Unit 6 Skin Integrity and Wound Care

puncture

The primary dangers of puncture wounds are internal bleeding and infection.

Warm, Moist Compresses

Warm, moist compresses improve circulation, relieve edema, and promote consolidation of purulent drainage. Heat from warm compresses dissipates quickly. To maintain a constant temperature, you need to change the compress often. You can use a layer of plastic wrap or a dry towel to insulate the compress and retain heat. Moist heat promotes vasodilation and evaporation of heat from the surface of the skin. For this reason a patient can feel chilly.

laceration

Torn, jagged wound

Collagen

a tough, fibrous protein

abrasion

is superficial with little bleeding and is considered a partial-thickness wound; Scraping or rubbing away of epidermis; may result in localized bleeding and later weeping of serous fluid.

Application of Heat and Cold Therapies part 1

A prerequisite to using any heat or cold application is a health care provider's order, which includes the body site to be treated and the type, frequency, and duration of application. You can administer heat and cold applications in dry or moist forms.

Sitz Baths

A patient who has had rectal surgery, an episiotomy during childbirth, painful hemorrhoids, or vaginal inflammation benefits from a sitz bath, a bath in which only the pelvic area is immersed in warm or, in some situations, cool fluid. The patient sits in a special tub or chair or a basin that fits on the toilet seat so the legs and feet remain out of the water. The desired temperature for a sitz bath depends on whether the purpose is to promote relaxation or to clean a wound. Prevent overexposure of patients by draping bath blankets around their shoulders and thighs and controlling drafts. A patient should be able to sit in the basin or tub with feet flat on the floor and without pressure on the sacrum or thighs.

Full-Thickness Wound Repair: Hemostasis

A series of events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury. During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair.

Acute Care: Bandages and Binders

A simple gauze dressing is often not enough to immobilize or provide support to a wound. Binders and bandages applied over or around dressings provide extra protection and therapeutic benefits by the following: 1. Creating pressure over a body part (e.g., an elastic pressure bandage applied over an arterial puncture site) 2. Immobilizing a body part (e.g., an elastic bandage applied around a sprained ankle) 3. Supporting a wound (e.g., an abdominal binder applied over a large abdominal incision and dressing) 4. Reducing or preventing edema (e.g., a stretch pressure bandage applied to the lower leg) 5. Securing a splint (e.g., a bandage applied around hand splints for correction of deformities) 6. Securing dressings (e.g., elastic webbing applied around leg dressings after a vein stripping) Binders are bandages that are made of large pieces of material to fit a specific body part. Most binders are made of elastic or cotton. An abdominal binder and a breast binder are examples.

Assessment of Wounds: Wound Appearance

A surgical incision healing by primary intention should have clean, well-approximated edges. Crusts often form along wound edges from exudate. A puncture wound is usually a small, circular wound with the edges coming together toward the center. If a wound is open, the edges are separated, and you inspect the condition of tissue at the wound base. The outer edges of a wound normally appear inflamed for the first 2 to 3 days. Within 7 to 10 days a normally healing wound resurfaces with epithelial cells, and edges close. Table 48-5 lists assessment characteristics for abnormal wound healing in primary and secondary wounds. Skin discoloration usually results from bruising of interstitial tissues or hematoma formation. Blood collecting beneath the skin first takes on a bluish or purplish appearance. Gradually, as the clotted blood is broken down, shades of brown and yellow appear.

negative-pressure wound therapy (NPWT)

A treatment modality for wounds is negative-pressure wound therapy (NPWT) or vacuum-assisted closure (one brand name is V.A.C.). NPWT is the application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid. NPWT supports wound healing by edema reduction and fluid removal, macro deformation and wound contraction, and micro deformation and mechanical stretch perfusion. Secondary effects include angiogenesis, granulation tissue formation, and reduction in bacterial bioburden. Wear time for the dressing is anywhere from 24 hours to 5 days. An airtight seal must be maintained.

Acute Care: Comfort Measures

A wound is often painful, depending on the extent of tissue injury; and wound care often requires the use of well-timed analgesia before any wound procedure. Administer analgesic medications 30 to 60 minutes before dressing changes (depending on the time of peak action of a drug). Carefully removing tape, gently cleaning wound edges, and carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound.

Nursing Process: Assessment

Baseline and continual assessment data provide critical information about a patient's skin integrity and the increased risk for pressure ulcer development. Focusing on specific elements such as a patient's level of sensation, movement, and continence status helps guide the skin assessment (Box 48-4).

Heat and Cold Therapy: Assessment for Temperature Tolerance

Before applying heat or cold therapies, assess a patient's physical condition for signs of potential intolerance to heat and cold. Assess the skin, looking for any open areas such as alterations in skin integrity (e.g., abrasions, open wounds, edema, bruising, bleeding, or localized areas of inflammation) that increase a patient's risk for injury. Also assess neurological function, testing for sensation to light touch, pinprick, and mild temperature variations. Sensory status reveals the ability of a patient to recognize when heat or cold becomes excessive. Assess a patient's mental status to be sure that he or she can correctly communicate any issues with the hot or cold therapy. Assessment also includes identification of conditions that contraindicate heat or cold therapy. Warm applications are contraindicated when a patient has an acute, localized inflammation such as appendicitis because the heat could cause the 1218appendix to rupture. If a patient has cardiovascular problems, it is unwise to apply heat to large parts of the body because the resulting massive vasodilation disrupts blood supply to vital organs. Cold is contraindicated if the site of injury is already edematous. It further retards circulation to the area and prevents absorption of the interstitial fluid. Cold therapy is also contraindicated in the presence of neuropathy, because the patient is unable to perceive temperature change and damage resulting from temperature extremes. One other contraindication for cold therapy is shivering. Cold applications sometimes intensify shivering and dangerously increase body temperature.

eschar

Black, brown, tan, or necrotic tissue; Thick layer of dead, dry tissue that covers a pressure ulcer or thermal burn. It may be allowed to be sloughed off naturally, or it may need to be surgically removed.

Factors Influencing Pressure Ulcer Formation and Wound Healing: Psychosocial Impact of Wounds

Body image changes often impose a great stress on a patient's adaptive mechanisms. They also influence self-concept and sexuality. Factors that affect a patient's perception of a wound include the presence of scars, stitches, drains (often needed for weeks or months), odor from drainage, and temporary or permanent prosthetic devices.

Packing a Wound

The first step in packing a wound is to assess its size, depth, and shape. The dressing needs to be flexible and in contact with the entire wound surface. Make sure that the type of material used to pack the wound is appropriate. If gauze is the appropriate dressing material, saturate with the ordered solution, wring out, unfold, and lightly pack into the wound. The entire wound surface needs to be in contact with part of the moist gauze dressing. It is important to remember not to pack a wound too tightly. Overpacking causes pressure on the wound bed tissue. Pack the wound only until the packing material reaches the surface of the wound.

Full-Thickness Wound Repair

The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and maturation.

Full-Thickness Wound Repair: Inflammatory Phase

The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment (e.g., ankle or neck). Leukocytes (white blood cells) reach a wound within a few hours. Collagen appears as early as the second day and is the main component of scar tissue. In a clean wound the inflammatory phase establishes a clean wound bed. The inflammatory phase is prolonged if too little inflammation occurs, as in a debilitating disease such as cancer or after administration of steroids. Too much inflammation also prolongs healing because arriving cells compete for available nutrients.

epithelialization

The main activities during the proliferative phase of wound healing are the filling of a wound with granulation tissue, wound contraction, and wound resurfacing

Acute Care: Dressings

The more extensive a wound, the larger the dressing required. For example, a bulky dressing applied with pressure minimizes movement of underlying tissues and helps immobilize the entire body part. A bandage or cloth wrapped around a penetrating object should immobilize it adequately. The correct dressing selection facilitates wound healing. The dressing type depends on the assessment of the wound and the phase of wound healing. When you identify the objectives for the wound care, the dressing choice becomes clear. For surgical wounds that heal by primary intention, it is common to remove dressings as soon as drainage stops. In contrast, when dressing a wound healing by secondary intention, the dressing material becomes a means for providing moisture to the wound or helping in debridement.

Wound Management: Debridement

Removal of necrotic tissue is necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing. It is important to remember that during the debridement process some normal wound observations include an increase in wound exudate, odor, and size. Plan to administer an ordered analgesic 30 minutes before debridement. Methods of debridement include mechanical, autolytic, chemical, and sharp/surgical. Autolytic debridement is the removal of dead tissue via lysis of necrotic tissue by the white blood cells and natural enzymes of the body. You can accomplish chemical debridement with the use of a topical enzyme preparation, Dakin's solution, or sterile maggots. Topical enzymes induce changes in the substrate, resulting in the breakdown of necrotic tissue. Dakin's solution breaks down and loosens dead tissue in a wound. Apply the solution to gauze and apply to the wound. Sterile maggots are used in a wound because it is thought that they ingest the dead tissue. Surgical debridement is the removal of devitalized tissue with a scalpel, scissors, or other sharp instrument. Other methods of mechanical debridement are wound irrigation (high-pressure irrigation and pulsatile high-pressure lavage) and whirlpool treatments.

Evaluation: Patient Outcomes

The outcomes selected for a patient in the plan of care are the milestones you hope to achieve in order to meet goals of care. You evaluate nursing interventions for reducing and treating pressure ulcers by determining the patient's response to nursing therapies and whether he or she achieved each goal. You will evaluate patients with impaired skin integrity on an ongoing basis for factors that contribute to skin breakdown and wound status. For example, during direct patient contact, if a patient continues to be diaphoretic or incontinent, apply wound assessment skills to note the condition of the skin and decide if additional therapies are needed. If the identified outcomes are not met for a patient with impaired skin integrity, questions to ask include the following: • Was the etiology of the skin impairment addressed? Were the pressure, friction, shear, and moisture components identified; and did the plan of care decrease the contribution of each of these components? • Was wound healing supported by providing the wound base with a moist protected environment? • Were issues such as nutrition assessed and a plan of care developed that provided the patient with the calories to support healing?

Risk Factors for Pressure Ulcer Development: Moisture

The presence and duration of moisture on the skin increases the risk of ulcer formation. Moisture reduces the resistance of the skin to other physical factors such as pressure and/or shear force. Prolonged moisture softens skin, making it more susceptible to damage. Immobilized patients who are unable to perform their own hygiene needs depend on nurses to keep the skin dry and intact.

Cold, Moist, and Dry Compresses

The procedure for applying cold, moist compresses is the same as that for warm compresses. Apply cold compresses for 20 minutes at a temperature of 15° C (59° F) to relieve inflammation and swelling.

Cold Soaks

The procedure for preparing cold soaks and immersing a body part is the same as for warm soaks. The desired temperature for a 20-minute cold soak is 15° C (59° F). Control drafts and use outer coverings to protect the patient from chilling. It is often necessary to add cold water during the procedure to maintain a constant temperature.

Full-Thickness Wound Repair: Proliferative Phase

The proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of a wound with granulation tissue, wound contraction, and wound resurfacing by epithelialization. Collagen mixes with the granulation tissue to form a matrix that supports the reepithelialization. Collagen provides strength and structural integrity to a wound. During this period a wound contracts to reduce the area that requires healing. Finally the epithelial cells migrate from the wound edges to resurface. In a clean wound the proliferative phase accomplishes the following: the vascular bed is reestablished (granulation tissue), the area is filled with replacement tissue (collagen, contraction, and granulation tissue), and the surface is repaired (epithelialization).

Factors Influencing Heat and Cold Tolerance

The response of the body to heat and cold therapies depends on the following factors: • A person is better able to tolerate short exposure to temperature extremes than prolonged exposure. • Exposed skin layers and certain areas of the skin (e.g., the neck, inner aspect of the wrist and forearm, and perineal region) are more sensitive to temperature variations. The foot and palm of the hand are less sensitive. • The body responds best to minor temperature adjustments. If a body part is cool and a hot stimulus touches the skin, the response is greater than if the skin were already warm. • A person has less tolerance to temperature changes to which a large area of the body is exposed. • Tolerance to temperature variations changes with age. Patients who are very young or old are most sensitive to heat and cold. • If a patient's physical condition reduces the reception or perception of sensory stimuli, tolerance to temperature extremes is high, but the risk of injury is also high. • Uneven temperature distribution suggests that the equipment is functioning improperly.

Assessment of Pressure Ulcers: Pain

The routine assessment of pain in surgical patients is critical to selecting appropriate pain management therapies and to determine a patient's ability to progress towards recovery. Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risk.

Scientific Knowledge Base: Skin

The skin has two layers: the epidermis and the dermis (Figure 48-1). The epidermis, or the top layer, has several layers. The stratum corneum is the thin, outermost layer of the epidermis. It consists of flattened, dead, keratinized cells. The cells originate from the innermost epidermal layer, commonly called the basal layer. Cells in the basal layer divide, proliferate, and migrate toward the epidermal surface. The dermis, the inner layer of the skin, provides tensile strength; mechanical support; and protection for the underlying muscles, bones, and organs. Collagen (a tough, fibrous protein), blood vessels, and nerves are found in the dermal layer.

Assessment of Wounds: Drains

The surgeon inserts a drain into or near a surgical wound if there is a large amount of drainage. Exercise caution when changing a dressing around drains that are not sutured in place to prevent accidental removal. 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 a wound. Assess the number and type of drains, drain placement, character of drainage, and condition of collecting equipment. Observe the security of the drain and its location with respect to the wound. Next note the character of drainage. If there is a collecting device, measure the drainage volume. Because a drainage system needs to be patent, look for drainage flow through and around the tubing. When a drain is connected to suction, assess the system to be sure that the pressure ordered is being exerted. Evacuator units such as a Hemovac or Jackson-Pratt (Figure 48-11) exert a constant low pressure as long as the suction device (bladder or container) is fully compressed.

Partial-Thickness Wound Repair

Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers. Tissue trauma causes the inflammatory response, which in turn causes redness and swelling to the area with a moderate amount of serous exudate. The epithelial proliferation and migration start at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. A wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells only migrate across a moist surface. In a dry wound the cells migrate down into a moist level before migration can occur. New epithelium is only a few cells thick and must undergo reestablishment of the epidermal layers. The cells slowly reestablish normal thickness and appear as dry, pink tissue.

Types of Dressings part 1

To avoid causing damage to the periwound skin, it is important that the dressing technique that you use to treat pressure ulcers and other wounds is not excessively moist. Most pressure ulcers require dressings. The type of dressing is usually based on the stage of the pressure ulcer, the type of tissue in the wound, and the function of the dressing (Table 48-8 pg1209). Gauze sponges are the oldest and most common dressing. They are absorbent and are especially useful in wounds to wick away wound exudate. The 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 (leaving the gauze only moist), unfolded, and lightly packed into the wound.

approximated

To come close together, as in the edges of a wound

Acute Care: Wound Management

To maintain a healthy wound environment, you need to address the following objectives: prevent and manage infection, clean the wound, remove nonviable tissue, maintain the wound in a moist environment, eliminate dead space, control odor, eliminate or minimize pain, and protect the wound and periwound skin. A wound does not move through the phases of healing if infected. Preventing wound infection includes cleaning and removing nonviable tissue. Clean pressure ulcers only with noncytotoxic wound cleaners such 1206as normal saline or commercial wound cleaners. Noncytotoxic cleaners do not damage or kill fibroblasts and healing tissue. Irrigation is a common method of delivering a wound-cleansing solution to the wound. Wound irrigation debrides necrotic tissue with pressure that can remove debris from the wound bed without damaging healthy issues. One method to ensure an irrigation pressure within the correct range is to use a 19-gauge angiocatheter and a 35-mL syringe that delivers saline to a pressure ulcer at 8 psi. A moist environment supports the movement of epithelial cells and facilitates wound closure. A wound that has excessive exudate (drainage) provides an environment that supports bacterial growth, macerates the periwound skin, and slows the healing process. If excessive 1208wound exudate is present, evaluate the volume, consistency, and odor of the drainage to determine if an infection is present.

Risk Factors for Pressure Ulcer Development: Friction

Unlike shear injuries, friction injuries affect the epidermis or top layer of the skin. The denuded skin appears red and painful and is sometimes referred to as a sheet burn. A friction injury occurs in patients who are restless, in those who have uncontrollable movements such as spastic conditions, and in those whose skin is dragged rather than lifted from the bed surface during position changes or transfer to a stretcher.

Irrigation

Use an irrigating syringe to flush the area with a constant low-pressure flow of solution. The gentle washing action of the irrigation cleanses a wound of exudate and debris. Irrigation is particularly useful for open, deep wounds; wounds involving an inaccessible body part such as the ear canal; or when cleaning sensitive body parts such as the conjunctival lining of the eye. Irrigation of an open wound requires sterile technique. Use a 35-mL syringe with a 19-gauge soft angiocatheter to deliver the solution. This irrigation system has a safe pressure and does not damage healing wound tissue. It is important to never occlude a wound opening with a syringe because this results in the introduction of irrigating fluid into a closed space. Always irrigate a wound with the syringe tip over but not in the drainage site. Make sure that fluid flows directly into the wound and not over a contaminated area before entering the wound.

Acute Care: First Aid for Wounds

Use first-aid measures for wound protection and management in an emergency situation. Under stable conditions a variety of interventions ensure wound healing. When a patient suffers a traumatic wound, first-aid interventions include stabilizing cardiopulmonary function, promoting hemostasis, cleaning the wound, and protecting it from further injury.

Securing Dressings

Use tape, ties, or a secondary dressing to secure a dressing over a wound site. You will most often use strips of tape to secure dressings. Nonallergenic paper and silicone tapes minimize skin reactions. Common adhesive tape adheres well to the surface of the skin, whereas elastic adhesive tape compresses closely around pressure bandages and permits more movement of a body part. It is important to assess skin under tape at each dressing change. When applying tape, ensure that it adheres to several inches of skin on both sides of the dressing and that it is placed across the middle of the dressing. When securing a dressing, press the tape gently. Make sure to exert pressure away from a wound so that tension occurs in both directions away from the wound, minimizing skin distortion and irritation. Never apply tape over irritated or broken skin. To remove tape safely, loosen the ends and gently pull the outer end parallel with the skin surface toward the wound. Apply light traction to the skin away from the wound as the tape is loosened and removed. The traction minimizes pulling of the skin. To avoid repeated removal of tape from sensitive skin, secure dressings with pairs of reusable Montgomery ties.

fluctuance

Soft, boggy feeling when tissue is palpated; usually a sign of tissue infection.

Changing Dressings

Sometimes (e.g., with chronic nonsurgical wounds) you will use clean medical aseptic technique for a dressing change. You will wear clean gloves, but the dressing materials are in sterile packages and are carefully placed over the wound. Deep wounds that require irrigation are usually irrigated with a sterile solution. For example, chronic pressure ulcer wounds use a clean technique. On the other hand, a fresh surgical wound may require sterile technique, which requires the use of sterile gloves so as not to introduce microorganisms into a healing wound. A health care provider's order for changing a dressing indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. An order to "reinforce dressing prn" (add dressings without removing the original one) is common right after surgery, when the health care provider does not want accidental disruption of the suture line or bleeding. After the first dressing change, describe the location of drains and the type of dressing materials and solutions to use in the patient's care plan. Often it is necessary to teach patients how to change dressings in preparation for home care. In this situation, demonstrate dressing changes to a patient and family and then provide an opportunity for them to practice.

Assessment of Wounds: Stable Setting

When a patient's condition is stabilized (e.g., after surgery or treatment), assess the wound to determine progress toward healing. If the wound is covered by a dressing and the health care provider has not ordered it changed, do not inspect it directly unless you suspect serious complications such as a large volume of bright red bleeding, excessive odor, or severe pain under the dressing. In such a situation inspect only the dressing and any external drains. When removing dressings, take care to avoid accidental removal or displacement of underlying drains. Because removal of dressings can be painful, consider giving an analgesic at least 30 minutes before exposing a wound. Assess the wound thoroughly using standard measurements.

Complications of Wound Healing: Dehiscence

When an incision fails to heal properly, the layers of skin and tissue separate. This most commonly occurs before collagen formation (3 to 11 days after injury). A patient who is at risk for poor wound healing (e.g., poor nutritional status, infection) is at risk for dehiscence. Obese patients have a higher risk of wound dehiscence because of the constant strain placed on their wounds and the poor healing qualities of fat tissue Dehiscence can happen in abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. When there is an increase in serosanguineous drainage from a wound in the first few days after surgery, be alert for the potential for dehiscence.

Critical Thinking

When caring for patients who have impaired skin integrity and chronic wounds, integrate knowledge from nursing and other disciplines, previous experiences, and information gathered from patients to understand the risk to skin integrity and wound healing. Knowledge of normal musculoskeletal physiology, the pathogenesis of pressure ulcers, pressure ulcer stages, normal wound healing, and the pathophysiology of underlying diseases enables you to have a scientific basis for care.

Acute Care: Drainage Evacuation

When drainage interferes with healing, evacuation is achieved by using either 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 with significant drainage. The skin barriers are soft material applied to the skin with adhesive. Drainage flows on the barrier but not directly on the skin. Assess for volume and character of drainage every shift and as needed. When the drainage evacuator fills, measure output by emptying the contents into a graduated cylinder and immediately reset the evacuator to apply suction.

Assessment of Wounds: Palpation of Wound

When inspecting a wound, observe for 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. The patient is normally sensitive to palpation of wound edges. Extreme tenderness indicates infection.

Safety Guidelines for Nursing Skills

When performing the skills in this chapter, remember the following points to ensure safe, individualized patient-centered care: • When changing wound dressings, follow proper aseptic technique. Keep a plastic bag within reach to discard dressings and prevent cross-contamination. Keep extra gloves within reach to allow a change of gloves if the gloves become soiled. • If irrigating a wound, use goggles and other personal protective equipment when the risk for splash exists. • When applying an elastic bandage, check the extremity where the bandage is applied for temperature or sensation changes.

Assessment: Through the Patient's Eyes

When pressure ulcers or chronic wounds develop, the course of treatments is lengthy and costly. Because a patient and family need to be involved with wound-care management, it is important to know a patient's expectations. Does the patient expect to have home care? Is there the expectation the patient will heal to allow a quick return to work? It is important to assess each patient's perception of what is occurring with the wound-healing interventions. For example, why are certain dressings being used and how do they work? As a nurse, you want to determine a patient's and family's understanding of wound assessment; wound interventions; and supportive interventions such as positioning, nutrition, and ambulation.

Prevention of Pressure Ulcers: Topical Skin Care and Incontinence Management

When you clean the skin, avoid soap and hot water. Use cleaners with nonionic surfactants that are gentle to the skin. After you clean the skin and make sure that it is completely dry, apply moisturizer to keep the epidermis well lubricated but not oversaturated. Make an effort to control, contain, or correct incontinence, perspiration, or wound drainage. When patients have an incontinent episode, gently clean the area, dry, and apply a thick layer of moisture barrier to the exposed areas. A moisture barrier protects the skin from excessive moisture and bacteria found in the urine or stool. Bowel incontinence can sometimes be better managed with proper diet and medications. Urinary incontinence is treated with behavioral techniques, medication, and surgery. Behavioral techniques help patients learn ways to control their bladder and sphincter muscles. Two examples are bladder and habit training, also called timed voiding. Consider using absorbent pads and garments only after trying these measures. Use only products that wick moisture away from the patient's skin.

Assessment of Wounds: Emergency Settings

When you judge a patient's condition to be stable because of the presence of spontaneous breathing, a clear airway, and a strong carotid pulse, inspect the wound for bleeding. An abrasion is superficial with little bleeding and is considered a partial-thickness wound. The wound often appears "weepy" because of plasma leakage from damaged capillaries. A laceration sometimes may bleed more profusely, depending on the depth and location of the wound. Lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep cause serious bleeding. Puncture wounds bleed in relation to the depth, size, and location of the wound. The primary dangers of puncture wounds are internal bleeding and infection. Inspect wounds for foreign bodies or contaminant material. Most traumatic wounds are dirty. Soil, broken glass, shreds of cloth, and foreign substances clinging to penetrating objects sometimes become embedded in a wound. The size and depth of a wound are the next steps in assessment. Use a disposable wound-measuring device to measure wound width and length. Measure depth by using a cotton-tipped applicator in the wound bed. When an injury is a result of trauma from a dirty penetrating object, determine when the patient last received a tetanus toxoid injection.

Planning: Teamwork and Collaboration

With early discharge from health care settings, it is important to consider a patient's plan for discharge. Anticipating the patient's discharge wound-care needs and related equipment and resources such as referral to a home care agency or outpatient wound-care clinic helps to improve not only wound healing but also the patient's level of independence. Patients and their family caregivers often need to continue the objectives of wound management after discharge (Box 48-7).

Complications of Wound Healing: Evisceration

With total separation of wound layers, evisceration (protrusion of visceral organs through a wound opening) occurs. The condition is an emergency that requires surgical repair. When evisceration occurs, a nurse places sterile gauzed soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues can be compromised. Immediately place damp sterile gauze over the site, contact the surgical team, do not allow the patient anything by mouth (NPO), observe for signs and symptoms of shock, and prepare the patient for emergency surgery.

Wound Classifications part 1

Wound classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound (Table 48-1), and descriptive qualities of the wound tissue such as color.

secondary intention

Wound closure in which the edges are separated; granulation tissue develops to fill the gap; and, finally, epithelium grows in over the granulation, producing a larger scar than results with primary intention.

Complications of Wound Healing: Infection

Wound infection is present when the microorganisms invade the wound tissues. The local clinical signs of wound infection can include erythema; increased amount of wound drainage; change in appearance of the wound drainage (thick, color change, presence of odor); and periwound warmth, pain, or edema. A patient may have a fever and an increase in white blood cell count. Laboratory tests such as a wound culture, tissue biopsy, or swab culture can be done to evaluate the wound for infection. A surgical wound infection usually does not develop until the fourth or fifth postoperative day. A patient will have a fever, tenderness and pain at the wound site, and an elevated white blood cell count. The edges of the wound will appear inflamed.

Factors Influencing Pressure Ulcer Formation and Wound Healing: Infection

Wound infection prolongs the inflammatory phase; delays collagen synthesis; prevents epithelialization; and increases the production of proinflammatory cytokines, which leads to additional tissue destruction. Indications that a wound infection is present include the presence of purulent drainage; change in odor, volume, or character of wound drainage; redness in the surrounding tissue; fever; or pain.

Process of Wound Healing

Wounds can be classified by the extent of tissue loss: partial-thickness wounds that involve only a partial loss of skin layers (the epidermis and superficial dermal layers) and full-thickness wounds that involve total loss of the skin layers (epidermis and dermis). The significance of determining if a wound is a partial or full thickness lies in the mechanism of healing. A partial-thickness wound heals by regeneration; and a full-thickness wound heals by forming new tissue, a process that can take longer than the healing of a partial-thickness wound. A clean surgical incision is an example of a wound with little tissue loss. The surgical incision heals by primary intention. The skin edges are approximated, or closed, and the risk of infection is low. Healing occurs quickly, with minimal scar formation. In contrast, a wound involving loss of tissue such as a burn, pressure ulcer, or severe laceration heals by secondary intention. The wound is left open until it becomes filled by scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. If scarring from secondary intention is severe, loss of tissue function is often permanent.

Assessment: Wounds

Wounds should be assessed on an ongoing basis: at the time of injury, during wound care, when a patient's overall condition changes, and on a regularly scheduled basis. Regardless of the setting, it is important that you initially obtain information regarding the cause and history of the wound, treatment of the wound, wound description, and response to therapy.

Evaluation

You evaluate nursing interventions for reducing and treating pressure ulcers by determining the patient's response to nursing therapies and whether he or she achieved each goal. To evaluate outcomes and responses to care, you measure the effectiveness of interventions. The optimal outcomes are to prevent injury to the skin, to reduce injury to the skin and underlying tissues, and possible wound healing with restoration of skin integrity.

Classification of Pressure Ulcers part 2

You need to assess the type of tissue in a wound base; then use this information to plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue. You need to assess the type of tissue in a wound base; then use this information to plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue. You need to assess the type of tissue in a wound base; then use this information to plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue. Wound exudate should describe the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. Examine the periwound area for redness, warmth, and signs of maceration and palpate the area for signs of pain or induration.

vacuum-assisted closure (V.A.C.)

a device that helps in wound closure by applying localized negative pressure to draw the edges of a wound together

wound

a disruption of the integrity and function of tissues in the body

hematoma

a localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because pressure from the expanding hematoma obstructs blood flow.

Factors Influencing Pressure Ulcer Formation and Wound Healing: Tissue Perfusion

Oxygen fuels the cellular functions essential to the healing process; therefore the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing. Patients with peripheral vascular disease are at risk for poor tissue perfusion because of poor circulation.

Economic Consequences of Pressure Ulcers

Paralysis and spinal cord injury are common preexisting conditions among younger adults with primary diagnosis of pressure ulcers. Older adults admitted to acute and long-term facilities are a vulnerable population. In a study examining early intervention of high-risk patients admitted to the emergency department in an acute care facility, early prevention was 81% likely to be cost-effective. When a pressure ulcer occurs, the length of stay in a hospital and the overall cost of health care increase. The actual cost of treatment is difficult to estimate. The occurrence of pressure ulcers is also costly for health care institutions and third-party payers. 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 a hospitalization.

Wound Repair

Partial-thickness wounds are shallow, involving loss of epidermis and possible loss of dermis. These wounds heal by regeneration because epidermis regenerates. An example of a partial-thickness wound is a scrape or an abrasion. Full-thickness wounds extend into the dermis and heal by scar formation because deeper structures do not regenerate. Pressure ulcers are an example of full-thickness wounds.

Risk Factors for Pressure Ulcer Development: Impaired Mobility

Patients unable to independently change positions are at risk for pressure ulcer development. For example, a morbidly obese patient who is seriously ill will be weakened and less likely to turn independently. Patients with spinal cord injuries have decreased or absent motor and sensory impairment and are unable to reposition off bony prominences.

Risk Factors for Pressure Ulcer Development: Alteration in Level of Consciousness

Patients who are confused or disoriented, those who have expressive aphasia or the inability to verbalize, or those with changing levels of consciousness are unable to protect themselves from pressure ulcer development.

Assessment of Pressure Ulcers: Predictive Measures

Perform pressure ulcer risk assessment systematically. Use an assessment tool such as the Braden Scale (in lecture module) or a tool preferred by your agency. Lower numerical scores on the Braden Scale indicate that the patient is at high risk for skin breakdown. A benefit of the predictive instruments is to increase a nurse's early detection of patients at greater risk for ulcer development. Once you identify these patients, institute appropriate interventions to maintain skin integrity and implement prevention strategies.

Prevention of Pressure Ulcers: Support Surfaces (Therapeutic Beds and Mattresses)

Support surfaces are "specialized devices for pressure redistribution designed for management of tissue loads, microclimate, and/or other therapeutic functions (i.e., any mattress, integrated bed system, mattress replacement, overlay, seat cushion, or seat cushion overlay)". Support surfaces reduce the hazards of immobility to the skin and musculoskeletal system. When selecting support surfaces, consider a patient's unique needs. Knowledge about support-surface characteristics (Table 48-7 pg1205) helps you in clinical decision making.

Suspected Deep-Tissue Injury—Depth Unknown

Suspected deep-tissue injury is a purple or maroon localized area of discolored intact skin or a blood-filled blister caused by damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler compared to adjacent tissue. It may begin as a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment

Assessment: Skin

Perform skin assessment of a patient when you initiate care and then at a minimum of once a shift (see agency policies). However, high-risk patients have more frequent skin assessments such as every 4 hours. Assess the skin for signs of skin breakdown and/or ulcer development. Assessment for tissue pressure damage includes visual and tactile inspection of the skin. Pay particular attention to areas located over bony prominences; next to medical devices; and under casts, traction, splints, braces, collars, or other orthopedic devices. Consider adults with medical devices (e.g., tubes, drainage systems, and oxygen devices) to be at risk for pressure ulcers. Carefully assess skin exposed to adhesive tape or other adhesive devices, which cause skin and tissue injury and increase risk for pressure ulcer development. When you note hyperemia, gently palpate the reddened tissue; differentiate whether the skin redness is blanchable or nonblanchable. Blanchable erythema may result from normal reactive hyperemia that should disappear within several hours or from inflammatory erythema with an intact capillary bed. Nonblanchable erythema indicates structural damage to the capillary bed/microcirculation. This is an indication for a category/stage I pressure ulcer. Body surfaces subjected to the greatest weight or pressure are at greatest risk for pressure ulcer formation.

Pathogenesis of Pressure Ulcers

Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors 1186contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance.

Pressure Ulcers

Pressure ulcer, pressure sore, decubitus ulcer, and bedsore are terms used to describe impaired skin integrity related to unrelieved, prolonged pressure. A pressure ulcer is localized injury to the skin and other underlying tissue, usually over a bony prominence (e.g., sacrum, greater trochanter), as a result of pressure or pressure in combination with shear and/or friction. Any patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition is at risk for pressure ulcer development. Examples of patients who are at risk for development of pressure ulcers include the following: • Older adults, those who have experienced trauma • Those with spinal-cord injuries (SCI) • Those who have sustained a fractured hip • Those in long-term homes or community care, the acutely ill • Individuals with diabetes • Patients in critical care settings

Prevention of Pressure Ulcers

Preventing pressure ulcers is a priority in caring for patients and is not limited to patients with restrictions in mobility. Impaired skin integrity usually is not a problem in healthy, immobilized individuals but is a serious and potentially devastating problem in ill or debilitated patients.

Wound Management: Protection

Protecting a wound from further injury is key. A strategy to prevent surgical wound dehiscence is to place a folded thin blanket or pillow over an abdominal wound so a patient can splint the area during coughing. Because coughing increases the intraabdominal pressure, the patient applies light but firm pressure over the wound when coughing to support the healing tissue. A patient may also wear an abdominal binder to make movement less uncomfortable and to provide support for the abdomen and surgical site.

Heat and Cold Therapy: Effects of Cold Application

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.

nonblanchable erythema

Redness of the skin caused by dilation of the superficial capillaries. The redness persists when pressure is applied to the area, indicating tissue damage.

Cleaning Skin and Drain Sites: Basic Skin Cleaning

Clean surgical or traumatic wounds by applying noncytotoxic solutions with sterile gauze or by irrigation. The following 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 a 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 most contaminated area 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. Drain sites are a source of contamination because moist drainage harbors microorganisms. If a wound has a dry incisional area and a moist drain site, cleaning moves from the incisional area toward the drain. To clean the area of an isolated drain site, clean around the drain, moving in circular rotations outward from a point closest to the drain.

fibrin

Clots form a fibrin matrix that later provides a framework for cellular repair.

Commercial Hot and Cold Packs

Commercially prepared disposable hot packs apply warm, dry heat to an injured area. Commercially prepared cold packs that are similar to the disposable hot packs for dry applications are available. When using cold compresses, observe for adverse reactions such as burning or numbness, mottling of the skin, redness, extreme paleness, and a bluish skin discoloration.

Prediction and Prevention of Pressure Ulcers

Consistent, planned skin-care interventions are critical to ensuring high-quality care. Whenever you are in direct contact with a patient, observe the skin for breaks or impaired skin integrity. Impaired skin integrity occurs from prolonged pressure (e.g., from lying in one position, or from rubbing of external devices), fecal or urinary incontinence, and/or immobility, leading to the development of pressure ulcers.

Assessment of Pressure Ulcers: Body Fluids

Continual exposure of the skin to body fluids increases a patient's risk for skin breakdown and pressure ulcer formation. Some body fluids such as saliva and serosanguineous drainage are not as caustic to the skin, and the risk of skin breakdown from exposure to these fluids is low. However, exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown.

Principles for Applying Bandages and Binders

Correctly applied bandages and binders do not cause injury to underlying and nearby body parts or create discomfort for a patient. For example, a chest binder should not be so tight as to restrict chest wall expansion. Before applying a bandage or binder, a nurse's responsibilities include the following: • Inspecting the skin for abrasions, edema, discoloration, or exposed wound edges • Covering exposed wounds or open abrasions with a dressing • Assessing the condition of underlying dressings and changing if soiled • Assessing the skin of underlying areas that will be distal to the bandage for signs of circulatory impairment (coolness, pallor or cyanosis, diminished or absent pulses, swelling, numbness, and tingling) to provide a means for comparing changes in circulation after bandage application After applying a bandage, the nurse assesses, documents, and immediately reports changes in circulation, skin integrity, comfort level, and body function (e.g., ventilation or movement).

Wound Management: Education

Education of the patient and caregivers is an important nursing function (Rolstad et al., 2016). A variety of educational tools, including videotapes and written materials, are available for you to use when teaching patients and caregivers/family to prevent and treat pressure ulcers and care for wounds.

Planning: Setting Priorities

Establish nursing care priorities in wound care on the basis of the comprehensive patient assessment and goals and established outcomes. These priorities also depend on whether the patient's condition is stable or emergent. An acute wound needs immediate intervention; whereas in the presence of a chronic, stable wound, the patient's hygiene and education on wound care is more important. When there is a risk for pressure ulcer development, preventive interventions such as skin-care practices, elimination of shear, and positioning are high priorities. Promotion of wound healing is a major nursing priority. Other patient factors to consider when establishing priorities include patient preferences, daily activities, and family factors.

Heat and Cold Therapy: Bodily Responses to Heat and Cold

Exposure to heat and cold causes systemic and local responses. Systemic responses occur through heat-loss mechanisms (sweating and vasodilation) or mechanisms promoting heat conservation (vasoconstriction and piloerection) and heat production (shivering). Local responses to heat and cold occur through stimulation of temperature-sensitive nerve endings within the skin. This stimulation sends impulses from the periphery to the hypothalamus, which becomes aware of local temperature sensations and triggers adaptive responses for maintenance of normal body temperature. 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 injuries from heat and cold applications (Table 48-9).

Ice Bags or Collars

For a patient who has a muscle sprain, localized hemorrhage, or hematoma or who has undergone dental surgery, an ice bag is ideal to prevent edema formation, control bleeding, and anesthetize the body part. Proper use of the bag requires the following steps: 1. Fill the bag with water, secure the cap, invert to check for leaks, and pour out the water. 2. Fill the bag two-thirds full with crushed ice so you are able to easily mold it over a body part. 3. Release any air from the bag by squeezing its sides before securing the cap because excess air interferes with conduction of cold. 4. Wipe off excess moisture. 5. Cover the bag with a flannel cover, towel, or pillowcase. 6. Apply the bag to the injury site for 30 minutes; you can reapply the bag in an hour.

Factors Influencing Pressure Ulcer Formation and Wound Healing: Nutrition

For patients weakened or debilitated by illness, nutritional therapy is especially important. A patient who has undergone surgery and is well nourished still requires at least 1500 kcal/day for nutritional maintenance. Normal wound healing requires proper nutrition (Table 48-4). Deficiencies in any of the nutrients result in impaired or delayed healing. Physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals zinc and copper. Calories provide the energy source needed to support the cellular activity of wound healing. Protein needs especially are increased and are essential for tissue repair and growth. A balanced intake of various nutrients (i.e., protein, fat, carbohydrates, vitamins, and minerals) is critical to support wound healing. Provide 30 to 35 kcal/kg of body weight for adults with a pressure ulcer who are assessed as being at risk of malnutrition. Serum proteins are biochemical indicators of malnutrition. Serum albumin is probably the most frequently measured of these laboratory parameters.

shearing force

Force exerted against the skin while the skin remains stationary and the bony structures move.

Unstageable/Unclassified: Full-Thickness Skin or Tissue Loss—Depth Unknown

Full-thickness tissue loss in which actual depth of an ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed is unstageable. Until enough slough and/or eschar are removed to expose the base of a wound, the true depth cannot be determined; but it will be either a category/stage III or IV. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the natural (biological) cover of the body" and should not be removed.

Heat and Cold Therapy: Effects of Heat Application

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

First Aid for Wounds: Cleaning

Gently cleaning a wound removes contaminants that serve as sources of infection. However, vigorous cleaning using a method with too much mechanical force causes bleeding or further injury. For abrasions, minor lacerations, and small puncture wounds, first rinse the wound with normal saline and lightly cover the area with a dressing. When a laceration is bleeding profusely, only brush away surface contaminants and concentrate on hemostasis until the patient can be cared for in a clinic or hospital. According to the WOCN guidelines, normal saline is the preferred cleaning agent. It is physiologically neutral and does not harm tissue. Normal saline keeps the wound surface moist to promote the development and migration of epithelial tissue. Gentle cleansing with normal saline and application of moist saline dressings are commonly used for healing wounds.

induration

Hardening of a tissue, particularly the skin, because of edema or inflammation

Local Effects of Heat and Cold

Heat and cold stimuli create different physiological responses. The choice of heat or cold therapy depends on local responses desired for wound healing (Table 48-10 pg1218).

Types of Dressings part 4

Hydrogel dressings are gauze or sheet dressings impregnated with water or glycerin-based amorphous gel. Hydrogel dressings are for partial-thickness and full-thickness wounds, deep wounds with some exudate, necrotic wounds, burns, and radiation-damaged skin. They can be very useful in painful wounds because they are very soothing to a patient and do not adhere to the wound bed and thus cause little trauma during removal. Hydrogel has the following advantages: • Is soothing and can reduce wound pain • Provides a moist environment • Debrides necrotic tissue (by softening the necrotic tissue) • Does not adhere to the wound base and is easy to remove Foam and alginate dressings are for wounds with large amounts of exudate and those that need packing. Foam dressings are also used around drainage tubes to absorb drainage. Calcium alginate dressings are manufactured from seaweed and come in sheet and rope form. The alginate forms a soft gel when in contact with wound fluid. These highly absorbent dressings are for wounds with an excessive amount of drainage and do not cause trauma when removed from the wound. Do not use these in dry wounds, and they require a secondary dressing.

Acute Care: Suture Care

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). Special scissors with curved cutting tips or special staple removers slide under the skin closures for suture removal. The health care provider usually specifies the number of sutures or staples to remove. If the suture line appears to be healing in certain locations better than in others, some health care providers choose to have only some sutures removed (e.g., every other one). To remove staples, insert the tips of the staple remover under each wire staple. While slowly closing the ends of the staple remover together, squeeze the center of the staple with the tips, freeing it from the skin. To remove sutures, first check the type of suturing used. Never pull the visible part of a suture through underlying tissue. Sutures on the surface of the skin harbor microorganisms and debris. The part of the suture beneath the skin is sterile. Before taking out the sutures, cleanse the suture line with normal saline. Clip suture materials as close to the skin edge on one side as possible and pull the suture through from the other side.

Pressure Intensity

If the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur. If the patient has reduced sensation and cannot respond to the discomfort of the ischemia, tissue ischemia and tissue death result. The clinical presentation of obstructed blood flow occurs when evaluating areas of pressure. After a period of tissue ischemia, if the pressure is relieved and the blood flow returns, the skin turns red. You assess an area of hyperemia by pressing a finger over the affected area. If it blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode, thus called blanchable hyperemia. However, if the erythematous area does not blanch (nonblanchable erythema) when you apply pressure, deep tissue damage is probable. When checking for pressure ulcers in dark-skinned patients, dark skin may not show the blanch response. Instead, after applying light pressure, look for an area darker than the surrounding skin or one that is taut, shiny, or indurated (hardened). Over time, as tissues become more damaged, the area becomes cooler to the touch.

Factors Influencing Pressure Ulcer Formation and Wound Healing: Age

Increased age affects all phases of wound healing. A decrease in the functioning of the macrophage leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization.

pressure ulcer

Inflammation, sore, or ulcer in the skin over a bony prominence.

Evaluation: Through the Patient's Eyes

It is important to include the patient and family caregiver in the evaluation process. Review whether their expectations of care were met. For example, is the patient satisfied with the level of comfort achieved during wound care? Chronic wounds such as pressure ulcers take time to heal, so home care is likely. Does the patient feel comfortable or confident in being able to perform wound care at home? Does the family caregiver feel she or she has the information needed to know when to report a problem with a wound? If patient and family caregiver expectations are unmet, revise your plan of care to select the best ways to support and re-educate.

Pressure Duration

Low pressure over a prolonged period and high-intensity pressure over a short period are two concerns related to duration of pressure. Both types of pressure cause tissue damage. Extended pressure occludes blood flow and nutrients and contributes to cell death. Clinical implications of pressure duration include evaluating the amount of pressure (checking skin for nonblanching hyperemia) and determining the amount of time that a patient tolerates pressure (checking to be sure after relieving pressure that the affected area blanches).

Full-Thickness Wound Repair: Maturation

Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces. Collagen fibers undergo remodeling or reorganization before assuming their normal appearance.

Hemorrhage

bleeding from a wound site

Drainage evacuators

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

Blanching

occurs when the normal red tones of the light-skinned patient are absent

evisceration

protrusion of visceral organs through a wound opening

Granulation tissue

red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing

slough

stringy substance attached to wound bed

Dehiscence

the partial or total separation of wound layers; Separation of the edges of a wound, revealing underlying tissues

Debridement

the removal of nonviable, necrotic tissue

reactive hyperemia

the transient increase in blood flow that occurs following a brief period of ischemia

Sutures

threads or metal used to sew body tissues together

Assessment of Wounds: Character of Wound Drainage

Note the amount, color, odor, and consistency of wound drainage. The amount of drainage depends on the type of wound. For example, drainage is minimal after a simple appendectomy. In contrast, it is moderate for 1 to 2 days after drainage of a large abscess. When you need an accurate measurement of the amount of drainage within a dressing, weigh the dressing and compare it with the weight of the same dressing that is clean and dry. The general rule is that 1 g of drainage equals 1 mL of volume of drainage. Another method of quantifying wound drainage is to chart the number of dressings used and the frequency of change. Types of drainage include: serous, sanguineous, serosanguineous, and purulent. An example of an accurate recording follows: Abdominal incision in the RLQ is 5 cm in length; edges well approximated without inflammation or exudate. 1.2 cm diameter circle of serous drainage present on one 4 × 4 gauze changed every 8 hours.

Planning: Goals and Outcomes

Nursing care is based on a patient's identified needs and priorities. You establish goals and expected outcomes, and from the goals you plan interventions according to the risk for pressure ulcers or the type and severity of the wound and the presence of any complications such as infection, poor nutrition, peripheral vascular diseases, or immunosuppression that can affect wound healing. A goal frequently identified when working with a patient with a wound is to see the wound progressing toward healing within a 2-week period. The outcomes of this goal can include the following: • Increase in the percentage of granulation tissue in the wound base • No further skin breakdown • Increase in caloric intake by 10% These outcomes are reasonable if the overall goal for the patient is to heal the wound. Other goals of care for patients with wounds include the following: promoting wound hemostasis, preventing infection, promoting wound healing, maintaining skin integrity, gaining comfort, and promoting health.

Implementation: Prevention of Pressure Ulcers

Nursing interventions for patients who are immobile or have other risk factors for pressure ulcers focus on prevention. Table 48-6 describes basic nursing care measures for preventing ulcers based on a patient's risk factors. Prevention minimizes the impact that risk factors or contributing factors have on pressure ulcer development. Three major areas of nursing interventions for prevention of pressure ulcers are: (1) skin care and management of incontinence; (2) mechanical loading and support devices, which include proper positioning and the use of therapeutic surfaces; and (3) education.

Wound Management: Nutritional Status

Nutritional support of a patient with a wound is based on the appreciation that nutrition is fundamental to normal cellular integrity and tissue repair. You will provide 30 to 35 calories/kg of body weight for individuals with a pressure ulcer who are assessed to be at risk for malnutrition. Increased caloric intake helps replace subcutaneous tissue. Patients will also receive vitamin and mineral supplements if suspected or known deficiencies exist. A patient can lose as much as 50 g of protein per day from an open, high exudative pressure ulcer. Although the recommended intake of protein for adults is 0.8 g/kg/day, a higher intake up to 1.8 g/kg/day is necessary for healing. Increased protein intake helps rebuild epidermal tissue.

Key Points

• Pressure ulcers contribute to patient discomfort and decreased functional status, increased length of stay in acute and extended care settings, and increased cost of care. • Wound assessment determines progress toward pressure ulcer healing; do not use the staging system for this purpose. • Assess all patients on an ongoing basis for risk factors that contribute to development of any type of impaired skin integrity such as blistering or burning sensation. • Alterations in mobility, sensory perception, level of consciousness, and nutrition and the presence of moisture increase the risk for pressure ulcer development. • Pressure, shearing force, and friction are contributing factors to the development of pressure ulcers. • Meticulous ongoing assessment of the skin and identification of risk factors are important in decreasing the opportunity for pressure ulcer development. • Preventive skin care is aimed at controlling external pressure on bony prominences and keeping the skin clean, well lubricated and hydrated, and free of excess moisture. • Proper positioning reduces the effects of pressure and guards against the shearing force. • Therapeutic beds and mattresses redistribute the effects of pressure; however, base selection on assessment data to identify the best support surface for individual needs. • Cleaning and topical agents used to treat pressure ulcers vary according to the stage of the pressure ulcer and condition of the wound bed. Assessment of the ulcer enables the nurse to select proper skin-care agents. • Direct nutritional interventions at improving wound healing through increasing protein and calorie levels. • Wound assessment requires a description of the appearance of the wound base, size, presence of exudate, and periwound skin condition. • The chances of wound infection are greater when a wound contains dead or necrotic tissue, when foreign bodies lie on or near the wound, and when the blood supply is reduced. • The principles of wound first aid include control of bleeding, cleaning, and protection. • A moist environment supports wound healing. • An acute sprain, closed fracture, or bruise responds best to cold applications. • The selection of the type of dressing is determined by the type and condition of a wound. • Use medical versus surgical asepsis when applying dressings on a clean chronic wound versus a new surgical wound.

First Aid for Wounds: Hemostasis

After assessing the type and extent of a wound, control bleeding by applying direct pressure with a sterile or clean dressing such as a washcloth. After bleeding subsides, an adhesive bandage or gauze dressing taped over the laceration allows skin edges to close and a blood clot to form. If a dressing becomes saturated with blood, add another layer of dressing, continue to apply pressure, and elevate the affected part. Avoid further disruption of skin layers. Pressure dressings used during the first 24 to 48 hours after trauma help maintain hemostasis. Normally allow a puncture wound to bleed to remove dirt and other contaminants such as saliva from a dog bite. When a penetrating object such as a knife blade is present, do not remove the object. The presence of the object provides pressure and controls some bleeding. Removal causes massive, uncontrolled bleeding. Except for skull injuries, apply pressure around the penetrating object but not on it and transport the patient to an emergency facility.

Planning

After identifying nursing diagnoses, develop a plan of care for a patient who has the problem-focused or risk diagnosis for Impaired Skin Integrity. Patients who have large, chronic wounds or infected wounds have multiple nursing care needs. A concept map helps to individualize care for a patient who has multiple health problems and related nursing diagnoses (Figure 48-14 pg1200). This map helps you use critical thinking skills to organize complex patient assessment data into related nursing diagnoses with the patient's chief medical diagnosis.

Acute Care: Cleaning Skin and Drain Sites

Although a moderate amount of wound exudate promotes epithelial cell growth, some health care providers order cleaning a wound or drain site if a dressing does not absorb drainage properly or if an open drain deposits drainage onto the skin. Wound cleaning requires good hand hygiene and aseptic techniques. You sometimes use irrigation to remove debris from a wound.

Classification of Pressure Ulcers part 1

As a nurse, you need to perform an initial assessment of a pressure ulcer using systematic parameters. Then you will evaluate at regular intervals to determine the status and progress toward wound healing and to plan appropriate interventions.. Assessment includes wound location, depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions (if present, include sinus tracts and tunneling), exudate description (if present, odor), and condition of surrounding skin. Staging systems for pressure ulcers are based on describing the depth of tissue loss. Pressure ulcers do not progress from a stage III to a stage I; rather, a stage III ulcer demonstrating signs of healing is described as a healing stage III pressure ulcer.

Acute Care: Management of Pressure Ulcers

Aspects of pressure ulcer treatment include local care of the wound and supportive measures such as adequate nutrients and redistribution of pressure. Before treating a pressure ulcer, reassess the wound for location, stage, size, tissue type and amount, exudate, and surrounding skin condition. Acute wounds require close monitoring (every 8 hours). Chronic wound assessment occurs less frequently. Several healing and documentation tools are available to document wound assessments over time. Using a tool helps link assessment to outcomes so an evaluation of the plan of care follows objective criteria.

Assessment of Wounds: Psychosocial

Assess how the wound is influencing the patient's self-perception and socialization. Ask the patient to describe how the wound affects his or her view of self. Does the patient have unwarranted fears that the wound will not heal? Does a chronic wound interfere with the patient's willingness to participate in social activities at home? Does it affect the patient's ability to continue working? Make sure that the patient's personal and social resources for adaptation are a part of your assessment. Is there a family caregiver who is able to assist with wound care in the home?

Assessment of Pressure Ulcers: Mobility

Assessment includes documenting the level of mobility and the potential effects of impaired mobility on skin integrity. Documenting assessment of mobility includes obtaining data regarding the quality of muscle tone and strength. For example, determine whether the patient is able to lift his or her weight off of the sacral area and roll the body to a side-lying position. Finally, assess a patient's activity tolerance to determine if the patient can be transferred to a chair or ambulated more often to relieve pressure from lying down. You must assess mobility as part of baseline data. If a patient has some degree of mobility independence, reinforce the frequency of position changes and measures to relieve pressure. The frequency of position changes is based on ongoing skin assessment and is revised as data change.

Assessment of Pressure Ulcers: Nutritional Status

An assessment of patients' nutritional status is an integral part of the initial assessment data for all patients, especially those at risk for impaired skin integrity. Malnutrition is a risk factor for pressure ulcer development. Weigh the patient, and perform this measure more often for at-risk patients. A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 lbs in a brief period are all signs of actual or potential nutritional problems. Also assess the patient's appetite and food preferences to determine what food choices might be added to better supplement the diet. Assess the patient's mouth and skin for signs of nutritional deficiencies.

Types of Dressings part 2

Another type of dressing is a self-adhesive, transparent film that traps moisture over a wound, providing a moist environment. The transparent film dressing is ideal for small superficial wounds such as a Stage I pressure ulcer or a partial-thickness wound. 1210Use a 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 • Does not require a secondary dressing

Assessment: Pressure Ulcers

Assessment for pressure ulcer risk includes using an appropriate predictive measure and assessing a patient's mobility, nutrition, presence of body fluids, and comfort level

Nursing Diagnosis

Assessment reveals clusters of data to indicate whether a problem-focused diagnosis of Impaired Skin Integrity or a risk diagnosis of Risk for Impaired Skin Integrity exists. For example, a postoperative patient has purulent drainage from a surgical wound and reports tenderness around the area of the wound. These data support a nursing diagnosis of Impaired Skin Integrity related to infection (Box 48-6). Multiple nursing diagnoses are associated with impaired skin integrity and wounds: • Risk for Infection • Imbalanced Nutrition: Less Than Body Requirements • Acute or Chronic Pain • Impaired Physical Mobility • Impaired Skin Integrity • Risk for Impaired Skin Integrity • Ineffective Peripheral Tissue Perfusion • Impaired Tissue Integrity Some patients are at risk for poor wound healing because of the presence of previously defined conditions that impair healing. Thus, even though a patient's wound appears normal, the nurse identifies nursing diagnoses such as Impaired Nutrition or Ineffective Peripheral Tissue Perfusion that direct nursing care toward support of wound repair. An alteration in comfort with the diagnosis of Acute Pain and Impaired Mobility have implications for a patient's eventual recovery. For example, a large abdominal incision causes enough pain to interfere with the patient's ability to turn in bed effectively, making him or her at risk for impaired skin integrity.

Risk Assessment of Pressure Ulcers

By identifying at-risk patients, you are able to put interventions into place and spare patients with little risk for pressure ulcer development the unnecessary and sometimes costly preventive treatment. Prevention and treatment of pressure ulcers are major nursing priorities. The Braden Scale is the most widely used risk-assessment tool for pressure ulcers and is in the WOCN guidelines as being a valid tool to use for pressure ulcer risk assessment. The Braden Scale contains six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The total score ranges from 6 to 23; a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden Scale in the general adult population is 18.

Complications of Wound Healing: Hemorrhage

Hemorrhage, or bleeding from a wound site, is normal during and immediately after initial trauma. Hemostasis occurs within several minutes unless large blood vessels are involved or a patient has poor clotting function. Hemorrhage occurring after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (e.g., a drain). A surgical drain may be inserted into tissues beneath a wound to remove fluid that collects in underlying tissues. You detect internal bleeding by looking for distention or swelling of the affected body part, a change in the type and amount of drainage from a surgical drain, or signs of hypovolemic shock. A hematoma appears as a swelling, change in color, sensation, or warmth that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because pressure from the expanding hematoma obstructs blood flow.

Assessment of Wounds: Wound Cultures

If you detect purulent or suspicious-looking drainage, report to the health care provider because a specimen of the drainage may need to be obtained for culture. Never collect a wound culture sample from old drainage. Clean a wound first with normal saline to remove skin flora. Aerobic organisms grow in superficial wounds exposed to the air, and anaerobic organisms tend to grow within body cavities. Gram stains of drainage are often performed as well. This test allows the health care provider to order appropriate treatment earlier than when only cultures are done. No additional specimens are usually required. The gold standard of wound culture is tissue biopsy.

Warm Soaks

Immersion of a body part in a warmed solution promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution. Sometimes a soak is also accompanied by wrapping the body part in dressings and saturating them with the warmed solution. Position the patient comfortably, place waterproof pads under the area to be treated, and heat the solution to about 40.5° to 43° C (105° 1220to 110° F). After immersing the body part, cover the container and extremity with a towel to reduce heat loss. It is usually necessary to remove the cooled solution and add heated solution after about 10 minutes.

Category/Stage I: Nonblanchable Redness

Intact skin presents with nonblanchable redness of a localized area, usually over a bony prominence. Discoloration of the skin, warmth, edema, hardness, or pain may also be present. Darkly pigmented skin may not have visible blanching but its coloring may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones.

blanchable hyperemia

Redness of the skin caused by dilation of the superficial capillaries. When pressure is applied to the skin, the area blanches, or turns a lighter color.

First Aid for Wounds: Protection

Regardless of whether bleeding has stopped, protect a traumatic wound from further injury by applying sterile or clean dressings and immobilizing the body part. A light dressing applied over minor wounds prevents entrance of microorganisms.

Category/Stage II: Partial-Thickness

Partial thickness loss of dermis presents as a shallow, open ulcer with a red-pink wound bed without slough. It may also present as an intact or open/ruptured serum-filled or serosanguineous-filled blister. It presents as a shiny or dry shallow ulcer without slough or bruising (see Figure 48-4, B). The presence of bruising indicates deep tissue injury. This category should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation.

Risk Factors for Pressure Ulcer Development: Impaired Sensory Perception

Patients with altered sensory perception for pain and pressure are more at risk for impaired skin integrity than those with normal sensation. Patients with impaired sensory perception of pain and pressure are unable to feel when a part of their body undergoes increased, prolonged pressure or pain.

tissue ischemia

Point at which tissues receive insufficient oxygen and perfusion.

Prevention of Pressure Ulcers: Positioning

Positioning interventions redistribute pressure and shearing force to the skin. Elevating the head of the bed to 30 degrees or less decreases the chance of pressure ulcer development from shearing forces. A standard turning interval of 1 1/2 to 2 hours does not always prevent pressure ulcer development. Consider repositioning the patient at least every 2 hours if allowed by his or her overall condition. When repositioning, use positioning devices to protect bony prominences. The WOCN guidelines (2010) recommend a 30-degree lateral position (Figure 48-15), which should prevent positioning directly over the bony prominence. To prevent shear and friction injuries, use a transfer device to lift rather than drag the patient when changing positions. For patients at risk for skin breakdown who are able to sit in a chair, limit the amount of time they sit to 2 hours or less at any given time. Teach the patient to shift weight every 15 minutes while sitting. Rigid and donut-shaped cushions are contraindicated because they reduce blood supply to the area, resulting in wider areas of ischemia.

Implementation: Health Promotion

Prompt identification of high-risk patients and their risk factors helps to identify the interventions needed to prevent pressure ulcers.

Risk Factors for Pressure Ulcer Development: Shear

Shear force is the sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary. For example, shear force occurs when the head of the bed is elevated and the sliding of the skeleton starts but the skin is fixed because of friction with the bed. It also occurs when transferring a patient from bed to stretcher and the patient's skin is pulled across the bed. The underlying tissue capillaries are stretched and angulated by the shear force. As a result, necrosis occurs deep within the tissue layers. The tissue damage is deep in the tissues and causes undermining of the dermis.

Assessment of Wounds: Wound Closures

Surgical wounds are closed with staples, sutures, or wound adhesives. A frequent skin closure is the stainless-steel staple. The staple provides more strength than nylon or silk sutures and tends to cause less irritation to tissue. Look for irritation with redness around staple or suture sites, and note whether closures are intact. Dermabond is a liquid tissue adhesive that forms a strong bond across approximated wound edges, allowing normal healing to occur below. It can be used to replace small sutures for incisional repair.

hemostasis

Termination of bleeding by mechanical or chemical means or the coagulation process of the body.

Tissue Tolerance

The ability of tissue to endure pressure depends on the integrity of the tissue and the supporting structures. The extrinsic factors of shear, friction, and moisture affect the ability of the skin to tolerate pressure: the greater the degree to which the factors of shear, friction, and moisture are present, the more susceptible the skin will be to damage from pressure. The second factor related to tissue tolerance is the ability of the underlying skin structures (blood vessels, collagen) to help redistribute pressure.

Dressings: Purposes of Dressings

A dressing serves several purposes: • Protects a wound from microorganism contamination • Aids in hemostasis • Promotes healing by absorbing drainage and debriding a wound • Supports or splints a wound site • Promotes thermal insulation of a wound surface • Provides a moist environment When the skin is broken, a dressing helps reduce exposure to microorganisms. However, when drainage is minimal, the healing process forms a natural fibrin seal that eliminates the need for a dressing. Wounds with extensive tissue loss always need a dressing. Pressure dressings promote hemostasis. Check pressure dressings to be sure that they do not interfere with circulation to a body part. The primary function of a dressing on a healing wound is to absorb drainage. Most surgical gauze dressings have three layers: a contact or primary layer, an absorbent layer, and an outer protective or secondary layer. If a gauze dressing sticks to a surgical incision, lightly moisten it with saline solution. This saturates the dressing and loosens it from the incisional area, thus preventing trauma to the incisional area during removal. When wounds such as a necrotic wound require debriding, a moist-to-dry dressing technique can be considered. You place the moist dressing (contact dressing) over the wound bed, cover with a clean gauze and allow the contact layer to dry. In this case the contact dressing is allowed to dry so it sticks to underlying tissue and debrides the wound during removal. Dressings applied to a draining wound require frequent changing to prevent microorganism growth and skin breakdown. Minimize periwound skin breakdown by keeping the skin clean and dry and reducing the use of tape. A dressing needs to support a moist wound environment if the wound is healing by secondary intention.

Types of Dressings part 3

Hydrocolloid dressings are dressings with complex formulations of colloids and adhesive components. They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as wound exudate is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds. This type of dressing has the following functions: • Absorbs drainage through the use of exudate absorbers in the dressing • Maintains wound moisture • Slowly liquefies necrotic debris • Is impermeable to bacteria and other contaminants • Is self-adhesive and molds well • Acts as a preventive dressing for high-risk friction areas • May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing The hydrocolloid dressing is useful on shallow-to-moderately deep dermal ulcers.

Factors Influencing Pressure Ulcer Formation and Wound Healing

Impaired skin integrity resulting in pressure ulcers is primarily the result of pressure. However, additional factors, including shear force, friction, moisture, nutrition, tissue perfusion, infection, and age, increase the patient's risk for pressure ulcer development and poor wound healing.

Category/Stage III: Full-Thickness Skin Loss

In full-thickness tissue loss subcutaneous fat may be visible; but bone, tendon, and muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. It may include undermining and tunneling. The depth of a category/stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and category/stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep category/stage III pressure ulcers.

Category/Stage IV: Full-Thickness Tissue Loss

In full-thickness tissue loss with exposed bone, tendon, or muscle, subcutaneous fat may be visible; but bone, tendon, and muscle are not exposed. Slough or eschar may be present. It often includes undermining and tunneling. The depth of a category/stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue; and these ulcers can be shallow. Category/stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.

primary intention

Primary union of the edges of a wound, progressing to complete scar formation without granulation.