Foundations: CH. 48 - Skin Integrity and Wound Care

Pressure injury

damage of the skin and the subcutaneous tissue caused by prolonged pressure usually developing over a bony prominence or related to pressure from a medical device or other device

Full Thickness Wound Repair

inflammatory (up to 3 days) proliferative (3-24 days) remodeling (up to 1 yr.)

Partial Thickness Wound Repair

inflammatory response (24hrs.) epithelial proliferation/migration reestablishment of epidermal layers

Induration

local hard area on the skin, usually a sign of an excessive deposit of collagen or calcium

deep tissue injury

persistent non-blanchable deep red, maroon, or purple discoloration caused by shearing

Tissue ischemia

when living tissue is deprived of oxygen - depriving tissue of adequate blood flow is the same as depriving tissue of oxygen

reverse staging

*STAGES CANNOT GO BACKWARDS*, not appropriate, tissue that had been damaged cannot regenerate muscle or dermis, as pressure ulcer heal, the stage assigned does not change, ex- pressure ulcer stage III and is currently healing would be documented as "healing stage III ulcer"

Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board). 2. Have head of bed elevated when transferring patient. 3. Have head of bed flat when repositioning patient. 4. Raise head of bed 60 degrees when patient is positioned supine. 5. Raise head of bed 30 degrees when patient is positioned supine.

1, 3, 5

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.

1, 4

Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment

1, 4, 5

Medical adhesives, such as tape securing a wound dressing, cause MARSI. Which of the following interventions reduce the risk for MARSI? 1. Gently loosen the ends of the tape and gently pull the outer end parallel with the skin surface toward the wound. 2. Change dressing only when saturated. 3. Apply adhesive remover. 4. Use Montgomery ties to secure the dressing. 5. Immobilize area of wound.

1,3, 4

What is the removal of devitalized tissue from a wound called? 1. Debridement 2. Pressure distribution 3. Negative-pressure wound therapy 4. Sanitization

1

When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch? 1. A local skin infection requiring antibiotics 2. Sensitive skin that requires special bed linen 3. A Stage 3 pressure injury needing the appropriate dressing 4. Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

4

Match the pressure injury stages with the correct definition. ___ 1.Stage 1 ___ 2.Stage 2 ___ 3.Stage 3 ___ 4.Stage 4 ___ 5.Unstageable pressure injury a. Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, and moist, and may also present as an intact or ruptured serum-filled blister. Adipose tissue (fat) and deeper tissues are not visible. Granulation tissue, slough, and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence-associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive-related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). b. Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep-tissue pressure injury. c. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining, and/or tunneling often occurs. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss, this is an Unstageable pressure injury. d. Full-thickness loss of skin, in which adipose tissue (fat) is visible in the ulcer, and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and bone are not exposed. If slough or eschar obscures the extent of tissue loss, this is an unstageable pressure injury e. Full-thickness skin and tissue loss in which the extent of tissue damage within the injury cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact, without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

1b, 2a, 3d, 4c, 5e

Which of the following nursing activities apply to an MDRPI? (Select all that apply.) 1. Assess skin under devices every 2 hours. 2. Cushion at risk areas (e.g., ears, nose with foam or protective dressing). 3. Choose correct size of device. 4. Observe for erythema or irritation that conforms to pattern or shape of device. 5. Observe under casts and splints.

2, 3, 4, 5

Which of the following is an indication for a binder to be placed around a surgical patient with a new abdominal wound? (Select all that apply.) 1. Collection of wound drainage 2. Provision of support to abdominal tissues when coughing or walking 3. Reduction of abdominal swelling 4. Reduction of stress on the abdominal incision 5. Stimulation of peristalsis (return of bowel function) from direct pressure

2, 4

Dehiscence

A partial or total separation of wound layers; risks are poor nutritional status, infection, or obesity most commonly occurs before collagen formation can occur 5-12 days after suturing Pts often report a feeling of something "giving way" increase in serosanguineous drainage in first few days after surgery

Hemorrhage occurring after hemostasis indicates:

A slipped surgical suture A dislodged clot Infection Erosion of a blood vessel by a foreign object (e.g., a drain)

Negative-pressure wound therapy (NPWT)

A vacuum-assisted closure (V.A.C) wound care modality used to faciliate healing and manage drainage removing wound exudates and reducing edema, macrodeformation and wound contraction, and microdeformation and mechanical stretch perfusion Secondary effects include angiogenesis, granulation tissue formation, and reduction in bacterial bioburden

Laboratory Data Wound Care

Blood Studies Wound cultures: Swabbing Needle Aspiration Tissue biopsy

Wound care nursing diagnoses

Risk for Impaired Skin Integrity Impaired Skin Integrity Impaired Tissue Integrity Risk for Infection Pain

How does mobility affect skin integrity?

Unable to turn leads to increased pressure When being moved, shearing and friction will lead to breakdown

Implications of assessing dark skin

Use natural lighting assess skin temperature and subepidermal moisture (slight moistening of the skin aids in detection of early pressure injury)

Secondary intention

Wound edges not approximated Tissue loss Heals from inner layer to surface left open until it fills with scar tissue greater chance of infection severe scarring can lead to loss of function

Do you need an order for wound care?

Yes

Reactive hyperemia

a bright red flush on the skin occurring after pressure is relieved

adhesive strips

a combination of both a sterile dressing and a bandage used for small cuts and abrasions

Tunnel wound

a wound with an entrance and exit site

measuring tunneling and undermining

Sterile, cotton tipped applicator moistened with saline should be inserted into tunneled or undermined area and measure in cm assess directionally like a clock with 1200 pointing toward pt's head

Serosanguineous

Pale, red, watery: mixture of clear and red fluid

Fluctuance

Palpable fluid beneath the skin indicative of infection/pus

How does lifestyle affect skin integrity?

Tanning, bathing, piercings, tattoos

Wound care nursing interventions

Prevention meticulous skin care and moisture control adequate nutrition frequent repositioning therapeutic massages client/family teaching

How does nutrition affect wound healing?

Protein: maintains the skin, repairs minor defects, preserves intravascular volume Best measure of nutritional status is pre albumin levels Vitamin C, Zinc, Copper (formation of collagen) Vitamin A (reduces negative effects of steroids) Dehydration leads to poor turgor

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.

Primary intention

Clean surgical incision/edges approximated Minimal scarring Wound is closed Low risk of infection EX. hematomas, surgical incision that is sutured or stapled

JP Drain (Jackson Pratt)

Closed-suction soft tube usually placed post-op to drain blood and inflammatory fluids from wound Included in output

cold therapy

Cold therapy is designed to treat localized inflammation that presents as edema, hemorrhage, muscle spasm or pain. But cold can further compromise blood flow so you wouldn't use it on a pressure injury or PVD or thin skinned patients

How does sensation level affect skin integrity?

Diminished sensation leads to increased risk for pressure and breakdown

Stage IV

Full thickness skin and tissue loss to fascia, muscles, bone, or support structures like joints Necrosis including slough and eschar bole, undermining, sinus tracts, and tunneling are common

Complications of Wound Healing

Hemorrhage Infection Dehiscence Evisceration Fistula formation (connects somewhere it should)

Phases of Wound healing

Hemostasis Inflammatory Proliferation (new tissue formation) Maturation (remodeling)

internal hemorrhage

Look for distention or swelling of the effected body part, a change in the type and amount of drainage from the surgical drain, or signs of hypovolemic shock.

Puncture wound

bleed in relation to the depth, size, and location of the wound usually a small, circular wound with the edges coming together toward the center primary dangers: internal bleeding and infection

Contusion

bruise, injury

Wound Closures

adhesive strips sutures surgical staples surgical glue

crushing injury

an injury caused by compression that involves both direct tissue injury caused by circulation disturbance resulting from pressure on blood vessels

penetrating wound

an open wound that breaks the skin and enters a body area, organ, or cavity

Provide _________ approx __________ prior to wound care

analgesic medication; 30 mins

Wound drainage evacuators

are 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

Hemorrhage may occur

externally or internally

unstageable pressure ulcer

full thickness skin and tissue loss obscured with stable eschar (which is non movable)

Stage III

full thickness skin loss may extend down to but not though the fascia dermis will not be visible subcutaneous fat may be visible, but bone, tendon or muscle are not exposed or palpable deep crater that may include undermining or tunneling may see slough or unstable eschar (which is movable)

wound care interventions

cleansing/irrigating caring for a drainage device (Jackson-Pratt Hemovac) Debridement Applying NPWT (negative pressure) Dressing a wound (hydrocolloids/hydrogels) Supporting/Immobilizing a wound (binders/bandages)

Serous

clear, watery plasma

Approximated

closed, with the wound's edges touching each other

purosanguineous exudate

contains blood and pus

Nonblanchable erythema

if the erythematous area does not blanch (stays red) when you apply pressure, deep tissue damage is probable

if a lot of blood under dressing, what do you do?

keep that dressing on and reinforce it with another dressing

How does moisture affect skin integrity?

leads to maceration (softening of the skin)

Laceration

may bleed more profusely (especially if the patient is taking anticoagulants or other blood thinners), depending on the depth and location of the wound EX. minor scalp lacerations tend to bleed profusely because of the rich blood supply to the scalp Lacerations greater than 5 cm (2 inches) long or 2.5 cm (1 inch) deep cause serious bleeding

Stage I

nonblanchable erythema of intact skin Dark skin may not have visible blanching, but just a different color than surrounding tissue area my be more painful, firm, or soft, or warmer than adjacent tissue NEVER massage reddened area ... it will cause further damage

How does age affect skin integrity?

older adult skin: less elastic, drier, reduced collagen, areas of hyperpigmentation, more prone to injury

Stage II

partial thickness skin loss with exposed dermis shallow open ulcer with red/pink wound dbed without slough or bruising May also be present as an intact or open/ruptured serum-filled or serosanguineous filled blister should NOT be used to describe skin tears, tape burns, incontinence dermatitis, maceration, excoriation

How does fever affect skin integrity?

depletes moisture increases metabolic rate

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

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

Wound

disruption of the integrity and function of tissues in the body

Exudate

drainage from a wound describe the amount, color, consistency, and odor of wound drainage

Debridement

emoval of nonviable, necrotic tissue necessary to rid the wound of a source of infection, enable visualization of the wound bed, and provide a clean base necessary for healing method of debridement depends on which is most appropriate for a patient's condition and outcomes of care

Medical adhesive-related skin injury (MARSI)

erythema and/or other manifestation of cutaneous abnormality (including but not limited to vesicle, bulla, erosion, or skin tear) persists 30 minutes or more after removal of a device or adhesive securing the device occurs when the attachment between the skin and an adhesive is stronger than the skin cells, causing the surface epidermal to detach from the underlying layers

Evisceration

protrusion of visceral organs through a wound opening place sterile gauze soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues blood supply to the tissues can be compromised 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

Granulation tissue

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

Regeneration

replacement of destroyed tissue by the same kind of cells only in epidermal wounds no scarring

What does the Braden Scale evaluate?

sensory perception, moisture, activity, mobility, nutrition, friction and shear

Types of wound debridement

sharp (scalpel, scissors) mechanical (whirlpool, wet-to/no dry dressing , lavage) enzymatic (collagen based, papain-urea-chorophyllin-copper) autolytics (dressings)

hydrogels

sheets, granules, or gels with a high water content, creating a jelly-like consistency that does not adhere to the wound bed. soft, cooling texture promotes patient comfort. enhance epithelialization by providing moisture to the wound bed used to soften slough or eschar in necrotic wounds, and they can be used in infected wounds.

Shearing force

sliding movement of skin and subcutaneous tissue while the underlying muscle and bone are stationary Deep tissue injury

How does infection affect wound healing?

slows it down; bacteria cause necrosis, sloughing, and increased scarring

Slough

soft yellow or white tissue; stringy substance attached to wound bed must eventually be removed by a qualified health care provider or by means of an appropriate wound dressing before the wound is able to heal

Epithelialization

stage of wound healing in which epithelial cells form across the surface of a wound; tissue color ranges from the color of "ground glass" to pink

surgical staples

stainless-steel wire (shaped like a staple) used to close a surgical wound

Hemostasis

stoppage of bleeding when blood vessels constrict and platelets gather

Abrasion

superficial with little bleeding and is considered a partial-thickness wound wound often appears "weepy" because of plasma leakage from damaged capillaries

Open Wounds

surface of the skin remains intact, but the underlying tissues may be damaged create significant risk of infection ex. incisions, lacerations, abrasions, punctures

Closed wounds

surface of the skin remains intact, but the underlying tissues may be damaged Ex. Contusions, hematomas, stage I pressure ulcers

Friction

the resistance that one surface or object encounters when moving over another Ex. skin against coarse bed linens injury of the epidermis

Who does the first dressing change?

the surgeon because it is important for them to asses the wound and determine if healing is taking place or if there is a concern

Surgical Sutures

thread or wire used to hold tissue and skin together

Measuring depth of a wound

use a sterile flexible applicator and insert into wound at 90 degree angle with tip down. Mark and measure.

hydrocolloids

wafers, pastes, or powders that contain hydrophilic (water-loving) particles When applied to a wound, the hydrophilic particles interact with exudate to form a gel that keeps the wound moist The dressing forms a protective layer against friction and bacteria ideal for wounds with minimal drainage, such as partial-thickness wounds or stage 2 pressure injury.

Blanching

when the normal red tones of the light-skinned patient are absent When checking for pressure injuries in patients with darkly pigmented skin, dark skin may not show the blanch response

Purulent

yellow, green, or brown exudate

A WOUNDD PICTURE

Appearance: periwound- discoloration around the wound hematoma, maceration, undermining crepitus, blistering, erythema, epiboly, slough, eschar Wound or ulcer location Odor? Ulcer category Necrotic tissue? Nutritional status Dimension Drainage Pain? Induration? Color of wound bed Tunneling? Underminding? Redness Edge of skin Edema

Onset of the wound

Acute: wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity Causes: Trauma/surgical incision Wound edges are clean and intact Chronic: wound that fails to proceed through at orderly and timely process Causes: vascular compromise, chronic inflammation, repetitive insult to tissue Continued exposure to insult impedes wound healing EX. pressure injury, arterial ulcers, venous stasis ulcers, diabetic foot ulcers

Eschar

Black, brown, tan or necrotic tissue Needs to be removed before healing can proceed

Sanguineous

Bright red; indicates active bleeding

abscess

Collection of pus underneath the skin

Pressure injuries are also called

Decubitus ulcers, bed sores, pressure sores, pressure ulcer, dermal ulcer

Extrinsic risk factors for pressure injury

Friction Pressure Shearing Exposure to moisture

tertiary intention

Granulation tissue brought together Left open for several days to allow edema or infection to resolve or exudate to drain; then are closed EX., wounds that are contaminated and require observation for signs of inflammation

Intrinsic risk factors for pressure injury

Immobility Impaired sensation Malnourishment Aging Fever Edema

How do medications affect skin integrity?

Side effects: itching, rashes

Excoriation

Skin sore or abrasion produced by scratching or scraping

Surgical glue

Sterile substance used for closure of small wounds or surgical sites and is commonly used in feline declaws

How does the Braden scale work?

The higher the number, the lower the risk for skin impairment scores range from 6-23 not at risk for pressure injury is 16 and above

Incision wound

Cutting or sharp instrument; wound edges in close approximation and aligned

Medical device-related pressure injury (MDRPI)

Occurs when the skin or underlying tissues are subjected to sustained pressure or shear from medical devices or equipment Critically ill patients and neonates most risk