Upgrade to remove ads
Only $2.99/month

Nursing Taylor Chapter 31: Skin Integrity and Wound Care

Terms in this set (45)

Skin
Largest Organ of the Body

Three layers of the skin:
Epidermis
avascular, renewed every 15-30 days, stratified epithelial cells; no blood vecels

Dermis
main support structure, highly vascular, contains nerves, hair follicles, and elastic connective tissue

Subcutaneous Tissue
anchors the skin to the underlying tissues; adipose tissue; stores fat for energy, insulation

Mucous Membranes
Line body cavities that open to the outside of the body.
Functions of the Skin
Protection,
Temperature Regulation,
Psychosocial,
Sensation,
Vitamin D Production,
Immunologic,
Absorption,
Elimination.
Factors Affecting the Skin
*Unbroken and healthy skin and mucous membranes defend against harmful agents.

*Resistance to injury is affected by age, amount of underlying tissues, and illness.

*Adequately nourished and hydrated body cells are resistant to injury.

*Adequate circulation is necessary to maintain cell life.
Developmental Considerations
2 yo and younger infant's skin and mucous membranes are thinner and weaker, so easily injured and subject to infection.

A child's skin becomes increasingly resistant to injury and infection.

The maturation of epidermal cells is prolonged, leading to thin, easily damaged skin.

Circulation and collagen formation are impaired, leading to decreased elasticity and increased risk for tissue damage from pressure.
Causes of Skin Alterations
*Very thin and very obese people are more susceptible to skin injury.

*Excessive perspiration during illness predisposes skin to breakdown (fluid loss during illness causes dehydration; skin appears loose and flabby).

*Jaundice causes yellowish, itchy skin.

*Diseases of the skin cause lesions that require care.
Wound
break or disruption in the normal integrity of the skin and tissues:


Intentional Wounds
Result of a planned invasive therapy or treatment (surgery, lumbar puncture)
- clean edges and little bleeding
Unintentional Wounds
Result of from trauma, accidents (gunshots, burns)
- jagged edges, uncontrolled bleeding, high risk of infection

Open wounds
occur from intentional and unintentional trauma where the skin surface is open
ex: incisions and abrasions (разрезы и потертости)
Closed wounds
results from a blow, force, or strain cause by a fall, assault, or crash; skin surface is not broken
ex: ecchymosis (кровоподтек) and hematoma

Acute Wound
Wound edges are well approximated (приближены) and the risk of infection is lessened.
Chronic Wounds
Healing is impaired, wound edges are not approximated, increased risk of infection

Partial-thickness wound
all or a portion of the dermis is intact.
Full thickness wound
the entire dermis and the sweat glands and the hair follicles are severed.
Complex wound
the dermis and underlying subcutaneous fat tissue are damaged and destroyed.
Types and Causes of Wound
(Table 31-3)
Incision Cut by sharp instrument

Contusion Blunt instrument. Skin is intact. Bruising

Abrasion Friction. Top layer of skin

Laceration (рваная рана) Tearing of skin. Blunt or irregular object. Loose flap of skin and tissue. Tissue not aligned

Puncture Blunt or sharp object. Needle

Penetrating Foreign object entering the skin

Avulsion (отрыв) Tearing from structure. Possible damage to blood vessels, nerves

Chemical Toxic agent causing cellular necrosis

Thermal High or low temp.

Irradiation Ultraviolet light or radiation exposure

Pressure ulcer Bad circulation caused by pressure with friction

Venous ulcer Injury or poor venous return.

Arterial ulcer Injury and underlying ischemia. Atherosclerosis or thrombosis

Diabetic ulcer Diabetic neuropathy

Desiccation Dehydration

Maceration Overhydration

Necrosis Death of tissue

Biofilm Thick grouping of microorganisms. Slimy (слизь) impairs wound healing

Epithelialization Epithelial cell migration

Evisceration (потрошение) Wound completely separates with protrusion of viscera through the incisional area.

Fistula (свищ) An abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another.

Edema Swelling at a wound site that interferes with blood supply to the area.
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 affect wound healing.

Response to wound is more effective if proper nutrition is maintained.
Phases of Wound Healing
Hemostasis - blood vessels constrict and blood clotting begins through platelet activation and clustering.

Inflammatory phase - white blood cells move to the wound.

Proliferation phase - granulation tissue is formed to fill the wound.

Maturation phase - collagen is remodeled forming a scar.
Hemostasis
Occurs immediately after initial injury

Involved blood vessels constrict and blood clotting begins

Exudate (liquid) is formed causing swelling and pain

Platelets stimulate other cells to migrate to the injury to participate in other phases of healing

Increased perfusion results in heat and redness
Adequate skin Perfusion requires
1) heart must be able to pump adequately

2) volume of circulating blood must be sufficient

3) arteries & veins must be patent & functioning well

4) local capillary pressure must be higher than external pressure
Inflammatory Phase
Follows hemostasis and lasts about 4 to 6 days.

WBCs move to the wound.

Macrophages enter wound area and remain for extended period.

They ingest debris and release growth factors that attract fibroblasts to fill in wound.

Patient has generalized body response.

Begins at time of injury

Prepares wound for healing
Proliferation Phase
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.

A thin layer of epithelial cells forms across wound

Granulation tissue (new) forms a foundation for scar tissue development.
Maturation Phase
Final stage of healing begins about 3 weeks to 6 months after injury.

Collagen is remodeled.

New collagen tissue is deposited.

Scar (avascular collagen tissue) becomes a flat, thin, white line.
Factors Affecting 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 the wound affects healing

Health status: corticosteroid drugs and postoperative radiation therapy delay healing

Immunosuppression

Medication use
Wound Complications
Infection - 2-7 days after injury
Hemorrhage - usually within the first 48 hrs.
Dehiscence and evisceration - surgical emergency
Fistula formation - usually due to infection or abscess
Pressure Ulcer + Staging
A wound with a localized area of injury to the skin and/or underlying tissue.
Bad circulation caused by pressure with friction:
- External pressure compressing blood vessels; ischemia - deficiency of blood in a particular area
- Friction or shearing forces tearing or injuring blood vessels

Stage 1
nonblanchable (не бледнеющая) erythema (redness) of a localized area over a bony prominence.

Stage II
partial thickness skin loss and presents as a shallow (неглубокий), open ulcer.

Stage III
full thickness skin loss; not involving underlying fascia: subcutaneous fat may be visible but bone, tendon, or muscle is not exposed.
R̲e̲qu̲i̲r̲e̲s̲ débridement through wet-to-dry dressings, surgical intervention, or proteolytic enzymes

Stage IV
Full thickness tissue loss with extensive destruction to bone, tendon, muscle.

Unstageable
base of ulcer covered by slough and/or eschar (струп) in wound bed. (DTI) Deep tissue injury
Slough
Yellow, tan, gray, green, or brown fibrinous tissue that consists of fibrin, pus, and proteinaceous material. Slough can be found on the surface of a previously clean wound bed and it is thought to be associated with bacterial activity.
Eschar
Tan, Brown, Black thick leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
Measurement of a Pressure Ulcer
Size of wound

Depth of wound

Presence of undermining, tunneling, or sinus tract
Cleaning a Pressure Ulcer
Clean with each dressing change.

Use careful, gentle motions to minimize trauma.

Use 0.9% normal saline solution to irrigate and clean the ulcer.

Report any drainage or necrotic tissue.
Wound Assessment and Drainage
Inspection for sight and smell

Sutures, drains or tubes, and manifestation of complications

Palpation for appearance, drainage, and pain

Serous Drainage
Composed primarily of the clear, serous portion of the blood and from serous membranes. Clear and watery.

Sanguineous Drainage
Consists of large numbers of red blood cells and looks like blood.

Serosanguineous Drainage
Mixture of serum and red blood cells.

Purulent Drainage
Made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria.
Wound Dressings' Purposes
- Provide physical, psychological, and aesthetic comfort
- Remove necrotic tissue
- Prevent, eliminate, or control infection
- Absorb drainage
- Maintain a moist wound environment
- Protect wound from further injury
- Protect skin surrounding wound
Sings of Infection in Wound
- 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.
RYB Wound Classification
Red-Protect
Yellow-Cleanse
Black-Debride
Debridement
Removal of devitalized tissue and foreign material.

Autolytic Debridement
Uses transparent films, the body's own enzymes and defense mechanisms.

Bio-surgical Debridement
Use of sterile fly larvae
Transparent Films (Tegaderm)
used in:
-minimal drainage, small/partial thickness, stage I pressure ulcers, IV's, superficial
Hydrocolloid Dressings (Duoderm)
Used In:
-Partial and full-thickness wounds
- light to moderate drainage
- with necrosis/slough
- NOT for wounds w/ infection
Hydrogels
Used in:
-Partial and full-thickness wounds
-Necrotic wounds
- Burns and dry wounds
- minimal exudate
-infected wounds
Alginates
Used in:
-Infected or noninflected wounds
- moderate-heavy exudate
-Partial-full thickness wounds
- tunneling wounds
-moist red and yellow
Foams
Used in:
-Absorbing light-heavy amounts of drainage
-around tubes/drains
-NOT with dry eschar
Antimicrobials
Used in:
- protect from bacterial contamination and reduce contamination
- acute/chronic wounds
Tipe of dressings
Gauze dressings absorb blood or drainage.

Montgomery straps are strips of tape with eyelets which are used to secure a gauze dressing that needs frequent changing.

Transparent dressings like OpSite are used to protect intravenous insertion sites.

Hydrocolloid dressings like Tegasorb are used to keep a wound moist.
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
Heat Application
DILATES vessels
INCREASES tissue metabolism
INCREASES local blood flow
REDUCES muscle tension
HELPS relieve pain
Cold Applications
CONTRICTS vessels
REDUCES muscle spasms
REDUCES pain+inflammation
CONTROLS bleeding
Types of Bandages
Roller bandages
Circular turn
Spiral turn
Figure-of-eight turn
Recurrent-stump bandage
Types of Binders
Straight — used for chest and abdomen

T-binder — used for rectum, perineum, and groin area

Sling — used to support an arm
Type of Drainage Systems
Open systems - Drains into dressings
- Penrose drain

Closed systems - Drains into a suction device
- Jackson-Pratt drain
- Hemovac drain
Penrose Drain
- Open Drainage System
- Provides sinus tract
- Typically used after incision and drainage of abscess in abdominal surgery.
- Doesn't have a collection device
- Promotes drainage passively
- Drainage moves from area of higher pressure to area of lower pressure
Jackson-Pratt and Hemovac Drains
- Closed Systems
- Decreases dead space by collecting drainage
T-Tube
Used for Bile drainage
Color Classification of Open Wounds - RYB
R = red — protect
Y = yellow — cleanse
B = black — debride
Mixed wound — contains components of RY&B wounds where B is treated first then Y > R
Wound Repair Intentions
Primary Intention
- Well approximated (skin edges tightly together)

Secondary Intention
- Edges aren't well approximated
- Takes longer to heal
- Has more scar tissue

Tertiary Intention/Delayed Primary Closure
- Left open after several days to allow edema or infection to resolve or fluid to drain and are then closed.
Nutritional Risk for Pressure Ulcer
Albumin < 3.2
(normal 3.5-5)

Prealbumin < 19
(normal 16-40)

Lymphocytes < 1800
(normal 1000-4000)

Hemoglobin A1C > 8%
(normal < 6%)

Glucose > 120
(normal 70-120)

Body weight > 5-10%
Topics for Home Health Care Teaching
Supplies
Infection prevention
Wound healing
Appearance of the skin/recent changes
Activity/mobility
Nutrition
Pain
Elimination
THIS SET IS OFTEN IN FOLDERS WITH...