Skin Integrity, Capstone Project Example

Introduction

Skin integrity is one of the indicators of quality of care. The incidence of bed sores due to pressure in hospitals and long-term care facilities is a problem which can become quickly out of control is not properly monitored and treated. Pressure sore stages can be reduced through early detection. Carefully monitoring the skin integrity of each bed-bound patient is vital to maintaining good skin integrity and control. Older populations and patients with diabetes are particularly susceptible to developing issues with skin integrity. Skin integrity is not always created by pressure but can develop from friction and moisture. The state of the patient’s immune system, body temperature and co-existing diagnoses also complicate the problem.

The Institute of Medicine (IOM) and the Quality and Safety Education for Nurses (QSEN) are organizations dedicated to high standards of care. Addressing the nursing student and current working nurses for the attitude of improvement of the quality and care and safety of patients is at the forefront of the goals and missions. Ensuring the knowledge and skill sets meet the standards for quality care is a major objective of IOM and QSEN. Specific competencies were developed for measures of safety.

Following the competences of IOM and QSEN is important to limiting and lessening the problems and issues associated with skin integrity. Pressure sores can compromise a patient’s entire health structure and ultimately end in amputation or death. The distinctiveness of the body’s skin system is as vital an organ as any internal appendage. Although there has been studies conducted on skin integrity, the need for further research is evident by the ongoing research in universities and laboratories. Finding new technology, processes and procedures to deal with pressure sores and ulcers, increases patient safety and quality of care. Innovation in the development of techniques and technology fosters the training of healthcare professionals in all aspects. Faculty development, nursing involvement and education of student nurses will support and provide insight to research. Patient centered care, teamwork, communication, error-reduction, and evidenced based practice are all components of IOM and QSEN competencies; exceptional qualities for high quality patient safety and care.

Research in skin integrity diagnoses will also provide new information to assist physicians and nurses in the care of patients. Educating faculty professors in teaching roles to students address the challenges for education and practice based administration of care. Promoting student involvement to build a foundation of education and experience helps cement the concepts into routine practice methods.

Literature Review

Identified Nursing Problem

Pressure ulcers have been a problem for years; dating back to early historical records. Skin integrity issues have also been referred to as decubitus and ischemic ulcers.  The problem is not less disconcerting today than 400 years ago when it was felt that a ‘pneuma’ resulting from nerve severance with loss of blood supply, caused skin ulceration (Darrell, 1975). Pressure ulcers are common and begin under many circumstances. This is a highly preventative problem.

In addition to adverse health outcomes, the financial impact of treating pressure ulcers is substantial (Reddy, Gill, Rochon, 2006)  This health condition ranks third, just after cancer and heart diseases; estimating millions of dollars spent in just one year. Pressure ulcers also have legal ramifications. Legal suits over poor quality of care as evidenced by a pressure ulcer are also a financial concern.  Conducting research into causes, treatments and cures is an ongoing endeavor for scientists and physicians.

Staging the existing ulcer is the first step in determining how difficult the problem and the type of treatment necessary. Stage I is demonstrated by intact skin with non-blanching redness in one area that is usually seen at a bony prominence.  The area may be painful to the patient.  Stage II demonstrates partial thickness loss of the dermis which can be seen as shallow with a red or light pink bed; there may be blister formation. This may look shiny; however, there will not be any bruising; which may indicate deep tissue injury. At this stage the determination must be made to eliminate skin tears or tape burns from the diagnosis. Also maceration or excoriation should be diagnosis elimination.  Stage III reveals full thickness tissue loss. The appearance of subcutaneous fat may be present; however, bone, tendon or muscle will not be seen. There may be slough, undermining and tunneling present.  Stage IV will reveal exposed bone, muscle or tendon. There may also be slough, eschar, undermining and tunneling.The last stage is ‘unstageable’ and is a serious condition for the patient. There will be full thickness tissue los with the base of the ulcer covered by various colored slough with possible tan, brown or black eschar directly in the wound bed itself. If there is stable eschar on the surface this should never be removed as it is the biological cover, the body’s natural defense. The true depth of the wound cannot be determined unless the slough or eschar is removed.  This presents a problem if the eschar is stable; dry, adherent and intact without fluctuance or erythema.

Nursing Practice and Literature Support

Important risk factors for the development of pressure ulcers include impairments in mobility, nutrition and skin health (Reddy, Gill, Rochon, 2006).  Research conducted on these risk factors along with classifications by setting revealed a few approaches for prevention of ulcers. Supporting surfaces such as pillows and cushions reduce pressure by assisting with body weight contributing to pressure were determined to be helpful in ulcer prevention. Nutrition is also important to the skin integrity. Supplementation is helpful for patients who are not able to have an adequate diet intake.

Repositioning is the most popular method of pressure ulcer treatment. However, it is usually not as effective is used alone. Working the muscles through exercises either with a physical therapist or family member will help alleviate pressure and allow the skin to have room to breathe while helping to add tone to the muscles for recovery.  Maintaining the right level of moisture is also helpful in preventing ulcers. Skin should not be too moist or too dry. Either condition can create the beginnings of a pressure ulcer.

In elderly patients the treatment of incontinence is vital to good skin integrity. Urinary or fecal incontinence can create a breeding ground for skin breakdown. Heightened levels of care are necessary for this group of patients. However, this research study failed to show prevention. Staff provided exercise as well as incontinence care for two hours per day for 32 weeks; this multifaceted intervention did not reduce pressure ulcer incidence relative to the control group subjected to the usual care of the facility (Reddy, Gill, Rochon, 2006).  This does not mean that longer periods of time are acceptable in care for incontinent patients. Going longer than the usual standard of care creates other health related concerns and has not been proven to contribute to pressure ulcers.

Research studies also demonstrate the level of nursing care directly corresponds to the development of pressure ulcers. Nurses must watch closely for any skin changes, including areas which may look burned or bruised. Due to the financial indications some healthcare payors are questioning the correlation between nursing care and incidence of pressure ulcers. According to the Centers for Medicare and Medicaid, health care organization may not be reimbursed for a surgical procedure is a patient acquires a pressure ulcer during the procedure or during the postoperative hospital stay (Benholm, 2008).  The reasoning is that nurses may not be devoting enough time and energy watching patients for ulcer development.

Further research studies for prevention are warranted. Nurses should watch first to see if the patient has any co-morbidities subjecting them to potential ulcer development. Nutrition, age, chronic problems, existing ulcers and even obesity are conditions which should trigger the nursing personnel to be on high alert for evaluation and close monitoring.  However, all patients are at risk as a result of immobilization during any procedure and the altered neurological status caused by anesthetic agents (Benholm, 2008). Continual monitoring is required to help in the prevention of new ulcers and treatment of existing sores. Prolonged pressure over bony prominences can also lead to pressure ulcers; monitoring not only the skin but the structure of the patient’s body is vital (Schultz, 2005).

Nursing ability to identify a patient at potential risk is just as important as understanding the treatments. This is the first line of defense. Research has demonstrated that over-identification of stage I ulcers as a limitation to proper diagnosis and treatment (Schultz, 2005).  This study found also the over-identification of ulcers associated on the patient’s heels and sacral areas. This suggests that nursing training may be limited and further research should be done to assess the training of nurses in this region. This study demonstrated a specific idea that individual susceptibility to tissue tolerance must be considered and patients with poor peripheral circulation are at greater risk of developing pressure ulcers related to decreased tissue tolerance (Schultz, 2005).

Predicting which patient is susceptible to pressure ulcers can also be done through the Braden Scale for Predicting Pressure Sore Risk. This scale was specifically created to help nurses determine patients’ risk of developing pressure ulcers (Stotts, Gunningberg, 2007). Nurses are concerned with the prevention of ulcers as they affect the health risks and finances. In addition, the nurse must also be concerned with the patient’s comfort, as well as their mental, emotional and social well being.

The Braden Scale for Predicting Pressure Sore Risk, developed in 1980, does not prevent ulcers but prompts the nurse to use preventive strategies based on the results (Stotts, Gunningberg, 2007).  The test takes about a minute and uses sensory perception, activity, mobility, skin moisture, nutritional intake and friction and shear as the criteria for assessment. The nurses score the exam and follow a guide for the level of risk the patient demonstrates. This assists in nursing care plans and approach to the problem.

Research on the Braden Scale for Predicting Pressure Score Risk has a high predictive validity; effectively predicting the development of pressure ulcers in patients.  One study showed a positive predictive validity at 61% correctly predicting the development and a 86% negative predictive validity, correctly predicting the ulcer would not develop (Stotts, Gunningberg, 2007).  Studies also demonstrated this scale to be sensitive and specific; allowing nurses to feel confident in the results.

Patients with spinal cord injuries are extremely susceptible to developing ulcers. The muscle and fat tissue peripheral to the injured spine become atrophic and patients spend a great deal of time in a wheelchair; irritating and injuring the ischiogluteal bursa (Fujisawa, Michiko, Nakamura, Furuta, Ishii, Kawachi, and Otsuka,  2010). A bursa is similar to an ulcer and can be confusing, creating the possibility of an incorrect diagnosis. Nursing care for patients with spinal cord injuries should be carefully monitored. Misdiagnosing can lead to adverse health effects for the patient.  Although there are few reports of a true perforated ischiogluteal bursa, it not a rare condition but simply misdiagnosed as an incurable decubitus ulcer (Fujisawa, et.al, 2010).

Consistent documentation by the nursing personnel is important to accurately track the progression of pressure ulcer development and to plan treatments for wound healing (Benholm, 2008).  In Germany a computerized system within a network of existing wound care centers proved to be extremely effective in modeling treatment and sharing information. A computerized documentation system can generate a large and valid database of wound characteristics, would-healing dynamics and wound care (Coerper, Wicke, Pfeffer, Koveker, & Becker, 2004). Ten centers entered into a two year pilot project of 4,175 patients with 7,951 chronic non-healing wounds. This endeavor proved to be successful for  the identification of wounds for treatment and healing. Using a standardized system of documentation assisted the health care professionals in obtaining information and treatment options.

Case Example

Charlie H., a 62-year-old diabetic gentleman presented to the hospital with trauma to his right arm. While walking along an icy sideway Charlie slipped and fell; bumping his forearm against a walkway railing in his neighborhood. Due to his frail condition and multiple diagnoses, he was admitted for observation. Along with juvenile diabetes, Charlie had a history of cardiovascular disease and stent placement approximately five years prior to this hospitalization. He is a dedicated patient, closely monitoring his diet and blood sugars. He walks two to three miles a day. He actively participates in his health care and is compliant with his regimen. He has a past history of one-pack a day smoking from the age of 16 until he quit at the age of 35.

After his admission he was carefully monitored for blood sugar elevation and the trauma he experienced to his arm.  His arm was x-rayed and was only bruised.  However, his blood tests revealed an elevated blood sugar and triglyceride level. He admitted to having experienced heart palpitations a few days prior to his trauma.  However, he felt it was due to stress and ignored the symptoms. Further testing was ordered to evaluate his cardiovascular status.

Charlie also showed us where he had a sore on the heel of his foot which had just started to bother him and cause discomfort.  The nursing staff decided this sore should be closely monitored to assess for infection or ulcer formation. Charlie also demonstrated a tendency towards fragile skin. The nursing personnel felt this sore could become problematic and decided to quickly make this issue as a priority for quality care and safety of this kind and cooperative patient.

As Charlie’s arm began to feel better although still bruised, the nurses routinely changed his position in bed every two hours. We also encouraged him to be up and walking as much as he could. The cardiovascular testing also helped keep him active.  We ensured he had regular meals and monitored his intake; both food and water.  We checked the sore every two hours and kept the skin clean and dry. We fashioned a pillow under his knee at an angle to help keep the sore from lying directly on the bed. We monitored his temperature and blood pressure on a regular routine.

Charlie’s cardiovascular results came back normal. It was felt by the attending physician that the trauma and stress had caused abnormalities in his blood work. His blood sugar remained constant and within an appropriate range. The sore began to heal with nursing care and there were no signs of redness or tenderness around the area. The sore seemed to be from ill-fitting shoes. We instructed him on the care of proper fitting shoes and the importance of not developing sores and ulcers due to his diabetes and the increased chance of infection and pressure sores. He was discharged and returned home with a written list of instructions. His daughter checked him out of the hospital and she was also instructed on the importance of skin care, proper fitting shoes and avoidance of falls and trauma. She will accompany him to his primary care physician for follow up in one week.

Overall the facility I work in follows the IOM and QSEN philosophies and guidelines for patient safety and quality care. During Charlie’s stay the nursing educator’s brought in the nursing students on regular rounds. The instructors used Charlie’s hospital stay to demonstrate the high quality of care and supervision of his injured arm and his heel sore. Since pressure sores can quickly deteriorate into ulcerations and create further health compromise, the students were instructed on the effective and efficient methods for skin integrity.

Conclusion

Practice

Prevention.  The most effective practice for skin integrity is prevention; when applicable. The Braden Scale for Predicting Pressure Sore Risk is effective in initial presentation for both prevention and treatment of existing pressure sores. In prevention the effectiveness and efficiency of close monitoring cannot be stressed enough.  The beginnings of a site of redness should immediately cause concern and action. Patients should also not be overly sedated as this contributes to bed pressure from no movement. The identification of high-risk patients with repositioning and conscientious skin care with proper hygiene is very effective in the prevention of pressure ulcers and sores.

Treatment.  When a pressure sore has already developed the first measure is to determine the level and stage of the sore. Treatment will depend on the stage of the sore.  Specifically the treatment involves pressure reduction, direct ulcer care with management of the pain, infection and any malnutrition. In the later stages of treatment surgical intervention may be necessary. In the case of compromised patients amputation may be the only solution.

When repositioning the patient the use of lifting devices or cushions are highly effective. The main concern is to monitor and reposition on a continual and frequent basis. Protective padding and support surfaces are also useful in repositioning. The heat and moisture status must be watched in repositioning to allow the flow of air and reduction of moisture but not allowing too little moisture to the wound. Some facilities have specialized beds which are also useful for some types of ulcers. Infection control and pain management are also components of the treatment of an existing ulcer.

In the event necrotic tissue needs to be removed to treat the pressure sore, debridement is performed. Allowing dead tissue to remain with surrounding healthy tissue is a breeding ground for bacterial growth. There are several options for debridement. Autolytic debridement is used in stage III and IV wounds and involves occlusive or semi-occlusive dressings. This method uses the body’s moisture to soften the eschar. There is no pain associated with this method.  This is safe for the patient; however, it is not as effective and rapid as with surgical debridement.

Enzymatic debridement uses chemical enzymes to rid the wound of necrotic tissue. It is fast acting and does not damage the healthy tissue as long as the procedure is carried out appropriately. This can be used on any wound that has a large amount of debris or eschar formation. A major disadvantage to this method is the high cost and it requires a prescription. Additionally, it can cause inflammation and this can cause discomfort to the patient.  This method is also harder to perform as the application of the chemicals can only be applied to the wound itself and should never touch healthy tissue.

On method which has been used for many years is called mechanical debridement.  Also called hydrotherapy it occurs when a dressing is allowed to turn from moist to wet. The dressing is then removed and this creates a form of non-selective debridement. This method is used most often in wounds that have only a moderate amount of necrotic tissue. This procedure is relatively inexpensive. Considerations for not using this method are the amount of time it takes and it can create pain for the patient. There is also a risk of tissue maceration and infection. Limiting complications is important to consider when determining a method to use.

For serious necrotic damage and in the case of associated infection, surgical debridement is the most effective method. Surgical and laser debridement under anesthesia is the fastest and is highly effective. The procedure can be performed at the bedside or in the operating room; dependent on the severity of the sore. This method can be costly and painful. However, it is selective and the amount of tissue removal is easily controlled by the physician. The surgeon will use surgical instruments such as scalpels and forceps to remove the area predetermined to be necrotic.

Education

The guidelines for educating staff include the specific conditions which can create an ulcer as well as the preventive and treatment measures for patients.  Nursing students are taught that the age of the patient as well as how mobile they are is very important in identifying high risk patients. Poor nutritional status as well as mental, neurological and other physical problems attribute to the problem. Moisture should be monitored as well as friction and shearing from moving the patient from bed-to-bed or bed-to-chair. Wrinkled or crumbed bed sheets are also a problem for high-risk patients and should be monitored along with the other risk assessment monitoring.

Research

Continual research on pressure ulcers will ensure technology and processes and procedures for better care of skin integrity problems. Identifying at-risk patients, high-risk patients, treatments, facility characteristics and health care professional techniques will provide new methods for prevention and treatment of pressure ulcers. Predictor model development and improvements will also assist in identifying and staging pressure sores. The National Pressure Ulcer Long-Term Care Study was organized in 2004 to specifically research these criteria.  Other organizations, researchers and treatment facilities also work to determine nursing protocols to assist in recognizing, treating and care giving to patients. Research on the variables of pressure ulcers and the specific dynamics will provide comprehensive data for evidence based practices.

Summary

Quality of care in the health care industry includes core values to include excellence, integrity, innovation and collaboration. Patients who enter the hospital and develop pressure sores can signal a problem with quality care in certain situations. However, there is always the chance a patient will develop bed sores depending on their personal health conditions and problems. Recognizing the importance of recognizing the high risk patients and carefully and methodically monitoring the patients is high quality care. Nursing care education and research are beneficial to keep health care professionals current on techniques and procedures for wound care.

References

Benholm, B. (2008). Perioperative pressure ulcers. American Operating Room Nursing Journal (AORN). Feb., 2008.  Retrieved from http://findarticles.com/p/articles/mi_m0FSL/is_2_87/ai_n24958280

Coerper, S., Wicke, C., Pfeffer, F., Koveker, G., Becker, H.D. (2004) Documentation of 7051 chronic wounds using a new computerized system within a network of wound care centers.  Archives of Surgery. March, 2004, 139(3). Retrieved from http://archsurg.ama-assn.org/cgi/content/full/139/3/251

Darrell, S.J.  (1975). Pressure sores classification and management. Current Orthopedic Practice. Oct. 1975:112, 101-113.

Fujisawa, Y., Ito, M., Nakamura, Y., Furuta, J., Ishii, Y., Kawachi, Y., Otsuka, F.  Perforated ischiogluteal bursitis mimicking a gluteal decubitus ulcer in patients with spinal cord injury.  Archives of Dermatology. August 8, 2010; 146(8).  Retrieved from http://archderm.ama-assn.org/cgi/content/full/146/8/932

Reddy, M., Gill, S.S., Rochon, P.A.  (2006). Preventing pressure ulcers; a systematic review. Journal of American Medical Association (JAMA). 2006;296:974-984. Retrieved from http://jama.ama-assn.org/cgi/content/full/296/8/974

Schultz, Alyce. Predicting and preventing pressure ulcers in surgical patients.  American Operating Room Nursing Journal (AORN). May, 2005. Retrieved from http://findarticles.com/p/articles/mi_m0FSL/is_5_81/ai_n13793209/

Stotts, N.A., Gunningberg, L. (2007). How to try this: predicting pressure ulcer risk. American Journal of Nursing (AJN). Nov., 2007:107(11), 40-48.  Retrieved from http://www.nursingcenter.com/prodev/ce_article.asp?tid=751548