Skin Integrity/Wound Care (review sheet)

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N221/N217 - Exam 2

risks/contributing factors to pressure ulcer formation

shearing force - friction - pressure (rotate every 2 hours - pressure occludes blood flow - #1 cause of pressure ulcers) - poor skin integrity - poor nutritional status - dehydration - low albumin (<3g = risk for pressure ulcer) - poor care - ^ bed rest - age (older = ^ risk)

shearing force

(internal) muscle is moving, skin is not (ie. shlumping in bed)

friction

(outer layer of skin) ie - stuck to plastic chair

interventions to prevent pressure ulcers

PRESSURE RELIEF: rotate q90mins-2hrs - get out of bed/move 1+ times/day - good nutrition (protein, vit C & A, zinc, copper) - monitor labs (albumin >3g) - stay hydrated - skin barrier cream - use draw sheet to move - specialty bed (air circulation) - pillows/wedges/blankets to relieve pressure - keep clean (re: incontinence, excessive drainage, necrotic tissue)

pressure ulcer Stage 1

erythema (redness) - non-blanching - skin is intact

pressure ulcer Stage 2

skin loss - epidermis or dermis - superficial (abrasion, blister, shallow crater)

pressure ulcer Stage 3

full thickness - subcutaneous tissue - extend to fascia - deep crater

pressure ulcer Stage 4

full thickness loss - extensive destruction - tissue necrosis - damage (muscle, bone, supporting structures)

wound healing PRIMARY INTENTION

closure by sutures, stiches, Steri-Strips, or staples - utilized when healing is expected within 10 days and new tissue formation is minimally required (epidermis & dermis)

wound healing SECONDARY INTENTION

wound that is allowed to remain open to granulate in and contract ... ie. traumatic and post-surgical wounds

wound healing process (4 stages)

classic model is divided into three or four sequential, yet overlapping,phases: (1) HEMOSTASIS (platelets aggegate to form fibrin clot, vasoconstriction) (not considered a phase by some), (2) HOMEOSTASIS/INFLAMMATORY (prostaglandin released, bacteria and debris are phagocytosed and removed, growth factors secreted) , (3) PROLIFERATIVE (angiogenesis, fibroblasts, collagen deposition, granulation tissue formation, epithelialization, and wound contraction) and (4) MATURATION/REMODELING (occurs after wound is closed) (collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis) can take 6mos-2 years

BRADEN SCALE (predicting pressure sore risk)

score is 6-23...<17 = at risk...15-18 (low risk) 13-14 (moderate risk) 10-12 (high risk) <10 (very high risk) = requires interventions...SENSORY PERCEPTION (ability to respond to pressure-related discomfort); MOISTURE (degree to which skin is exposed to moisture); ACTIVITY (degree of physical activity); MOBILITY (ability to change and control body position); NUTRITION (usualy food intake pattern); FRICTION & SHEAR (1-3)

evaluation parameters for pressure ulcers

amount of drainage - size/appearance of periwound area - clinical manifestations of infection (swelling, pain, reddnes, heat) - PUSH (Pressure Ulcer Scale for Healing)

PUSH = Pressure Ulcer Scale for Healing:

assesses length X width, exudate amount, and tissue type ... scores are summed and graphed to monitor progess ... ^ score = wound is deteriorating (good)

wound healing TERTIARY INTENTION

delayed closure to allow for drainage of fluid, contamination control, and/or a plan for surgical intervention at a later date

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