Skin Integrity and Wound Care

Created by saharper 

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Use of maggots?

Debride wounds

Epidermis

Outer 4-5 layers; protects skin from physical & mechanical trauma

Dermis

Fibrous & connective tissue & blood vessels; strength & elasticity to skin

Subcutaneous

Connective & adipose tissue; provides insulation & calorie reserve

Shear

Force exerted against skin

Friction

Results from two surfaces rubbing against each other

Moisture (Incontinence, diaphoresis)

Reduces skin's resistance to other forces such as pressure or shear

Poor Nutrition

Causes tissue to become susceptible to breakdown (Hypoalbuminemia results in edema)

Infection

Increases metabolic needs making tissue susceptible to ischemic injury

Age

Loss of dermal thickness and increased risk for skin tears

Guidlines for Prevention & Mgmt of Pressure Ulcers

Predictive tool for pressure ulcer development; identification of patients at risk

Braden Scale

Six subscales used to identify patients at risk for pressure ulcer development

Pressure Ulcer Etiology

Ischemia with tissue hypoxia (develops within 2 hrs).
Unreleived pressure or mechanical trauma.
Over a period of time

Significance of the Braden Scale

Older Adult Patient with a score of 18 or below: at risk
Should be used when client first enters the facility, again Q 24 hrs & whenever his condition changes

Tissue ischemia

Obstructed blood flow to tissues causing tissue death

Reactive hyperemia

Dilation of superficial capillaries causing "redness" of skin

Blanchable hyperemia

An area that appears red and warm will turn a lighter color with palpation

Nonblanchable hypermia

Redness that persists after palpation, indicating tissue damage (Stage I P.U>)

Stage I

Intact skin nonblanchable erythema "redness"

Stage II

Partial-thickness loss of skin
Shallow, open ulcer
Intact or open/ruptured serum-filled blister

Stage III

Full-thickness loss of skin
Subcutaneous fat may be visible
Undermining & tunneling may be present

Stage IV

Full-thickness loss of skin with exposure of bone, tissue or muscle
Undermining & tunneling are common

Wound classification

By depth; superficial, partial-thickness, full-thickness.
Acute vs Chronic

Superficial

Involves only the epidermis

Partial-thickness

Extends from the epidermis into the dermis

Full-thickness

Through the dermis into the subcutaneous and beyond

Emergency Setting Wound Assessment

Abrasion, laceration, puncture, wound contamination, need for tetanus

Stable Setting Wound Assessment

Dressing, ecchymosis, wound drainage, odor, drains, wound culture

What wounds are most apt to become chronic?

Pressure, diabetic, vascular

Primary Intention

Wound healing process where skin edges close, little to no tissue loss, no infection (approximated, surture, staples)

Secondary Intention

Wound healing process where healing occurs gradually, skin edges do not close (wound left open), granulation occurs

Partial Thickness

Wound healing process where wound repair is needed

Full Thickness

Wound healing process where wound repair is needed because of loss of epidermis and dermis

Partial Thickness wound healing

Inflamation, epidermal repair, dermal repair

Full thickness wound healing

Hemostasis, inflamation, proliferation, remodeling

Phase 1 Hemostasis

Platelets collect & deposit fibrin to form a blood clot, vasoconstriction

Phase 2 Inflammation

Phagocystosis by white blood cells, scab formation

Phase 3 Proliferation

Primary intention wound develops new tissue (period of granulation) and collagen. The wound contracts with epithelialization.
Secondary intention wound fills in with granulation tissue, followed by contractionand epithelialization.

Phase 4 Remodeling

Collagen becomes more elastic and stronger for the scar tissue

Keloid

abnormal amount of collagen; hypertrophic scar

Mature wound

Collagen is formed into a scar, to increase the strength of the wound. Yet still only 80% as strong as the original tissue. Scar should become thinner & paler over time.

Clinical s/s of infection

Erythema, induration, pain fever, odor, color changes, purulent drainage

Complications of wound healing

Hemorrhage, infection, dehiscence (seperation), evisceration (extrusion), fistula

Hemorrhage

internal or external, hematoma

Infection

Prevents healing, increases tissue damage

Dehiscence

Partial or total seperation of layers of skin and tissue

Evisceration

Wound layers separate below the facial layer, visceral organs protrude

Fistula

Abnormal opening between two organs or between an organ and skin

When are s/s of infection likely to occur?

Contaminated or Traumatic Wound - 2 to 3 days
Surgical Wound - 4 to 5 days

VAC

vacumn-assisted closure

Penrose

drainage tube

T-tube

drainage tube

Jackson-Pratt

drainage evacuator

Hemovac

drainage evacuator

Factors Impacting on Skin Integrity

Age, impaired mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture, fever, contamination or infection, lifestyle

Sanguineous

bloody

Serosanguineous

golden liquid & blood

Serous

gold colored liquid

purulent

infection

purosanguieous

infection & blood

Primary Nursing Diagnosis

Impaired Skin Integrity
Impaired Tissue Integrity

Gauze

dry or moist, most common form used

Transparent film

Traps moisture over the wound

Hydro-colloid

Maintains a moist environment

Absorption dressings

beads, powders or pastes, ribbon dressings, alginates

Hydrogel

Maintains a moist environment

How to clean a wound

top to bottom or from center outward, around drains from center outward in a circular motion

Wound care no no's

Do not use Betadine, hydrogen peroxide, acetic acid

Red

protect - granulation

Yellow

Cleanse - slough

Black

Debride - eshar

Heat therapy

Vasodilation to increase blood flow & delivery of O2, nutrients, antibodies & leukocytes to the area

Cold therapy

Vasoconstriction to limit post-injury bleeding and swelling

Debridement

Sharp, Mechanical, Chemical, Autolytic

Sharp Debridement

Scalpel

Mechanical Debridement

Wet-to-damp dressing, wound irrigation, whirlpool

Autolytic Debridement

The most selective with least damage to tissues, takes the longest

Types of heat therapy

Warm compress, warm soak, sitz bath, commercial hot pack, hot water bottle, heating pad

Types of cold therapy

Aquathermia pad, moist cold compress, cold soak, ice bag or collar, commercial cold pack

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