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Skin integrity & wound care Exam 3
Terms in this set (184)
The skin is the body's
first line of defense, protecting the underlying structures from invasion by organisms
The integumentary system is made up of the
skin, the subcutaneous layer directly under the skin, and the appendages of the skin, including glands in the skin, hair, and nails. The integumentary system also includes the blood vessels, nerves, and sensory organs of the skin.
The skin has two layers, what are they?
epidermis and dermis. An underlying layer, the subcutaneous layer (or hypodermis), is sometimes included in descriptions as the third layer of the skin
The top layer, or outermost portion of the skin
epidermis. The epidermis is composed of layers of stratified epithelial cells.
second layer of skin
-consists of a framework of elastic connective tissue comprised primarily of collagen.
-Nerves, hair follicles, glands, immune cells, and blood vessels are located in this layer
The dermis rests on the
The subcutaneous tissue that connects the skin to the superficial muscles.
The subcutaneous tissue consists of adipose tissue, made up of lobules of fat cells, and connective tissue. This layer stores fat for energy, serves as a heat insulator for the body, and provides a cushioning effect for protection. This fatty tissue layer contains blood and lymph vessels, nerves, and fat cells.
The skin has multiple functions:
protection, temperature regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, and elimination.
Functions of the Skin: protection
Acts as a barrier to water, microorganisms, and damaging ultraviolet rays of the sun
• Protects against infection
• Protects against injury to underlying tissues and organs
• Prevents loss of moisture from the surface and underlying structures
Functions of the Skin: temperature regulation
Draws heat from the skin as perspiration occurs and evaporates
• Dissipates heat as blood vessels in the skin dilate
• Compensates for cold conditions with the constriction of blood vessels in the skin to diminish heat loss
• Compensates for cold through the contraction of pilomotor muscles that cause the hair to stand on end, forming a layer of air on the body for insulation (gooseflesh or goose bumps)
Functions of the Skin: Psychosocial
• Contributes to the external appearance and is a major contributor to self-esteem
• Plays an important role in identification and communication
Functions of the Skin: sensation
• Provides the sense of touch, pain, pressure, and temperature through millions of nerve endings
• Allows the body to adjust to the environment through sensory impulses, in conjunction with the brain and spinal cord
Functions of the Skin: vitamin d production
• Activated by ultraviolet rays from the sun to produce vitamin D
Functions of the Skin: immunologic
• Triggers immunologic responses when broken
Functions of the Skin: absorption
• Absorbs substances, such as medications, for local and systemic effects
functions of the skin: Elimination
• Excretes small amounts of water, electrolytes, and nitrogenous wastes in sweat
Factors Affecting Skin Integrity
Unbroken and healthy skin and mucous membranes serve as the first lines of defense against harmful agents.
Resistance to injury of the skin and mucous membranes varies among people. Factors influencing resistance include the person's age, the amount of underlying tissues, and illness conditions.
Adequately nourished and hydrated body cells are resistant to injury. The better nourished the cell is, the better able it is to resist injury and disease.
Adequate circulation is necessary to maintain cell life. When circulation is impaired for any reason, cells receive inadequate nourishment and cannot remove wastes efficiently.
In children younger than 2 years, the skin is thinner and weaker than it is in adults.
An infant's skin and mucous membranes are injured easily and are subject to infection. Careful handling of infants is required to prevent injury to and infection of the skin and mucous membranes.
A child's skin becomes increasingly resistant to injury and infection.
The structure of the skin changes as a person ages. In older adults, 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. Changes that occur in the skin with aging are discussed in Focus on the Older Adult (on page 1047).
•Homosexuality, multiple sexual partners, IV drug users, hemophiliacs, bisexual males, partners of these demographics
•Changes in health status-Dehydration or malnutrition, Decreased sensory
•Therapeutic measures-Bed rest, casts, medications, aquathermia unit, radiation therapy
TABLE 32-2, PG 1046
Focus on Older Adult
•Subcutaneous and dermal tissues thin
•Sebaceous and seat gland decrease
•Cell renewal is shorter
•Collegen fiber less organized
Some things to note---avoid tape if possible, check skin frequently, pad boney prominences, assess pressure points of redness after 30 minutes
Clean perineal area daily, but not full bath, apply skin mostiurizes, liquid hydration, avoid harsh soaps and hot water
Causes of Skin Alterations
•Very thin and very obese people are more susceptible to skin injury.
•Fluid loss during illness causes dehydration.
•Excessive perspiration during illness predisposes skin to breakdown OR incontinence of urine and stool.
•Jaundice causes yellowish, itchy skin.
•Diseases of the skin, such as eczema and psoriasis, may cause lesions that require special care.
what is a wound?
a break or disruption in the normal integrity of the skin and tissues. That disruption may range from a small cut on a finger to a third-degree burn covering almost all of the body. Wounds may result from mechanical forces (such as surgical incisions) or physical injury (such as a burn).
Types of Wounds
•Intentional or unintentional
•Open or closed
•Acute or chronic
the result of planned invasive therapy or treatment. These wounds are purposefully created for therapeutic purposes. Examples of intentional wounds include those that result from surgery, intravenous therapy, and lumbar puncture. The wound edges are clean and bleeding is usually controlled. Because the wound was made under sterile conditions with sterile supplies and skin preparation, the risk for infection is decreased, and healing is facilitated.
are accidental. These wounds occur from unexpected trauma, such as from accidents, forcible injury (such as a stabbing or a gunshot), and burns. Because the wounds occur in an unsterile environment, contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. These factors create a high risk for infection and a longer healing time.
Types of wounds: incision
Cutting or sharp instrument; wound edges in close approximation and aligned
Types of wounds: contusion
Blunt instrument, overlying skin remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hematoma
Types of wounds: Abrasion
Friction; rubbing or scraping epidermal layers of skin; top layer of skin abraded
Types of Wounds: laceration
Tearing of skin and tissue with blunt or irregular instrument; tissue not aligned, often with loose flaps of skin and tissue
Types of Wounds: puncture
Blunt or sharp instrument puncturing the skin; intentional (such as venipuncture) or accidental
Types of Wounds: penetrating
Foreign object entering the skin or mucous membrane and lodging in underlying tissue; fragments possibly scattering throughout tissues
Types of Wounds: avulsion
Tearing a structure from normal anatomic position; possible damage to blood vessels, nerves, and other structures
Types of Wounds: chemical
Toxic agents such as drugs, acids, alcohols, metals, and substances released from cellular necrosis
Types of Wounds: thermal
High or low temperatures; cellular necrosis as a possible result
Types of Wounds: irridation
Ultraviolet light or radiation exposure
Types of Wounds: pressure ulcers
Compromised circulation secondary to pressure or pressure combined with friction
Types of Wounds: venous ulcers
Injury and poor venous return, resulting from underlying conditions, such as incompetent valves or obstruction
Types of wounds: Arterial ulcers
Injury and underlying ischemia, resulting from underlying conditions, such as atherosclerosis or thrombosis
Types of Wounds: Diabetic ulcers
Injury and underlying diabetic neuropathy, peripheral arterial disease, diabetic foot structure
An open wound
occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.
A closed wound
results from a blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash. The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas.
such as surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is low. Acute wounds usually progress through the healing process without interruption.
do not progress through the normal sequence of repair. The healing process is impeded. The wound edges are often not approximated, the risk of infection is increased, and the normal healing time is delayed (>30 days). Chronic wounds remain in the inflammatory phase of healing (discussed in the next section). Chronic wounds include any wound that does not heal along the expected continuum, such as wounds related to diabetes, arterial or venous insufficiency, and pressure injuries.
Wound healing is a process of
tissue response to injury. Injured tissues are repaired by physiologic mechanisms that regenerate functioning cells and replace connective tissue cells with scar tissue.
Wound repair occurs by
Primary, secondary, and tertiary intention
Wounds healed by primary intention are
well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.
Wounds healed by secondary intention have
edges that are not well approximated. Large, open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. If a wound that is healing by primary intention becomes infected, it will heal by secondary intention. Wounds that heal by secondary intention take longer to heal and form more scar tissue
Wounds healed by tertiary intention, or delayed primary closure, are
those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed
Principles of Wound Healing
Intact skin is the first line of defense against microorganisms. A break in the integrity of the skin increases the risk for infection. Careful hand hygiene before caring for a wound is probably the single most effective method for preventing wound infections.
The body responds systemically to trauma in any of its parts. For example, a surgical incision can cause a variety of systemic reactions, including increased body temperature, increased heart and respiratory rates, anorexia or nausea and vomiting, musculoskeletal tension, and hormonal changes.
An adequate blood supply is essential for the body's normal response to any injury. The blood transports increased numbers of leukocytes, erythrocytes, and platelets to the site of injury. Antibodies are carried by the plasma. Increased circulation to the injured part removes toxins and debris and provides nutrients and oxygen. Areas of the body with a good blood supply, such as the head and the neck, heal faster than areas in which the blood supply is not as great, such as the distal part of an extremity.
Normal healing is promoted when the wound is free of foreign material, such as excessive exudate, dead or damaged tissue cells, pathogenic organisms, or embedded fragments of bone, metal, glass, or other substances. In some situations, a collection of pus or foreign body is walled off and healing occurs around it to form an abscess.
The ability to handle altered skin integrity depends on the extent of the damage and the person's general state of health. The capacity to deal adequately with a wound is limited when a healthy person sustains a massive injury, when the patient has a chronic illness or a depressed immune system, or when the patient is very young or very old.
The body's response to a wound is more effective if proper nutrition has been maintained.Undernourished patients are at greater risk for developing a wound infection because they have difficulty mounting their cell-mediated defense system associated with T-lymphocyte activity, and some leukocytic functions are diminished in the presence of protein deficiency.Although the role of fatty acids in wound healing is not well understood, certain quantities of glucose are necessary to meet the energy requirements for wound healing.Various vitamins, minerals, and trace elements are also needed for efficient wound healing. Vitamin A is necessary for collagen synthesis and epithelialization. Vitamin B complex serves as a cofactor of enzyme reactions needed for wound healing. Vitamin C is needed for collagen synthesis, capillary formation, and resistance to infection. Vitamin K is needed for the synthesis of prothrombin. Zinc, copper, and iron assist in collagen synthesis. Manganese serves as an enzyme activator.
Phases of Wound Healing
•Hemostasis-happens immediately after injury
•Granulation tissue occurs
•Maturation-Begins 3 weeks after injury
hemostasis phase of wound healing
•Occurs immediately after initial injury
•Involved blood vessels constrict and blood clotting begins.
•Exudate is formed, causing swelling and pain.
•Increased perfusion results in heat and redness.
•Platelets stimulate other cells to migrate to the injury to participate in other phases of healing.
Inflammatory phase of wound healing
•Follows hemostasis and lasts about 4 to 6 days
•White blood cells move to the wound.
•Macrophages enter the wound area and remain for an extended period.
•They ingest debris and release growth factors that attract fibroblasts to fill in the wound.
•The patient has a generalized body response.
proliferation phase of wound healing
•Begins within 2 to 3 days of injury and may last up to 2 to 3 weeks
•New tissue is built to fill the wound space through the action of fibroblasts.
•Capillaries grow across the wound.
•A thin layer of epithelial cells forms across the wound.
•Granulation tissue forms a foundation for scar tissue development.
maturation phase of wound healing
•Final stage of healing; begins about 3 weeks to 6 months after injury
•Collagen is remodeled.
•New collagen tissue is deposited.
•Scar becomes a flat, thin, white line.
Local Factors Affecting Wound Healing
•Necrosis (death of tissue)
•Presence of biofilm (thick grouping of microorganisms)
Local Factors Affecting Wound Healing: PRESSURE
Pressure disrupts the blood supply to the wound area. Persistent or excessive pressure interferes with blood flow to the tissue and delays healing.
Local Factors Affecting Wound Healing: DESSICATION
(DEHYRDATION) Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This cell death causes a crust to form over the wound site and delays healing. Wounds that are kept moist (not wet) and hydrated experience enhanced epidermal cell migration, which supports epithelialization (epithelial cell migration to the wound bed;
Local Factors Affecting Wound Healing: MACERATION
(OVERHYDRATION) Maceration, softening and breakdown of skin, results from prolonged exposure to moisture. Overhydration of cells related to urinary and fecal incontinence can also lead to maceration and impaired skin integrity. This damage is related to moisture, changes in the pH of the skin, overgrowth of bacteria and infection of the skin, and erosion of skin from friction on moist skin.
Local Factors Affecting Wound Healing: TRAUMA
Repeated trauma to a wound area results in delayed healing or the inability to heal.
Local Factors Affecting Wound Healing: EDEMA
Edema at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue.
Local Factors Affecting Wound Healing: INFECTION
Bacteria in a wound increase stress on the body, requiring increased energy to deal with the invaders. Infection requires large amounts of energy be spent by the immune system to fight the microorganisms, leaving little or no reserves to attend to the job of repair and healing. In addition, toxins produced by bacteria and released when bacteria die interfere with wound healing and cause cell death.
Local Factors Affecting Wound Healing: EXCESSIVE BLEEDING
Excessive bleeding results in large clots. Large clots increase the amount of space that must be filled during healing and interferes with oxygen diffusion to the tissue. In addition, accumulated blood or drainage of any type is an excellent place for growth of bacteria and promotes infection
Local Factors Affecting Wound Healing: NECROSIS
(DEATH OF TISSIE) Dead tissue present in the wound delays healing. Dead tissue appears as slough—moist, yellow, stringy tissue—and eschar appears as dry, black, leathery tissue. Healing of the wound will not take place with necrotic tissue in the wound. Removal of the dead tissue must occur for healing to begin
Local Factors Affecting Wound Healing: BIOFILM
Wound biofilms are the result of wound bacteria growing in clumps, embedded in a thick, self-made, protective, slimy barrier of sugars and proteins. This barrier contributes to decreased effectiveness of antibiotics against the bacteria (antibiotic resistance) and decreases the effectiveness of the normal immune response by the patient (Baranoski & Ayello, 2016; Hess, 2013). The bacteria also produce a protective matrix that attaches the biofilm to the wound surface. Biofilms impair wound healing and contribute to chronic wound inflammation and wound infection
What is immunosuppression?
decreased or absent immune response. body cant fight off infection
Systemic Factors Affecting Wound Healing
•Age: children and healthy adults heal more rapidly
•Circulation and oxygenation: adequate blood flow is essential to deliver nutrients and oxygen and to remove local toxins, bacteria, and other debris
•Nutritional status: healing requires adequate adequate proteins, carbohydrates, fats, vitamins, and minerals.
-Calories and protein are necessary to rebuild cells and tissues.
•Wound condition: specific condition of the wound affects healing
•Health status: corticosteroid drugs and postoperative radiation therapy delay healing
large amounts of subcutaneous and tissue fat (which has fewer blood vessels) in people who are obese may slow wound healing because fatty tissue is
more difficult to suture, is more prone to infection, and takes longer to heal
Vitamins A and C are essential for
epithelialization and collagen synthesis.
Zinc plays a role in
proliferation of cells
Corticosteroids decrease the_________, which may delay healing.
Radiation depresses _______ function, resulting in decreased leukocytes and an increased risk of infection.
Chemotherapeutic agents impair or stop proliferation of all rapidly growing cells, including
cells involved in wound healing.
Prolonged antibiotic therapy increases a patient's risk for
secondary infection and superinfection.
Wound complications include
infection, hemorrhage, dehiscence, evisceration, and fistula
Wound complications: INFECTION
•Occurs when immune system fail to control growth
•Invasion of microorganisms occurs at the time of trauma, surgery, or anytime after the initial wound occurs
•Contaminated wounds are more likely to become infected
•Infection occurs 2-7 days after initial injury or surgery
•Signs and symptoms
•Purulent drainage, increased drainage, pain, redness, swelling in or around wound
•Increased body temperature, increased WBC
•Delayed wound healing, discoloration of granulation in tissue
vWound infections can lead to chronic wounds, osteomyelitis, sepsis
Wound complications: HEMMORRHAGE
•May occur from a slipped suture, dislodged clot, infection or erosion of blood vessel by a foreign body.
•Assess the dressing and wound frequently first 48 hours, and no less than every 8 after thereafter
•If bleeding occurs apply pressure, may need packing and fluid replacement
•Large internal bleeding can lead to ischemia
-Always replace volume lost even if it isn't blood products!
Wound complications: DEHISCENCE AND EVISCERATION
•Dehiscence is partial or total separation of wound layers as a result of excessive stress on unhealed wounds
•Evisceration is the most serious complication of dehiscence
•Wound completely separates and intestines protrude through the incisional site.
•Risks-obese or malnourished, smokers, anticoagulant use, infected wounds, excessive coughing, vomiting or straining
•Increase or excessive fluid from wound may point to potential dehiscence.
•If occurs cover wound with sterile towels moistened with normal saline, place in low fowlers with knees slightly elevated, stay with patient, notify PCP immediately
-This situation is an emergency that requires prompt surgical repair, so the patient should be kept NPO
Wound complications: FISTULA
•Abnormal passage from an internal organ or vessel to outside of body or from one organ to another.
•May be created surgically
•Results of an infection---forms abscess---pressure to tissues leads to unnatural passage.
•Delayed healing, infection, fluid and electrolyte imbalances, skin breakdown
the risk of infection is increased in a surgical wound created during a procedure involving the intestines because
The risk for contamination with fecal material is high.
An increase in the flow of (serosanguineous) fluid from the wound between postoperative days 4 and 5 may be a sign of an
is a collection of infected fluid that has not drained
Psychological Effects of Wounds
•Impact on activities of daily living
•Change in body image
•Localized area of injury to skin and/or underlying tissues by pressure
•Acute and chronic
•Most common reason is soft tissue compressed between a bony prominence and external surface for prolonged period of time
•Also occur frequently soft tissue undergoes pressure with friction or shear.
•Common terms: decubitus ulcer, pressure sore, bedsore
•Costly to patient self esteem, quality of life, expense
•Preventable and early intervention is key
What is a pressure injury?
defined as localized damage to the skin and underlying tissue that usually occurs over a bony prominence or is related to the use of a (medical or other) device
-The terms decubitus ulcer, pressure sore, and bedsore are also used to refer to this type of wound.
Common sites for pressure ulcers
occiput, scapula, elbows, sacrum, heels, ear, greater trochanter, knees
Most pressure injuries occur in older adults as a result of a combination of factors, including
aging skin, chronic illnesses, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness.
Two mechanisms contribute to pressure injury development:
(1) external pressure that compresses blood vessels and (2) friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin.
Of the susceptible areas, most pressure injuries occur over the
sacrum and coccyx, followed by the trochanter and the calcaneus (heel).
Insufficient circulation deprives tissue of oxygen and nutrients, which leads to
ischemia (deficiency of blood in a particular area), hypoxia (inadequate amount of oxygen available to cells), edema, inflammation, and, ultimately, necrosis and ulcer formation
occurs when two surfaces rub against each other. The injury, which resembles an abrasion, also can damage superficial blood vessels directly under the skin. A patient who lies on wrinkled sheets is likely to sustain tissue damage as a result of friction. The skin over the elbows and heels often is injured due to friction when patients lift and help move themselves up in bed with the use of their arms and feet. Friction burns can also occur on the back when patients are pulled or slid over sheets while being moved up in bed or transferred onto a stretcher
results when one layer of tissue slides over another layer. Shear separates the skin from underlying tissues. The small blood vessels and capillaries in the area are stretched and possibly tear, resulting in decreased circulation to the tissue cells under the skin. Figure 32-5 illustrates how shearing forces occur. Patients who are pulled, rather than lifted, when being moved up in bed or from bed to chair or stretcher are at risk for injury from shearing forces. A patient who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a patient who sits in a chair but slides down.
In addition to pressure, friction, and shear, a combination of causes contributes to pressure injury development. These include
immobility, nutrition and hydration, skin moisture, mental status, and age
Risks for Pressure Injury Development: IMMOBILITY
Patients who spend long periods of time in bed or seated without shifting their body weight properly are at great risk for developing a pressure injury.
-Patients who are unconscious and paralyzed, those with cognitive impairments, or those with other physical limitations such as a fracture, are subject to pressure injuries if they are allowed to remain in any one position for an extended period. People who are emotionally depressed ordinarily do not move around much, placing them at risk for pressure injury formation. Additional factors that cause immobility and may result in this serious problem include surgery and the use of tranquilizers or sedatives.
Risks for Pressure Injury Development: NUTRITION AND HYDRATION
Protein-calorie malnutrition predisposes a person to pressure injury formation because poorly nourished cells are damaged easily. Protein deficiency leading to a negative nitrogen balance, electrolyte imbalances, and insufficient caloric intake also predisposes the skin to injury. Other deficiencies can increase risk. For example, vitamin C deficiency causes capillaries to become fragile, with resultant poor circulation to the area. The condition of the teeth or fit of dentures may also exacerbate the problem of inadequate dietary intake. Dehydration as well as edema can interfere with circulation and subsequent cell nourishment.
Risks for Pressure Injury Development: MOISTURE
In general, prolonged moisture on the skin reduces the skin's resistance to trauma, particularly damage from friction and shear. When skin is damp (from incontinence, perspiration, or drainage), it requires less friction to blister and abrade, which can lead to a pressure injury. Moisture from urinary and/or fecal incontinence has been linked to an increased likelihood of sacral pressure injury
Risks for Pressure Injury Development: MENTAL STATUS
The more alert a person is, the more likely the person is to protect skin integrity by relieving pressure periodically and maintaining adequate skin hygiene. Apathy, confusion, or a comatose state can diminish these self-care abilities and increase the likelihood of skin breakdown.
Risks for Pressure Injury Development: AGE
Older adults are at a greater risk for pressure injury because the aging skin is more susceptible to injury. Chronic and debilitating diseases, more common in this age group, may adversely affect circulation and oxygenation of dermal structures. Other problems, such as malnutrition and immobility, compound the risk of pressure injury development in older adults.
Factors Affecting Pressure Ulcer Development
•Poor skin hygiene
•Diabetes mellitus and other chronic conditions
•Diminished sensory perception
•Previous skin injuries
•History of corticosteroid therapy
•Increased body temp
•Multiple organ dysfunction (MODS)
•Terminal illness, dying process
assessment for pressure ulcers
•Location and size
•Color and type of wound tissue
•Presence of abnormal pathways
•Visible necrotic tissue
•Exudates or drainage, amount and type
•Presence or absence of granulation
•Visible evidence of epithelialization
•Periwound skin condition
Pressure Ulcer Assessment
•Nutritional status—albumin <3.2, prealbumin < 19mg/dL, decrease body weight of 5-10%
•Moisture and incontinence
•Appearance of existing pressure ulcer
A tool for predicting pressure ulcer risk
-The lower the number, the higher the risk
Using the Braden scale, a score of 19 to 23 indicates no risk; 15 to 18, mild risk; 13 to 14, moderate risk; 10 to 12, high risk; and 9 or lower, very high risk
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
•Unstageable: base of ulcer covered by slough and/or eschar in wound bed
PRESSURE ULCERS STAGE 1
nonblanchable erythema of intact skin
PRESSURE ULCERS STAGE 2
Partial-thickness skin loss involving epidermis or dermis.
-RED PINK WOUND BED NO SLOUGH
PRESSURE ULCERS STAGE 3
-Full-thickness skin loss involving damage or loss of subcutaneous tissue.
-SUB Q TISS VISIBLE, NO BONE, TENDON, MUSCLE EXPOSED,
SLOUGH MAY BE REPRESENT,
UNDERMINING AND TUNNELING MAY BE PRESENT
SHALLOW TO DEEP DEPENDING ON AREA AND TISSUE
PRESSURE ULCERS STAGE 4
Full-thickness skin loss with damage to muscle, bone, or supporting structures.
SLOUGH OR ESCAR
UNDERMINING AND TUNNELING LIKELY
MAKE EXTEND TO SUPPORTING STRUCTURES
PRESSURE ULCERS UNSTAGEABLE
-Full thickness tissue loss
-Base of ulcer covered with slough and eschar
-Need to remove slough to determine true depth of tissue involvement
deep tissue pressure injury
persistent non-blanchable deep red, maroon, or purple discoloration
yellow, tan, gray, green, or brown dead tissue
tan, brown, or black hardened dead tissue (necrosis) in the wound bed
Reassessment: ACUTE CARE SETTING
On admission, then reassess every shift and with any change in condition
Reassessment: LONG TERM CARE SETTING
On admission, then reassess weekly for 4 weeks, then quarterly and whenever the resident's condition changes
Reasssessment: HOME HEALTH CARE
On admission, then reassess at every visit
Wound assessment involves inspection (sight and smell) and palpation for
appearance, drainage, odor, and pain.
When infection is present, the wound is
swollen and deep red
Measurement of a Pressure Ulcer
•Size of wound
•Depth of wound
•Presence of undermining, tunneling, or sinus tract
•Record as : L x W x D
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 or a wound care cleanser.
•Report any drainage or necrotic tissue.
Wound exudate: SEROUS
is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery.
Wound exudate: SANGUINEOUS
consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.
Wound exudate: SEROSANGUINEOUS
is a mixture of serum and red blood cells. It is light pink to blood tinged.
Wound exudate: purulent
is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
•Inspection for size and smell
•Palpation for appearance, drainage, and pain
•Sutures, drains or tubes, and manifestation of complications
•REDA—Redness, edema, drainage, approximation
•Wound on sacrum, 3cm x 4cm x 2cm, stage 3, undermining at the 9:00 position 3 cm deep, pink to red moist wound bed with granulating tissue, slight amount of slough, small amount of serous drainage on dressing, no odor noted, peri skin intact no redness or edema.
fluid, such as pus, that leaks out of an infected wound (wound drainage)
wound drainage assessment
Assess the amount, color, odor, and consistency
Norton scale for pressure ulcers
Risk factor assessment
• Physical condition
• Mental condition
• Good -4, Fair-3, Poor-2, Very bad-1
• Range 5-20, At risk if score≤14, <10=high risk
age and gender (sex), build and weight, continence, skin type, mobility, nutrition, and special population-specific risks
Perform a pain assessment at
each dressing change; measure and document the level of pain before, during, and after a procedure.
Follow facility protocols regarding repositioning, which may indicate
turning bed-bound patients every two hours and repositioning chair-bound patients every hour.
PREVENTING PRESSURE INJURIES
Assess the skin of patients at risk on a daily basis. Pay particular attention to bony prominences.
Cleanse the skin routinely and whenever any soiling occurs. Use a mild cleansing agent, minimal friction, and avoid hot water.
Maintain higher humidity in the environment and use skin moisturizers for dry skin.
Avoid massage over bony prominences.
Protect the skin from moisture associated with episodes of incontinence or exposure to wound drainage.
Minimize skin injury from friction and shearing forces by using proper positioning, turning, and transferring techniques. Use lubricants, protective films, dressings, and padding to diminish the effects of friction on the skin.
Use appropriate support surfaces (tissue load management surfaces).
Investigate reasons for inadequate dietary intake of protein and calories. Administer nutritional supplements or more aggressive nutritional intervention as needed.
Continue efforts to improve mobility and activity. If this is unrealistic, attempt to maintain current level of activity, mobility, and range of motion.
Document measures used to prevent pressure injuries and the results of these interventions.
Positioning devices such as pillows, foam wedges, or pressure-reducing boots can prove helpful to
keep body weight off bony prominences. For example, unless contraindicated, a standard pillow placed under the length of the calves raises the heels off the bed and alleviates pressure.
a "specialized device for pressure redistribution designed for management of tissue loads, micro-climate, and/or other therapeutic functions".
Support surfaces are pressure-reducing or pressure-relieving devices. The most common support surfaces are seating devices (air, fluid foam, or gel cushions); air-, gel-, or water-filled mattress overlays; static flotation mattresses; alternating air mattresses; low-air-loss beds; and air-fluidized beds.
protective covering placed over a wound
Closed wound care
uses dressings to keep the wound moist, promoting healing. A moist environment is best for wound healing. When a dressing is placed over a wound, the wound fluid keeps the surface of the wound moist. As a result, epidermal cells migrate more rapidly, maximizing healing.
Many different types of dressings are available, but all have essentially the same purposes:
Provide physical, psychological, and aesthetic comfort
Prevent, eliminate, or control infection
Maintain moisture balance of the wound
Protect the wound from further injury
Protect the skin surrounding the wound
Debride (remove damaged/necrotic tissue), if appropriate
Stimulate and/or optimize the healing response
Consider ease of use and cost effectiveness
removal of devitalized tissue and foreign material
There are three basic types of primary dressings:
those that maintain moisture, those that absorb moisture, and those that add moisture
Types of Wound Dressings: Telfa
Types of Wound Dressings: Gauze dressings
usually to cover surgical wounds
Types of Wound Dressings: Transparent dressings
oxygen exchange, protects
Types of Wound Dressings: Hydrocolloid
moderate absorption, change 3-7 days, protects and cushions.
Partial- and full-thickness wounds
Stage 2 and stage 3 pressure injuries
Prevention at high-risk friction areas
Wounds with light to moderate drainage
Wounds with necrosis or slough
First- and second-degree burns
Not for use with wounds that are infected
Types of Wound Dressings: hyrdogels
-Maintains moist wound bed, autolytic debridement, secondary dressing required.
Partial- and full-thickness wounds
Stages 2-4 pressure injuries
First- and second-degree burns
Wounds with minimal exudate
Radiation tissue damage
Types of Wound Dressings: alginates
Absorbs, maintains moist wound bed, autolytiv, secondary dressing.
Partial- and full-thickness wounds
May remain in place for 1-3 days
Stage 3 and stage 4 pressure injuries
Infected and noninfected wounds
Wounds with moderate to heavy exudate
Tunneling wounds; undermining
Moist red and yellow wounds
Not for use with wounds with minimal drainage or dry eschar
Types of Wound Dressings: foams
moist wound bed, non adherant, protects, up to 7 days.
Partial- and full-thickness wounds
May remain in place 3-5 days (7 days for foams with silver), depending on exudate
Stages 2-4 pressure injuries
Absorb light to heavy amounts of drainage
Use around tubes and drains
Not for use with wounds with dry eschar
Types of Wound Dressings: antimicrobials
reduce to prevent infection.
Partial- and full-thickness wounds
Stages 2-4 pressure injuries
Primary dressing over skin graft(s) and donor sites
Draining, exuding, and nonhealing wounds of any kind (pressure injury, venous/arterial, diabetic, surgical)
Acute and chronic wounds
Presence of 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.
Wound care management
•Goal to promote tissue and repair so skin integrity is restored. Return patient to prior level of functioning before wound.
•Wounds can be dressed or open to air
•Close wound care keeps wound bed moist to promote healing
•Dressings protect, absorb, provide thermal insulation, bacterial barrier, reduce pain.
•Purpose of dressing:
•Provide physical, psychological and aesthetic comfort
•Prevent, eliminate or control infection, protect from further injury
•Absorb drainage and maintain moist wound bed
•Protect surrounding skin
•Use standard precautions
•Perform hand hygiene and put on clean gloves
•Remove tapes and dressings in the direction of hair growth, use a push pull method, lift corner of dressing away from skin and puss the skin away from dressing.
•Carefully lift the adhesive barrier from surrounding skin
•Slowly remove the dressing, noting the amount, type, color, and odor of drainage
Remove gloves and perform hand hygiene
Cleaning approximated wounds
•Use standard and transmission precautions
•Moisten a sterile gauze pad or swab with the prescribed agent and squeeze out excess solution
•Use anew swab or gauze for each circle
•Clean the wound in full or half circles, clean to dirty (center working out)
•Clean to at least one inch beyond the wound of the new dressing.
If dressing not being applied, clean to at least 2 inches beyond the wound margins
Applying new dressing
•Check wound care orders or nursing care plan
•Perform hand hygiene
•Use standard precautions and appropriate transmission precautions if indicated
•Check the patient's identification
•Explain to patient what you are doing
•Apply skin barrier if necessary
•Place dressing over wound and make sure it extends 1 inch beyond wound
•Remove gloves when the dressing is in place before handling tape if used
•Do not apply tape under tension
•Perform hand hygiene
•Do steps one through nine for dressing a wound
•Moisten packing material as necessary and indicated by manufacturers instructions
•Loosely pack the wound cavity just until the wound surfaces and edges are covered. If tunneling pack tunneling area first.
•Ensure all wound surfaces are covered and kept moist
•Do not allow packing to overlap the wound edges
•Cover with appropriate top dressing
Types of Bandages
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
•Assess, pay attention to bony prominences
•Cleanse routinely and when soiling occurs, use mild agents, minimal friction, and avoid HOT water
•Maintain higher humidity, moisturize dry skin
•Avoid massage over boney prominences
•Protect skin from moisture from incontinence
•Minimize skin injury from friction and shear with proper positioning, turning, transferring. Use protective films, dressings, and padding.
•Appropriate support surfaces
•Investigate inadequate dietary intake. Administer nutritional supplements or more aggressive nutritional interventions if necessary
•Interventions to improve mobility and activity
•Document all measures used to prevent pressure ulcers and results.
Color Classification of Open Wounds
•R = red—protect, --new tissue, gentle cleansing, dressing change only when necessary.
•Y = yellow—cleanse—wound cleansers and irrigation
•B = black—debride—mechanical or autolytic
•Pg 1063, box 32-4
•Hand hygiene and gloves
•Remove dressing and asses, remove gloves
•Set up sterile field, if indicated and supplies
•Clean wound according to wound care orders
•Dry wound and change gloves
•Take swabs from specimen tube and roll around in wound in 3 places.
•Insert swabs in tube and ensure the swabs have not touched anything doing.
•Skill 31-6, pg 1023-1025
Topics for Home Health Care Teaching
•Appearance of the skin/recent changes
Negative pressure wound therapy (NPWT or hyperbariactic
•Promotes healing using negative pressure chambers
•Negative pressure results in stimulating cell proliferation, blood flow to wounds and the growth of new blood vessel growth.
•Contraindicated unrelieved pressure, anticoagulant therapy, poor nutritional status, immunosuppressant therapy.
•Cant use in clients with pace makers or very poor circulation
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
Effects of Applying Heat
•Dilates peripheral blood vessels
•Increases tissue metabolism
•Reduces blood viscosity and increases capillary permeability
•Reduces muscle tension
•Helps relieve pain
Effects of Applying Cold
•Constructs peripheral blood vessels
•Reduces muscle spasms
Devices to Apply Heat
•Hot water bags or bottles
•Electric heating pads
•Warm, moist compresses
Devices to Apply Cold
•Cold compresses to apply moist cold
Cleaning Wounds With Unapproximated Edges
Use standard precautions; use appropriate transmission-based precautions when indicated.
Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution.
Use a new swab or gauze for each circle.
Clean the wound in full or half circles, beginning in the center and working toward the outside (Figure B).
Clean to at least 1 in beyond the end of the new dressing.
If a dressing is not being applied, clean to at least 2 in beyond the wound margins.
Types of Tape:Adhesive (can cause occlusion, allergy, skin maceration, shearing)
Used for strength, support, and economy
To secure dressings and splints
To strap joints to prevent athletic injuries
To immobilize or stabilize body parts
To provide pressure
To approximate wound edges
Types of Tape:Paper, plastic, acetate
Increased comfort, decreased allergic and skin problems
To close small wounds
To secure dressings
Types of Tape: Microfoam
Used for compression or pressure dressings
Bandages and binders are used to
secure dressings, apply pressure, and support the wound.
strips of cloth, gauze (e.g., roller gauze, Kerlix, Kling), or elasticized material
designed for a specific body part and include slings, abdominal binders, chest binders, and T-binders
a continuous strip of material wound on itself to form a cylinder or roll. Plain gauze, elastic webbing, and stretchable roller bandages are made in various widths and lengths.
used primarily to anchor a bandage. In a circular turn, wrap the bandage around the body part, completely overlapping the previous bandage turn.
a bandage that is laid back and forth across the tape of a dressing and then anchored
Montgomery straps make it possible to
care for a wound without removing adhesive strips with each dressing change.
a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing
drainage system that uses a compressed bulb, applies slight suction within the wound
are naturally occurring proteins. Recombinant platelet-derived growth factor (PDGF) is the only exogenous (introduced from outside the body) growth factor that has shown to be effective in wounds with delayed healing
Hyperbaric oxygen therapy (HBOT)
an advanced wound care technology used to facilitate repair of wounds with compromised healing. It involves placing patients in a hyperbaric, pressurized chamber, where they breathe 100% oxygen, which greatly increases the amount of oxygen dissolved in the plasma.
Sutures are removed when
the wound has developed enough tensile strength to hold the wound edges together during healing.
Nursing care is considered effective if the patient, family member, or caregiver expresses satisfaction with prevention and treatment measures and can accomplish the following:
Participate effectively in preventive and treatment regimens
Prevent development of any additional areas of skin breakdown
Demonstrate progressive healing of pressure injury or other wound
Improve overall physical condition (including nutritional state and mobility status)
Remain free of infection at any pressure injury or other wound site
Communicate the need for additional support (environmental, physical, psychosocial)
Unbroken and healthy skin and mucous membranes serve as _____ against harmful agents.
the first lines of defense
Actual and potential emotional stressors related to wounds include
pain, anxiety, fear, activities of daily living, and changes in body image.
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