Foundation: Chapter 48 Skin Integrity & Wound Care

Jackson-Pratt Drainage Device

Evacuator units such as a Hemovac or Jackson-Pratt (shown here) exert constant low pressure as long as the suction device (bladder or container) is fully compressed

Film Dressing

-film dressing as a secondary dressing and for autolytic debridement of small wounds. It has the following advantages: -Adheres to undamaged skin -Serves as a barrier to external fluids and bacteria but still allows the wound surface to "breathe" because oxygen passes through the transparent dressing -Promotes a moist environment that speeds epithelial cell growth -Can be removed without damaging underlying tissues -Permits viewing a wound

Mechanical Debridement: wound Irrigation

(high-pressure irrigation and pulsatile high-pressure lavage) . Pressurized irrigation involves applying streams of water, delivered at either high or low pressure, to wash away bacteria, foreign matter, and necrotic tissue from the wound. However, if the pressure is too great, there may be a risk of forcing bacteria and debris deeper into the wound or damaging viable tissue

Cleaning Skin

**These three principles are important when cleaning an incision or the area surrounding a drain** 1. Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin. 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to the most contaminated area.

Hematoma

- A hematoma is a localized collection of blood underneath the tissues. - localized collection of blood underneath the tissues. - appears sweeping, change in color, sensation or warmth - bluish discoloration.

Dehiscence

- Dehiscence is the partial or total separation of wound layers. - A patient who is at risk for poor wound healing is at risk for dehiscence. - 3-11 days after injury. - occurs after a sudden strain such as coughing, vomiting, sitting up. - increase of serosanguineous drainage from wound - obese patients are at risk.

Cleaning Wound

-Apply noncytotoxic solution. -Clean surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze or by irrigation. -After applying a solution to sterile gauze, clean away from the wound. Never use the same piece of gauze to clean across an incision or wound twice.

Full thickness wound repair:

- Full-thickness wounds heal via inflammatory response, proliferation, and remodeling. -Hemostasis is a series of events designed to control blood loss, establish bacterial control, and seal the defect that results when an injury occurs. Clots form a fibrin matrix that later provides a framework for cellular repair. -In the inflammatory stage, damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues. -With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. Main activities during this phase include filling of the wound with granulation tissue, contraction of the wound, and resurfacing of the wound by epithelialization. -Remodeling, or maturation, the final stage of healing, sometimes takes place for longer than a year, depending on the depth and extent of the wound. Complications include hemorrhage, infection, dehiscence, evisceration, and fistulas.

Hemorrhage

- Hemorrhage, or bleeding from a wound site, is normal during and immediately after initial trauma. - hemorrhage occurring after homeostasis indicates a slipped surgical suture, dislodged clot, infection, erosion of blood vessels by a foreign object.

Implementation

- Protect bony prominences, skin barriers for incontinence. -Turn every 1 to 2 hours as indicated. -Decrease the amount of pressure exerted over bony prominences. - 30 degree lateral position to avoid pressure points are avoided.

Local effects of cold:

- The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. - The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia. -The skin initially takes on a reddened appearance, followed by a bluish-purple mottling, with numbness and a burning type of pain. -Skin tissues freeze from exposure to extreme cold.

Partial thickness wound repair:

- The form that wound repair takes depends on the wound's thickness. Partial thickness will heal via the inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers.

Prevention of Pressure Ulcers

- When a patient develops a pressure ulcer, the length of stay is extended and the overall cost of care increases. - Prevention includes special beds and mattresses, good hygiene, good nutrition, adequate hydration, and impeccable nursing care. - The Centers for Medicare and Medicaid Services (CMS) implemented a policy effective October 1, 2008, whereby hospitals no longer receive additional reimbursement for care related to eight conditions, including stage III and IV pressure ulcers that occur during the hospitalization.

Assessing a Wound

- When a patient's condition is stabilized, assess the wound to determine progress toward healing. - Observe whether wound edges are closed. A surgical incision healing by primary intention should have clean, well-approximated edges. -Note the amount, color, odor, and consistency of drainage. Types of drainage. -The health care provider inserts a drain into or near a surgical wound if a large amount of drainage is noted. -When inspecting a wound, observe swelling or separation of wound edges. While wearing gloves, lightly press the wound edges, detecting localized areas of tenderness or drainage collection. If pressure causes fluid to be expressed, note the character of the drainage. -If you detect purulent or suspicious-looking drainage, obtaining a specimen of the drainage for culture may be necessary.

Infection

- Wound infection is the second most common health care-associated infection. - The edges of the wound appear inflamed. -If drainage is present, it is odorous and purulent and causes a yellow, green, or brown color, depending on the causative organism.

Eschar

- black or brown necrotic tissue.

Wound Healing: SECONDARY INTENTION

- loss of tissue such as a burn, pressure ulcer, or severe laceration - The wound is left open until it becomes filled by scar tissue. - It takes longer for a wound to heal higher chance of infection.

Dermis

- provides tensile strength, mechanical support, and protection to underlying muscles, bones, and organs. - The dermis is made of collagen, blood vessels, and nerves. - Collagen is a tough fibrous protein. Fibroblasts, which are responsible for collagen formation, are the only distinctive cell type within the dermis.

Wound Healing: PRIMARY INTENTION

- skin edges are approximated or closed & the risk of infection is low. - healing occurs quickly with minimal scar formation

Braden Scale

- used to assess for pressure ulcer risk. -Sensory perception: ability to respond meaningfully to pressure- related discomfort. -moisture: degree to which skin is exposed to ulcer -activity: degree of physical activity -mobility: ability to change & control body position nutrition: usual food intake pattern and friction and shear

Laceration

-A laceration sometimes bleeds more profusely, depending on the depth and location of the wound.

Pressure Ulcer

-A pressure ulcer is a localized injury to the skin and underlying tissue, usually over a bony prominence. It results from pressure in combination with shear and/or friction. -Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in dark-skinned patients.

Skin provides:

-A protective barrier against disease-causing organisms -A sensory organ for pain, temperature, and touch -Vitamin D synthesis - 15% of the total body wieght

Wound Culture

-A skin or wound culture is a test to find and identify germs (such as bacteria, a fungus, or a virus) that may be growing on the skin or in a wound. -A sample of skin, tissue, or fluid is collected from the affected area and placed in a container with a substance (called growth medium or culture medium) that helps organisms grow

Abrasion

-An abrasion is superficial with little bleeding and is considered a partial-thickness wound.

During a dressing change

-Assess the skin beneath the tape. -Perform thorough hand hygiene before and after wound care. -Wear sterile gloves before directly touching an open or fresh wound. -Remove or change dressings over closed wounds when they become wet or if the patient has signs or symptoms of infection, and as ordered.

Suture Care

-Consult health care facility policy. -Always refer to health care facility policy and procedures for wound care and wound irrigation. The patient's history of wound healing, the site of surgery, the tissues involved, and the purpose of the sutures determine the suture material used. -Policies vary within institutions as to who is able to remove sutures. If it is appropriate that the nurse remove them, a health care provider's order is required. -An order for suture removal is not written until the health care provider believes that the wound has closed (usually in 7 days).

Gauze: Dry or Moist

-Gauze sponges are absorbent and are especially useful in wounds to wick away the wound exudate. -Gauze is available in different textures and in various lengths and sizes; 4 × 4 is the most common size. -Gauze can be saturated with solutions and used to clean and pack a wound. -When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out, unfolded, and lightly packed into the wound.

Local effects of heat

-Heat generally is quite therapeutic, improving blood flow to an injured part. -However, if heat is applied for 1 hour or longer, the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area. -Periodic removal and reapplication of local heat restore vasodilation. -Continuous exposure to heat damages epithelial cells, causing redness, localized tenderness, and even blistering.

Drainage Evacuators

-Portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage -When drainage interferes with healing, evacuation is achieved by using a drain alone or a drainage tube with continuous suction. -You may apply special skin barriers, including hydrocolloid dressings similar to those used with ostomies around drain sites. The skin barriers are soft material applied to the skin with adhesive. -Drainage flows onto the barrier but not directly onto the skin. -If available, consult the enterostomal/wound care nurse.

Prepare patient for dressing change

-Prepare the patient for a dressing change -Evaluate pain. -Describe procedure steps. -Gather supplies. -Recognize normal signs of healing. -Answer questions about the procedure or wound.

Purpose of Dressing

-Protect a wound from microorganism contamination -Aid in hemostasis -Promote healing by absorbing drainage and debriding a wound -Support or splint the wound site -Protect patients from seeing the wound (if perceived as unpleasant) -Promote thermal insulation of the wound surface

Types of wound drainage:

-Serous: clear, watery plasma -Purulent: thick, yellow, green, tan or brown -Serosanguineous: pale, pink, watery mixture of clear & red fluid. -Sanguineous: Bright red, indicates active bleeding

Irrigation

-To remove exudates, use sterile technique with 35-mL syringe and 19-gauge needle

Transparent Film dressing

-Transparent film dressing is ideal for small superficial wounds such as partial-thickness wounds and to protect high-risk skin.

Evisceration

-With total separation of wound layers, evisceration or protrusion of visceral organs through a wound opening occurs. The condition is an emergency that requires surgical repair.

Heat & Cold Therapy

-You will need to identify and understand normal body responses to localized temperature variations. -Heat and cold applied to an injured body part provide therapeutic benefit. However, level of consciousness influences the ability to perceive heat, cold, and pain. If a patient is confused or unresponsive, the nurse needs to make frequent observations of skin integrity after therapy begins. (Contraindications are reviewed on the next slide.) -Bodily responses: A person initially feels an extreme change in temperature but within a short time hardly notices it. This is dangerous because a person insensitive to heat and cold extremes can suffer serious tissue injury. -You need to recognize patients most at risk for injury from heat and cold applications.

Wound Management

-You will want to take a holistic approach to wound management. You will want to work with the dietitian, the wound care nurse, and the pharmacist to ensure that all patient needs are met.

Hydrogel Dressing

-maintains a moist surface to support healing -Hydrogel dressings are gauze or sheet dressings impregnated with water- or glycerin-based amorphous gel. -Hydrogel has the following advantages: 1. Is soothing and can reduce wound pain 2. Provides a moist environment 3. Debrides necrotic tissue (by softening necrotic tissue) 4. Does not adhere to the wound base and is easy to remove

Hydrocolloid Dressing

-protects the wound from surface contamination -Hydrocolloid dressings are dressings with complex formulations of colloid, elastomeric, and adhesive components. They are adhesive and occlusive. -has a gel as fluid is absorbed and maintains a moist healing environment. - Hydrocolloids support healing in clean granulating wounds and auto debride necrotic wounds; they are available in a variety of sizes and shapes. -This type of dressing has the following functions: 1. Absorbs drainage through the use of exudate absorbers in the dressing 2. Maintains wound moisture 3. Slowly liquefies necrotic debris 4. Is impermeable to bacteria and other contaminants 5. Is self-adhesive and molds well 6. Acts as a preventive dressing for high-risk friction areas 7. May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing

Granulation Tissue

-red, moist tissue composed of new blood vessels. -presence of progression towards healing.

Slough

-soft, yellow or white tissue. - stringy substance attached to wound bed. - removed by a skilled clinician before the wound is able to heal.

Pathogenesis of Pressure Ulcer

1. pressure intensity -If pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged time, tissue ischemia occurs. If left untreated, tissue death results. -Blanching occurs when the normal red tones of skin are absent. Blanching does not occur in dark-skinned patients. 2. pressure duration -Pressure duration assesses low and extended pressures. Low pressures over a prolonged time can cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. 3. tissue tolerance -The ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures.

Penrose Drain

A Penrose drain lies under a dressing; at the time of placement, a pin or clip is placed through the drain to prevent it from slipping farther into the wound.

Types of Suture method

A. Intermittent. Removal of intermittent suture. A, Cut suture as close to skin as possible, away from the knot. B, Remove suture and never pull contaminated stitch through tissues. To remove sutures, first check the type of suturing used. With intermittent suturing, the surgeon ties each individual suture made in the skin. Continuous suturing, as the name implies, is a series of sutures with only two knots: one at the beginning and one at the end of the suture line. Retention sutures are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal. Never pull the visible portion of a suture through underlying tissue. Sutures on the surface of the skin harbor microorganisms and debris. The portion of the suture beneath the skin is sterile. Pulling the contaminated portion of the suture through tissues can lead to infection. Clip suture materials as close to the skin edge on one side as possible, and pull the suture through from the other side. B. Continuous. C. Blanket continuous. D. Retention.

Autolytic Debridement

Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids. Autolysis uses the body's own enzymes and moisture to re-hydrate, soften and finally liquefy hard eschar and slough. Autolytic debridement is selective; only necrotic tissue is liquefied. It is also virtually painless for the patient.

Bandages & Binders

Bandages and binders are applied over or around dressings to provide extra protection and/or therapeutic benefits by creating pressure over a body part, immobilizing a body part supporting a wound, reducing or preventing edema, or securing a splint or dressing. When binder or bandages are applied, an assessment must be made. most common is abdominal binder An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs. Secure an abdominal binder with safety pins, Velcro strips, or metal stays.

Nutritions in wound healing

Calories: protein protection Protein: collagen formation & wound remolding, immune function vitamin C: capillary wall integrity, immunological function Vitamin A: Wound closure, inflammatory response, can reverse steroid effects on skin & delay healing Vitamin E: Zinc: host defenses, collagen formation Fluid: for all cell function

Chemical Debridement

Chemical debridement may use topical enzymes to induce changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the type of enzyme used, the preparation digests or dissolves the tissue. These preparations require a health care provider's order. Dakin's solution breaks down and loosens dead tissue in a wound.

Heat is contraindicated:

For areas of active bleeding For an acute localized inflammation Over a large area if a patient has cardiovascular problems warm applications are contraindicated when the patient has an acute, localized inflammation such as appendicitis because heat causes the appendix to rupture. If a patient has cardiovascular problems, it is unwise to apply heat to large portions of the body because the resulting massive vasodilation disrupts the blood supply to vital organs.

Cold is contraindicated:

If the site of injury is edematous In the presence of neuropathy If the patient is shivering If the patient has impaired circulation Cold further retards circulation to the area and prevents absorption of the interstitial fluid. If the patient has impaired circulation (e.g., arteriosclerosis), this further reduces blood supply to the affected area.

Montgomery Ties

Montgomery ties are shown in these photos. A, Each tie is placed at side of dressing. B, Securing ties encloses dressing. To avoid repeated removal of tape from sensitive skin, secure dressings with pairs of reusable Montgomery ties. Each section consists of a long strip; half contains an adhesive backing to apply to the skin, and the other half folds back and contains a cloth tie or a safety pin-and-rubber band combination that you fasten across a dressing and untie at dressing changes. A large, bulky dressing often requires two or more sets of Montgomery ties.

Puncture Wound

Puncture wounds bleed in relation to the depth and size of the wound.

Types of Bandages

Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin

Pressure Ulcer stages:

Stage I: Non-blanchable erythema -Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Stage II: Partial thickness -Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. Stage III: Full thickness skin loss -Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Stage IV: Full thickness tissue loss -Full thickness tissue loss with exposed bone, tendon or muscle. -Unstageable: Full of tissue loss in which actual depth of the ulcer is completely slough - Suspected Deep tissue injury: purple or maroon localized are of discolored intact skin or blood- filled blister.

Surgical Debridement

Surgical debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.

Surgical Wound

Surgical wounds are closed with staples, sutures, or wound closures.

V.A.C. (Vacuum-Assisted Closure)

The vacuum-assisted closure (V.A.C.) is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together. Modifications have been made to the V.A.C. The V.A.C. Instill allows intermittent instillation of fluids into the wound, especially those wounds not responding to traditional (negative-pressure wound therapy (NPWT). NPWT is used in treating acute and chronic wounds. The schedule for changing NPWT dressings varies, depending on the type of wound and the amount of drainage. Wear time for the dressing is anywhere from 24 hours to 5 days. As the wound heals, granulation tissue lines its surface. The wound has a stippled or granulated appearance. The surface area sometimes increases or decreases, depending on wound location and the amount of drainage removed by the NPWT system. NPWT is also used to enhance the take of split-thickness skin grafts. It is placed over the graft intraoperatively, decreasing the ability of the graft to shift and evacuating fluids that build up under it. An airtight seal must be maintained.

Risk factors for pressure ulcer development

These six factors contribute to pressure ulcer formation. Any patient who is experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. 1. IMPAIRED SENSORY PERCEPTION: Patients with altered sensory perception for pain and pressure are at risk because they cannot feel their body sensations. 2.. IMPAIRED MOBILITY: Patients who are unable to independently change position are at risk because they cannot change or shift off of bony prominences. 3.. ALTERATION IN LEVEL OF CONSCIOUSNESS: Patients who are confused or disoriented or who have alterations in level of consciousness are unable to protect themselves. 4. SHEAR: Shear is the force exerted parallel to skin, resulting from both gravity pushing down on the body and resistance (friction) between the patient and a surface. 5. FRICTION: Friction is the force of two surfaces moving across one another, such as the mechanical force exerted when the body is dragged across another surface. 6. MOISTURE: Prolonged moisture softens the skin, making it more susceptible. Skin needs to be dry & intact.

Drainage Evacuators

This photo shows setting of suction on the drainage evacuator. 1. With drainage port open, raise level on diaphragm. 2. Push straight down on lever to lower diaphragm. 3. Closure of port prevents escape of air and creates vacuum pressure. Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. Ensure that suction is exerted and that connection points between the evacuator and the tubing are intact. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder, and immediately reset the evacuator to apply suction.

Mechanical Debridement: Whirlpool

Whirlpool therapy uses powered irrigation and can be very effective at loosening and removing surface wound debris, bacteria, necrotic tissue, and exudate from the wound

Epidermis

top layer 1. stratum corneum is the thin, outermost layer that is flattened with dead keratinized cells. -The thin stratum corneum protects underlying cells and tissues from dehydration and prevents entrance of certain chemical agents. -The stratum corneum allows evaporation of water from the skin and permits absorption of certain topical medications. 2. basal layer divides, proliferates, and migrates toward the epidermal surface. separated by a membrane called, dermal- epidermal junction.