Chapter 31: Skin Integrity and Wound Care

What are the nursing interventions for nutrition and hydration?

increase fluid intakes, protein, vitamin C. use lotions to prevent fluid loss

What are the five different wound complications?

infection, hemorrhage, dehiscence, evisceration, and fistula

True or False: Chronic wounds remain in the inflammatory phase of healing

True

If dehiscence occurs, what is something the patient might say?

"something has suddenly given away"

True or False: Patients who are taking corticosteroid drugs or require postoperative radiation therapy are at high risk for delayed healing and wound complications.

True

What are the two mechanisms that contribute to pressure ulcer development?

1. external pressure that compresses blood vessels and 2. friction and shearing forces that tear and injure blood vessels and abrade the top layer of skin

What is the normal range for prealbumin?

16 mg/dL to 40 mg/dL (less than 19 affects wound healing)

T-tube (purpose and example)

For bile drainage. after gall bladder surgery

Effects of applying cold

Constructs peripheral blood vessels Reduces muscle spasms Promotes comfort

Closed drainage system

Hemovac, Jackson-Pratt

Open drainage system

Penrose

What is hypoxia?

inadequate amount of oxygen available to cells

Acute Wounds

(ex: surgical incisions) usually heal within days to weeks, wound edges are well approximated and the risk for infection is lessened, usually move through healing process without difficulty

What is the normal range for albumin?

3.5 mg/dL to 5.0 mg/dL (less than 3.2 affects wound healing)

What is the normal glucose range?

70 mg/dL to 120 mg/dL (more than 120 affects wound healing)

Which wound complication is dehiscence and evisceration?

A. Dehiscence B. Evisceration

Appling external heating pad

Hand hygiene and put on PPE Close curtains Assess skin prior to placing device Plug in and warm the unit Assess condition of the skin and patients response to heat at intervals; maximum vasodilation and therapeutic effect occur at 20 - 30 minutes Remove gloves and discard Monitor time heating pad is in place (up to a maximum of 30 minutes) Be sure patient is not lying on the heating pad

What is the Braden Scale?

An assessment form used for a patient who already has impaired skin integrity and is at risk for a pressure sore. (mental status, continence, mobility, activity, nutrition).

Stage IV Pressure Ulcer

Full-thickness loss WITH exposed bone, tendon, or muscle. Exposed bone/tendon is visible or directly palpable. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. Depth depends on anatomic location. Extend into muscle and/or supporting structures (ex. fascia, tendon, or joint capsule), making osteomyelitis possible.

Unstageable

Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown)and/or eschar (tan, brown, black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefor stage, cannot be determined. Stable (dry, adherent, intact,, without erythema, or fluctuance) eschar on the heels serves as "the body's natural cover+ and should not be removed

Stage III Pressure Ulcer

Full-thickness tissue loss. SubQ fat may be visible but bone, tendon, or muscle are NOT exposed. Bone/tendon is not visible or directly palpable. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Depth varies by anatomic location.

Effects of applying heat

Dilates peripheral blood vessels Increases tissue metabolism Reduces blood viscosity and increases capillary permeability Reduces muscle tension Helps relieve pain

What is the maturation phase?

Final stage of healing, begins about 3 weeks after the injury, possibly even months or years. scar is formed.

What is the inflammatory phase?

Follows hemostasis and lasts 4-6 days. WBC move to the wound. leukocytes arrive first to ingest bacteria and cellular debris. after 24 hours macrophages enter the wound area and remain for an extended period. acute inflammation is characterized by pain, heat, redness, and swelling at the site of injury. patient has a generalized body response; mildy elevated temp, increased number of WBC, and generalized malaise.

What are the 4 phases of wound healing?

Hemostasis, Inflammatory Phase, Proliferation Phase, and Maturation Phase

Devices to apply cold

Ice bags Cold packs Hypothermia blankets Moist cold

What are the risks for pressure ulcer development?

Immobility, nutrition and hydration, skin moisture, mental status, and age

Stage I Pressure Ulcer

In tact skin with nonblanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. May be difficult to detect in darker skin tones.

Stage II Pressure Ulcer

Partial-Thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, WITHOUT slough. Presents as a shiny or dry shallow ulcer without slough or bruising. May also present as an intact or open/rupture serum-filled blister.

Who is most at risk for evisceration?

Patients who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining.

Assessing Wounds: Depth

Perform hand hygiene, put on gloves. moisten a sterile, flexible applicator with saline and insert it gently into the wound at a 90-degree angle with the tip down. mark the point on the swab that is even with the surrounding skin surface, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin. remove the swab and measure the depth with a ruler.

What are the three wounds repair?

Primary Intention, Secondary Intention, and Tertiary Intention

Deep Tissue Injury

Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. Difficult to detect in dark skin tone. Painful, firm, boggy, warmer, or cooler as compared to adjacent tissue. Evolution may include a thin blister over a dark wound bed. May further evolve and become covered by a thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

RYB Wound Classification

R-Red-Protect (proliferative stage of healing) Y-Yellow-Cleanse (exudates, slough) B-Black-Debride (eschar, necrotic tissue) (removal)

True or False: A pressure ulcer may form in as little as 1 to 2 hours if the patient has not moved or been repositioned to allow circulation to flow to dependent areas.

True

True or False: Chronic wounds include any wound that does not heal along the expected continuum, such as wounds related to arterial or venous insufficiency, and pressure ulcers

True

Special considerations when using a heating pad

Use caution with children and older adults Spinal cord injury (unable to move) Peripheral neuropathy (unable to feel heat and burning) Patients with thin and damaged skin

assessing Wounds: Tunneling

Use standard precautions; use appropriate transmission-based precautions when indicated. perform hand hygiene and put on gloves. determine the direction: moisten a sterile, flexible applicator with saline and gently insert a sterile applicator into the site where tunneling occurs. view the direction of the applicator as if it were the hand of a clock. the direction of the patient's head represents 12 o'clock. moving in a clockwise direction, document the deepest sites where the wound tunnels. determine the depth: while the applicator is inserted in to the tunneling, mark the point on the swab that is even with the wound's edge, or grasp the applicator with the thumb and forefinger at the point corresponding to the wound's margin. remove the swab and measure the depth with a ruler.

Tertiary

What phase of wound healing is this?

Presence of Infection

Wound is swollen, deep red color, hot on palpation, drainage increased and possible purulence, foul odor may be noted, wound edges may be separated with dehiscence present

What is the definition of a wound?

a break or disruption in the normal integrity of the skin and tissues

Wound complications: Fistula

a fistula is an abnormal passage from an internal organ or vessel to the outside of the body or from one internal organ or vessel to another. the presence of a fistula increases the risk for delayed healing, additional infection, fluid, and electrolyte imbalances, and skin breakdown.

What is granulation tissue?

a thin layer of epithelial cells forms across the wound, and the blood flow across the wound is reinstituted. this new tissue forms the foundation for scar tissue development

Intentional Wound

a wound that is the result of a planned invasive procedure, wound edges are clean, and bleeding is usually controlled, risk for infection is decreased and healing is facilitated

What is a pressure ulcer?

a wound with a localized area of injury to the skin and/or underlying tissue. can be acute or chronic wound. bony prominence

Dehiscence and evisceration of an ___________ incision is a medical emergency. Place the patient in the low Fowler's position and cover the exposed ______ contents. Do not leave the patient alone. Notify the primary care provider immediately.

abdominal

What can wound infections lead to?

development of chronic wounds, osteomyelitis (bone infection), and sepsis (presence of pathogenic organisms in the blood or tissues).

Unintentional Wound

accidental, a wound that is the result of unexpected trauma, contamination is likely, wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled, high risk for infection and longer healing time

What are some systemic factors or wound healing?

age, circulation to and oxygenation of tissues, nutritional status, wound condition, health status, immunosuppression, and medication use.

Gauze, iodoform gauze, NuGauze (purpose and example)

allow healing from base of wound. infected wounds, after removal of hemorrhoids

What is the proliferation phase?

also known as fibroblastic, regenerative, or connective tissue phase. lasts for several weeks. new tissue is built to fill wound space, primarily through the action of fibroblasts.

What is a sign of an impending dehiscence?

an increase in the flow of fluid from the wound between postoperative days 4 and 5.

What is an enterovaginal fistula?

and abnormal connection between the rectum and vagina.

What are some examples of unintentional wounds?

can occur from unexpected trauma such as from accidents, forcible injury (stabbing or gunshot), and burns.

What are the nursing interventions for age?

check skin frequently, pad bony prominences, apply lotions, encourage adequate hydration

What are the nursing interventions for moisture?

cleanse perineal area daily, apply lotions as needed, toilet patient

Serous drainage

composed primarily of the clear, serous portion of the blood and from serous membranes. Clear and watery

If dehiscence occurs, what does the nurse do?

cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician

Hemovac (purpose and example)

decreases dead space by collecting drainage. after abdominal or orthopedic surgery

Jackson-Pratt (purpose and example)

decreases dead space by collecting drainage. after breast removal, abdominal surgery

What is ischemia?

deficiency of blood in a particular area

What is desiccation?

dehydration

Begin applying a bandage to the _____ part of the area.

distal

Chronic Wounds

do not progress through the normal sequence of repair. healing process is impeded. wound edges are often not approximated, risk for infection increased, normal healing time is delayed

Assessing Wounds: Size

draw the shape and describe it, measure the length, width, and diameter (if circular)

The ________________ is effective for use around joints, such as the knee, elbow, ankle, and wrist.

figure-eight-turn

A patient who lies on wrinkled sheets is likely to sustain tissue damage as a result of ___________. The skin over the elbows and heels often is injured due to ___________ when patients lift and help move themselves up in bed with the use of their arms and feet.

friction

What is full thickness?

heals by granulation, wound contraction and epithelialization

What is hemostasis?

hemostasis occurs immediately after the initial injury. blood clotting. exudate is formed, accumulation of exudate causes swelling and pain, increased perfusion results in heat and redness. platelets are responsible for releasing substances that stimulate other cells to migrate to the injury to participate in the other phases of healing

Sanguineous drainage

large numbers of red blood cells and looks like blood. bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding.

Purulent drainage

made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.

Wound complication: Hemorrhage

may occur from a slipped suture, a dislodged clot at the wound site, infection, or the erosion of a blood vessel by a foreign body, such as a drain. check wound/wound dressing frequently within the first 48 hours and than every 8 hours after that.

Serosanguineous drainage

mixture of serum and red blood cells. light pink to blood tinged.

Wound complication: Dehiscence and Evisceration

most serious postoperative wound complications. dehiscence is the partial or total separation of wound layers as a results of excessive stress on wounds that are not healed. evisceration is the most serious complication of dehiscence, the wound completely separates, with protrusion of viscera through the incisional area.

Friction

occurs when two surfaces rub against each other. the injury, which resembles abrasion, also can damage superficial blood vessels directly under the skin.

What is maceration?

overhydration

What are the nursing interventions for immobility?

pressure points need to be examined frequently and protected; special mattresses; be aware of patients with reduced sensitivity (paralyzed, circulatory insufficiency)

What are some local factors that affect wound healing?

pressure, desiccation, maceration, trauma, edema, infection, excessive bleeding, necrosis, and the presence of biofilm.

What are drains used for?

protect the surrounding skin, collect exudate, measure drainage, contain microorganisms, reduce the frequency of care

What are the functions of skin?

protection, temperature regulation, psychosocial, sensation, vitamin D production, immunologic, absorption, elimination

Penrose (purpose and example)

provides sinus tract. after incision and drainage of abscess, in abdominal surgery

Closed Wound

results from a blow, force or strain trauma (fall, assault, motor vehicle accident). skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Ex: ecchymosis, and hematomas

Shear

results when one layer of tissue slides over another layer. shear separates the skin from underlying tissues.

Patients who are pulled, rather than lifted, when being moved up in bed or from bed to chair or stretcher are at risk for injury from _________________________. Also when the patient slides down in bed or in a chair.

shearing forces

Open Wound

skin surface is broken providing a portal of entry for microorganisms, bleeding, tissue damage, and increased risk for infection, and delayed healing may occur. Ex: incisions, and abrasions

the _______ _______ is useful for the wrist, fingers, and trunk.

spiral turn

What are some examples of intentional wounds?

those that result from surgery, intravenous therapy, and lumbar puncture

What is partial thickness?

tissue destruction extends into but not though the dermis. heals by epithelialization.

Cleaning a wound with unapproximated edges

use standard precautions. moisten sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. use new swab or gauze for each circle. clean the wound in full or half circles, beginning in the center and working toward the outside. clean to at least 1 inch beyond the end of the new dressing. if a dressing is not being applied, clean to at least 2 inches beyond the wound margins.

Cleaning a wound with approximated edges

use standard precautions. moisten sterile gauze pad or swab with the prescribed cleansing agent. use now swab or gauze for each DOWNWARD stroke. clean from TOP to BOTTOME. work OUTWARD from the incision lines parallel to it. wipe from the clean area toward the less clean.

Wound complication: Infection

wound infection results when the patient's immune system fails to control the growth of microorganisms, symptoms usually become apparent within 2-7 days after the injury or surgery. symptoms include: purulent drainage; increased drainage, pain, redness, and swelling in and around the wound; increased body temp; and increased WBC count, delayed healing and discoloration of granulation tissue in the wound

What is primary intention?

wounds healed by primary intention are well approximated (skin edges tightly together). Intentional wounds with minimal tissue loss, such as those made by a surgical incision with sutured approximated edges, usually heal by primary intention.

What is secondary intention?

wounds healed by secondary intention have edges that are not well approximated. large open wounds, such as from burns or major trauma, which require more tissue replacement and are often contaminated, commonly heal by secondary intention. wounds healed by secondary intention take longer to heal and form more scar tissue.

What is tertiary intention?

wounds healed by tertiary intention, or delayed primary closure, are those wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed.