Unit 3 Part D Ch. 48 Skin Integrity and Wound Care

Secondary intention

-Wound healing where edges can't be easily approximated and wound fills with granulation

Shear

-Force directed parallel to a surface

Blanching

-Occurs when the normal red tones of the light-skinned patient are absent

Tertiary Intention

-Wounds that are left open -This allows for debridement of nonviable tissue -When the wound appears clean, tissue looks healthy, it is closed

Surgical and Traumatic Wounds - Emergency Setting

-After a traumatic wound, when you judge a patient's condition to be stable because of the presence of spontaneous breathing, a clear airway, and a strong carotid pulse, inspect the wound for bleeding. Inspect traumatic wounds for foreign bodies or contaminant material. Most traumatic wounds are dirty. Assess the size and depth of a wound. When an injury is a result of a trauma from a dirty penetrating object, determine when the patient last received a tetanus toxoid injection.

Surgical and Traumatic Wounds - Wound Appearance

-A surgical incision healing by primary intention should be clean, well-approximated edges. There may be some redness at the edges of the incision that can be present for the first few days after surgery. Crusts often form along wound edges from exudate. If a wound is open, the edges are separated, and you inspect the condition of tissue at the wound base. The outer edges of a wound normally appear inflamed for the first 2-3 days, but this slowly disappears. Within 7-10 days a normally healing wound resurfaces with epithelial cells, and edges close. If infection develops, the area directly surrounding the wound becomes brightly inflamed and swollen. Skin discoloration usually results from bruising of interstitial tissues or hematoma formation. Blood collecting beneath the skin first takes a bluish or purplish appearance. Gradually, as the clotted blood is broken down, shades of brown and yellow appear.

Complete an assessment for a patient with impaired skin integrity

-A wound assessment provides the foundation for developing a care plan, including selection of the correct treatment or dressing.

Hemostasis

-A series of physiological events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury

Classification of pressure injuries

-A staging system classifies pressure injuries. Accurate staging requires knowledge of the skin layers. A major drawback of a staging system is that you cannot stage an injury when it is covered with necrotic tissue because the necrotic tissue is covering the the depth of the injury. In serious wounds with necrotic tissue, the wound must be debrided or removed to expose the wound base to allow for assessment. -Pressure injury staging describes the pressure injury depth at the point of assessment. Thus, once you have staged the pressure injury, this stage endures even as it heals. Pressure injuries do not progress from a stage 3 to a stage 1; rather, a stage 3 injury demonstrating signs signs of healing is described as a healing stage 3 pressure injury.

Describe the differences in nursing care with acute and chronic wounds

-Acute wounds are usually traumatic or surgical and should move predictably through the wound healing process. Chronic wounds are caused by vascular compromise, reinjury, or chronic inflammation and fail to close or heal in a timely fashion.

Dressings for Unstageable pressure injury

-Adherent film -Gauze plus ordered solution -Enzymes -None

Wounds and Pressure Injuries - Nutritional Status

-An assessment of a patient's nutritional status is an integral part of the initial assessment data for any patient, especially one at risk for impaired skin integrity. The Joint Commission recommends nutritional assessment within 24 hours of admission. Assess the patients mouth and teeth for oral sores and ill-fitting dentures that impact nutritional intake.

Steps to apply moist to dry dressing

-Apply sterile gloves -Assess wound and surrounding skin -Moisten gauze with prescribed solution -Gently wring out excess solution and unfold -Loosely pack until all wounds surfaces are in contact with gauze -Cover and secure topper dressing

Wounds and Pressure Injuries - Mobility

-Assessment includes documenting the baseline level of mobility and the potential effects of impaired mobility on skin integrity. Documenting assessment of mobility includes obtaining date regarding the quality of muscle tone and strength. Assess the patient's activity tolerance to determine whether the patient can be transferred to a chair or ambulated more often to relieve pressure from lying down.

Explain the factors that impede or promote wound healing

-Assessment of the patient with a wound will include systemic and local implications that affect wound healing and must be addressed with the appropriate interventions that address those complications. -Many factors that affect wound healing need to be considered in managing a patient with a wound. The negative factors, such as diabetes and smoking, need to be addressed, and the positive effects, such as adequate protein intake, need to be supported.

Eschar

-Black, brown, tan, or necrotic tissue

TABLE 48.4 Role of Selected Nutrients in Wound Healing

-Calories- fuel for cell energy "protein protection" -Protein- fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function -Vitamin C- collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant -Vitamin A- epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation, can reverse steroid effects on skin and delayed healing -Zinc- collagen formation, protein synthesis, cell membrane and host defenses -Fluid- essential fluid environment for all cell function

Chronic vs Acute wounds

-Chronic- due to: vascular compromise, chronic inflammation, repetitive exposure to cause, do not heal well or in a typical manner -Acute- due to: trauma or surgery, heal in an orderly manner without complications

Approximated

-Closed, with the wound's edges touching each other

Dressings for Stage 2

-Composite film -Hydrocolloid -Hydrogel covered with foam or gauze dressing

Drainage evacuators

-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

Wound Closure

-DRAINS- Penrose, Hemovac, Jackson-Pratt, Wound VAC -DRESSINGS(moist to dry)- for protection, aids in homeostasis, promotes healing, splints the site, provides thermal insulation, moist environment

Vacuum assisted closure

-Device that assists 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

Surgical and Traumatic Wounds - Drains

-Drains provide a means for fluid or blood that accumulates within a wound bed to drain out of the body. Assess the number and type of drains, drain placement, character of drainage, and condition of collecting equipment.

Other risk factors for pressure injury

-Fecal or urinary incontinence- -Poor nutritional status- -Age- -Paralysis- -Hip fracture- -Admission to a HC facility- -Diabetes- -Admission to critical care-

Exudate

-Fluid, such as pus, that leaks out of an infected wound

Puncture wounds

-Forceful injury used by a sharp, pointed object that penetrates the skin, usually narrower and deeper than a cut or scrape

Stage 4 Pressure Injury

-Full-thickness 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, undermining, and/or tunneling often occur. -Depth varies by anatomical location.

Stage 3 Pressure Injury

-Full-thickness loss of skin, in which adipose 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 in deep wounds. -Undermining and tunneling may occur. -Fascia, muscle, tendon, ligament, cartilage, and/or bone are NOT exposed.

Unstageable Pressure Injury

-Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer 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 on the heel or ischemic limb should not be softened or removed.

Complications of wound healing

-Hemorrhage- internal or external -Infection- redness, warmth, drainage, pain, fever, increased WBC's -Dehiscence- partial, total, occurs after a strain of the wound: those who are at risk- obese, diabetic, smokers -Evisceration- total separation of the wound, emergency, place sterile gauze soaked in saline over the organs

Dressings for Stage 3

-Hydrocolloid -Hydrogel covered with foam dressing -Calcium alginate -Gauze

Dressings for Stage 4

-Hydrogel covered with foam dressing -Calcium alginate -Gauze

Blanchable hyperemia

-If it blanches (turns lighter in color) and the erythema returns when you remove your finger, the hyperemia is transient and is an attempt to overcome the ischemic episode

-Dehiscence

-Partial or total separation of wound layers

Surgical and Traumatic Wounds - Wound Cultures

-If you detect purulent or suspicious-looking drainage, report to the health care provider because a specimen of the drainage may need to be obtained. Never collect a wound culture sample from old drainage. Gram stains of drainage are often performed. The gold standard of wound culture is tissue biopsy.

Risk factors contributing to pressure injury

-Impaired sensory perception- patients with this are unable to feel when a part of their body undergoes increased, prolonged pressure or pain -Impaired mobility- patients who are unable to independently change positions are at risk -Alteration in level of consciousness- patients who are comatose, confused, or disoriented; those who have expressive aphasia or the inability to verbalize; and those with changing levels of consciousness are unable to protect themselves from pressure injury -Shear- the damage that shear causes occurs at the deeper fascial level of tissues over the bony prominence, underlying tissue capillaries are stretched and angulated, as a result necrosis occurs deep within tissue layers -Friction- these injuries affect the epidermis, leads to pressure injury formation only when it causes harmful shear stress and strain -Moisture- reduces the resistance of the skin to other physical factors such as pressure, friction, or shear

Secondary intention

-Infected wounds, stage 2 pressure injury, burns -Involves loss of tissue -Sometimes related to infected wounds -Heals from the inside out -Fills in the wound with scar tissue -Wound is healing without s/s of infection, the bed shows granulation, or the are is contracting or filling

Deep-Tissue Pressure Injury

-Intact or nonintact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. -Pain and temperature change often precede skin color changes. -Discoloration may appear differently in darkly pigmented skin. -This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. -The wound may evolve rapidly to reveal extent of tissue injury or may resolve without tissue loss. -If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full-thickness pressure injury. -DO NOT use deep-tissue pressure injury to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Pathology of pressure injury

-Intensity of the pressure -Causes tissue ischemia -Low pressure over a long period of time -High pressure over a short period of time -Duration of the pressure -Tissue tolerance

Wounds and Pressure Injuries - Body Fluids

-It is important to prevent and reduce the patient's exposure to body fluids; when exposure occurs, provide meticulous hygiene and skin care. Continual exposure of the skin to body fluids increases a patient's risk for skin breakdown and pressure injury formation. Exposure to urine, bile, stool, ascitic fluid, and purulent wound exudate carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illnesses or poor nutrition.

Discuss the risk factors that contribute to pressure injury formation

-It is important to understand what risk factors may contribute to pressure injury formation in order to plan interventions to reduce or eliminate factors and prevent pressure injury formation.

Skin

-Largest organ of the body, has layers: epidermis and dermis

Pressure injury

-Localized damage to the skin and underlying soft tissue -Usually over a bony prominence -Injury to the tissue is related to prolonged pressure or due to shear

Induration

-Localized hardening of the soft tissue, the area becomes firm, but not as hard as bone

Discuss the normal process of wound healing

-Most wounds heal in a normal trajectory, but chronic wounds may fail to heal; an overview of normal wound healing is key to understanding how to assess a plan of care for the patient with a wound. Valid and reliable risk-assessment tools assess a patient's risk for developing a pressure injury and are completed on admission to a healthcare agency and on a regularly scheduled basis.

-Non-blanchable hyperemia

-No color change, significant tissue damage

Stage 1 Pressure Injury

-Nonblanchable erythema of intact skin, 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.

Dressings for Stage 1

-None -Transparent dressing -Hydrocolloid

Surgical and Traumatic Wounds - Character of Wound Drainage

-Note the amount, color, odor, and consistency of wound drainage. The amount of drainage depends on the type of wound. When you need an accurate measurement of the amount of drainage within a dressing, weigh the dressing and compare it with the weight of the same dressing that is clean and dry. If the drainage has a pungent or strong odor, you should suspect infection. Describe the appearance of the wound according to characteristics observed, the types of closures used, and the dressing changes performed.

Wound and Pressure Injuries - Predictive Measures

-On admission to acute care, rehabilitation hospitals, nursing homes, home care, and other HC facilities, patients are assessed for risk of pressure injury development. Assessment for pressure injury risk includes using an appropriate predictive measure and assessing a patient's mobility, nutrition, presence of body fluids, and comfort level. A benefit of the predictive instruments is to increase a nurse's early detection of patients at greater risk for injury development. Perform reassessment for pressure injury risk on a scheduled basis.

TABLE 48.6 Assessment of Abnormal Healing in Primary and Secondary Intention Wounds

-PRIMARY INTENTION WOUNDS- incision line poorly approximated, drainage present more than 3 days after closure, inflammation increased in first 3-5 days after injury, no healing ridge by day 9 -SECONDARY INTENTION WOUNDS- pale or fragile granulation tissue, hypergranulation present, wound exudate is purulent, nonviable tissues such as necrotic or slough in wound base, fruity or earthy or putrid odor present after wound base is cleansed, presence of fistula(s) or tunneling or undermining

Fluctuance

-Palpable fluid beneath the skin indicative of infection/pus

Stage 2 Pressure Injury

-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 is not visible, 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 heal. -This stage should not be used to describe moisture-associated skin damage, including incontinence-associated dermatitis, intertriginous dermatitis, medical adhesive-related skin injury, or traumatic wounds.

Apply critical thinking when providing care to patients at risk for or with actual impaired skin integrity

-Perform wound irrigation in a manner that avoids further injury to tissue. -Exposure to heat and cold causes normal systemic and local responses but can also cause injury to the skin if applied too long or incorrectly. -An elastic bandage applied too tightly can result in circulatory impairment.

Purulent

-Pertaining to pus, containing or composed of pus

Tissue ischemia

-Point at which tissues receive insufficient oxygen and perfusion, restriction of blood flow to tissues

Assessing patient's skin integrity and for pressure injury

-Press a finger over the affected area -See if the area turns pale in color -Then the area should turn a red/pink color when released -Then the area is noted as blanchable -If not, possibly deep tissue damage -If patient has a darker skin tone, compare one side to the other -Blanching isn't the only way to assess -Check for firmness of the tissue, edema, sensation, warmth or cooler temperatures of the area

Describe the pressure injury staging system.

-Pressure injury stages describe the depth of tissue injury, which will guide treatment.

Describe the differences in wound healing by primary and secondary intention

-Primary and secondary intention wounds differ in each phase of wound healing, which impacts the plan of care.

Primary intention

-Primary union of the edges of a wound, progressing to complete scar formation without granulation

Laceration

-Produced by the tearing of soft body tissue, often irregular or jagged

Evisceration

-Protrusion of viscera through an wound opening

Granulation tissue

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

Debridement

-Removal of nonviable, necrotic tissue

Table 48.3 Braden Scale for Pressure Ulcer Risk

-SENSORY PERCEPTION-Ability to respond appropriately to pressure-related discomfort: 1. Completely limited 2. Very limited 3. Slightly limited 4. No impairment -MOISTURE- Degree to which skin is exposed to moisture: 1. Constantly moist 2. Very moist 3. Occasionally moist 4. Rarely moist -ACTIVITY- Degree of physical activity: 1. Bedfast 2. Chairfast 3. Walks occasionally 4. Walks frequently -MOBILITY- Ability to change and control body position: 1. Completely immobile 2. Very limited 3. Slightly limited 4. No limitations -NUTRITION- Usual food intake pattern: 1. Very poor 2. Probably inadequate 3. Adequate 4. Excellent -FRICTION AND SHEAR- 1. Problem 2. Potential problem 3. No apparent problem -Evidence based tool used to predict risk for developing a pressure ulcer or skin injury -Scores are <9-23

TABLE 48.2 Types of Wound Drainage

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

Epithelialization

-Stage of wound healing in which epithelial cells form across the surface of a wound

Slough

-Stringy substance attached to wound bed

Surgical and Traumatic Wounds - Wound Closures

-Surgical wounds are closed with staples, sutures, or wound adhesives. Staples and dermabond are types of closures for surgical wounds.

Negative-pressure wound therapy (NPWT)

-The application of subatmospheric (negative) pressure to a wound through suction to facilitate healing and collect wound fluid

Friction

-The force of two surfaces moving across one another such as the mechanical force exerted when skin is dragged across a coarse surface such as bed linens

Wounds and Pressure Injuries - Pain

-The routine assessment of pain in surgical patients is critical to selecting appropriate pain management therapies and to determine the patient's ability to progress toward recovery. Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure injury risk.

Reactive hyperemia

-The transient increase in organ blood flow that occurs following a brief period of ischemia

Primary intention

-These are surgical wounds or traumatic clean wounds -Little tissue loss -If healing well note the wound as: clean, dry, intact with edges approximated, no s/s of infection

Assessing patient's with a darker skin complexion

-Use natural light- localized area may be shaded purple, blue, or violet -Do not use only vision to assess- note changes in sensation, temperature, tissue consistency, examine areas with less pigment to know the underlying skin color -Assess pressure areas and localized skin color changes- color remains unchanged when pressure is applied, color changes occur at site of pressure that differ from patient's usual color, if an area was previously injured it will usually be colored differently due to healing of the tissue, purple color usually means the skin is deeply injured

Surgical and Traumatic Wounds - Stable Setting

-When a patient's condition is stabilized, assess the wound to determine progress toward healing

Surgical and Traumatic Wounds - Palpation of Wound

-When inspecting a wound, observe for swelling and separation of wound edges. While wearing clean gloves, lightly press the wound edge, detecting localized areas of tenderness or drainage collection. If pressure causes fluid to be expressed, note the characteristics of drainage. The patient is normally sensitive to palpation of wound edges. Extreme tenderness indicates infection.

TABLE 48.1 Wound Classification

ONSET AND DURATION -Acute- wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity -Chronic- wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity HEALING PROCESS -Primary intention- wound that is closed -Secondary intention- wound edges not approximated -Tertiary intention- wound that is left open for several days; then wound edges are approximated