What are the structures of skin?
Epidermis and Dermis
What are the functions of skin?
-Maintain body temperature
-Protection from friction and shear, dehydration, ultraviolet light, and radiation.
-Perception of temperature and pain
-Perception of pressure, touch, and vibration
-Excretion of small amounts of salts and perspiration
-Vitamin D synthesis
-Preventing loss of water and electrolytes
What are some developmental considerations in children, adolescents and adults?
-Infant's skin and mucous membranes are easily injured and subject to infection
-Child's skin becomes increasingly resistant to injury and infection
-Requires special care because of toilet and play habits
-Adolescent has enlarged sebaceous glands and increased secretions
-Adult's tissue becomes thinner and wrinkles appear; liver spots occur
Pressure Ulcers: Pathogenesis
What are the risks for pressure ulcer development?
-Impaired sensory perception
-Alteration in level of consciousness
-Impaired sensory perception
What should you assess for when checking the Skin?
-Skin: color, temperature, turgor, integrity
-Risk for pressure ulcers: Norton and Braden scales
-Exposure of skin to body fluids
What is denuded skin and what causes it?
-Shearing forces have affected skin
-Superficial layer of skin torn away
-Friction causes denuding
What is blistering and at what stage does this occur?
-Plasma fluids leak between tissue layers
What are the characteristics/classifications of a stage I pressure ulcer?
persistent red, blue, or purple tones; no open skin areas
What are the characteristics/classifications of a stage II pressure ulcer?
partial-thickness skin loss; presents as an abrasion or blister
What are the characteristics/classifications of a stage IV pressure ulcer?
full-thickness skin loss with extensive destruction, necrosis, or damage to muscle, bone, other structures
What are the different types of wounds?
-Intentional or unintentional
-Open or closed
-Acute or chronic
-Partial thickness, full thickness, complex
Describe partial thickness in skin.
inflammatory response, epithelial proliferation and migration, reestablishment of epidermal layers
Describe full thickness in skin.
inflammatory phase, proliferative phase, and remodeling
What are the principles of wound healing?
-Intact skin is the first line of defense against microorganisms
-Surgical asepsis is used in caring for a wound
-The body responds systematically to trauma of any of its parts
-An adequate blood supply is essential for normal body response to injury
-Normal healing is promoted when wound is free of foreign material
-The extent of damage and the person's state of health affects wound healing
-Response to wound is more effective if proper nutrition is maintained
What are the phases of wound healing?
Describe phase 1 in wound healing.
Inflammatory (Defensive) Phase
-Begins at time of injury
-Prepares wound for healing
-Hemostasis (blood clotting) occurs
-Vascular and cellular phase of inflammation-
macrophages enter site to clear away microorganism and cellular debris & swelling occurs as plasma fluid leaks in
Describe phase 2 in wound healing.
-Phase begins within 2 to 3 days of injury and may last up to 2 to 3 weeks
-New tissue is built to fill wound space through action of fibroblasts
-Capillaries grow across wound
-Thin layer of epithelial cells forms across wound
-Granulation tissue forms foundation for scar tissue development
Describe phase 3 in wound healing.
-Final stage of healing begins about 3 weeks after injury to possibly 6 months
-Collagen is remodeled
-New collagen tissue is deposited
-Scar becomes a flat, thin, white line
What are the factors that affect wound healing?
-Age—children and healthy adults heal more rapidly
-Circulation and oxygenation—adequate blood flow is essential
-Nutritional status—healing requires adequate nutrition
-Wound condition-specific condition of wound affects healing
-Health status—corticosteroid drugs and postoperative radiation therapy delay healing
What are wound complications?
-Dehiscence and evisceration
What are the psychological effects of wounds?
-Change in body image
What are the factors affecting pressure ulcer development that you should recognize when doing skin assessment?
-Fecal and urinary incontinence
-Altered level of consciousness
-Spinal cord and brain injuries
What are the characteristics of eschar?
cornified or dried out dead tissue ,tan, brown, black
What are the characteristics of slough?
liquified or wet dead tissue, white, yellow, light tan
What is undermining?
bigger area of tissue destruction than can be seen (extends under the edge)
What are the stages of pressure ulcers?
* Stage I — nonblanchable erythema of intact skin
* Stage II — partial-thickness skin loss
* Stage III — full-thickness skin loss; not involving underlying fascia
* Stage IV — full-thickness skin loss with extensive destruction
What do you assess in a stage I pressure ulcer?
-Intact skin with non-blanchable redness
-The area may be painful, firm, soft, warm or cool as compared to surrounding tissues
What do you assess in a stage II pressure ulcer?
-Partial Thickness involves epidermis and dermis
-Presents as blister or superficial crater
What do you assess in a stage III pressure ulcer?
-Extends through dermis and into subcutaneous tissue
-Deep crater, Tendon, muscle or bone are not visible
What do you assess in a stage IV pressure ulcer?
-Full thickness skin loss
-Extensive destruction to the bone or supporting structures
-Will see muscle, bone, tendon, or ligaments
What do you assess in a unstageable pressure ulcer? (NPUAP additional category)
A wound can not be properly staged until the deepest layer of viable tissue is visible. If a wound in covered with necrotic tissue (slough or eschar), it can't be properly staged and should be documented as unstageable. Exception: In long term care, this may still be called stage IV.
-Completely covered with necrotic tissue (slough or eschar)
-Cannot visualize base of wound
What is Deep Tissue Injury?
A variation of pressure ulcer that initially appears as bruised tissue (appears darkened). Injury location is in the muscle bed or subcutaneous fat layer. The skin is usually in tact at the time of the time of assessment.
What are the characteristics of Deep Tissue Injury?
-Skin may appear as a deep red, purple hue, and progress to a blister, necrosis rapidly.
-May appear as a deep bruise, May be preceded by pain, area warm to touch, skin
-Often appears 1 to 5 days after a surgical procedure
What are 3 Proposed etiologies of Deep Tissue Injury?
1. Pressure to skin and soft tissue cause ischemia (inadequate blood flow)
2. Muscle injury associated with decreased nutrient supply
3. Injury to fascia from shearing forces
How do you measure a pressure ulcer?
-Measure linear wound according to length x width x depth. Think of the wound as a clock with the patient's head at 12:00 position and the feet at the 6:00 position.
-Depth of wound-insert Q tip in wound for depth
-Note Presence of undermining or tunneling
- Measure in centimeters
What are chronic wounds?
-Wound that will not Heal in an orderly set of stages and in a predictable amount of time.
-Acute wound that fails to heal normally
-Stuck in Inflammatory Phase
-Cannot heal secondary to a physiologic problem
What are the Nursing Diagnoses for Wounds?
-Risk for infection
-Imbalanced nutrition: less than body requirements
-Impaired skin integrity
-Impaired tissue integrity
What are some Planning/Outcomes for Wounds?
Goals and Outcomes Examples
-Wound improvement within 2 weeks
-No further skin breakdown around bony prominences
-Increase in caloric intake by 10%
What are the interventions for cleaning a pressure ulcer?
-Clean with each dressing change
-Use careful, gentle motions to minimize trauma
-Use 09% normal saline solution to irrigate and clean the ulcer
-Report any drainage or necrotic tissue
What are the interventions for dressing a pressure ulcer?
-Keep ulcer tissue moist and surrounding skin dry
-Place moist dressings only on the wound surface
-Use dressing that absorbs exudate but maintains moist environment
-Use skin sealant or moisture-barrier ointment on surrounding skin
-Secure dressing with the least amount of tape possible
-Use wet-to-dry dressings for debridement, when ordered
-Pack wound cavities loosely with dressing material
What are some best interventions for treating pressure ulcers?
-Float heels off the bed with pillows
-Protect skin from moisture
-Protect skin from friction and shear
-Consult a dietitian for nutritional concerns
What are Non Pressure Ulcer Wounds?
Non Pressure wounds are classified as partial thickness or full thickness wounds
-Venous Stasis wounds
-Skin tears related to trauma
How should you assess for a draining wound?
-Inspection for sight and smell
-Palpation for appearance, drainage, and pain
-Sutures, drains or tube, manifestation of complications
What are factors that detect the presence of an infection?
-Wound is swollen
-Wound is deep red in color
-Wound feels hot on palpation
-Drainage is increased and possibly purulent
-Foul odor may be noted
-Wound edges may be separated with dehiscence present
What are the 3 types of wound drainage?
What should you document when assessing skin?
-Variations in Normal skin
-Temperature - Cold, cool, and hot
-Color - Cyanotic, Pale, Dusky, Jaundiced (yellowed), Flushed, Ashen
-Moisture - Clammy, Diaphoretic, Fragile, Moist, Itching, Flaking (or Cracking)
-Turgor - Non-elastic, tight
-Integrity - Not intact (specify by describing the wound or abnormality
What are the types of drainage systems?
Open systems -Penrose drain
Closed systems -Jackson-Pratt drain, Hemovac drain
What are the Color Classifications of Open Wounds?
R = red—proliferative stage of healing; reflects color of normal granulation
Y = yellow—characterized by oozing; needs to be cleansed
B = black—covered with thick eschar; requires debridement
Mixed wound—contains components of RY&B wounds
What are the Factors Affecting the Response to Hot and Cold Treatments?
-Method and duration of application
-Degree of heat and cold applied
-Patient's age and physical condition
-Amount of body surface covered by the application
What are the Effects of Applying Heat?
-Dilates peripheral blood vessels
-Increases tissue metabolism
-Reduces blood viscosity and increases capillary permeability
-Reduces muscle tension
-Helps relieve pain
Do's & Don'ts of heat therapy
-Instruct client to report any change is sensation or discomfort ( application is too warm)
-In a hospital setting, don't leave client unattended for too long if heat sensation is poor—consider diabetics with peripheral neuropathy—impaired sensation due to prolonged exposure to elevated glucose.
-Remember that elderly are at greater risk for burns due to decreased sensation of pain.
-Young children are more easily burned than adults.
What are the Effects of Applying Cold?
-Constructs peripheral blood vessels
-Reduces muscle spasms
Devices to Apply Heat
-Hot water bags or bottles
-Electric heating pads
Devices to Apply Cold
Moist Heat (Advantages & Disadvantages)
Advantages: Softens wound exudate. Penetrates deeper than dry. Doesn't promote sweating
Disadvantages:Tissue macerationincreased risk for burns
Cools too rapidly
Dry Heat (Advantages & Disadvantages)
Advantages: Less burn risk. No Skin maceration. Dry heat devices stay warm longer.
Disadvantages: May increase sweating, dries tissues.
Evaluation to wound healing
-Determine progress toward healing outcomes by reassessing pressure ulcers and wounds with dressing changes and no less than every 7 days.
-Photograph ulcers and wounds at least once a week in the hospital and long term care settings.
-Re-assess daily using Braden or other scale.