disease or a vascular problem. In addition:

  • Purpura spots don’t blanch when pressed.
  • There is usually no kind of pain associated with purpura.
  • Purpura may be palpable (that is, you can feel a rash-like texture with your fingers) or unpalpable.
  • Unpalpable purpura comes in different types, including petechiae, which are flat purpura spots under 3 mm. These pinpoint-sized spots may be quite difficult to identify in darker skin.
  • Flat purpura spots that are larger than 5 mm are called ecchymosis. These spots tend to be irregular in shape (ranging from a dark maroon to a purple), and can be seen on the skin or in the mucus membranes.

It’s important to note that ecchymosis and bruising are not the same thing, though you may hear some clinicians use these terms interchangeably. Again, ecchymosis is a kind of purpura, and is not caused by blunt force.

Suspected Deep Tissue Injury

Suspected Deep Tissue Injuries (sDTIs) also share some qualities with bruises in that they are non-blanchable, intact, and appear in similar colors – purple or maroon. Alternately, they may be a blood-filled blister.

But here’s the key difference: sDTIs are due to damage from pressure or shear, and not blunt force.  Therefore, you’re more likely to find them over a bony prominence and in patients with a history of immobility. The most common site for an sDTI is the heel.

When you touch the tissue of sDTIs with your fingertips, it could be painful, firm, mushy, boggy, and warmer or cooler compared to adjacent tissue.  It’s important to use palpation on all dark-skinned patients on high-risk areas, because visual assessment cannot be trusted. Swift identification of sDTIs is important because unlike bruises, which will resolve on their own, sDTIs can deteriorate rapidly, exposing additional layers of tissue despite treatment or offloading.

Do you know the difference?

Now that you’ve learned about the differences between bruises, sTDIs and other similar skin conditions, what do you think? Have you been able to distinguish the true identity of patient lesions in the past, or has it been difficult to properly assess them? Has your facility emphasized the need to distinguish between these types of lesions? And which type do you find the most difficult to identify? We’d love to hear more about your experiences – please leave your comments below.

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.

Essential Steps for Skin Tear Prevention

Thursday, February 11th, 2016

Skin tears are a common condition for the patients we care for, which is why it’s so important for clinicians to know who is at risk, and what can be done to minimize them. 

Skin Tear Prevention

Painful. Disfiguring. Traumatic. Skin tears are all of these things, plus they can lead to further complications and serious infections. Unfortunately, they also happen to be a very common condition for the patients we care for. In fact, an estimated 1.5 million skin tears occur each year – and that’s just among institutionalized adults.

In addition to causing pain and discomfort, skin tears can be difficult to treat, and are a direct reflection of the quality of care delivered at our facilities. This is why it is imperative for clinicians to know who is at risk for skin tears, and what we can do to prevent them from happening.

Who is at risk?

Although skin tears can occur among all ages, the youngest and oldest patients are at the highest risk. This is due to the structure of both immature and aging skin. In addition, those who are dependent on caregivers for daily activities are particularly vulnerable, since they are regularly positioned and transferred for such things as bathing and dressing. Others who are higher at risk include:

  • Older adults who ambulate independently
  • Those who are critically ill or have multiple risk factors
  • People with a history of skin tears
  • Anyone with impaired mobility
  • Those with sensory or cognitive deficits
  • Patients with visible changes in the skin such as edema, dry skin or purpura
  • Patients on four or more regularly prescribed medications
  • Patients on specific types of medications, including analgesics, antidepressants, anticoagulants, and steroids
  • People who are agitated and combative – they are more likely to bump into objects
  • Those with cardiac, pulmonary or vascular disorders

Skin tear prevention

The truth is that skin tears are not completely preventable. Since part of our job is to support our patients’ independence and improve their quality of life, at some point or another, skins tears will occur. The good news is that, as caregivers, there are things we can do to keep them at a minimum.

Improve patient environments

A patient’s environment can be modified in simple ways that can make a big difference when it comes to skin tear prevention. For instance, you can make sure there is adequate lighting in your patient’s room or living space. Seniors, for example, typically need more light in order to see clearly and avoid accidents. Next, pad furniture corners and other objects that may cause blunt force trauma when bumped, and remove throw rugs that may buckle or slip.  In addition, ensure that the patient is not wearing rings or other jewelry that can snag the skin.

Care for skin properly

Proper skin care can can go a long way in preventing tears. Skin is better able to resist tearing when it’s well-nourished and hydrated, which means nutrition plays a key role. Therefore, consult with a dietitian about the patient’s diet, and make sure they are receiving adequate fluids.

Frequent baths can dry out the skin, which increases the likelihood of skin tears. This can be a problem when facility regulations mandate that patients must have daily or weekly full baths.  If you find that frequent bathing is contributing to dry skin, adjust the full-bath schedule to twice a week, with spot baths in between.  Also, it’s important that when administering a bath, you:

  • Use lukewarm water (not hot)
  • Use soapless, pH-balanced solutions with no rinse or emollient soap
  • Pat the skin dry – do not rub

To keep the skin hydrated following a bath, apply a moisturizing agent. The stratum corneum – or outermost layer of the skin – needs at least 10% moisture. Moisturizers should be applied while the skin is still damp (not completely dry and not soaking wet) to trap that moisture.

There are three types of moisturizers:

  • Humectants promote the retention of moisture, replacing the oils in the skin
  • Occlusives provide a layer of oil on the skin surface, slowing water loss
  • Emollients soften and spread easily on the skin.

A humectant will pull the moisture up from the dermis into the epidermis to help keep skin intact (it’ll even pull moisture out of the air in the room). But humectants need to be coupled with an occlusive product to trap the moisture. In other words, you need to add a layer of oil on the skin’s surface to slow down evaporation.

Meanwhile, we want our skin to be able to slide, right? And that’s the role of emollients. They make the stratum corneum smooth and less susceptible to friction, which can create that skin tear.

More strategies for prevention are to cover fragile skin with long sleeves, pants and knee-high socks, or products such as DermaSaver® or Posey® SkinSleeves™.  If something rubs up against the patient, the clothing or the device will move and hopefully not tear the epidermis from the dermis.

Be gentle, learn more

It goes without saying that we should be extra gentle when lifting, repositioning or transferring patients. By taking your time and softening your touch when caring for those at higher risk of skin tears, the frequency of such occurrences can be decreased.

Educating ourselves and our patients is also an important part of preventing skin tears. We need to understand the risk factors, keep the skin as nourished and moisturized as possible, avoid dangerous edges and surfaces in the environment, and treat patients gently.Skin Tear Webinar Coupon Code

For even more details on the prevention, staging and treatment of skin tears, view this free one-hour webinar recorded at the 2015 Wild On Wounds (WOW) National Conference. For access, click here and use the code SKINTEARS.

What do you think?

Were you already aware of who is most at risk for skin tears, and does this affect how you treat patients? And are there any preventative measures you regularly put in place that seem to help? If you have additional ideas, or any stories to share, please leave them below!

 

Wound Care Education Institute® provides online and onsite courses in the fields of Skin, Wound, Diabetic and Ostomy Management. Health care professionals who meet the eligibility requirements may sit for the prestigious WCC®, DWC® and OMS national board certification examinations through the National Alliance of Wound Care and Ostomy® (NAWCO®). For more information see wcei.net.