79 terms

Skin Integrity and Wound Care

Use of maggots?
Debride wounds
Outer 4-5 layers; protects skin from physical & mechanical trauma
Fibrous & connective tissue & blood vessels; strength & elasticity to skin
Connective & adipose tissue; provides insulation & calorie reserve
Force exerted against skin
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)
Increases metabolic needs making tissue susceptible to ischemic injury
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
Involves only the epidermis
Extends from the epidermis into the dermis
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
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
internal or external, hematoma
Prevents healing, increases tissue damage
Partial or total seperation of layers of skin and tissue
Wound layers separate below the facial layer, visceral organs protrude
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
vacumn-assisted closure
drainage tube
drainage tube
drainage evacuator
drainage evacuator
Factors Impacting on Skin Integrity
Age, impaired mobility, nutrition, hydration, diminished sensation, impaired circulation, medications, moisture, fever, contamination or infection, lifestyle
golden liquid & blood
gold colored liquid
infection & blood
Primary Nursing Diagnosis
Impaired Skin Integrity
Impaired Tissue Integrity
dry or moist, most common form used
Transparent film
Traps moisture over the wound
Maintains a moist environment
Absorption dressings
beads, powders or pastes, ribbon dressings, alginates
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
protect - granulation
Cleanse - slough
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
Sharp, Mechanical, Chemical, Autolytic
Sharp Debridement
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