An Overview of Maintaining Skin Integrity for Individuals with Spinal Cord Injury

Objectives The Skin You’re In: An Overview of Maintaining Skin Integrity for Individuals with Spinal Cord Injury • Identify Skin Risk Factors and interventions for Skin Care in the Spinal Cord Injured Patient • Identify treatments for impaired skin integrity and cost containment issues in the Spinal Cord Injured Patient Taking a look under Simple A/P of Skin ( the largest organ of the body) Epidermis • Outer Layer that contains 5 sub-layers. As the cells move into the higher layers, they flatten and eventually die. • The top of the epidermis layer is made of dead flat skin cells. • Its Constantly be rubbed, scrubbed and replaced with new skin cells every 2 weeks 1 Too much “shedding” leads to over dryness Dermis What makes your skin so sensitive • It’s the middle Layer that contains blood vessels, hair roots and sensitive nerve endings. • Think of “hair standing on end” a blister or shaving nubs that pop up. Peeling from a blister Subcutaneous • The inner layer that contains fat cells and sweat glands. This layer helps control body temperature and provides a way to rid the body of waste products Bruise Its all about the skin your in… 2 In a Spinal Cord Injured Patient Interruption of nerve pathways causes changes in sensation • Pressure, sharpness, hot or cold are felt differently or not at all (anesthetic skin) • Spasticity creates shearing damage to the skin as it rubs up against clothing, bedding and wheelchair parts. • The gradual sliding of gravity and wrinkling of the skin …And the lack of dermatomes • “Dermatomes” are the skin’s nerve endings which becomes eliminated below the SCI site which cause the absence of sensation. What's below the injured skin is not the same as the skin above • Decreases amino acid concentration • Decrease the proportion of Type 1 to Type 2 collagen • SCI also paralyzes sweating in dermatomes below the injury level. • Decrease blood flow >Abnormal vascular reactions • Autonomic hyperexcitability- Abnormal increase in sweating above the injury site, often the upper torso and face. Sometimes only on one side of the face and not the other. • Decrease PO2-5X less then the innervated skin • Abnormal vascular reactions (postural hypotension) Honest Facts that cause skin break down • Poor nutrition • Dehydration • Excess moisture due to sweating, bowel and bladder accidents • Decrease blood supply to skin • Excessive exposure to heat, cold, chemicals • Excessive pressure over bony areas 3 Knowing your body shape and size can help determine the skins needs Incidence of Skin breakdown in SCI Patients • Incidence of SCI continues to be 80% male, 20% female • Substantial physiological differences exist between genders • Increase incidence with as the SCI person ages Law of Gravity What goes up, must come down Shearing Friction Moisture 4 Pressure Typical “set up” for a pressure ulcer Bone over skin that can causes an ulcer Most Problematic area for shearing Too much rubbing Shear and Friction 5 The “Soreness” around Pressure Ulcers Quick review on Staging Pressure Ulcers Why so “sore”? Undamaged skin Stage I 6 Stage II Stage III Stage IV Deep Tissue Injury Shearing Injury This is what shearing really looks like 7 Pressure Pressure Points Reclining Pressure Points Sitting Pressure Points Its time build on your knowledge Got damaged skin? How do you fix it? 8 Take the preventative approach! Promoting healthy skin You Are What You Eat! • Good diet and fluid intake • Hygiene • Selecting proper clothing • Awareness of temperature extremes • Pressure relief strategies, weight shifts and positioning • Managing Stressors Nutrition Pay attention to your intake • Proteins (lean meats, soy, dairy) • Vit. Vit. A and C (building blocks for tissue) • MineralsMinerals- copper, zinc and iron • A minimum of two liters of fluid a day avoid fluids that act as diuretics which can cause excess fluid loss (coffee, tea, beer) You don’t always need to make a fashion statement! Long Term Nutritional needs • Calcium- Can prevent Osteoporosis, improve muscle and nerve functioning. It’s also necessary for blood clotting. • Fiber-”Invaluable” in maintaining healthy bowel function, as patients who have SCI are prone to constipation due to immobility. Fiber can be found in vegetables, fruits and starches. • Protein-Essential for healthy muscle, skin and immune system. Avoid diets that are high in protein and low in carbs; this may contribute to kidney problems Salt (Sodium)- It regulates fluid balance, contraction of muscles, conduction of nerve muscles. Too much sodium can cause water retention ,heart and kidney disease, and stroke. Water- Regulates the body temperature, adds in the digestion of food, prevents urinary tract infections and kidney stones. “Water is the key to bowel management”. A aSCI patient to strive to drink at least 8 glasses of water a day! Just make good choices! • Dress for the weather! (Wear breathable clothing like wools and cotton blends.) • Wear socks with shoes. Shoe size should be one size larger than prior to injury. • Avoid sitting on seams and back pockets. (Watch out where you place your cell phone!) • Too looseloose- Loose clothing can form wrinkles that can cause pressure on your skin. • Too tighttight- Overly tight clothing can hinder circulation. 9 Other skin and clothing tips Can someone please explain…. • Heat- Avoid sunburn by using sun-blocks all over including feet. Check Vinyl seats before you sit on them to make sure they aren’t too hot. When camping, keep feet a safe distance from the campfire. • Cold- Be sure to dress warmly to prevent frostbite, if out in the cold for long periods of time. Dressing in layers of clothing will provide extra warmth. Avoid putting frozen foods or bags of ice on your lap. Overall good skin care Look familiar • Avoid using “antibacterial” soaps. These reduce the skin’s acidity which helps protect from infection. • Skin fold, creases, and “other nooks and crannies” need washing more frequently- twice daily is the best. Clean up soiled skin immediately to prevent skin breakdown. • Avoid talc powders, they can actually promote yeast growth! Do not over use moisturizing creams over bony areas since they may soften skin and promote skin breakdown. • Finger and toe nail care is a must! See a podiatrist for any toe nail deformities (especially if you have Diabetes). Cut nails straight across to avoid ingrown nails. Common skin problem from not keeping skin clean No Pressure Here! 10 Tried and true pressure relief techniques Pressure Redistribution Support Surfaces- Medicare Coverage Criteria Less obvious techniques (subtle movements count) Group 1 Pressure Redistribution Support Surface Products • Foam mattress overlays –foam height 2” or greater • Gels • Must be durable, waterproof • Can be directly placed on a hospital bed frame Group 1 Support Surfaces • Completely immobile-patient cannot make changes in body position without assistance. • Limited mobility-patient cannot independently makes changes in body position significantly enough to alleviate pressure • Any Stage Pressure Ulcer on the trunk or pelvis Group 2 Support Surfaces • Multiple Stage II pressure ulcers located on the trunk or pelvis. The patient has been on a comprehensive ulcer treatment program for at least one month and also using a Group 1 support surface • The ulcers have worsen or remained the same for at least one month. • Large or multiple Stage III or IV pressure ulcer on trunk or pelvis • Mycocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis within the past 60 days of surgery • The patient has been on a group 2 or group 3 support surface prior to a recent discharge from a hospital or nursing facility within the past 30 days. 11 Group 2 Support Surfaces • An air pump or blower which provides either sequential inflation and deflation of air cells or a low interface pressure throughout the mattress • Inflated cell height which air is circulating at 5 inches or greater. Air pressure provides adequate patient lift, reduces pressure and prevents bottoming out Wheelchair cushions • Always use a skin protection seat cushion • Any skin issues qualify for a wheelchair cushion • Any absent or impaired sensation in the pelvic area qualifies for a positioning seat cushion ie “scoop” sacral ischium seats. • Don’t use a extra pillows over wheelchair cushions • Needs to be evaluated by PT/OT • Should have pressure mapping done if new skin breakdowns occur • New cushion every 2-3yrs depending on the cushion • A surface deigned to reduce friction and shear and that can be placed directly on a hospital bed frame. Pressure Mapping Support Surfaces can ONLY Redistribute Pressure! • Used to assess distribution of various anatomic locations. • A pressure mapping device that pinpoints areas of concern are more helpful vs visualizing whole body pressure. • NPUAP is in process of developing standardized testing methodology for pressure redistribution surfaces to accurately compare products. It’s your turn now Personal Story “Mike” is a para, injured over 10 years ago. He was in an acute care hospital during the winter because of a respitory infection. While there, he developed a pressure ulcer on his buttocks and one heel. He admits to not checking his skin while there but expected the staff would do so and thought he would have the right kind of bed to prevent this. He had not had a pressure ulcer in about 8 years 12 CMS changes on October 1,2008 A great Question! What do acute care hospitals have in place to help prevent this from happening? Will mentioning a sore in his medical records be enough of a red flag for future care? Agency for Healthcare Research and Quality (AHRQ) Guidelines and Interventions • All patients skin inspected daily • Use positioning techniques • Moisturize skin • Incontinence management • Written turning schedule Stage III and Stage IV pressure ulcers were added to the list of preventable hospital acquired conditions. Payment to these hospitals is denied if these conditions develop. Reporting System for Pressure Ulcers at BMC • If any skin breakdown occurs after 24 hours of admission (if within 24 hours, can modify admission assessment) • To be completed with hospital acquired alteration in skin integrity(can be related to trauma-skin tear, device, tape or pressure, allergic reaction, etc.) • Written care plan for prevention interventions • Nutrition evaluation • Teaching patient and family Risk Assessment Tool Braden Scale (Most common) • • • • • More than a number; it involves identifying the risk factors that contributed to the score and minimizing those specific deficits Sensory perception Moisture Mobility Nutrition Friction & Shear **Patient is considered at risk for skin break down with a Braden Scale of 18 or less.** • Admitted stage III & IV or unstageable pressure ulcers, from an outside facility. So why so important? • A Stage 3 or 4 hospital acquired pressure ulcer is considered a serious reportable event (SRE). • DPH mandates that we report an SRE within 7 days and conduct a root cause analysis within 30 days. • A root cause analysis is a confidential review, coordinated by the Risk Management Dept. • The purpose is to identify problems and correct to prevent future occurrences. • New CMS regulations, not reimbursable. 13 BRADEN RISK ASSESSMENT SCALE SCORE SENSORY PERCEPTION Ability to respond meaningfully to pressure-related discomfort 1. MOISTURE Degree to which skin is exposed to moisture 1. ACTIVITY Degree of physician activity 1. Completely Limited: Unresponsive (does not moan, flinch, or grasp) to painful stimuli, due to diminished level of consciousness or sedation. OR limited ability to feel pain over most of body surface. 2. Very Limited: Responds only to painful stimuli. Cannot communicate discomfort except by moaning. Constantly Moist: Skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time patient is moved or turned. Bedfast: Confined to bed. 2. Very Moist: Skin is often, but not always most. Linen must be changed at least once a shift. 2. Chairfast: Ability to walk severely limited or nonexistent. Cannot bear own weight and/or must be assisted into chair or wheelchair. 3. Slightly Limited: Responds to verbal commands, but cannot always communicate discomfort or need to be turned. OR has some sensory impairment that limits ability to feel pain or discomfort in 1 or 2 extremities. 3. Occasionally Moist: Skin is occasionally moist, requiring an extra linen change approximately once a day. 3. Walks Occasionally: Walks occasionally during day, but for very short distances with or without assistance. Spends majority of each shift in bed or chair. 4. No impairment: Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort. 4. Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. 4. Walks Frequently: Walks outside the room at least twice a day and inside room at least once every 2 hours during waking hours. MOBILITY Ability to change and control body position 1. Completely Immobile: Does not make every slight changes in body or extremity position without assistance. 2. Very Limited: Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. 3. Slightly Limited: Makes frequent though slight changes in body or extremity position independently. NUTRITION Usual food intake pattern 1. Very Poor: Never eats a complete meal. Rarely eats more than ____ of any food offered. Eats 2 servings or less of protein (meat or dairy products) per day. Takes fluids poorly. Does not take a liquid dietary supplement. OR is NPO and/or maintained on clear liquids of IVs for more than 5 days. 2. Probably Inadequate: Rarely eats a complete meal and generally eats only ½ of any food offered. Protein intake includes sonly 3 servings of meat or dairy products per day. Occasionally will take a dietary supplement OR receives less than optimum amount of liquid diet or tube feedings. FRICTION AND SHEAR 1. Problem: Requires moderate to maximum assistance in moving. Complete lifting without sliding against sheets is impossible. Frequently slides down in bed or chair, requiring frequent repositioning with maximum assistance. Spasticity, contractures or agitation lead to almost constant friction. 2. Potential Problem: Moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair, restraints, or other devices. Maintains good relatively good position in chair or bed most of the time but occasionally slides down. 3. Adequate: Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) each day. Occasionally will refuse a meal, but will usually take a supplement if offered. OR is on a tube feeding or TPN regimen which probably a meet most of nutritionally needs. 3. No Apparent Problem: Moves in bed and in chair independently and has sufficient muscle strength to lift up completely during move. Maintains good position in bed or chair at all times. 4. No Limitations: Eats most of every meal. Never refuses a meal. Usually eats a total of 4 or more servings of meat and dairy products. Occasionally eats between meals. Does not require supplementation. TOTAL SCORE A word about wound care products Just remember, ask a Professional Health Care person! Don’t rely on product gimicks, or magic remedies Some other Product Guidelines 14 You don’t have to go there alone, there are so many SCI resources you can contact! Ok folks, that’s a wrap! Any Questions? 15