Musculoskeletal Case Study

What risk factor does using a draw sheet prevent or minimize?

Friction

What major factors increase risk for developing a pressure injury?

Immobility, nutritional status, incontinence, decreased sensory perception, lowered mental awareness.

What would you expect a stage 3 pressure injury to look like?

A stage 3 injury has full-thickness tissue loss. Subcutaneous fat tissue might be visible, but bone, tendon, and muscle are not exposed. Slough can occur but will not obscure the depth of tissue loss. This is usually a deep crater with undermining or tunneling present.

Why are patients placed on specialty mattresses still at risk for skin breakdown?

Although they reduce pressure, or off-load pressure points, there is no such thing as complete pressure relief. A specialty mattress does not replace the need to reposition the patient at regular intervals and manage moisture.

What problems can be created by packing a wound too full?

As wounds heal, they contract. If a wound is packed too tightly, it creates a pressure insult to the wound bed and causes a secondary pressure injury or further tunneling.

When collecting a wound culture with a swab, the nurse should culture the a. Wound drainage b. Healthy-appearing tissue c. Most necrotic-appearing tissue d. Very outer edges of the wound

B. Culture the healthiest-appearing tissue in the center of the wound

Compare friction vs. shear

Both are mechanical injuries. Friction occurs when the skin slides against a surface; shear is a force applied parallel to the plane of the skin in the opposite direction to the force being applied. Shear is the result of gravity. For example, the head of the bed is elevated, and the patient slowly slides toward the foot of the bed. The skin of the sacrum meets the resistance of the bed surface while gravity pulls the patient's body toward the foot of the bed. This means the skin and the bones are going in opposite directions, thereby pulling and stretching tissue and distorting vessels within the area, causing destruction of both. Friction can happen without shear, but shear always begins with friction.

What wound documentation is necessary?

Date; wound location and state; depth; the presence, location, and extent of any undermining or tunneling tract; exudate if present and its type, color, odor, and approximate amount; pain if present and its nature and frequency; wound bed color and type of tissue or character including evidence of healing or necrosis; and description of wound edges and surrounding tissue. A photo may be taken depending on agency policy.

How often should patients be reassessed for the risk of developing an injury? ​

In most settings, a comprehensive skin assessment is done daily, and on transfer or discharge. In some settings, however, it may be done as often as every shift.

Why do the heels have the greatest incidence of breakdown, even when the patient is on a specialty mattress?

It is difficult to redistribute pressure when the body part is small. Heel interface pressure can exceed capillary closing pressure quickly, even on a specialty mattress.

Knowing that R.L. incontinent, is frail, has right-sided weakness, and has a pressure injury, what consultations or referrals could you initiate?

Nutritional assessment from the dietician, specialty bed assessment, wound nurse or team assessment for suggestions on managing pressure injury.

Why is a specialty mattress used for immobile or compromised patients?

Specialty mattresses "off-load" pressure points by redistributing pressure over a larger surface. There are several classifications, each with general guidelines for placement based on a patient's condition, height, weight, and risks.

The nurse systematically assesses the injury and confirms the presence of a stage 3 wound with moderate yellow drainage. There is no tissue necrosis or debris. What does it mean to "stage" a wound?

Staging involves noting the different tissue layers involved in the insult.

As part of a pts admission assessment, you conduct a skin assessment to a pt who just has a catheter. What areas of the pts body with PVD and and injury to right hip will you pay particular attention to?

The first area to assess is the known injury to the right hip. You would then assess all other bony prominences because they are vulnerable to pressure injuries. Examine in skinfolds and the perianal area for candidiasis. Examine the skin and take pulses below the knees because she has a history of peripheral vascular disease.

What are the advantages of using a validated risk assessment tool to document her skin condition on admission?

These tools give a systematic approach for assessment. Many facilities have a policy requiring the use of a scale, such as Braden or Norton, when a patient is admitted to identify those at risk for developing a pressure injury. The results guide the treatment of existing injuries and the implementation of appropriate interactions to prevent injuries. ​

Describe the technique for packing a tunneled wound.

To pack a tunneled wound: Open or unfold the material that will be placed in the wound bed. Fluff the gauze. Pour prescribed solution over gauze to moisten it. Wring out excess fluid. Lay moisture material over wound surface with forceps until all surfaces are in contact with the moisture material and the wound is loosely filled. Do not allow the material to touch the surrounding skin. Fill the wound, making sure all dead space from sinus tracts, undermining, or tunneling is loosely packed with the material. Leave a tail to assist with removing the gauze. Avoid packing the wound too tightly or having the material extend beyond the top if the wound.

What is a tunneling wound? What risk factors are associated with tunneling?

Tunneling wounds have a channels or passageways that extend from a wound into and through the surrounding subcutaneous tissue or muscle. They often are difficult to treat and might persist for long periods. They often are associated with infections, pressure injury, nonhealing wounds, or improperly dressed wounds, including dressed with materials that dehydrate wounds or were packed with too much or too little packing.

Describe 6 interventions aimed at minimizing friction and shear.

Unless contraindicated, keep the head of the bed at or below 30 degrees If the head of the bed is elevated, limit the elevation time. Use the knee gatch to help keep the torso from sliding down in the bed. Use transfer devices to lift the body off the bed/chair, such as mechanical lifts Keep skin well hydrated and moisturized with hypoallergenic lubricating oils, creams, or lotions that lower the surface tension on the skin and reduce friction. Use transparent film, hydrocolloid dressings, or skin sealants on body prominences (such as elbows) to decrease friction Lubricate or powder bedpans before placing under the patient. Roll patient to place the bedpan rather than pushing and pulling it in and out. Protect skin from moisture. Excess moisture weakens skin integrity and destroys the outer layer so that less force is needed to wound the skin.

Elevated skin temperature and perspiration increase risk for pressure injury. Write 4 specific measures to manage the microclimate.

Use absorbent underpants and briefs to wick incontinence moisture away from the skin versus trapping moisture against the skin, causing maceration. Check for incontinence a minimum of every 2 hours, and as needed. Cleanse skin gently after each incontinent episode with water or pH-balanced cleanser. Avoid excess friction and scrubbing, which can further traumatize skin. Use moisture barrier protectant on skin (e.g. creams, ointments, film-forming skin protectants) as needed to protect skin or to treat non-intact skin. Change linen often for excess perspiration.

What intervention can you initiate to protect pt's heels? Place a pillow, foam wedge, or device under the length of her lower leg and calf to suspend, or "float" the heels. The heels need to be elevated only high enough to slip a piece of paper under easily.

What intervention can you initiate to protect R.L.'s heels? Place a pillow, foam wedge, or device under the length of her lower leg and calf to suspend, or "float" the heels. The heels need to be elevated only high enough to slip a piece of paper under easily.

What factors influence the choice of a wound dressing?

Wound dressings are chosen based on the characteristics of the wound bed. The choice of a dressing depends on the type of wound tissue in the base of the wound, the amount and type of drainage, the presence of infection, the location of the wound, the size of the wound, undermining, tunneling, edema, cost-effectiveness, and comfort of the patient.

Each health care setting should have a policy that outlines how to assess patients' risk for developing a pressure injury. What should be included in that assessment?

a. Activity and mobility level b. General condition of the skin c. Presence of coexisting physical conditions, including diabetes, cardiovascular instability, low BP, and oxygen use d. Nutritional status, including, hemoglobin, serum albumin levels, and weight e. Fecal and urinary incontinence and general skin moisture