Chapter 36: Skin Integrity and Wound Healing

Use the Rule of 30 to guide your positioning:

Elevate the head of the bed 30° or less, and when the patientis on her side, position the patient at a 30° angle to avoid direct pres-sure on the trochanter. If the head of the bed is elevated more than30°, limit the time in this position to minimize pressure and shear.

Tertiary Intention

-also called delayed primary closure,when twosurfaces of granulation tissue are brought together -This technique may be used when the wound is clean-contam-inated or contaminated. Initially the wound is allowed to healby secondary intention. When there is no evidence of edema,infection, or foreign matter, the wound edges are closed bybringing together the granulating tissue and suturing the sur-face.

Hemovac drain:

-attached to a collection device -The surgeon may order a device to be "placed to suction." -Thismeans that you will compress the device to create suction andfacilitate removal of drainage (

Penrose drain:

-is a flexible latex tube that is placed in thewound bed but usually not sutured into place. A clip or pinmay be attached to keep it from slipping further into thewound. You may be asked to advance the drain by graduallyremoving it from the wound bed

Evisceration

-is total separation of the layers of a wound inwhich internal viscera protrude through the incision

Braden Scale:

-is used to identify persons at risk fordeveloping pressure ulcers. The Braden scale evaluates sixmajor risk factors: sensory perception, moisture, activity,mobility, nutrition, and friction and sheer. -The final score reflects the patient's risk; thelower the score, the more likely the patient will develop apressure ulcer. -A score of 18 or less for hospitalized patientsindicates risk.

Stage 1 pressure ulcer

Localized area of: - INTACT SKIN with -NONBLANCHABLE redness -usually over a bony prominence. Discoloration willremain for > 30 minafter pressure isrelieved.

Drains: When assessing drains you have to look at:

# of drains Drain placement Character of drainage Condition of collecting equipment Types of drain: Penrose Hemovac Jackson Pratt or JP

Infection

- When Microorganisms are introduced to a wound during an injury, during surgery, or after surgery. -Suspect infection if awound fails to heal. Symptoms of and infection- -Localized swelling, redness, heat, pain,fever (temperatures higher than 38°C [100.4°F]), foul-smellingor purulent drainage, or a change in the color of the drainagemay also indicate infection.

Jackson Pratt or JP drain:

-Attached to a collection device Compress the bulb of the Jackson-Pratt drainto create suction and remove wound drainage.

Types of Dressing: p.1250-1251

-KNOW THE DIFFERENT TYPES OF DRESSINGS USED FOR DIFFERENT WOUNDS - FUNCTION OF GAUZE (USES) -Type of Dressing is Order Driven Types: Gauze sponge Nonadherent gauze (Telfa) Transparent film Hydrocolloid Hydrogel Foam and Alginate

Purlent exudate

-The THICK, often ODOR, drainage that is seen in infected wounds is called purulent exudate. -Yellow green It contains pus, a protein-rich fluid filled with WBCs, bacteria,and cellular debris. I

Pressure ulcers most commonly develop over bony promi-nences,but can occur under casts, splints, or other assistivedevices. Skin is compressed between the bone and the hardsurface of the bed or chair, reducing blood flow to the area. P.1231

-To the left Illustrates the pressure points in the supine,lateral, prone, and sitting positions (KNOW THIS ) -To the right are the bony prominences that are affected. FIGURE 36-8Most commonly, pressure ulcers develop overthe bony prominences. A, Sitting. B, Lateral. C, Supine. D,Prone

Hemmorrhage

-Whenever a capillary network is interrupted or a blood vesselis cut, BLEEDING occurs. -The risk of hemor-rhage is greatest in the first 24 to 48 hours following surgery orinjury. Bleeding may be internal or external.

What are the ways for you to mange Moisture?

1. (Incontinence Care)Provide skin care regularly soon after each incontinence episode. Apply incontinence or mois-ture barrier cream to protect perineal skin from urine andstool. 2. (Bathing) Gently bathe fragile skin, using a mini-mum of force and friction, as washcloths can be abrasive. Usea mild, emollient cleansing soap only as needed and not rou-tinely; and be sure to rinse thoroughly and gently pat the skin dry 3. (Lotions and Massage)If the patient's skin is dry, apply amoisturizing lotion using a gentle massaging motion to promote circulation and wound healing. 4.(Linens) Keep the linen soft, clean, dry, and free from wrin-kles by changing it frequently. Moisture and wrinkles in thesheets can damage to skin integrity.

Abdominal Binder p.1253

1. Measure Currectly to make sure they have the proper fitting abdominal binder 2. An Abdominal Binder is used to provide support to the ab-domen. It is often ordered when there is an open abdominalwound that is healing by secondary intention. The binderdecreases the risk of dehiscence. Abdominal binders may bestraight or multitailed. -Binders may be used to keep a wound closed when there isdanger of dehiscence, or to immobilize a body part to aid inthe healing process.

Prevention of Pressure Ulcers: Interventions

1.Pressure ulcer admission assessment- all patients (ex. Braden scale) 2.Reassess risk daily- all patients 3.Inspect skin daily 4.Manage moisture 5.Optimal nutrition and hydration 6.Minimize pressure NO MASSAGE OVER BONY PROMINENCE p.1243-1244

Dressing- The purpose of a dressing is:

1.Protect wound from microorganism contamination 2.Hemostasis 3.Promote healing: debridement and exudate absorption 4.Support/splint site 5.Protect client from seeing wound 6.Thermal insulation of wound surface 7.Moist environment

2. Reassess Risk Daily

1.Reassess your hospitalized patient for risk daily because his condition can change frequently and rapidly. 2.Any time your patient's condition changes or he is transferred to another unit,reassess his risk. 3. Monitor a nursing home resident weekly for the first 4 weeks, then quarterly or whenever the patient's condition changes or deteriorates. 4.Reassess home patients with every visit

Key points in in Pressure Ulcer

1.Reverse staging does not occur as an ulcer heals. -The healing process cannot cause a stage IV pressure ulcer tobecome a stage III ulcer. 2.Pressure ulcers become progressivelymore shallow by filling with granulation tissue, but lost mus-cle, subcutaneous fat, and dermis are not replaced. 3.Therefore,reverse staging does not accurately characterize what is phys-iologically occurring in the ulcer. Instead, pressure ulcersmaintain their original staging classification throughout thehealing process, but they are described as healing (e.g., "stageIV ulcer: healing" or "stage I ulcer: healing").

Sitting-Fowlers (Sitting up in a chair)

1.Vertebrae(spinal processes) 2.Sacrum 3.Pelvis(ischial tuberosity) 3.Heels(calcaneus)

Nursing Interventions for Dehiscence

1.maintain-ing bedrest with head of bed elevated at 20° 2. The kneesflexed.

Stage 3 Pressure Ulcer

A deep cratercharacterized by 1.FULL THICKNESS SKIN LOSS with 2.DAMAGE OR NECROSIS of SUBCUTANEOUS TISSUE May extend down to, but not through, underlying fascia. Bone/tendon is not visibleor directly palpable.

Non-blanching

A red spot that does not change color when you touch it. If the redness does not disappear quickly, tissue damage has occurred. In darker individuals, you need to look for a dark blue or blue prominence in the skin.

An adequate intake of _______ helps prevent pressure ulcers and promote tissue healing?

Adequate intake of calories, protein,vitamin C, and zinc is necessary to prevent pressure ulcers andpromote healing of injured tissue

Healing Process p. 1227

All wounds heal through a physiological process in whichepithelial, endothelial, and inflammatory cells, platelets, andfibroblasts migrate into the wound to bring about tissue re-pair and regeneration. T Primary Intention Secondary Intention Tertiary Intention

Suspect Deep-Tissue Injury: p.1233

An area of skin that is intact but discolored. -It might be purplish or deep red, painful, boggy,or have a blister.

Assessment of Bony Prominences: Know common sites IMP!

Know where pressure ulcers may develop depending on the position they are in: Sitting-Fowlers Lateral Supine Prone Pg. 1231 Figure 36-8

Support Surfaces: p.1244

Any patient at risk should be placed on a pressure-redistrib-uting device.

Hydrogel

Are sheets, granules, or gels. with a high water content, creating ajelly-like consistency that does notadhere to the wound bed. Use: - For minimal drainage ■ Promote a moist environment. ■ Rehydrate the wound bed. ■ Promote autolysis. ■ Promote comfort. ■ Soften slough or eschar in necrotic wounds. Caution: Have limited absorptive capabilities (notpractical for wounds with significantexudate). ■ Easily macerate periwound skin due tohigh moisture content.

Hydrocolloid

Are wafers, pastes, or powdersthat contain hydrophilic (water-loving) particles. ■ Used under compression. Use: ■ For light to moderate drainage ■ Promote a moist environment. ■ Provide a protective layer against friction/caustic agents. ■ Promote autolysis .■ Mold to the shape of the body, making them usefulfor difficult areas, such as heels or between buttocks. Caution: ■ Not the dressing of choice for wounds that require frequent dressing changes .■ Do not allow the wound to be visualized. ■ Not recommended for woundssurrounded by friable or sensitive skin(difficult to remove). ■ Should not be used on infected woundsbecause they are impermeable tooxygen, moisture, and bacteria. ■ May facilitate the growth of anaerobicbacteria.

6. Minimize pressure

As a result, you must provide -Frequent Position changes. -Use the rule of 30 to guide your positioning -To protect skin during turning or repositioning, use lift devices or drawsheets, heel and elbow protectors, or sleeves a

SANguineous exudate

BLOODY DRAINAGE with deep wounds or wounds inhighly vascular areas. -It indicates damage to capillaries. -Fresh bleeding produces bright red drainage, -Whereas older,dried blood is a dark, red-brown color.

Supine(Face UP)

Back of head Scapulae Elbows(olecranonprocess) Sacrum Heels(calcaneus)

1. Pressure Ulcer Admission

Braden and Norton scales, to assess the risk of pressure ulcers You should use these scales to assess the patient on ad-mission to any type of facility

Prone(Face Down)

Cheek and ear(zygomaticbone) Shoulder(acromialprocess) Breasts(women) Genitalia(men) Knees(patellas) Toes(phalanges)

Serous exudate

Clean wounds typically drain serous exu-date. -It is WATERY in consistency and contains very little cellu-lar matter. -Serous exudate consists of serum,the straw-coloredfluid that separates out of blood when a clot is formed.

Evisceration Nursing Interventions

Evisceration is a surgical emer-gency. 1.Immediately cover the wound with sterile towels or dress-ings soaked in sterile saline solution -to prevent the organs fromdrying out and becoming contaminated with environmental bac-teria. 2. Have patient stay in bed with knees bent to minimizestrain on the incision. 3. Notify the surgeon and 4.ready the patientfor a surgical procedure

4. Manage Moisture

Excess moisture creates a risk for skin breakdown

Complications of Wound Healing

Hemorrhage,Infection, Dehiscence, Evisceration, Fistulas

They are caused by unrelieved pressure, or pressure in combination with shearing forces, which compromises blood flow to an area,resulting in ischemia(inadequate blood supply) in the underlying Tissue. Tissue ischemia leads to issue anoxia(lack of oxygen and cell death) this is known as

How Pressure Ulcers Develop

What are some of the common uses for a Transparent Film?

IV SITES

SEROSANguineous exudate

In new wounds, you will most commonly see serosanguineous drainage, a combination of: BLOODY and SEROUS DRAINAGE

Risk Factors for Pressure Ulcers

Internal: Impaired sensory perception Impaired mobility Alteration in LOC Extrinsic factors: Shear:occurs when the epidermal layer slides over thedermis, causing damage to the vascular bed. Friction:damages the outer protective epidermal layer, decreasing the amount of pressure needed to develop skin lesions. Moisture:especially in the form of urine or feces, macerates the skin and also decreases the amount of pressure requiredto produce ulceration. Intrinsic Forces and Extrinsic p.1231)

Stage 4 Pressure Ulcer

Involves 1.full-thicknessskin loss with extensivedestruction, tissue necrosis, or damage to muscle, bone, orsupport structures. 2. EXPOSED BONE/TENDON IS VISIBLE OR DIRECTLY PALPABLE 3. SLOUGH OR ESCHAR may be PRESENT 4. UNDERMINIG And SINUS TRACTS are COMMON

Unstageable Pressure Ulcers

Involves full-thicknessskin loss. -The base of the wound isobscured by slough (tan,yellow, gray, green, orbrown necrotic tissue)or eschar (tan, black, orbrown leathery necrotictissue).

Stage 2 Pressure Ulcer

Involves: -PARTIAL THICKNESS LOSS OF DERMIS -Stage 2 Pressure ulcers are OPEN but SHALLOW and with a RED PINK WOUND BED -NO SLOUGH or Bruising May also be an intact oropen/ruptured serum-filled blister, or a shinyor dry shallow ulcerwithout slough orbruising.

Risk Assessment: Braden Skin Assessment Scale

KNOW PARAMETERS!!!! Braden Skin assessment scale -Sensory perception -Moisture -Activity -Mobility -Nutrition -Friction and shear

Pressure Ulcers

Localized injury to the skin and other underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear and/or friction. Theyare caused by unrelieved pressure, or pressure in combination with shearing forces, which compromises blood flow to an area,resulting in ischemia(inadequate blood supply) in the underlying

Wound Assessment/Documentation: p.1238

Location Type wound Size- length, width, depth; centimeters Undermining or tunneling Periwound Extent and type of tissue in wound base Drainage Pain- wound or tissue Nutritional status

Foam and Alginate

Made from semipermeablehydrophilic foam that forms animpermeable barrier over the wound .■ Made into wafers, rolls, andpillows; have film coverings; andare adhesive or nonadhesive. ■ Used to provide compression. Use: -For minimal to large wounds ■ Absorbency ■ Insulation ■ Provide comfort. ■ Promote a moist environment. ■ Protects friable periwound skin. ■ Can be shaped around body contours. ■ May be used in combination with alginates or films. Cautions: Do not use with wounds that havetunneling or tracts. ■ Not recommended for dry, desiccatedwounds. ■ May macerate periwound skin if dressing becomes oversaturated.

5. Optimal Nutrition and hydration

Nutrition is vital to skin integrity. Patients with rapid weightloss, high metabolic demands, limited intake, or decreasedserum albumin are particularly at risk for developing pressureulcers. Monitor hydration status and offer water (if appropriate)whenever you reposition the patient.

What kind of patients are more at risk for Dehiscence?

Obese clients are also more likely to experience dehiscence because fatty tissue does not heal readily andthe patient's mass increases the strain on the suture line.

Wound Classification:

Onset and Duration: Acute: -Orderly and timely reparative process; anatomical and functional integrity maintained table 36- Chronic -Fails to proceed orderly and timely; loss of anatomical and functional integrity

Pathology of Pressure Ulcers: P.1230

Pressure Intensity-Minimal pressure required to collapse a capillary Pressure Duration- Low pressure over a long period of time or high pressure for a short period of time Tissue Tolerance- Tissues ability to withstand the pressure

Dehiscence

Rupture (separation) of one or more layers of a wound iscalled dehiscence -The most common causes of dehiscence are: 1. poor nutritional status 2.Inadequate closure of the muscles, 3.Wound infection. Dehiscence is usually associated with abdominal wounds.Patients often report feeling a pop or tear, especially with sud-den straining from coughing, vomiting, or changing positionsin bed.

Types of Wound Drainage(Exudate)

Serous Purulent Serosanguineous Sanguineous

What is the difference between Shear and Friction?

Shear is : Epidermal Layer sliding over the DERMIS Friction is: DAMAGE to the OUTER EPIDERMAL LAYER

Lateral(On Side)

Side of head(parietal andtemporal bones) Shoulder(acromialprocess) Ear llium Greatertrochanter Knee(medialand lateralcondyles) Malleolus(medialand lateral)

Gauze Sponge

Simplest and most widely used dressings ■ Made of woven and nonwovenfibers of cotton, rayon, polyester,or a combination of these. ■ Impregnated with antimicrobialagents, medications, or moisture,and others contain petrolatum tokeep the wound moist. ■ May be packed as sterile ornonsterile, in bulk or in smaller packages. Use: For LARGE WOUNDS ■ Cleansing ■ Protection ■ For packing large wounds, cavities, or tracts, deep ordirty wounds, or heavily draining wounds. ■ Used in combination with amorphoushydrogels,saline, or medications. Caution: Labor intensive ■ Can stick to wound tissue and damagenew, regenerated cells with the gauzeremoval. ■ Does not ensure a moist woundenvironment, as they allow for fluid evaporation. ■ May be applied incorrectly—must befluffed to avoid pressure or overpackingof a wound. ■ Dressing change interval is dependenton the amount of fluid saturation of thegauze. Frequent dressing changesdisrupt the wound bed and cause thewound to become hypothermic (cold),which physiologically impairs cell growthfor healing.

3. Inspect Skin Daily

Skin care begins with regular inspection of the skin—at leastdaily for patients at risk—and usually every 8 to 12 hours forinstitutionalized patients. Be sureto check pressure points for: -erythema, tenderness, or edema.Instruct family members and caregivers about the impor-tance of early detection of skin problems. In obese patients,skin damage can occur under breasts, abdominal folds, oranywhere skin contacts skin.

Classification of Pressure ulcers: p.1233

Staging and Wound Classification Pressure ulcers are classified by the degree of tissue involvement

How do You Prevent Evisceration?

To prevent evisceration: - a binder may be applied andactivity modified. -The surgeon should be notified of the dehis-cence and may visit the patient to examine the wound.

True or False Do not massage overbony prominences, which can irritate the area and lead to tissue injury

True

You may delegate turning and position changes to the NAP. Turning and movement preventtissue damage from ischemia, thereby preventing pressure ulcers True or False

True

Primary Intention is:

When a wound involves minimal or no tissue loss and has edges that are well approxi-mated (closed). -primary(first) intention healing takes place Little scarring is expected. A clean surgical incisionheals by this method.

Adjunctive Wound Care Therapys:

Wound Vac- Negative Pressure Wound Therapy -Using a specializedpump, negative pressure is placed on a wound packed withfoam or gauze dressings to create a vacuum.

Patient/Family Teaching: p.1245

Wound is: Wet →dry it Open →cover it Unclean →clean it Necrotic →don't scrub it Dry →moisten it

When should you use the Braden Scale:

You should use this scale to assess the patient on -admission to the facility and -again in 48 to 72 hours.

Fistulas is:

an ABNORMAL PASSAGEWAY: connecting two body cavities ora cavity and the skin. -Fistulas often result from infection. - An ab-scess forms, which breaks down surrounding tissue and createsthe abnormal passageway.

Transparent Film

are Clear and semipermeable. Use: -For minimal drainage to none ■ Promote a moist environment. ■ Occlusive with oxygen permeability .■ Promote autolysis. ■ Often used to dress IV sites. ■ Prevent external bacterial contamination. ■ Allow wound assessment without removing ordisturbing the dressing. ■ Can be placed over joints without inhibiting movement. Caution: If used over wounds that are draining,the tissues will become macerated. ■ Adhere to the skin, so do not use them on friable skin.

Intrinsic Factors that affect skin integrity

immobility and impaired sensation, as occurwith spinal cord injuries, stroke, or coma; poor nutrition; edema; aging; low arteriolar pressure; fever. Septicemia -isone of the most common principal reasons for hospitalizationamong patients with secondary pressure ulcers Poor nutrition or dehydration can weaken the skin andlead to pressure ulcers.

Where are Fistulas most common?

mostcommon in the gastrointestinal and genitourinary tracts.

Secondary Intention

occurs when a wound (1) involves exten-sive tissue loss, which prevents wound edges from approxi-mating, or (2) should not be closed (e.g., because it is infected). Note: Because the wound is left open, it heals from the inner layer tothe surface by FILLNG IN WITH BEEFY RED GRANULATION tissue -(a form of connective tissue with an abundant blood supply) -Wounds that heal by secondary intention heal moreslowly, are more prone to infection, and develop more scar tissue.