By: Mary Brennan, RN, MBA, CWON and Diane Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN

Editor's Note: On April 2, 2020, WoundSource hosted its first ever virtual conference, WoundCon Spring 2020. The conference hosted 13 CME/CE accredited sessions that were attended by over 6,000 health care professionals around the world. The response was so enthusiastic, we asked some of our speakers to answer the most frequently asked questions on their subjects. This is the eighth blog of a 13-part series; access the full series here.

What options are there for assessing skin in outpatient settings and home-based nursing care?

Mary: Just as a skin assessment is done in acute care settings, a skin assessment should be done in both settings. In an outpatient setting, a history is taken and a physical examination is done, so a question about any skin issues can be posed, and a visual assessment can be done and included on the visit form. For home health care, a Braden score is usually obtained, along with a full assessment on the initial visit.

How can we overcome psychosocial issues to prevent pressure injuries (PIs) in our patients?

Dr. Krasner: This is a hard question to answer. What psychological issues does the patient have? This can vary widely, as could the medication the person is on for its treatment. The medication may make them not sense the need to shift position. Second, patient and family education is critical. Just telling a person to move doesn’t get them to move. You need to explain that you are turning them or teaching them to shift their weight for a reason. If they are unable to understand, you must either reposition the person or use a mattress or chair cushion to do it. Chair cushions should be the correct size for the person, and an evaluation should be done by a physical therapist.

Want to learn more about pressure injury risk assessment? Gain full access to the WoundCon Spring sessions and earn CE/CME credit at WoundSource Academy
 

What can I do to prevent PI development in a patient with multiple comorbidities and on multiple medications to manage their other conditions?

Dr. Krasner: You need to be aware of how the medications and conditions are affecting the skin. Remember, skin is the largest organ in the body. Anything going on elsewhere affects it. For example, cardiac issues or decreased oxygen levels or even low blood pressures mean that less nutrition and oxygen are available for skin to stay healthy. Regardless of the Braden score, these patients are at high risk and need care planning for that risk, with frequent skin inspections, support surfaces, a nutrition consult, etc. Look beyond the Braden scale to the patient’s overall condition. Teaching the patient and family is critical. Explain the skin risk and treatment plan carefully. If the person is in hospice, then you may have skin failure. If there is a wound, be realistic about its trajectory. You may use the same treatment, but the goal is comfort and not healing, for example, pain control or odor management.

How should I modify my treatment if I have a patient with a relatively high Braden score but several comorbidities and depression?

Dr. Krasner: The Braden scale is only a guideline. Completing it doesn’t help if the care following it isn’t appropriate, Too often it is viewed as just another task to complete. A high score doesn’t always mean no risk. Clinical judgment and looking at the “big picture” of the patient’s overall health are important to provide care that is appropriate. Again, educate the patient and family. Obtain consults for other types of care and nutritional support.

About The Authors

Mary Brennan is currently the Assistant Director of Wound and Ostomy Care at North Shore University Hospital and served as the chairperson of the Northwell Health System’s task force on Pressure Injuries. While chairing a system wide initiative to reduce the incidence of pressure injuries, a reduction of 70% in the incidence of hospital acquired pressure injuries was realized by the 23 facilities within the system. She serves on the Editorial Advisory Board of Advances in Skin and Wound Care and has presented posters, abstracts, and published on a variety of skin and wound care issues. She has been working on the terminal tissue injury phenomenon beginning with the initial patient observed with these skin changes in 2008. She has been a principle investigator and co-principle investigator on research studies including three involving the terminal tissue injury.

Dr. Diane Krasner is a board-certified wound specialist with experience in wound, ostomy, and continence care across the continuum of care. She is a Fellow of the American Academy of Nursing and a Master of the American Professional Wound Care Association. Dr. Krasner is a consultant in wound and skin care and a legal nurse consultant/expert witness. Dr. Krasner received her Bachelor of Science in Nursing, Master of Science in Nursing, and PhD of Science in Nursing all from the University of Maryland School of Nursing (Baltimore, MD), and a Master of Science in Adult and Continuing Education from Johns Hopkins School of Continuing Studies. She was recently selected to receive the Annual John Boswick Memorial Award and Lectureship for lifelong achievement and dedication in the field of wound care. Dr. Krasner serves on the Board of Directors of the South Central Pennsylvania American Red Cross. Her research interests include wound pain, palliative wound care, and legal issues related to wound care. Dr. Krasner also has numerous publications in the wound care literature and has lectured nationally and internationally on wound and skin care.