Skin integrity and Wound care
How do we implement wound and pressure ulcer healing?
Wound: -maintain moist wound bed to promote healing -nutrition and fluids (increase protein, vitamins, zinc) -infection prevention -positioning Ulcers: -maintaining skin hygiene -avoiding skin trauma -providing supportive devices -treatment by following protocol -registered dietitian
Tertiary intention healing (Delayed primary intention.)
Wounds that are *left open for 3 to 5 days* to allow edema or infection to resolve or exudate to drain and are then closed with sutures, staples, or adhesive skin closures Ex: surgical wound left open until infection is better then closed.
Unstageable/unclassified pressure ulcer
completely obscured by slough and/or eschar TREAT: debridement- the removal of damaged tissue or foreign objects from a wound (done in the OR)
RYB color Guide- B
*B*lack (debride)- covered with thick necrotic tissue, or eschar. They require debridement- removal of the tissue so that it is able to be staged and healed. This is a surgical technique or is done by wound care specialists.
Phases of wound healing: #3 *Maturation*
*From day 21 until 1 to 2 years post injury* -collagen organize into a more orderly structure, the wound is remodeled and *scar becomes stronger but never as strong as original tissue. * -Sometimes an abnormal amount of collagen is laid down, which can result in a keloid.
Phases of wound healing: #2 *Proliferative*
*From post injury day 2 or 4 until day 21* -fibroblasts synthesize collagen which strengthens the wound. -granulation tissue is also formed (red color, fragile, and bleeds easily) *which is where we collect the sample* -Eschar: black tissue
RYB color Guide- R
*R*ed (protect)- to avoid disturbance of regenerating tissue. Protect with: hydrogel, alginate, mapelax HAM
RYB color Guide- Y
*Y*ellow (cleanse)- apply damptodamp *(wet to wet)* normal saline dressings, *irrigate the wound*, using *absorbent dressing* materials such as impregnated *hydrogel or alginate* dressings, and consulting with the primary care provider about the need for a topical antimicrobial *ointment* to minimize bacterial growth. HAT
serosanguineous exudate
*clear and blood-tinged drainage= pink-ish, normal* Ex: surgical incisions (expected) post-op
serous exudate
*clear portion of the blood* (serum) Light, no RBCs. Ex: fluid in a blister or burn
Hot and Cold
*heat:* *vasodilation* (can drop BP, fainting), increased capillary permeability, increased cellular metabolism, increased inflammation, *sedative effect*. Ex: *used for joint stiffness from arthritis, contractures, low back pain* *cold:* *vasocontrict*, decreased capillary permeability and metabolism, slowed bacterial growth, decrease inflammation, *anesthetic* Ex: used for *sprains, fractures, strains, post injury swelling/bleeding*
Complication of wound healing: *dehiscence*
*partial or total rupturing of sutured wound * Ex: abdominal wound From stress, coughing, that's why they were a binder post-op
*Hydrocolloids* (Duoderm) is used for...
*pressure ulcers II-IV and to absorb exudate* shallow ulcers and maintain an appropriate healing environment -waterproof *-can keep on for 7 days.* -they can be molded to uneven body surfaces -has 2 layers
Clean-contaminated wound
-*surgical wounds/incision* *Respiratory, GI, GU, or urinary tract HAS BEEN ENTERED*. These wounds show no evidence of inflammation *Treatment: dry sterile dressing or transparent*
Factors affecting skin integrity: *medications*
-Corticosteroids (anti-inflammatory): cause thinning of the skin sometimes their skin will peel off with the tape Many medications increase sensitivity to sunlight. -Antibiotics (tetracycline and doxycycline)- prolonged use makes you more susceptible to infection -Neoplastic: Chemotherapy drugs (methotrexate) -Psychotherapeutic drugs (TCAs)
Factors affecting skin integrity: *Chronic illnesses and their treatments*
-Diabetes -Peripheral vascular disease- less arterial circulation which effects their skin integrity. -Impaired peripheral arterial circulation may have skin on the legs that damages easily. -heart failure (edema)- causes decreased circulation
What are the labs used to tract wound healing?
-Leukocyte count (decreased amount can delay healing and increase possibility of infection) -Hemoglobin (low indicates poor oxygen delivery to the tissues) -Blood coagulation studies (prolonged coagulation times can result in excessive blood loss and prolonged clot absorption; Hypercoagulability can lead to clotting and deficient blood supply to the wound area) PT/INR, ESR -Serum protein analysis (uses albumin which is an important indicator for nutritional status) *A value below 3.5 g/dL indicates poor nutrition and may increase the risk of poor healing* and infection. -Wound culture and sensitivities: to see what's growing or not. Helpful in the selection of appropriate antibiotic therapy.
When should we take special precautions when implementing heat/cold?
-Neurosensory impairment -impaired mental status -impaired circulation -open wounds
VAC
-Vacuum assisted closure Use of suction equipment to apply negative pressure to a variety of wound types
What should we assess for treated wounds?
-appearance -size -drainage -presence of swelling -pain -status of drains/tubes
Partial thickness wound
-dermis, epidermis -heal by regeneration (renewal of tissues)
Full thickness
-dermis, epidermis, subcutaneous tissue, muscle, and bones -*Require connective tissue to repair* Ex: usually stage III and IV ulcers
What are nurses responsible for doing if a pt has a wound drain?
-empty, measure, describe drainage -changing the dressing -documenting the character (color, smell, amount, etc) within the pt record- I/Os Suction is generally continued for 3 to 7 days postop or until the wound is drainage free
Polyurethane foam (lyofoam) is used for..
-light to high exudate wound -pressure ulcers
What should we assess for untreated wounds?
-location -extent of tissue damage -LxWxD -Bleeding -foreign bodies -associated injuries -last tetanus toxoid injection to prevent seizure activity from infection
What should we assess for pressure ulcers?
-location of ulcer r/t bony prominence -size in cm -presence of undermining or sinus tracts -stage of ulcer -color of wound bed -location of necrosis or eschar -condition of wound margins -integrity of surrounding skin -clinical signs of infection (local and systemic)
When should we not use cold?
-open wounds (increase tissue damage) -impaired circulation -allergy of hypersensitivity
Elasticized
-provide pressure to an area Ex: elastic bandages on the lower extremities to improve venous circulation in legs
Gauze
-retain dressing on wounds -bandage fingers, hands, toes, and feet -supports dressing and permits air to circulate
How can we help avoid skin trauma?
-smooth, firm, and wrinkle free foundation -semi-fowler's position -frequent change of position -exercise/ambulation -lifting devices -reposition q2hrs -turning schedule -avoid massage over bony areas
When should we not use heat?
-the first 24 hrs after traumatic injury (increase bleeding) -active hemorrhage -noninflammatory edema -localized malignant tumor -skin disorder that causes redness or blisters
What are the 2 types of risk assessment tools?
1. *Braden scale:* pressure sore risk *below 18=at risk* -Categories: sensory, moisture, activity, mobility, nutrition, friction and shear -turn, diet, no wrinkles, devices, nutrition consult 2. *Norton's:* includes categories of: general physical condition (good, fair, poor, and very bad), mental state, activity, mobility, and incontinence. *below 14=at risk* Possible score of 24. ^norton's is very subjective^
What do we document for wounds?
1. *Length x Width x Depth* using centimeters. measure depth using parallel swabs 2. Exudate *amount* -none, light, moderate, heavy -color and type 3. *Tissue Type* -necrotic tissue (eschar) -slough: yellow or white tissue, adhere to ulcer -granulation tissue: pink of beefy red tissue with a shiny, moist granular appearance -epithelial tissue: superficial tissue, pink shiny tissue.
10 Risk factors for pressure ulcers:
1. Friction and shearing: pull and lift don't slide. 2. Immobility 3. Inadequate nutrition 4. Fecal and urinary incontinence: moisture causes skin maceration which is soft tissues by prolonged wetting/soaking 5. Decreased mental status: don't really respond to pain 6. Diminished sensation: loss of sensation in a body area 7. Excessive body heat 8. Advanced age 9. Presence of certain chronic conditions 10. Others: poor lifting, incorrect positioning, incorrect application of pressure-relieving devices
Where do we obtain a culture specimen from?
Base of the wound granulation tissue
How do we know if it's a stage 1 pressure ulcer or not?
Blanch test -if the pt is of a darker skin color: touch to see if the skin is warm
Contusion
Blow from a blunt instrument Closed, skin appears ecchymotic (bruised) because of damaged blood vessels
Complication of wound healing: *evisceration*
*protrusion of internal viscera through an incision* *-whenever dehiscence or evisceration occurs the wound should be quickly supported by large sterile dressings soaked in sterile normal saline and notify the surgeon immediately so it doesn't get dried out.*
purosanguineous exudate
*pus and blood*, not normal Ex: infected wound and bleeding
What happens if a patient shows up to the hospital with intact skin then they develop pressure ulcers during their stay in the hospital?
The insurance companies won't give any reimbursement for pressure ulcers. -that's why it's so important to do a complete assessment of the pts skin no matter how sick they are. Then reassess q4h or q2h if they are bed ridden bc that's when we do position changes. *document q2h*
Factors affecting skin integrity: *age*
The skin of both the very young and the very old is *more fragile and susceptible to injury* than that of most adults. Wounds also tend to heal more rapidly in infants and children -vascular changes, atherosclerosis, *less collagen tissue*, changes in immune system, nutritional deficiencies in older adults, *less elasticity, less muscle*
When skin is compressed with pressure it appears pale, when pressure is relieved what is the normal response?
The skin takes on a bright red flush called *reactive hyperemia* The flush is due to vasodilation, a process in which extra blood floods to the area to compensate for the preceding period of impended blood flow.
Incision
Sharp instrument (knife, scalpel) Open wound; once they are sealed together for healing, it is considered a closed wound
What are some pressure-relieving devices?
Waffle, wedge, heal protectors (have to relieve them once per a shift)
How do we cleanse a wound?
-midpoint and outward; and from top to bottom -clean to dirty
How can we treat pressure ulcers?
-minimize direct pressure -reposition client q2h (schedule and record) -provide pressure minimizing devices -clean and dress ulcer using surgical asepsis -never use alcohol or hydrogen peroxide -obtain C&S, if infected (need order) -provide ROM exercises
How can we help maintain skin integrity?
-minimize force and friction -use mild cleansing agents -avoid hot water -use moisturizing lotions/skin protection but not directly on bony prominence area -keep skin clean and dry -keep free of irritation and maceration
Stage II pressure ulcer
Partial-thickness skin loss (abrasion, blister, or shallow crater) involving *EPIDERMIS and possibly the DERMIS* TREAT: hydrocolloid can be left for 5-7 days. and everything with stage 1
Transparent film (Op-site, tegaderm) is used to...
Protect contamination -act as temporary skin *Facilitate wound assessment* *used for: incision, clean contaminated, IV, central lines* Ex: IV
Stage I pressure ulcer
Redness *doesn't* go away nonblanchable erythema signaling potential ulceration *epidermis* TREAT- use skin protective lotion, ambulate, turn q2h strictly, nutrition consult.
Healthy people 2020
Reduce the rate of pressure ulcers-related hospitalization among older people. -reviewed q10 years
sanguineous exudate
Consists of *large amounts of RBCs* which indicates damage to the capillaries. Ex: open wounds *bright sanguineous indicates fresh bleeding, whereas dark sanguineous denotes older bleeding*
Secondary intention healing
Extensive tissue loss and the edges cannot be approximated. *-repair time is longer (we don't know how many days)* *-scarring is greater* *-susceptibility to infection is greater* Ex: Pressure ulcers
Stage III pressure ulcer
Full-thickness skin loss involving damage or necrosis of *subq tissue that may extend don to, but not through underlying fascia (sheath enclosing muscle)* subq and muscle. TREAT: wound consult nurse, wet to dry dressing (clean with saline, put gauze inside, then sterile dressing)
Risk for infection r/t
If skin impairment is severe, pt is immunosuppressed, or wound is caused by trauma Ex: open wound
Phases of wound healing: #1 *inflammatory*
Immediately after injury; *lasts 3 to 6 days* 2 processes involved: -*Hemostasis: stop the bleeding causing vasoconstriction. Then we develop clot and eventually see a scab which will protect the skin from infection.* Normal: We will see redness, warmth, and exudate around the wound -Neutrophils move into interstitial space and are replaced by macrophages. *Phagocytosis: macrophages engulf microorganisms and cellular debris*
Complication of wound healing: *Infection*
Infection suggested by a change in wound color, pain, odor, or drainage is confirmed by performing a culture of the wound -severe infection causes fever and elevated WBCs.
Risk for impaired skin integrity r/t
braden scale less than 10 -vulnerable to alteration in epidermis and/or dermis which may compromise health GOAL: maintain skin integrity, avoid potential associated risk factors
Impaired skin integrity r/t
altered epidermis/dermis Ex: stage 2 pressure ulcers, any pt with a wound GOAL: progressive wound healing, regain intact skin
Collagen (gel, nu-gel) is used for...
clean, moist wound -assist in stopping the bleeding
Dirty or infected wounds
include wounds *containing dead tissue and* wounds with evidence of a clinical infection, such as *purulent drainage*. Ex: Gas gangrene (diabetics)
Complication of wound healing: *Hemorrhage*
massive abnormal bleeding Cause: dislodged clot, slipped stitch, erosion of a blood vessel Some patients will have a hematoma, a localized collection of blood underneath the skin that may appear as a reddish blue swelling (bruise). -confirm the hematoma with x/ray or CT scan
Exudate
material (fluid,cells) escaped from blood vessels during inflammatory process and is deposited in tissue or on tissue surfaces
rebound phenomenon
maximum therapeutic effect achieved and opposite effect begins
Contaminated wound
open, fresh, accidental wounds and surgical wounds involving a major break in sterile technique or a large amount of spillage from the GI tract. -they show evidence of inflammation. Ex: *pressure ulcers, bed sores,* Laceration, Puncture, Abrasion
Puncture
penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional.
When doing a dressing change the tape should be...
placed at the ends of the dressing and must be sufficiently long and wide to secure the dressing.
Impregnated non adherent (Adaptive) is used for..
post-op, superficial burn Woven or nonwoven *cotton* or synthetic materials that have saline. Require secondary dressings to secure them in place, retain moisture, and provide wound protection. Glue like, sometimes non-adherent
Impaired tissue integrity r/t
damage to mucous memebrane, cornea, integumentary system, muscular fascia, muscle, tendon, bone, cartilage, joint capsule, and/or ligament Ex: stage 3,4
Localized ischemia
decreased blood supply (circulation and oxygen) to the tissue so it dies.
Dry and Moist cold
dry: cold pack, ice bag, ice glove, ice collar moist: compress, cooling sponge bath
Dry and Moist heat
dry: hot water bottle, aquathermia pad, disposable heat pack, electric pad moist: compress, hot pack, soak, sitz bath
figure 8 turns are best used for
elbows, knees, or ankles because they permit some movement after application
Clear absorbent acrylic and Hydrogel (Tegaderm) is used for...
pressure ulcers and skin tears -can wear for 5-7 days
Acute pain r/t
related to nerve involvement within the tissue impairment or as a consequence of procedures used to treat the wound. PQRST
National Quality forum 2013 states that
stage III and IV are reportable events. -bc now bones and muscles are involved. Could mean pt was neglected, abused, or they have poor nutrition.
Bandage
strip of cloth used to wrap some part of the body to secure.
Abrasion
surface scrape, either unintentional or intentional (dermal abrasion to remove pockmarks) Open wound.
Give pain medication 30 mins before what?
the dressing is done
Laceration
tissues torn apart, often from accidents (machinery) -Open wound; edges are often jagged.
What is the purpose of a wound drain?
to allow discharge of serosanguineous fluid and pure human material to promote healing of underlying tissues. -inserted surgically -when changing dressing, be careful not to dislodge the drain
Clean (closed) wound
uninfected wounds. There is minimal inflammation and the respiratory, gastrointestional (GI), genital (GU), and urinary tracts are *NOT ENTERED*. They are primarily closed. If the tissues are traumatized without a break in the skin. Ex: CONTUSION, protrusion, hematoma
Sitz bath
used for vaginal infection, put over commode.
If the redness disappears from the pressure, then there is
NO tissue damage -if the redness stays= stage 1 pressure ulcer
Factors affecting skin integrity: *nutrition*
Nutrition provides us with protein and hydration to keep the skin healthy. Vitamin C. -Malnourished and elderly: don't have a lot of protein in their diets. -Obesity: adipose tissue usually has a minimal blood supply
A sling is often used for which pts
Ones with a pacemaker bc leads can be disconnected.
If patient has an abdominal binder what should we do as nurses?
Open it up and check around the area
Pressure Ulcer
Also called bed sore and Decubitus -injury to skin or underlying tissue, over bony prominence area
Primary intention healing
Also known as first intention Occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss. -formation of minimal granulation tissue and scarring Ex: surgical incision, tissue adhesive
Stage IV pressure ulcer
Bones are visible. -involves damage to the *bone and muscle*.
What can a heel protector help prevent?
Foot drop, pedal pressure ulcers
Penetrating wound
Penetration of the skin and the underlying tissues, usually unintentional (bullet, metal fragment) -Open wound
Alignates (algiderm) is used for..
Surgical wounds, PU
purulent exudate
Thicker than serous exudate because it contains *pus* The process of pus formation is called suppuration. Colors: blue, green, yellow
Your client has a Braden scale score of 17, Which is the appropriate nursing action?
Implement a turning schedule; the client is at increased risk of skin breakdown
