Nursing Fundamentals Chapter 48: Skin Integrity & Wound Care

Wound Healing

*2 types of wounds:* those with loss of tissue and those without *primary intention*: how surgical incision heals; skin edges are approximated (closed) with low risk of infection. heals quickly with minimal scar formation *secondary intention*: how wound involving loss of tissue (burns, pressure ulcer, or severe laceration) heals; left open until filled by scar tissue;longer healing with greater chance of infection

Complications of Healing: Infection

-*2nd most common health care associated infection* (nosocomial) -a wound is infected if purulent material drains from it, even if culture is not taken or has negative results -if drainage is present, it is odorous and purulent (causing yellow, free, or brown color)

Risk Assessment

-*Braden Scale:* a valid tool to use for pressure ulcer risk assessment; 6 subscales: sensory perception, moisture, activity, mobility, nutrition, and friction/shear (ranging from 6-23=lower indicates higher risk for ulcer development) -*Prevention:* economic consequences (problem in acute and restorative care)

Stage III

-*Full-thickness Skin Loss (Fat Visible)* -tendon, muscle, or bone NOT EXPOSED

Unstageable/Unclassified

-*Full-thickness Skin or Tissue Loss--Depth Unknown*

Stage IV

-*Full-thickness Tissue Loss (Muscle/Bone Visible)* -slough or eschar may be present

Stage I

-*Nonblanching Redness of Intact Skin* -intact skin presents with nonblanchable erythema -discoloration, warmth, edema, hardness, or pain

Stage II

-*Partial-thickness skin loss or blistering* -shiny or dry shallow ulcer without slough or bruising

Pathogenesis of Pressure Ulcers (Pressure Intensity)

-*tissue ischemia* occurs if pressure applied over a capillary exceeds normal capillary pressure and the vessel is occluded for a prolonged period of time -*blanching* (turns lighter in color) occurs when normal red tones of light skinned patient are absent; dark pigmented do not blanch

Wound Classification

-*wound:* disruption of the integrity and function of tissues in the body -classification systems describe the status of skin integrity, cause of the wound, severity or extent of tissue injury or damage, cleanliness of the wound, or descriptive qualities of the wound tissue such as color

Suspected Deep-Tissue Injury

-Depth Unknown

Risk Factors for Pressure Ulcer Development

-Impaired Sensory Perception -Impaired mobility -Alteration in level of consciousness -Shear: sliding movement of skin and subQ tissue while muscle and bone are stationary -Friction -Moisture

Factors Influencing Pressure Ulcer Formation and Wound Healing

-Nutrition: *table 48-4* -Tissue Perfusion -Infection -Age -Psychosocial Impact of wounds

Pathogenesis of Pressure Ulcers (Tissue Tolerance)

-ability of tissue to endure pressure depends on the integrity of the tissue and supporting structures -extrinsic factors of shear, friction, and moisture affect ability of skin to tolerate pressure -systemic factors such as poor nutrition, increased aging, hydration status, and low BP affect tolerance of tissue to external pressure

Pathogenesis of Pressure Ulcers (Pressure Duration)

-extended pressure occludes blood flow and nutrients and contributes to cell death -evaluate amount of pressure (checking skin for reactive hyperemia) and determine time patient tolerates pressure (checking to be sure after relieving pressure that affected area blanches)

Complications of Healing: Hemorrhage

-hemorrhage: (bleeding from wound site) normal during and immediately after initial trauma -hemorrhage occurring after hemostasis indicates a slipped surgical suture, dislodged clot, infection, or erosion of a BC by foreign object -*hematoma:* localized collection of blood underneath tissue -external hemorrhage is obvious-- observed by drainage

Health Promotion: Prevention

-immobile patients are at major risk for developing pressure ulcers -topical skin care and incontinence management -positioning -support surfaces (therapeutic beds and mattresses) Table 48-7

Dermis

-inner layer; provides tensile strength, mechanical support, and protection to the underlying muscles, bones, and organs -differs from epidermis bc is contains mostly CT and few skin cells; Collagen, BVs, and nerves are found here; Fibroblast (collagen formation) are distinct cell types within dermis

Positioning

-interventions reduce pressure and shearing force to the skin -elevate head of bed to <30 degrees decreases chance of ulcer development from shearing forces -reposition *every 1-2 hours* and protect bony processes -*30-degree lateral position is recommended* -after positioning, reassess skin and observe for *normal reactive hyperemia* -never massage reddened areas

At Risk Patients for Pressure Ulcers

-patient experiencing decreased mobility, decreased sensory perception, fecal or urinary incontinence, and/or poor nutrition

Factors Contributing to Pressure Ulcer Formation

-pressure is major cause -any factor that interferes with blood flow in turn interferes with cellular metabolism and fan or life of cells resulting in tissue ischemia and tissue death

Pressure Ulcers

-pressure ulcer, pressure sore, decubitus ulcer, and bedsore describe impaired skin integrity related to prolonged pressure -*pressure ulcer:* localized injury to the skin and other underlying tissue, usually over a body prominence, as a result of pressure or pressure in combination with shear and/or friction

Skin

-protective barrier and a sensory organ for pain, temperature, and touch; and it synthesizes vitamin D -2 layers: epidermis and the dermis separated by a membrane called the *dermal-epidermal junction* -if injured, the epidermis fans to resurface the wound and restore the barrier against invading organisms while the dermis responds to restore the structural integrity and physical properties

Nursing Diagnosis

-risk for infection -imbalanced nutrition: less the required -acute or chronic pain -impaired physical mobility -impaired skin integrity -risk for impaired skin integrity -ineffective peripheral tissue perfusion -impaired tissue integrity

Assessment

-skin -pressure (predictive measure, mobility, nutritional status, body fluids, pain) -wounds (emergency setting, stable setting, wound appearance, character of wound drainage, drains, wound closure, palpation of wound, wound cultures)

Epidermis

-top layer; has several layer with the stratum corneum as the thin, outermost layer -consists of flattened, dead, keratinized cells originating from the innermost epidermal layer (basal layer) -cells in the basal layer divide, proliferate, and migrate toward epidermal surface where they flatten and die after they reach corneum layer -constant movement ensures replacement of surface cells sloughed during shedding -corneum layer protects underlying cells from dehydration and prevents entrance of certain chemical agents

Complication of Healing: Evisceration

-total separation of wound layers -*evisceration*: protrusion of visceral organs through a wound opening -EMERGENCY that requires surgical repair

Complication of Healing: Dehiscence

-when wound fails to heal properly, the layers of skin and tissue separate -*dehiscence:* partial or total separation of wound layers

Abrasion/Laceration/Puncture

Abrasion: superficial with little bleeding and is considered a partial-thickness wound Laceration: bleeds more profusely, depending on the depth and location of wound Puncture: wound bled in relation to the depth and size of the wound

Full-Thickness Wound Repair

Hemostasis: control of blood loss, bacterial control, and seal the defect occurs when there is an injury; during this phase injured BVs constrict and platelets gather to stop bleeding (clots form fibrin matrix providing framework for cellular repair) Inflammatory phase: damaged tissue and mast cells secrete *histamine resulting in vasodilation of capillaries and exudation of serum and WBCs into damaged tissue* Proliferative phase: the filling of the wound with granulation tissue, contraction of the sound, and the resurfacing of the wound by *epithelialization* Remodeling:maturation, final stage of healing, can take more than a year, depending on the depth and extent of the wound

Drains

Penrose drain: lies under dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into wound Hemovac or Jackson-Pratt: evacuator unit that exerts a constant low pressure as long as the suction devise (bladder or container) is fully compressed "self suction"

Types of Wound Drainage

Serous: clear, watery plasma Purulent: thick, yellow, green, tan, or brown Serosangineous: pale, pink, watery; mixture of plasma and RBCs Sanguineous: bright red; indicates active bleeding

Slough/Eschar/Exudate

Slough: stringy substance attached to wound bed (must be removed before wound can heal) Eschar: black or brown necrotic tissue (must be removed before wound can heal) Exudate: describes amount, color, consistency, and order of wound drainage

Partial-Thickness Wound Repair

includes inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of epidermal layers