Wound Care Webinar: Pressure Injury Prevention & Treatment

August 10, 2021 Updated: December 29, 2021 54 min read 5 Comments

We hosted our first ever Level Up RN WEBINAR: Pressure Injury Prevention & Treatment on August 18, 2021.

Cathy Parkes BSN, RN, CWCN presented real-world, helpful information on pressure injury prevention and treatment. Participants were able to: 

  • Learn all about:
    • Skin assessment best practices
    • Patient risk assessment
    • Pressure injury staging
    • Wound treatment and charting best practices
  • Test your wound care knowledge
  • Get your wound care questions answered
  • Apply your learnings to better care for your patients
  • Chat with other attendees and connect with Cathy during Q&A

I'm Cathy Parkes with Level Up RN. I'm the chief educator there. I'm also a part-time wound care nurse at my hospital, so I do both things.

Let's see, this is my fifth year as a wound care nurse and I love it. So I started off on a Med-Surg-Tele floor and then I transferred into wound care.

And as a wound care nurse, I get to visit all the units in the hospital, and wound care is just a great career path for me. So at the end of the presentation, if you guys have questions about wound care nursing, I'm happy to answer those. I want to first take all the questions you all have about wound care in general, though.

So this is our-- like I shared, our first webinar and I'll be talking about pressure injury prevention and treatment. So this type of education-- the education I'm going to provide today-- is the same type of education I give to nurses at my hospital.

This is an hour long, and I can't get nurses to stand there and listen to me for a full hour when I'm at the hospital because they're too busy, but I've definitely given out training materials and education that covers these same topics.

A lot of the information I'll be covering is part of our wound care [flashcard] deck, so Wound Care for Nurses and there's a lot of other information in this [flashcard] deck as well, besides just pressure injury prevention and treatment. If you stay till the end of our webinar, we're giving out three decks of our wound care flashcards, so we will choose three participants randomly, and one of my team members will give me the names and I'll announce the winners at the end of the webinar.

So as you guys are listening, if you have questions about anything, there's a question and answer box. You can type your questions in and I will be taking breaks periodically to check that Q & A board and try to answer your questions. So I'll kind of stop two or three times throughout my presentation and kind of check that board. So feel free to type your questions in there. And we'll be doing some little quizzes, little knowledge checks along the way. You can type your answers into the chat for those.

So and then at the end of the presentation, I will be doing kind of an overall quiz showing you some pressure injuries so you can try to stage them. And so I will offer a disclaimer here before I get into my content that I'm going to have some gnarly pictures of some pressure injuries. So I'm guessing you're good to go with that since you want to be a nurse or you are a nurse. So just if you're not down with wounds, now is probably the time to go.

Alright, so let us move ahead here. Alright. Some of the outcomes that we want to achieve through this webinar:

I want you guys to be able to identify skin assessment and pressure injury prevention best practices.

I want you to be able to describe the cause of a pressure injury and feel confident in pressure injury staging,

and then I want you to be able to identify best practices for pressure injury charting as well as treatment.

So we're going to go through all of those topics, and I just want you guys to have a good understanding of all of this information.

I feel like in nursing school, we just kind of touch on things. We talk about staging, talk a little bit about prevention, but that's about it. And when you become a practicing nurse, wound care is a pretty significant part of your role, no matter what unit you'll be working on. So I find often that new grads and nursing students just don't feel 100% comfortable with wound care, and with staging pressure injuries. So I'm hoping this webinar will help you feel more confident.

All right. So let's talk about skin assessment. So pressure injury prevention really starts with that initial skin assessment on admission. It's the most important one we need to do for a couple of reasons.

One is we want to identify any wounds or pressure injuries that the patient has and get treatment started.

Also, we want to identify any wounds they have and pressure injuries, so we can chart those. So it will be noted in their chart that those wounds will be present on admission, and that they won't be hospital acquired.

So best practices for a skin assessment when the patient is being admitted is to have two nurses go in there and do the skin assessment. And we do this because two sets of eyes is better than one, and you also need help with positioning the patient, and I'll be honest here, spreading the butt cheeks, really holding up any skin folds, so you can really assess every square inch of their skin. So we really want two nurses in there. That is the best practice. That's what we do at my hospital.

Before you go in there to do your skin assessment, you want to make sure you have some kind of device that you can take pictures of the wounds with or a camera.

So we have what's called a rover at our hospital, so we could take a picture and that picture goes straight up to the patient's electronic medical record.

So you want to bring your camera in, and you want to bring a measuring device like a little strip, and you want to get that all ready with the patient's initials and the medical record number. You got to go in there with your buddy, with your second nurse, and you're really going to assess the patient head to toe, front and back, really paying attention to those bony prominences, and to those areas that often have pressure injuries.

So my best practice for how to do that assessment and document those wounds is when I go into the patient's room, I will do measurements of the wound taking the length, width and depth. I will write those on the measuring strip, and I'll write the location of the body part that I'm assessing. I'll put that measuring strip up next to the body part with the camera and take a picture.

The good part about that is that picture goes straight to the patient's chart. I don't have to worry about remembering measurements. I don't have to worry about taking that measuring strip out of the room, which you definitely don't want to do if the patient's on contact precautions. Later on, when I leave the patient's room, I can just bring that picture up on their chart and all my information is there, the measurements, and I got the wound picture, so I can describe it in my charting.

So what's really important is that we need to perform all of our charting on these wounds within the first 24 hours of admission, okay? And we need to document those within the first 24 hours.

If we wait to chart those pressure injuries until after 24 hours, then they are officially hospital-acquired pressure injuries and hospitals-- so that's really bad news because hospitals get fined. The state may come and audit us, it causes significant expense, etc.

So we definitely want to identify and take pictures of all those wounds within 24 hours.

Now, let's say you're looking at a wound and you're like, "I don't know if that's a pressure injury or if that's due to moisture." You're not sure exactly what it is.

It's okay. Take your best guess at what you think it is. You can pull in your mentor nurse, or your resource nurse to help you. Maybe they can look at it and say, "I really think that's a pressure injury." But if you're still unsure, then just do your best like, "Okay. I think it's a stage 2 pressure injury." Just chart it like that. Just make sure you get your charting done within the first 24 hours.

Then, you can put in for a wound consult. And then, I'll come out or your wound nurse, And I'll take a look at the wounds.

And if I need to change the staging or how that wound is classified, I can easily do that. It's not a big deal. What is a big deal is if there's no charting within 24 hours. So take your best shot at the charting. And that charting can be clarified later by a wound care nurse.

And then, the other thing you want to do is you want to start treatment for this wound because in the past, I've had some nurses who have admitted a patient. And they weren't sure what to do as far as treatment for a wound. And they put in for a wound consult.

Well sometimes, wound nurses don't work weekends and they don't work nights. At least no place that I'm [laughter] aware of do wound nurses work nights. So if you're admitting a patient on a Friday night and a nurse is not coming in until Monday, then that's a problem. We want to start treatment right away.

So I'm going to give you some kind of basic guidelines in this presentation so you can feel comfortable with initiating treatment for your patients so you don't have to wait for that wound care nurse to come.

Now, when the wound care nurse comes, they may change the treatment plan. That's not a problem.

At least you're doing something for your patient using some best practices that we're going to talk about in this webinar.

Alright. And then, you want to put in a wound consult any time you're unsure of staging and your resource and mentor nurse can't help you or if they're-- if the patient has severe wounds. So if the patient just has a stage one pressure injury or a stage two, you don't really need our help.

Your facility likely has a preformatted order set, so an order set with predetermined instructions for wound care for those minor pressure injuries. So find out about that at your facility. Make sure you're familiar with the wound care instructions. And just go ahead and start that wound care for the patient before the wound care nurse comes out.

All right. Pressure injuries-- so let me start by saying that a lot of you may have been referring to pressure injuries as pressure ulcers-- I'm guessing a lot of you because for a long time, that's what we called them.

So that is officially outdated terminology as is decubitus ulcer or bedsore. Now, when I'm explaining to a patient that they have a pressure injury, I may describe it as a bedsore because patients seem to understand that terminology better. But as a nurse, we are calling them pressure injuries these days.

So let's talk about the pathophysiology behind pressure injuries. So pressure injuries are damage to the skin and the underlying soft tissue due to intense, prolonged pressure to an area.

So basically what happens is you have a bony prominence and you have intense pressure. And if that pressure is prolonged and intense enough, then it really blocks off blood supply to that area. So we end up with inadequate perfusion.

And so when we don't have blood flow to that area that's getting all that pressure, then that area is not getting oxygen. It's not getting nutrients. And we're not removing waste products. So basically, we end up with tissue hypoxia and cell death. So that is kind of the pathophysiology behind pressure injuries.

And you can see we've got a picture here on the side kind of showing all the bony prominences and the areas that are more prone to pressure injuries. So when you're doing that head-to-toe skin assessment, you definitely want to assess for all of those areas.

You also want to look behind the ears because oxygen tubing can cause pressure injuries, any other medical devices. You really want to check everything. If the patient comes in with some kind of bandage or dressing, you're going to want to take that down so you can see what's underneath there.

All right. So once we've done our skin assessment and we've assessed our patient, we really need to identify who is at risk for pressure injuries. So there's a number of risk factors that predispose a patient to pressure injuries. And I've listed some of the more common ones here. So immobility is a big one, particularly paralysis.

So patients who are paraplegic or any kind of paralysis, they have a tough time with pressure injuries because if you think about it, when you're sitting here watching me over Zoom here if you sit still for a long enough time, your body will send you a signal that it's time to shift your weight, right? You need to shift your weight because you're getting kind of uncomfortable.

So that's your body's way of having your shift your weight so that you don't have too much pressure in one area and end up with a pressure injury.

Well, someone who has paralysis, they are not getting that message, right? If they lay or sit in one place for a long time, their body's not sending them the message that they need to shift their weight, that they're getting uncomfortable because they lack that sensation. And so, unfortunately, they end up with tissue hypoxia and the development of a pressure injury.

Other risk factors associated with pressure injuries include older age because with older age we have decreased subcutaneous tissue. And so those bony prominences can really be a problem. So older age is a problem.

Incontinence is a problem because any time the skin is too moist through sweating or incontinence, that definitely makes the patient at increased risk for skin breakdown.

Other risk factors include poor nutrition, especially insufficient protein. So I sound like a broken record all day when I'm at the hospital because I'm talking to every patient about protein intake because it's so important for preventing pressure injuries and also for the healing of wounds and pressure injuries.

Any time a patient has perfusion issues like peripheral arterial disease, that's a problem.

If they're on vasopressors, that's definitely a risk factor.

Diabetes is a huge risk factor. So up until recently, I actually shared an office with the diabetic educators at my hospital. And honestly, half of the patients that they saw were the patients I saw too, right? So they were doing diabetes education. And I was seeing those same patients for wounds.

People with diabetes are much more likely to have wounds. And they are much more likely to have complications when it comes to wound healing.

Other risk factors include smoking, corticosteroids, and prolonged surgery.

So a big one there, if a patient is getting back surgery and sometimes those back surgeries take a long time, six to eight hours they're in a prone position, so face down. If we don't properly cushion their head and provide that padding, they can end up with pressure injuries on their forehead and on their face because of that prolonged surgery.

Okay. So those are some risk factors. So at any hospital that I've ever been to, nurses are expected to assign a score using one of these two scales to identify patients who are at risk for pressure injuries.

So some hospitals may use a Norton scale.

My hospital uses the Braden scale.

And basically with each of these scales, they have subscales.

And so with the Norton scale, you would score the patient's condition from 1 to 4, so 4 meaning they're in good shape, not a lot of risk, 1 meaning there's a lot of risk, that they are not in good shape.

So you would score them 1 to 4 on each of these five subscales and then add up the scores. If their overall score is under 14, that means that patient is at high risk for pressure injuries.

The Braden scale works similarly. So there are six subscales there. You would rate each of those subscales from 1 to 4 except for friction shear which is 1 to 3. And you don't have to memorize all of these subscales.

Well, and I didn't have to do it in nursing school either. Hopefully [laughter], you don't have to memorize all the subscales in nursing school. Hopefully, you can just remember in general if the score is under 18 on a Braden scale. That means the patient's at high risk.

But in our charting system, they actually bring up the subscales. And I could just click boxes, right? And it automatically adds up my subscales to tell me my patient's Braden score.

So it's important to do this because we want to identify patients who are at risk for pressure injuries and then implement interventions that are going to help prevent those, okay? So I thought it might be fun to work through a little example together. So I put up the Braden score here, the Braden scale because that's what I use at my hospital.

And I'm not expecting you all to memorize all the subscales. So we have the subscales here, so sensory perception, moisture, etc.

And I have a little patient scenario here. So let me read it out loud. A 90-year-old patient uses a walker occasionally but spends a lot of time in bed. This patient is frequently incontinent. They do not like high-protein food. They have mild peripheral neuropathy. And they often need help with repositioning.

So let's go through what we would score each of these subscales together. And if you guys can put the number in the chat, I'll look and see how you guys are doing.

So some of the time the scoring can be a little subjective. You might be between two scores like, "Is it a 2 or is it a 3?" I usually give advice to the nurses at my hospital to just go on the low side.

If you're kind of between two numbers, go ahead and go on the low side.

Getting the exact right number isn't super important. It's really just important that we know in general if this patient's going to be at risk for skin breakdown.

So let's talk about sensory perception. How do we feel this patient would score? Is it one? Is it two, three, or four? What do you guys think? Okay, I'm seeing some twos, I'm seeing some threes. Nice. I give it a three, but two is totally-- would be acceptable as well. Nice job.

Okay, moisture. Our patient is frequently incontinent. So what do you think on moisture? Moisture, I would give it a two. This patient is likely going to be often moist because of that incontinence.

Alright. How about activity? So this patient uses a walker, occasionally, but spends a lot of time in bed. Okay, I'm seeing a lot of threes. Yeah? I gave it a three. This patient gets up, walks occasionally, but if you want to say chairfast, like two, that wouldn't be totally wrong, either.

How about mobility? This patient isn't completely immobile, so we probably wouldn't give them a one. But their mobility is pretty limited, so I would give them a two. That's what I would give them.

And then nutrition. So this patient does not like protein, right? So their nutrition is probably inadequate. They're eating, but they're not getting enough protein, and that is not doing them any favors as far as skin breakdown.

And how about friction and shear? What's the key thing here? The key clue here is that they need help with repositioning, so we are sliding that patient up and over. And when we do that, that puts them at risk for friction and shear. So it is definitely a potential problem for this patient.

So when I add up my numbers, I get to about 14, which means that this patient is at moderate risk for skin breakdown. Again, if you had slightly different numbers, it will still add up to probably be like 13, 14, 15. You're still going to be in the zone. And no matter what, we know this patient is going to need some extra help to prevent skin breakdown.

So let's talk about what we can do to help this patient who's at risk for skin breakdown. So I have some pictures here of products that we can use to help with that breakdown-- help prevent that breakdown.

And I just want to give a shout-out to Medline who was gracious enough to let me use these photos in my presentation. So we use Medline products at our hospital, and I just want to thank them for letting me include these products in my webinar today.

So skin breakdown starts with making sure the patient is on a pressure redistribution surface. So we want to make sure that patient is on a low air loss or a pressure redistribution surface like a foam mattress. So a low air loss bed is ideal, but not every hospital has one.

So at my hospital, if I have a patient who has pressure injuries or is at high-risk for pressure injuries, I will try to transfer them to a unit that has the really sophisticated beds that are low air loss and pressure redistribution. Unfortunately, that unit is full of COVID right now, so I can't transfer my patients there who don't have COVID.

So what you can do is get a specialty rental bed. So most hospitals have a contract with a bed company who can bring in a specialty mattress or a specialty bed that is low air loss and pressure redistribution. If the patient just has some minor pressure injuries, you can put a mattress topper on top of their bed as well, we call it a Gaymar at our hospital. That can help as well.

But you definitely-- if the patient has some more severe pressure injuries-- you definitely want to get them on a more sophisticated bed and that may necessitate you having to get a rental bed.

You want to keep the patient's-- the head of the bed less than 30 degrees, if possible, because if you have them really upright, then those sitting bones right? Those ischial tuberosities can cause pressure injuries over that area. So laying in a flatter position is better. We want to reposition our patient at least every two hours, so we want to put a wedge or a pillow under one hip and then two hours later, switch it out to the other hip.

Now sometimes I have a patient's family ask me, "Why aren't you turning them all the way over onto their side?" Well, guess what? We have hip bones there, and if we lay the patient all the way over on their hip, on their side, then they can end up with pressure injuries there with those greater trochanters. So we don't actually want them all the way over on their side. We just want them to be 20, 30 degrees kind of off the booty with a little pillow or wedge. Also, we can use a waffle seat cushion or Rojo cushion in the chair or the patient's wheelchair to assist with pressure redistribution when the patient is sitting down.

And then heel protector boots are really important as well. So there's a picture of a heel protector boot here that helps the heels elevate off the bed. So if a patient is bed-- if you have a patient that is bed-bound, not getting out of bed, then you need to go grab some heel elevation boots and get them on that patient. Because if those heels just sit there on the bed for a prolonged amount of time, they're going to end up with pressure injuries on those heels.

So make sure you get the boot on all the way such that the heel is raised off the bed like it's floating like it is here in this picture.

Alright. Padded dressings can be used. So here are some silicone foam dressings. So when I'm assessing a patient and I turn them over and I see really bony vertebrae or a big bony coccyx bone, then I go grab those foam dressings and I go ahead and slap those on to help provide protection for that patient.

You can also put pillows under the patient's arms because they may have skin breakdown on those elbows. So if you go into the ICU, they've got it all going on, right? They've got the sophisticated beds. They've got the pillows. They've got padded dressings. They've got a wedge under one hip. They are repositioning the patient every two hours.

They're doing all they can to help prevent pressure injuries there in the ICU because those patients are usually at very high risk.

In addition, we want to apply a moisture barrier cream if the patient has incontinence. So any time you get a patient who is incontinent of urine or bowel, go ahead and grab-- hopefully, you can grab it off your supply cart like we can at our hospital. But grab a zinc oxide based ointment to apply on there, and that will help protect the skin from moisture breakdown.

And that's really important. However, if your patient's skin is really dry, then we want to moisturize it. So we want skin that is soft and supple, but we don't want it too moist and we don't want it too dry.

And then lastly, we want to avoid tape on our patients whenever possible, especially elderly patients.

So I have seen people take up tape and it can take up the whole top layer of the skin if you are not careful. So we want to avoid using tape in the first place. So we can do this on the arms and the legs by using gauze wrap instead of tape.

Sometimes we won't be able to avoid using tape. If we need to use tape on a patient's skin, then just make sure we are taking it off very carefully using adhesive-remover wipes. These work a lot better than alcohol wipes.

So I know, as a new nurse before I became part of the wound care team, nurses are just all using the alcohol swabs to take up tape. But really, these adhesive-remover wipes work a lot better, so find out if you have some of those on your supply cart.

And then when you're taking up the tape, you want to use a push-pull technique. So you don't want to just pull the tape. You want to pull the tape as you're pushing down on the skin with an adhesive-remover wipe, and just take your time.

Alright. So this is my first break where I want to see about any questions. So I'm going to come over here to my questions, "Is skin breakdown in the skin folds considered a pressure ulcer as well?" This is from Layla. Excellent question. The answer is no. And we're actually going to talk about wounds that are caused due to moisture in the skin folds, which is called intertriginous dermatitis. So that is actually forthcoming in the presentation.

Alright. So that's it for questions so far. I will definitely stop back to check questions again during my next break.

So let's get into pressure injury staging. So this is the time where I'm about to show you some pictures. So we're going to assign pressure injuries a stage, either stage 1, 2, 3, 4, unstageable, or deep tissue injury. In addition, the patient may have a mucosal membrane pressure injury, which is not staged. And we'll talk more about that when I show a picture of that. We never reverse or back-stage a pressure injury as it heals.

So, for example, if a patient has a stage 4 pressure injury, which means there's bone exposed or muscle or tendon, as that wound heals and gets very shallow, it doesn't become a stage 2 pressure injury. It will always be a stage 4. It's a healing stage 4. And we can describe how it's healing and how it's very shallow now, but that pressure injury will always be a stage 4 pressure injury. We will not back-stage it.

However, if a patient starts off with a stage 2 pressure injury and it becomes a stage 3, a stage 4, we do re-stage it, right? It started up as stage 2, but now it's a stage 4.

So no back-staging, but definitely we can forward-stage if the wound gets worse, which we hope will never happen. That's our goal.

When it comes to a DTI, deep tissue injury, or an unstageable pressure injury, we will need to re-stage those pressure injuries as they evolve.

So we're going to talk more about unstageable and how it's covered in slough and eschar. So as that wound presents itself, then we will need to re-stage it.

DTIs, deep tissue injuries, will also evolve, and we will need to re-stage those as well.

And then we also do not stage wounds that are not due to pressure. So, for example, the question I answered about intertriginous dermatitis. That would not be a staged wound.

If a patient has a skin tear on their arm or a surgical wound on their stomach, we are not staging those wounds. We are only staging wounds that are caused by pressure.

Alright. Here we go with the pictures. We'll start off not too bad, and it'll get worse. So stage 1. So with a stage 1 pressure injury, there's no open wound. The damage is limited to the epidermis which you can see here.

Here are the different skin layers. So we got the epidermis, the dermis, the subcutaneous tissue, so adipose tissue. And then we have muscle and bone down here. So as we look at these pictures, you can also look here to see the depth of injury. So with a stage one pressure injury, the skin's intact. It's red and it is not blanchable, meaning when I push on that area it doesn't pale. It doesn't turn white. So I have a question for you guys. You can answer in the chat.

What stage is it if the skin is red and I push and it does blanch? If it blanches what stage is that?

Alright. It's not. Yeah. So good job. It is not a pressure injury. If the skin's red over a bony prominence but you push on it and it blanches, it's not a pressure injury yet.

So we're not going to stage it. However, it can easily turn into a pressure injury. So we're going to definitely want to take interventions to get the patient off of the area and really take care of that skin so it doesn't become a pressure injury.

Alright. So let's go to the next slide here. Oops. Let me go back. Sorry. All right.

Stage two, stage two, we have damage to the epidermis and the dermis. You can see it goes a little deeper. This is an open wound. Unlike stage one, we have partial thickness, skin loss, and our dermis is exposed. The wound base will be red. And it will likely be moist.

So another way that a stage two pressure injury presents is a serous-filled blister. So I often see those on heels. So if a patient has a heel pressure injury often that it'll be a blister that's filled with clear fluid, so serous fluid.

So with a stage two, it's very shallow. You just got that top layer of skin gone. And you see kind of a red wound base.

So as we get to stage three though, the damage extends into the subcutaneous tissue. So we have damage to the epidermis, dermis, and into the subcutaneous tissue.

We have full-thickness skin loss with exposed adipose tissue. Now, with a stage three, muscle, tendon, bone are not visible in the wound bed.

However, we may have tunneling or undermining present. And we'll talk more about tunneling and undermining a little later in my presentation. So don't worry about that.

So at my hospital sometimes the nurses have a tough time with stage three, staging that. And so the advice I give them is you know what stage two looks like, right? It's just that top layer of skin that's gone. And the wound bed is red.

And you know what stage four looks like because you have exposed bone tendon or muscle. Stage three will be in between, right? We're not seeing bone, tendon, muscle.

But it's also not really, really shallow. So you can see in this wound, this is not a super shallow wound, right? It's starting to get deeper. We know we're into that adipose tissue.

Alright. Alright. Stage four, so stage four damage extends down to the bone, muscle, or tendon. Obviously, it's an open wound. In this wound here we can see there's bone down there. You can palpate that bone.

We may also get tunneling or undermining with this wound.

Also, the big problem with a wound like this, of course, this is on the patient's bottom on their coccyx bone.

And that's a common place for a stage four pressure injury. And to add insult to injury, it's right next to the patient's anus.

So if they are having bowel incontinence, then that poop is going right into the wound and contaminating the wound bed. So this type of wound is at risk for osteomyelitis, which is a bone infection. It may require the patient to be on weeks or months of IV antibiotic therapy.

It may cause them to get a debridement of the bones. They may have to have some of that bone taken off surgically, and it can lead to sepsis. It can really be really dangerous. And so for some patients, they have to have a therapeutic ostomy. Actually, we need to divert the fecal stream to the front of the patient through an ostomy appliance to prevent contamination of this wound with bowel movements.

So that's something we do on a regular basis. So of course, we want to try to prevent wounds from getting to this point, but this is definitely a type of wound we see in the hospital. Patients come in with this type of wound.

Alright. And then we have unstageable. So unstageable does not mean that you don't know how to stage that pressure injury.

So occasionally, I'll be at work, I'll get a wound care order and it'll say-- it has the reason for the consult and it will say "Unstageable pressure injury." I'm like, "Oh, let me get over there. That patient may need surgery to get rid of this." I go over there and it's just red intact skin, and the nurse wasn't sure if it was moisture or pressure, so they called it unstageable. But that's not really legit, right?

Unstageable means that the wound bed is covered in slough or eschar, such that you cannot visualize the wound base. So I don't know how deep this wound is, right? When we get this eschar off, I'm guessing it's probably going to be a stage four because often with these unstageable pressure injuries, they end up being very deep, stage three or four. So slough and eschar, those are basically necrotic tissue.

So the way I describe slough to the nursing students who shadow me is that it kind of looks like chicken fat, right? So if your patient's pressure injury is covered with something that looks like chicken fat, it's kind of cream-yellow in color, then that's likely slough.

Eschar is black. It can be rubbery or it can be hard. But really, we need to try to debride this wound and to get the wound to heal. So we'll talk a little bit more about debridement in this presentation as well.

Alright. This is a deep tissue injury. So this is not just a bruise. A bruise is more superficial. A deep tissue injury with a DTI, the damage occurs at that bone muscle interface. It is much deeper than a stage one. So a stage one is red non-blanchable. A DTI will be purple or maroon in color, or it can present as a blood-filled blister.

So you can see this patient's got a DTI. It's starting to evolve. So with most DTIs, occasionally-- there's exceptions, but most DTIs will open up. Sometimes they'll open up to be quite deep. They'll end up being a stage three or stage four. Then maybe they may even turn into an unstageable pressure injury. So you can see what this bottom, this DTI is opening up and it's already at a stage three. This is not just injury to the dermis. You can see that we're into adipose tissue.

So when this whole thing opens up, it will definitely be a stage three or deeper. But we're not going to stage it yet because it hasn't evolved all the way. We're going to wait till this thing opens up completely and then assign a new stage. So for right now, we're calling this an evolving DTI.

Alright. Other pressure injuries, we have mucosal membrane pressure injuries. So this is like damage to the nare from an NG tube or damage to the mouth or tongue from an ET tube. So I couldn't find a good picture to show you. So Ellis, who is a key member of our level up RN team, she did something called moulage [artistic mock injuries], which I have never had never heard about until she told me. But she actually made this. This is her artwork. So everybody give a shout-out to Ellis in the chat because this is pretty amazing.

So how do we prevent this? Well, we want to reposition our device frequently and we want to secure it properly.

So we want to make sure that NG tube isn't taped up against the side of the patient's nose because that's definitely going to cause breakdown.

We need to make sure that ET tube is repositioned and not resting in one spot too long. So that's how we prevent those things from happening.

We also have medical device-related pressure injuries. So this is where the use of a medical device results in a pressure injury that usually presents in the pattern or shape of the device. So this picture here, it looks like some kind of orthopedic device. I'm not actually sure exactly what this is, but you can tell that it's definitely caused skin breakdown.

In fact, this is unstageable because it's covered in that slough, right? Chicken fat. So, we don't call it chicken fat. We call it slough. I'm just telling you what it looks like.

Other medical devices that can cause pressure injuries include oxygen tubing so that can cause pressure injuries behind the ear.

Urinary catheters, if they're taped down to the patient's leg too tight, that can cause pressure injuries. Bedpans are another problem. So if someone leaves an elderly patient on a bedpan for a prolonged amount of time? Guess what? They're going to end up with this ring around their bottom like a pressure injury that can be really severe and take a long time to heal.

Braces and restraints can also cause pressure injuries. So how do we prevent this? We always want to assess the skin under a device.

We want to reposition the patient or device to try to prevent pressure injuries, pad the skin under devices and secure the device properly. Okay?

And okay, I'm going to check questions now. Okay, I have more questions now. Last time I had one. I've got a whole list now.

Does backstaging screw up billing and coding? As far as I know, no, but I don't really get involved in billing and coding, thank goodness. So I'm not-- I can't say that confidently. I don't think it messes up anything.

What if the stage three completely heals but reopens after a few months? Would it be new staging or remain a stage three? So that's a good question. So sometimes we have a patient who's readmitted and we still have a record of their previous stage three that was healed.

So when a patient comes in with a healed pressure injury, you definitely want to chart it because when a pressure injury heals, that new skin over the area is very delicate is very fragile and is very likely that it may open up again unless we are extremely careful.

So if that same one opens up, I would still call it a stage three that had previously healed but now has opened. So I still would call it a stage three.

I attended some webinars in the past about burns, and I learned that stage three burn is not painful. Is this also applied to stage three pressure injuries? Some are, and some aren't. I see what you're saying. Some of the nerve endings are higher up in the skin layers. So sometimes if the wound is deeper, it does hurt less.

But the patient can usually still feel pressure and discomfort when we're caring for the wound unless they have some kind of lack of sensation like diabetic patients when I'm working on a pressure injury on their foot, they often don't feel anything. I'll be cutting away necrotic tissue and doing all my thing with no pain meds and they don't feel anything.

And that's good from a pain perspective that they don't feel it, but it's actually really bad from a wound development standpoint. That's kind of how they got to that point in the first place. Getting that wound because they didn't feel it when they injured their foot and they went around walked on a foot.

Like, somebody with diabetes and severe peripheral neuropathy may step on a nail. Have no idea they did it because they can't feel it. And then they walk around and it gets grossly infected and has to be surgically debrided. So I say it kind of varies as far as the pain.

Can a patient take liquid protein if they are not getting enough protein? Absolutely. So I will ask the patient, "Are you good? Do you eat meat? Do you eat poultry, fish, meat?" If they like, "Oh yeah, I love that. It's great." I'm like, "Okay, good, eat lots of that stuff."

If they're vegetarian or vegan, or do they eat dairy? Do they eat nuts, do they eat other foods that are high in protein? If that's the case, that's great.

But if they don't do a good job with protein, then we're definitely putting in a nutrition consult to have the nutritionist come talk to the patient and prescribe a protein drink, right?

So definitely a lot of my patients have protein supplement drinks. They need special ones. If they have diabetes, there's different types, and some of them taste different than others. So definitely the dietitian or nutritionist can work with the patient to get a good protein drink for your patients. So, absolutely.

What are some common situations that might cause a deep tissue injury? Also, I remember my professors bring up the fact that DTI can happen quickly. What is the rule of thumb on how quickly? They can happen quickly. If someone's sitting-- like we were talking about someone with paralysis and they're sitting in one spot and we're not getting oxygen to the area, that tissue can die very quickly. It can happen over the course of a day or two, even less than that. Even less than a day.

So sometimes ICU patients, they're found down, right? They found them down. And so they were unconscious in one position for a while. And they come in and sometimes those DTIs don't present themselves for another like 24 hours or 48 hours, but it definitely was caused by them being down and that prolonged pressure.

So sometimes before a DTI will appear, there may be some warmth over the area. If the patient is conscious, they may say that, "Oh, I'm having a lot of pain in this area." So pain and warmth may precede that DTI from appearing, but it happens very quickly.

Let's see, how can you tell an unstageable with exudate versus a stage three? Do you use rectal tube? How do you do infections with rectal tubes? Yeah, rectal tubes is the Dignicare's. This is the tube, you put in their anal is to try to collect that stool so it doesn't get in the wound, but it requires that the stool be liquid in order to be collected into that tube. So if it's semi-formed, it's not going to work. Also, those tubes leak a lot. Sometimes you can get a good seal and they can be helpful. But other times they leak and they just-- I've not seen really good luck with those. Yes.

So thank you for the very helpful presentation. Will you go over meds? Yes, we're going to talk about some meds, too.

Alright. Let's go through some more slides now.

Okay, so now we're going to talk about some wounds that are not pressure injuries but may be confused as pressure injuries.

So this is an incontinence-associated dermatitis or IAD. So when you have IAD or incontinence-associated dermatitis, the backside, the perineal area, will be red. It will be a kind of diffuse redness. So with a pressure injury, it'll be kind of localized over kind of one area.

But with incontinence, you'll find that the redness kind of extends kind of all over. And then sometimes you might see a rash-- a fungal rash because fungus loves moisture. So if you have a moist area like between folds or with a lot of moisture, then often will get a fungal rash there as well.

So how do we prevent this or treat this? So we want to try to get rid of the moisture, so if the patient's incontinent, we can try using a condom catheter or a PureWick.

We can apply a moisture barrier product. So here's a picture of Calmoseptine, which is an excellent product. So earlier I showed you a picture of Calazime.

Calazime and Calmoseptine are both-- they both contain zinc oxide, which is that moisture barrier. And this is just a great product. So any time your patient's incontinent, go ahead and grab a tube of this if you have that at your hospital. If not, whatever product they do have and just go ahead and protect that skin. So we just want to try to keep the area dry. So patients who are incontinent often want to wear diapers all the time. They want to wear diapers in their bed. And I really have to talk them out of their diapers. We have the ExtraSure pads underneath them, and those ExtraSure pads can really hold a lot of urine.

So I try to tell my patients, "How do you feel about going commando? Because we need to get some air in there." The diaper just traps moisture against their skin, and it is not helpful when we're dealing with skin breakdown due to incontinence. So get your patient commando if possible.

Use a PureWick or condom cap and definitely protect their skin with zinc oxide.

All right. And then someone asked me earlier, and I don't remember the name, but they asked about intertriginous dermatitis. So this is where we have skin breakdown at the base of the skin folds. So under the pannus, which is the patient's abdomen or under their breasts or between their buttocks.

So anywhere where we have trapped moisture, we can have skin breakdown, and then we may also get a fungal rash in those areas as well.

So prevention and treatment of this condition:

We want to try to get a mattress that has airflow. So one that's kind of circulating air and trying to keep that area dry. We want to try to get everything dry.

And then there's also these moisture-wicking products and they come in-- it looks like a Saran wrap box or a foil box, except for it doesn't have Saran wrap or foil. It has this fabric.

Then you pull it out from the box and you cut it and you kind of put it under the patient's fold and you want to leave two or three inches of fabric sticking out so that moisture can be wicked out of that space. You don't want to put the moisture wicking fabric like all the way in the folds so that you don't see it. You want to leave like a little edge sticking out two or three inches, and then it will wick that moisture.

And a lot of products, like InterDry is the one we use at our hospital, it is antimicrobial as well as antifungal. So it kind of does triple duty; it gets rid of the moisture, and it also treats any fungal or bacteria that is growing in that fold. So that is intertriginous dermatitis.

Let's talk about charting, okay? So we need to take measurements. We talked a little bit about that in the beginning, but I just wanted to go a little more in depth to make sure you know how to do this.

So when you are taking measurements of your patient's pressure injury, the length is going to be at 12 o'clock.

So imagine the patient's face is at 12 o'clock, just like we have here. So their head's at 12 o'clock, length will go this way. Even if the wound is going this way, this is still the length. So the length might be really small, and the width might be really big.

Length at 12 o'clock, width here from 9 to 3 o'clock, and then depth is straight down into the wound at the deepest portion of the wound. So you'll take a cotton tip applicator, which I don't have. So I have a pen here, pretend it's a cotton tipped applicator. We stick that in there. We kind of put our fingertip right at the skin's surface, pull it out of the wound, and then hold it up to the measuring strip to measure how deep that wound is. So that's how we get those measurements.

Now let's talk about tunneling and undermining because those can be confusing to nurses on how to chart those. So you can see over here we have tunneling.

So that means we can kind of stick a cotton tip applicator underneath the skin, and there's this tunnel. And the way we would chart this tunnel is we would first determine the direction of the tunnel.

So assuming up is 12 o'clock, we can see that this tunnel is at 9 o'clock, and then we would measure the depth. So we would stick our cotton tip applicator in there, put our finger down at the edge there, bring it out, and then kind of hold it up to your measuring strip.

So in this case, let's pretend this is 5 centimeters. So we have a 5 centimeter tunnel at 9 o'clock. Then we have undermining here. So the tunnel, you just put it in, and it doesn't really go in. You can't like wiggle it around. With undermining, you put the cotton tip applicator in, and you can rotate it around. It's like a cave underneath the patient's skin. So for undermining, you would chart that based on the times, with this being 12 o'clock up here.

So this undermining kind of goes from 7 o'clock to 11 o'clock, and the deepest part of this undermining is 3 centimeters.

So we would chart this 7 to 11 o'clock up to 3 centimeters. So that's how you would chart undermining if your patient has that.

Alright. We want to chart the pressure injury stage, of course. We want to chart the wound appearance. Is it red? Is it black? Is it yellow? Just really chart what you see. The different colors. Just chart everything. If you don't see an option in your charting system that fully describes what you're seeing, then put it in a comment, okay?

You want to chart the amount of drainage and what type of drainage. So serous drainage is clear drainage, sanguineous drainage is bloody drainage, and serosanguineous is in between, so it's like pink tinged kind of blood tinged drainage.

And then a patient may have purulent drainage as well. So this is going to be kind of white, yellow, beige drainage, and it could be malodorous.

And then you want to describe how much drainage. Is that scant? Is it small? Is it medium large, that type of thing.

And then you always want to chart your treatment. Okay? You want to make sure you're charting cleaning the wound. So sometimes nurses will look like to chart that they clean the wound, even though they totally did clean the wound. But the old saying, if you don't chart it, then it didn't happen, right? I can't know that it happened if you don't chart it. So make sure you chart that you clean the wound and make sure you chart it that you change the dressing.

And on the dressing itself, you want to list the date, time, your initials so we know exactly when that dressing was changed.

Okay. And then as far as treatment. Again, if the patient has a pressure injury, we want to get them on a pressure redistribution surface. We want to offload them from the area that's affected without causing any new pressure injuries.

If the patient has a pressure injury with intact skin like a stage one or a DTI, we want to swab or spray the area with a barrier film. So we use Cavilon at our hospital. But there's other brands as well.

If the patient has an open wound, so stage two, three four, etc, we want to use a dressing that maintains a moist, wound healing environment. And then if the patient has a severe pressure injury, then you want to put in for a wound consult, so we can come out and see the patient and initiate appropriate orders for them.

Alright. Let's talk more about-- well, we'll talk about this one. We are going to talk about some dressings, too. So if you are assessing your patient and you're like, "Ooh, if this wound has some purulent drainage and it smells", then chances are you're going to need to get a wound culture.

So I just want to talk about some best practices when it comes to wound culture, obtaining a wound culture.

First of all, you want to get it before the patient starts antibiotic therapy, whenever possible.

You want to irrigate the wound with normal saline first. Not wound cleanser, right? We're not trying to kill the bacteria in there.

We want to try to identify what bacteria is growing in there and then we want to swab a one-centimeter area of viable tissue in the wound. So if the wound has some areas that are red and some areas that are covered in eschar or slough, you want to actually hit the area of redness, you want viable tissue.

And then you want to make sure you don't touch that skin surface as you pull that culture swab out, put it straight into the tube and then you always want to label the site where you got it from and then send it to the lab for culture. It will take several days.

There may be a preliminary result in one day as far as what's growing in the wound, but it can take three or more days to get that final result.

Okay. So let's talk about debridement. So we have a patient who's got that slough or that eschar, how can we get that off and get that patient healing?

So we have autolytic debridement, which is where the patient's own white blood cells and natural enzymes slowly break down the necrotic tissue.

It requires a moist wound healing environment.

It requires the patient to have adequate white blood cells and good perfusion. So it's not a good option for every single patient.

Then we have enzymes that can be used. So an example is collagenase, which the brand name of that is Santyl, and that is a topical enzyme product that loosens necrotic tissue from the underlying wound bed.

The tricky part about this one is you can't use this product with any silver or iodine products, and you also shouldn't use wound cleanser because it inactivates the enzyme. So sometimes I'm hesitant to order those products just because I'm afraid that nurses will use a wound cleanser and not know.

We try to communicate and stuff. But as you know, nurses are pretty overwhelmed. They have a lot of stuff going on. So I try to keep things as simple as possible.

And we have chemical debriment. So some of you may have heard of Dakin's, which is basically a bleach solution. So you would only use this for a super dirty wound that you need to clean up. So it's for a wound that's full of necrotic tissue. It smells. It needs to be cleaned up.

So that bleach solution should not be used on a wound that is clean. If the wound's clean, then that is not the right product. It's just for dirty wounds.

And then we have sharp debridement. So as a wound nurse, I am certified to do conservative sharp debridement at the bedside for patients. So I can take out and I can cut away slough and necrotic tissue in a conservative way. If it's very firmly adhered, or there's a lot of it, then we're going to want to send the patient to surgery, to OR, to have surgical debridement of that wound.

One type of debridement is called mechanical debridement, which people refer to as a wet to dry dressing. This type of method is generally contraindicated, okay. So a wet to dry dressing is where you take a piece of gauze, and you wet it with saline, and you put it on the wound, and you let it dry, right, and then you peel it back. And the idea is that you're going to peel off the necrotic tissue and stuff that's on the wound bed.

But, A, it's very painful, so it's just not best practice anymore. And, B, it sometimes peels off like viable tissue, like good tissue in addition to that necrotic tissue, so we don't use it. Every once in a while, I'll get an old school doctor who will be like, "Why aren't we doing wet to dry?" And I'll explain, "We have better things. We have this enzyme preparation or we have other products," which we'll talk more about.

Okay. So like I said, in terms of topical wound care, after cleaning the wound, we want to provide a moist wound healing environment.

So we don't want that wound to be dry like a desert, but we also don't want it wet like a swamp. So I don't know how many of you like your parents, your mom or dad told you that, "Oh, just let it scab over. Scabs are good." So I'm here to tell you that scabs are not good and actually kind of slow down the wound healing process. So if your mom or dad told you that a scab is good, put it in the chat. And tell them— you can school them and tell them, "Scabs are actually not helpful. It delays wound healing," because, normally, you have a wound, and you'll have skin that wants to grow across that room-- across that room [laughter], across the WOUND, so epithelialization. If we have a scab in the way, that can't happen. So your body actually has to produce an enzyme to kind of dig under the scab. So that's why the corners of your scab start peeling up as time goes on. It has to do this extra work to try to get under the scab. So if there was no scab and we had a nice, moist wound bed, then that wound healing can happen a lot faster, and that skin can grow over the wound easily.

So in terms of how do we maintain a moist wound healing environment, if your patient's wound is draining heavily - it's a swamp - then we want to use a special product that will help absorb that moisture, right, that excess drainage. If your patient's wound is dry like a desert, then we're going to actually want to add wound gel to that wound to help with that autolytic debridement.

And then after we either mop up the excess moisture or add wound gel, we want to cover the wound and protect that wound, and then monitor the patient's response to therapy and check for signs and symptoms of infection.

So what are those? I bet you guys can tell me some signs and symptoms of wound infection.

We've got bad smell, right. That's a sign. If we got redness around the wound, if we have induration around the wound, that means hardness.

So if we put hard tissue, that's a sign of infection, if the patient has fever or increased pain.

Good. I'm seeing a lot of people coming out with all the good things to look for to make sure your patient isn't having an infection.

Alright. So let's talk about some products. So if you've walked into the supply room at your hospital, there's a lot of wound care products. So I'm not going to go through all of them, but I did want to highlight some of the ones I feel like are most helpful when treating pressure injuries.

So Mepilex or a silicone border foam product is very common in the hospital. That is a great product for pressure injuries with moderate drainage.

However, if you have a pressure injury that has heavy drainage, then really alginate is a great product. So alginate is made of seaweed and kelp. And it can absorb a lot of drainage. And it comes in regular alginate and also comes in silver alginate. So it's either calcium alginate or silver alginate. Silver alginate is anti-microbial. So silver, by nature, it's naturally antimicrobial.

So the alginate is impregnated with silver, so it kind of does double duty. It wicks up the moisture, and it also helps to have antibacterial action for the wound.

And then hydrogel is a wound gel, and that's what we use on dry pressure injuries because, again, in order for that wound to heal, we need sufficient moisture. And then if you do have a wound that is heavily draining, remember that you need to protect that peri-wound skin, the skin around the wound. So we're going to want to protect it with a skin barrier such as Cavilon or a moisture barrier like what we used with incontinence like Calazime.

Alright. And then let's talk about wound healing and systemic factors that play a role.

So we talked about diabetes. Diabetes definitely impairs wound healing. So for my patients with diabetes, I tell them they need to closely control their blood sugar levels.

Ideally, we want those blood sugar levels under 140. If they are over 140, then wound healing will slow down.

And if it's over 180, then wound healing is pretty much impaired. So we need to have tight blood sugar control. So as the nurse, if you see that their blood sugar levels are consistently high, then you definitely need to reach out to your provider to get maybe some better insulin coverage for that patient. Try to get their blood sugar levels under 140.

And then malnutrition is the other big problem that we see. So insufficient protein will definitely slow down wound healing. I've definitely seen a situation where if a patient is not getting sufficient protein, their wound is not healing.

And as soon as we get some TPN on board or get them a protein shake or two feedings, then all of a sudden that wound starts to heal.

So definitely initiate a nutrition consultation for your patient, and provide any ordered nutritional supplements.

Alright. So let me go back and take some questions again, and then we're going to get into our knowledge check, okay?

"Should we err on the side of upstaging? If we have to upstage, is it considered nosocomial?" No. Well, so it's hospital-acquired if that pressure injury shows up after 24 hours after admission, so that really determines whether it's hospital acquired or not. And in terms of staging, take your best guess. Try to get your mentor, a resource nurse, in there. Or if the wound care nurse is on the floor, definitely pull them in to help. If you don't get it right, or you're not sure what it is, put in a wound console, and we can come and fix that staging.

Let's see. "What's a good, inexpensive cream or ointment for dry skin?" Let's see. We use a couple of different things at our hospital. Lubriderm I think is one. Aquaphor is another really good one. Let's see.

"Would Triad help with IAD?" Yes. So Triad Cream is great for areas where you can't get a good stick with a dressing. So if it's in an area we're addressing, it's just not feasible, it's not sticking, it's too moist, whatever, then Triad Cream is one that is a good product. So that's great.

Let's see." Can you explain the difference between excoriation and maceration? I believe incontinence is related to maceration. Fellow RN's on the floor keep saying excoriation, but I think they mean maceration." So, yeah. So maceration is due to excess moisture. So I usually use that word to describe the periwound skin. So often with diabetes, if they have an ulcer, the skin will be callused and macerated. So if you have excess moisture, that is maceration. Excoriation may be due to friction or some other kind of damage. So you are right. Incontinence, I would call that maceration. That's a moisture-associated skin damage.

"So when it comes to scabs, if the patient already has one, can we, as medical professionals, remove it?" Well, my partner definitely does so at work, so she'll get in there and remove all those scabs, and open it up and then get some wound gel in there. Sometimes what I might do is actually just put some wound gel on it, and cover it up with like a hydrocolloid or some other dressing to basically cook down the scab. Really to just add all this moisture, and if I come back in a day or two, it'll just come off easily. So it might be fun to pick, but I usually don't do it. I usually just add like wound gel, and moisture, and kind of cover it up, and then come back, and it usually breaks it down for me. I don't have to do the work, though picking off scales from psoriasis patients is always super fun.

"Oh, how do you feel about the effectiveness of wound vacs? I had one on me before, and I feel like it took the wound longer to heal." I'm actually a huge fan of wound vac, so that's a lot of what I do at the hospitals. I do the wound vac dressing changes for my patients, and it does help wounds heal a lot faster.

So basically how a wound vac works, it applies suction to the wound, and that suction causes the cells at the base of the wound to become elongated. You're kind of stretching them up, and when they become elongated, they start releasing more granulation tissue.

So it's almost like you're sucking on those and they're like, "Okay, fine. Here's some scar tissue." So that wound vac helps the wound to fill up more quickly and to come together to contract more quickly.

And it also keeps it nice and clean, and it also avoids having to do daily dressing changes. So I do love wound vacs.

It can be uncomfortable as far as the dressing changes, and it's a little bit of a hassle to be able to-- when you go home with a wound vac, you have to carry one around but, in general, I find that wounds do heal faster with wound vacs, actually.

"How often do we need to change a dressing using Mepilex?" So usually Monday, Wednesday, Friday but if your wound is draining really heavily, it may need to be more often or if the Mepilex is on your patient's backside, and they're pooping or peeing all over it all the time, then more frequently. And, in fact, if they have a wound on their coccyx, and we're changing Mepilexes like five times a day due to incontinence, then really a Mepilex isn't the best solution for that patient.

It may be that we just need to put a zinc oxide ointment on there. Maybe we need to use the Triad cream.

We need to do something else because Mepilex's foam dressings are kind of expensive, which is fine if they're appropriate for the patient, but for having to replace them a lot, then we may need to add some alginate in there to help soak up some of the moisture and then maybe put a Mepilex on top of that.

"What cream would you recommend for a stage one?" I actually recommend Cavilon Barrier or some other barrier film, so it's kind of a liquid bandage, and it comes in like a spray, or it comes in those lollipops, and you can just put that over there on the stage one. So just protect the skin with that liquid bandage and then get the patient off of the area.

Alright. What do y'all think about doing some knowledge checks and a little quiz?

So first question, true or false?

Best practices include two nurses performing a skin check within 24 hours of patient admission, true or false?

Yes. Everybody is getting it right. Good job. The answer is true.

Alright, here we go. Second question, list three interventions that can be used to prevent skin breakdown. So that was towards the front end of my presentation, so tell me three interventions.

Go ahead and just throw-- yep, turn patient every two hours, barrier cream, excellent, pillows, special mattress.

Good. You guys got it all. So here are some of the things we talked about in the beginning, and you guys totally listened and our are nailing it so great job. Great job.

Okay. True or false, a wet to dry dressing is the best way to debride a word.

True or false? Yes! No, false. Good. So it's painful and sometimes debrides the healthy tissue, so we don't want to do that. False.

Okay. When getting a wound culture, you should swab the-- you should clean the wound with normal saline and then swab an area of viable tissue in the wound bed, true or false?

Yes, true. So no wound cleanser, just use that normal saline. True. Alright.

Alright. There's a little harder one. If a patient's pressure injury is draining heavily, what type of dressing would be appropriate to use? What was that thing I told you all?

Yes, alginate. Alginate is made of that kelp and seaweed, and it soaks up tons of drainage, and you get it in silver or without silver, so nice job, guys.

Alright. Name two systemic factors that impair wound healing. There's a lot of them, but we talked about two.

Yes, diabetes.

Yes PAD? For sure.

Malnutrition? Yeah. Here, two.

There's definitely more, but these are the two that we touched on earlier, but perfusion issues, paralysis. There's lots of others, too. But these are two big ones.

What intervention can be used to treat incontinence-associated dermatitis? What can we use to treat that? Yes, moisture barrier cream, a condom cath. Beautiful. So we can eliminate the moisture with a condom catheter or a PureWick, and we can use a barrier cream as well. And we want our patient to go commando, remember? No diapers if we can help it.

Sometimes I have to talk them into that.

Oh, okay, now we're into wounds. Name that stage. What stage is this pressure injury?

Yes. You guys are so good. DTI, deep tissue injury. Nice job.

Okay, you ready for the next one?

What stage is this pressure injury?

Yes. Stage two. Right? We just have that top layer of skin gone, damage into the dermis. It's nice, red, and moist, so this is a stage two pressure injury. Great job.

Alright. What stage is this pressure injury?

Yeah. Stage one. Now we're assuming-- I didn't tell you, but we're assuming this is not blanchable. That we're pushing on it, it doesn't blanch. So good job. Stage one.

Alright. Last one. What stage is this?

Alright. What is this thing covered in? What is this-- is covered in slough, right? It's chicken fat looking. That's right. So what does that mean if the wound base is covered in slough? Yes, unstageable. So if we can't see the wound base-- now with this one, I'm hopeful that it would not be too deep. I can see little peeks of red here, but I don't know for sure because it's still got all this slough.

So this would be an unstageable until we get that slough off and we can determine the wound base, okay? So that's unstageable.

Here are the references.

So again, this information was brought in from our wound care [flashcard] deck and we have lots of references here.

Alright. So let me see about who our winners are. I have three people winning. One of our wound care decks. And we have Angela, no last name. So hopefully, there's not more than one Angela. Angela, we have Reem M, R-E-E-M-M. And then I'm going to mess up this next name and I am super sorry, but Abby [inaudible]. And I'm sorry if I messed up your name, but-- Okay, so what do we want to do for these guys?

How do we want them to reach out to us? So support@leveluprn. Let us know that you are one of the three winners and we can get a wound care deck out to you.

Actually, I've just been told that our support person-- we have your email, so we will reach out to you if you're one of the three winners.

Also, we are having a back-to-school live event that's happening on the 24th at 4 p.m. Pacific, and we are doing giveaways at that event. So I hope you guys can join for that.

So that's the end of my presentation. I'm happy to answer questions. I would love to get your feedback.

It sounds like-- how did ya'll like it? Was it helpful? Did you learn some stuff? Awesome.

So let me see if there's any other questions here that I can answer for you guys.

Oh, wow. Well, there's a lot.

"How do we register for the back to school event?" Do they have to register or can they just show up? I'm talking to Angelina, my support person. So I think you can just show up.

Okay, "What's the main difference between chicken fat and subcutaneous tissue?" Well they can look a little bit the same. So the chicken fat was like you can kind of pull it, usually it's kind of stringy. Subcutaneous tissue, it's like firmly adhered. It's part of the the patient's tissue layer.

Let's see. "What options would you provide patients who are unable to afford prescriptions for things like Santyl if they continue wound care at home? Or how does your facility manage those kinds of barriers?"

If we start wound care with something like Santyl or PluroGel or some other expensive thing, I will have them take that home with them. I'm like, "You need to take home all those wound care stuff that I'm using and bring it home."

But if it's like a large surface area, we need to treat a lot, then Santyl is not going to be a really good, affordable option and we would just really have to look at alternative options that are going to work for the patient's budget. But for a small wound, they can usually take home the tube that we initiate at the hospital.

Also, I want to encourage you guys to sign up for our newsletter at leveluprn.com. We have a lot of exciting-- I mean, super exciting stuff in the pipeline that I know you guys are going to love, and I'm really excited. I can't spoil it here, but it's coming. So be the first to know. Sign up for our newsletter.

Let's see. "For patients with CKD and limitations on protein intake, what are ways as a nurse that we can help wounds heal?" Yeah, that's a tricky situation. So with CKD and if they're getting dialysis-- now, they're losing protein with each dialysis session. They can usually have sufficient amounts of protein that it allows for wound healing.

We usually don't have to limit their protein intake so severely because of their CKD such that it impairs wound healing.

So usually we work with the nutritionist to come up with a meal plan and with protein intake that's going to work for their kidney disease, as well as wound healing.

So we can usually strike a balance and we have at the hospital.

All right. "When is the new clinical skills deck available to buy?" It is coming very, very, very soon. I don't have it on my table here. We're just putting the final touches, there. It'll be very soon.

Let's see. "Can you do a Med-Surg webinar, like chronic illness acute?" One, that's a great idea, but also I would encourage you-- I have a whole video playlist for Med-Surg, so we have our medical surgical nursing flashcards and I have videos to go along with those that cover a huge range of topics that you see in Med-Surg. So definitely check that out on YouTube.

Let's see. "What medication for pressure injuries is usually used in NCLEX questions?" Well, some things that I've seen or know of that are important to know for NCLEX are a lot of things we talked about today.

So making sure the patient has sufficient protein in nutritional intake and then pressure redistribution and getting the patient off the area. I don't find that Enclex will ask you specific medication questions for pressure injuries, right? They're not going to ask you about Santyl or PluroGel or any of those other medications that we use at the hospital, but I would know about prevention and the importance of nutrition, and the importance of offloading the patient and pressure redistribution.

"Do we still use honey to treat wounds?" We do. We still have MediHoney at our hospital. We don't use it a lot, but we do use it occasionally.

"Could you do monthly webinars?" Maybe, we definitely have more webinars coming up. And I actually have some other team members, other nurses on our team who are going to do some amazing webinars as well. So definitely sign up for our newsletter and you will find out about our upcoming webinars.

I'm so glad that you guys enjoyed this. This is our first one, and you never know how things are going to go, but you guys are really sweet and really supportive. So thank you. Thank you so much.

And let's see. "Are these wounds in the flashcards I bought?" Well, if you bought Wound Care for Nurses, this has all the wound care stuff, so not only pressure injuries, it talks about lower extremity wounds, like venous stasis ulcers and arterial ulcers.

It talks about ostomies, it actually talks about wound vacs too. If I can get a hold of a wound vac I would love to do a webinar or a video on how to do wound vac dressing changes because that's kind of my jam. I really loved doing that at work.

Alright. I think that's it, guys. Let me see if there's anything else here and chat or any other questions.

For those of you, yes, someone's looking for pharmacology. I have a complete pharmacology playlist on YouTube. I go into all the medications that we cover in our flashcard deck, so definitely check that out.

Okay, so "what's the first step to become a WOCN?" Good question. So first of all, what we are seeing is an amazing job and I love it. A lot of autonomy, a lot of responsibility, but a lot of autonomy.

To become a WOCN, you do need your bachelor's.

So if you have your associate's degree in nursing, you can get your WCC, which is your wound care certification. But to get your WOCN, then you do need a bachelor's degree.

I got my wound care certification at Emory University in Atlanta. They have an online program that you can take, and then you go there for one week, for a bridge week, and I had a really good experience with that program, so I definitely recommend that. I was fortunate.

So I started at my hospital as a new grad on a Med-Surg floor, and then I went straight into wound care after my kind of residency, my new grad period, and I got brought on to wound care without any specific wound care experience, and my partners Rolene, especially, they just took me under their wing and they showed me everything about wound care.

So I was able to accumulate a lot of hours of wound care experience such that with Emory, I was able to enter their program and just audit it because I had 1500 hours of wound care experience and I was able to sit for my exam.

This is called the experimental pathway. So if you have experience in wound care and you audit the certified wound care class, then you can sit for the exam. And that's what I did. So I was super lucky. So I just audited it, I got my wound care experience and then I got certified.

So there's three different tracks. There's wound care, ostomy care and continence care. So I am just a certified wound care nurse. I definitely help with ostomies and ostomy teaching as well, but I don't have my certification in ostomies yet, although that's definitely a goal of mine. So you can get your certification in all three areas or just one or two areas, they're independent classes. So hopefully that helps.

"Can you rewatch this amazing webinar?" That's a good question. I know we recorded it. I have to find out what the plans are for posting that. So if you sign up for our newsletter, we can definitely let you guys know about that.

Okay, any other questions for me at all? And it doesn't even have to be wound care at this point because we spent an hour and a half on wound care, so if you have any other questions, I'm happy to answer those as well.

So someone asks "Is it a good idea to remove scabs?" I like to moisten and moisten them up and let them kind of come off by themselves versus being traumatic about it. So I do wound gel and cover it up with like a hydrocolloid dressing and then basically cook them down in a way.

So "Would removing the scab increase the risk for infecting the wound?" No, as long as you keep it covered, right, clean, you want to keep it clean, you want to keep it moist and you want to keep it covered so that it's protected.

So as long as it's not open and not covered, right, because that would be bad. We want to keep the wound covered, but that scab is just slowing down the wound process because it's super dry.

And like I said, the body has to create special enzymes to kind of like dig under the scab, to do wound healing, so if the scab is not there, it's going to heal a lot faster.

All right. "I'm sorry, you probably have answered this, which injury would get debrided?" So any pressure injury that is covered in slough or a scar really should be debrided. There are some exceptions to that.

So if a patient's bed-bound, they're always in the bed and they have an unstageable pressure injury on their heel, and they have some arterial issues like peripheral arterial disease, we actually don't want to mess with that scar, and we don't want to mess with that unstageable pressure injury if it's stable, eschar, we're going to just paint that area with iodine to try to keep it clean and dry, because if the patient has peripheral arterial disease, they have impaired blood flow to that area and they're not going to heal well.

If we open that up, it could get infected. It may not heal.

So we're actually just going to take a conservative route and just kind of brush iodine over the area and let it be stable eschar. So we don't do debris that.

But in general, if the patient can heal and doesn't have any of these systemic factors that impair wound healing, we would want to debrief anyone that has slough or eschar in it.

Okay. Alright. So I'm going to say goodbye now, again, thank you so much for coming. Thank you for supporting me, and I hope you learned a lot. I really had fun with this. So thanks again. And we will see you on another webinar soon. Okay, take care. Guys, thanks so much.


5 Responses

Brittney
Brittney

September 23, 2021

Is there a recording of the event? I attended, but would love to rewatch.

Francisca
Francisca

August 21, 2021

Starting LVN soon and would like to have some knowledge about wound care. Thanks

Adwoa
Adwoa

August 21, 2021

Am a student nurse and wants to know more about pressure injuries

Nixon
Nixon

August 18, 2021

I’m an LVN student and I would like to learn more about pressure injury care and proper documentation.

Judy
Judy

August 18, 2021

Thank you!

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