Skin/Wounds

Factor's affecting wound healing

-age -circulation and oxygenation -nutritional status -wound condition -health status

Tertiary intention healing

(Delayed primary healing) ALLOWED TO HEAL INITIALLY BY SECONDARY INTENTION, THEN SUTURED (PRIMARY INTENTION) wounds left open for several days to allow edema or infection to resolve or fluid to drain, and then are closed

Serous Drainage

- clear, watery plasma (straw-colored; clear, watery plasma)

proliferation phase of wound healing

-begins on 3rd, 4th day - lasts 2-3 weeks -macrophages continue to clear the wound of debris and stimulate fibroblasts which synthesize collagen -new capillary networks formed to provide oxygen and nutrients to spport collagen and for further synthesis of granulation tissue -tissue is deep pink -full thickness wound begins to close by contration as new tissue is grown -scarring influenced by degree of stress on wound

maturation phase of wound healing

-final phase begins about 3 weeks from injury -may take up to 2 years -collagen is lysed and resynthesized by macrophages, producing storng scar tissue -scar maturation, or remodeling -scar tissue slowly thins and becomes paler

Alginates, such as: Sorbsan Algicell Curasorb AQUACEL KALGINATE Melgisorb

Absorb exudate Maintain a moist wound environment Facilitate autolytic débridement Require secondary dressing Can be left in place for 1 to 3 days Infected and noninfected wounds Wounds with moderate to heavy exudate Partial- and full-thickness wounds Tunneling wounds Moist red and yellow wounds Not for use with wounds with minimal drainage or dry eschar

Collagens, such as: BGC Matrix Stimulin PROMOGRAN Matrix

Absorbent Maintain a moist wound environment Do not adhere to wound Compatible with topical agents Nonadherent Conform well to the wound surface Require secondary dressing to secure Partial- or full-thickness wounds Infected and noninfected wounds Skin grafts Donor sites Tunneling wounds Moist red and yellow wounds Wounds with minimal to heavy exudate

Skin assessments

Acute care setting: On admission, then reassessed at least every 24 hours or if the patient's condition changes. Reassess stable patients in intensive care units daily; reassess unstable patients every shift. Long-term care setting: On admission, then reassess weekly for 4 weeks, then quarterly and whenever the resident's condition changes Home health care: On admission, then reassess at every visit

Transparent films, such as: Bioclusive DermaView Mefilm Polyskin Uniflex OpSite Tegaderm

Allow exchange of oxygen between wound and environment Are self-adhesive Protect against contamination; waterproof Prevent loss of wound fluid Maintain a moist wound environment Facilitate autolytic débridement No absorption of drainage Allow visualization of wound May remain in place for 24 to 72 hours, resulting in less interference with healing Wounds with minimal drainage Wounds that are small; partial-thickness Stage I pressure ulcers Cover dressings for gels, foams, and gauze Secure intravenous catheters, nasal cannulas, chest tube dressing, central venous access devices

Antimicrobials, such as: SilvaSorb Acticoat Excilon Silverlon

Antimicrobial or antibacterial action Reduce infection Prevent infection Draining, exuding, and nonhealing wounds to protect from bacterial contamination and reduce bacterial contamination Acute and chronic wounds

Unintentional wounds

Are accidental. wounds occur from unexpected trauma, such as from accidents, forcible injury (such as a stabbing or a gunshot), and burns. Because the wounds occur in an unsterile environment, contamination is likely. Wound edges are usually jagged, multiple traumas are common, and bleeding is uncontrolled. These factors create a high risk for infection and a longer healing time.

Hydrocolloid dressings, such as: DuoDerm Comfeel PrimaCol Ultec Exuderm

Are occlusive or semi-occlusive, limiting exchange of oxygen between wound and environment Minimal to moderate absorption of drainage Maintain a moist wound environment Are self-adhesive Provide cushioning Facilitate autolytic débridement Protect against contamination May be left in place for 3 to 7 days, resulting in less interference with healing Partial- and full-thickness wounds Wounds with light to moderate drainage Wounds with necrosis or slough Not for use with wounds that are infected

Hemovac drain

CLOSED DRAIN SYSTEM, a surgical drain to prevent blood and lymphatic fluid buildup under your skin and encourage healing. drains fluid by passive suction

Yellow

Cleanse - Yellow in the wound may indicate the presence of exudate (drainage) or slough, and requires wound cleaning. These wounds are characterized by oozing from the tissue covering the wound, often accompanied by purulent drainage. Drainage can be whitish yellow, creamy yellow, yellowish green, or beige. To cleanse these wounds, nursing interventions include the use of wound cleansers and irrigating the wound.

Black

Debride - Necrotic tissue - Black in the wound may indicate the presence of an eschar (necrotic tissue), which is usually black but may also be brown, gray, or tan. The eschar requires débridement (removal) before the wound can heal. These wounds are often cared for by advanced practice nurses who are educated in the care of more complex wounds. After débridement, the wound is treated as a yellow wound and then, as healing progresses, a red wound

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, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact, without erythema, or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed.

Stage IV

Full-thickness tissue 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. The depth of a stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue and these ulcers can be shallow at these locations. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule), making osteomyelitis possible.

Stage III

Full-thickness tissue loss. Subcutaneous 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. The depth of a stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have subcutaneous tissue, and stage III ulcers at these locations can be shallow. In contrast, areas with significant adipose tissue can develop extremely deep stage III pressure ulcers.

Risk factors for Pressure Ulcer development

Immobility, nutrition and hydration, skin moisture, mental status, and age are factors in the development of pressure ulcers. In addition, patients compromised by the following conditions are at risk for pressure ulcer development: Dehydration Incontinence Skin hygiene Diabetes mellitus Diminished pain awareness Fractures History of corticosteroid therapy Immunosuppression Multisystem trauma Poor circulation Previous pressure ulcers Significant obesity or thinness

Stage 1

Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Stage I may be difficult to detect in individuals with dark skin tones. Stage I may indicate "at risk" persons.

Inflammatory phase of wound healing

Lasts 4-6 days; first WBC's get to the cite to ingest cell debris & bacteria. Then macrophage arrive & continue that same work while also releasing growth factors that stimulate epithelial cells & blood vessel growth. Fibroblasts are attracted by these growth factors, and fill in the wound to get ready for the next stage of healing. Cardinal signs are evident at the injury site. Acute inflammation is characterized by pain, heat, redness, and swelling at the site of the injury.

Foams, such as: Lyofoam Allevyn Biatain Mepilex Optifoam

Maintain a moist wound environment Do not adhere to wound Insulate wound Highly absorbent Can be left in place up to 7 days Some products need a secondary dressing to secure Absorb light to heavy amounts of drainage Use around tubes and drains Not for use with wounds with dry eschar

Hydrogels, such as: IntraSite Gel Aquasorb ClearSite Hypergel ActiFormCool

Maintain a moist wound environment Minimal absorption of drainage Facilitate autolytic débridement Do not adhere to wound Reduce pain Most require a secondary dressing to secure Partial- and full-thickness wounds Necrotic wounds Burns Dry wounds Wounds with minimal exudate Infected wounds

Appearance of wounds

Note the location of the wound. Location is described in relation to the nearest anatomic landmark, such as bony prominences. Document the size of the wound. Measurements are taken in millimeters or centimeters, measuring length, width, and depth

open wounds

Occurs from intentional or unintentional trauma. The skin surface is broken, providing a portal of entry for microorganisms. Bleeding, tissue damage, and increased risk for infection and delayed healing may accompany open wounds. Examples include incisions and abrasions.

Stage II

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 (which indicates suspected deep tissue injury). May also present as an intact or open/rupture serum-filled blister. This stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation.

Red

Protect - granulation tissue - new tissue

Sanguineous Drainage

RBC's looks like blood

Measuring the wound

Size of the Wound Draw the shape and describe it. Measure the length, width, and diameter (if circular). Depth of the Wound 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 (Figure B). Remove the swab and measure the depth with a ruler

Common sites for pressure ulcers

Supine - Occipital Bone, scapula, Vertebra, Sacrum, Coccyx, Calcaneus Prone - Frontal bone, Mandible, Humorous, Sternum, Tuberosity of Pelvis, Patella, Tibia Side Lying - Scapula, Ribs, Iliac crest, Greater Trochanter of Femur, Lateral knee, Lateral malleolus, Medial malleolus Wheelchair/Chair - scapula, Posterior knee, Sacrum, Ischium, Sole of feet

Measuring wound tunneling

Use standard precautions; use appropriate transmission-based precautions when indicated. Perform hand hygiene. Put on gloves. Determine 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 into 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. Document both the direction and depth of tunneling.

Cleaning Wounds with Unapproximated Edges

Use standard precautions; use appropriate transmission-based precautions when indicated. Moisten a sterile gauze pad or swab with the prescribed cleansing agent and squeeze out excess solution. Use a 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 wounds with approximated edges

Use standard precautions; use appropriate transmission-based precautions when indicated. Moisten a sterile gauze pad or swab with the prescribed cleansing agent. Use a new swab or gauze for each downward stroke. Clean from top to bottom. Work outward from the incision in lines parallel to it. Wipe from the clean area toward the less clean area.

Penrose Drain

a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing

intentional wound

a wound that is the result of a planned surgical or medical intervention surgery, intravenous therapy, and lumbar puncture. The wound edges are clean, and bleeding is usually controlled. Because the wound was made under sterile conditions with sterile supplies and skin preparation, the risk for infection is decreased, and healing is facilitated.

closed wound

blow, force, or strain caused by trauma such as a fall, an assault, or a motor vehicle crash. The skin surface is not broken, but soft tissue is damaged, and internal injury and hemorrhage may occur. Examples include ecchymosis and hematomas.

Chronic wounds

do not progress through the normal sequence of repair. The healing process is impeded. The wound edges are often not approximated, the risk of infection is increased, and the normal healing time is delayed. Chronic wounds remain in the inflammatory phase of healing. 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.

Jackson-Pratt drain

drainage system that uses a compressed bulb, applies slight suction within the wound

Purulent drainage

green/yellow - indicates infection

Wound assessments

inspection (sight and smell) and palpation for appearance, drainage, odor, and pain.

serosanguineous drainage

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

Skin functions

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

Acute wounds

surgical incisions, usually heal within days to weeks. The wound edges are well approximated (edges meet to close skin surface) and the risk of infection is lessened. move through the healing process without difficulty.

Braden Scale

the Braden scale (mental status, continence, mobility, activity, nutrition). 19 to 23 indicates no risk 15 to 18, mild risk 13 to 14, moderate risk 10 to 12, high risk and 9 or lower, very high risk

Friction

the resistance that one surface or object encounters when moving over another. A patient who lies on wrinkled sheets is likely to sustain tissue damage as a result of friction. The skin over the elbows and heels often is injured due to friction when patients lift and help move themselves up in bed with the use of their arms and feet. Friction burns can also occur on the back when patients are pulled or slid over sheets while being moved up in bed or transferred onto a stretcher.

primary intention healing

tissue surfaces are approximated (closed) and there is minimal or no tissue loss, formation of minimal granulation tissue and scarring

Shear

when one layer of tissue slides over another layer. 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 shearing forces. A patient who is partially sitting up in bed is susceptible to shearing force when the skin sticks to the sheet and underlying tissues move downward with the body toward the foot of the bed. This may also occur in a patient who sits in a chair but slides down.

secondary intention healing

wound in which the tissue surfaces are not approximated and there is extensive tissue loss; formation of excessive granulation tissue and scarring