Week 10: Monday Skin Integrity and Wound Healing

Discharge teaching case: A nurse is teaching Mr. T with a leg ulcer about tissue repair and wound healing. Which statement by the client indicates understanding?

"I'll eat plenty of fruits and vegetables For effective tissue healing, adequate intake of protein and vitamins A, B complex, C, D, E, and K are needed. Therefore, the client should eat a high-protein diet with plenty of fruits and vegetables to take in these nutrients. The treatment of the ulcer may or may not include covering it; a wound nurse would create the best plan for the client. Redness in a wound is a sign of inflammation

Wound classificatiton

***Know these and what they mean*** -superifical -penetrating -perforating -laceration -puncture -abrasion -contusion -clen - no brekas in sugical asepsisi -contaminated - amjor breaks in sugical aspeisis -infected -colonized -pressure ulcers (stave I-IV)

phase I bleeding homeostaiss

-begins immediatly after injury -inclueds homeostatis ( cessation of bleeding) due to vasoconstriction and platel aggregation -relase of hstamine, incrsing capillary permeabiltiy ( plamsa leaking and basodilation) -pt with antihistamines will have dleayed prsonis in early stages eg. those with allergies or COPD -edma helps put pressur over are to reduce bleeding

Wound Irrigation

-cleanses a wound using pressure -sterile Normal Sailu = usually perscribed and used -avoid caustic(Corrosive) agents ( eg. peroxide, idodien...) -pressure between 4-15 lbs/ square inch ( psi) eg. 60ml syringe with cateter tips -clens form proximal to distal, inner to outer, clenst to dirtiest -ue irrigation for large wouonds that need claning -ther are tiems when you need to use peroxie, in a snece its like debrevemetn bc it brings the dead blood cells bubleling up to the toop, but then need to clen out with saline, bc dont want to leave it on wound

other terapies: hydrotherapgy

-pulse leavage -whirlpool -adis in debrivemnet and claning -warm water vasiodilation ( avoid to haot, may burn pt) -Sitz bath: temrperature and length of time -> never longer then 20 minutes, temperature should be bohg down slwoley eg. the paralized pt law sute that got burned after goign to teh bathroom midway though it -> test it with my elbow or wrist to make sure its ok

Heat Therapy

-reduces pain and promotes ehaling though vasodilation -increses oxygen and nturints to aid in inflammmatory response -reuces edema by promoting removal of excessive intersitial fluid -promotes muscle relaxation

Basic principles of bandages and binders

-seucres dressings in place -dermine size needed -outer covering must cover entire wound -tape to secure ( intial, date, time)

other theapy electical stimulation

-stimulates nerves -tens units -for pain relief -electical signals direct cell migration in wound healing

Dehiscence

-surgical complication whent eh wound start to pull apart -commen in obest peopel with extra adipise, bc harder to get that to bidn to gether and grow back as one

Dibridement Methods

-surgical doen by PHP: cutting area making sure clen cut ara -Autolytic: lysis by your own fluids, keep mositure of pts own fluids int ehre to preen tit form drying out, eg. in burn patients -Enzymatic: use enxyames -Mechanical ( ie hydrotherapy) -> water therapy -Maggot therapy -> they eat the dead skin, sypically used fro surface owunds

When to use stapes insted of stutures

-use them fro an obes pt with lots of adipse tissue in abdoemn and they wont disintegrate or fall apart -nurses reposnsiblity to talek out staples --can sotmetiems cause redness right arouodn stapel

other theapy hyperbaric oxygen

-viergin amasion the only one that has this -for peole wit sever injuryes that can't heal, use oxygen to help it heal faster

Stage 4 Pressure Injury

-with exposed or directly palpable facea, muscle, tendon,ligaments, cartalige, or boen int eh ulcer -slowugh and or escar may be visable -epibole ( rolled eges, underminign and or tunnelign often occure -depth varries by antomical location -sepsisi, ostepymytes and many other problmes -fi slough or escar oobsucred the exten of tisue loss this is unstage pressure injguy

4 phases of wouond heling/regeneration

1. bleeding -blood clot forms -expetions are pwopel with antcoagulents who are uanble to form clots, pt with vlave replacemtns, alchoholics ( have afulty liver shihc is where the blody forms blood clots)** 2. Inflamation -those affectedd: immunospressed oncology pt ( bc they have to few WBC to start phagosytosis) 3. Proliferative 4. Remodeling

Wound Assessment

Apperance: -grnaulation tissue, exchar, slough, edema, tunneling, undermining, sinus tracts, color Drainage: -serous,- pale yellow or tranparten -seroussinguious, pale pink -sanguious, bright red -purulent -green yellow, bronw or white - mily like, sure sing of infection -and their amouont Pain, redness, heat, edema -could men fluid is underneath -if cold: worried about clot, or vessl cut in surgery as typically should be warm size and location on boyd presenace of suture/staples -if red around sutures may be allergic to tehm pressance of drains/ tubes wouond edges

Stage 2 Pressur Injury

PARTIAL THINKNESS SKIN LOSS WITH EXPOSED DERMIS -the wound bed is visable, pin or red, msoit and may also presen an intact or ruptured serum -filled blister -adipsoe fat not visable and deper tissue also not visable -granualtion tissue , slogh and escar are not preesen, these injues commoly result form advers micrclimate and sher int eh skin over the pelvis and shear is the heel -this stage shoud nto be used to describe mostrue associaceted skin damage (MASD) including ->incotince assocated dermiteis (IAD) -> intertrignous dermitis (ITD) ->meidcal adhesive related skin injury (MARSI) -> or tamatic wounds ( skin ters, brns, abrasions) - at risk of infection if using barrer cream

Case study Q: Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?

The client's skin is intact with non-blanchable redness of a localized area over a bony prominence -Clients who are immobilized and are in stationary positions without regular position changes are more likely to develop pressure ulcers because of pressure on the skin for extended periods. This is the definition of a stage 1 ulcer. The other answers are incorrect because they describe different stages of ulcerations -stage one big thing is skin is still intact

Dressings for Dry Wounds

Transparent: -gas exhaged between wound and enironemnt but bacteria preventedform entering -creats mosit ehling environemnt Hydrogels: -high water contetn enhances epithlizationa dn autolytic debrivement -needs cover dressing and wound edge barrier -can collect bacteri bc its wet Wet to Moist Gause dressing -keeps wound bed most -minimize trama to graulation tissue bc not ripping it all out every tiem do a dressing change -may want to use gels/ lubs

Case Study Mr. T has a past medical history significant for DM Type II, hypertension and depression who presents today complaining of throbbing 4/10 pain that increases when his legs are dependent and with ambulation. Refuses pain medications. He was grimacing with movement. Ambulation in room to bathroom, sits in chair for meals with legs elevated. Lives with wife at a nursing facility. Reading and watching the news are his favorite pass time. Does not like social activity. Eats only home-cooked food and especially love wife's oxtail soup and fried chicken. Family history of obesity and hypertension. No food allergies.

What are key problems -lack of movemnt, pain with movemtn PVD, obesiety and hypertention, and diete What type of wound would expect -PV ulcer, or bed ulcer What is a nursing diagnosis -impared skin integrity r/t exess of fluid as evidence by pain when walking an elevatind leg What is your intervention -kkepp leg elvated and reduce edema What are key teaching needs -monor edem in his leg and watch his diet, imporatnce of healthy diet and exercise

Keloid

abnormal amoutn fo collagen laid down, hypertophic scar ( common in dark skin)

scar aka Cicatrix froms

avasuclar tissue, doesn't sweat, grow har or tan

Braden Risk Assessment Scale

categoreis: -sensory preception -mostiure -activity -mobility -nutriont -friction and shear Scoring -top/ideal =23 -sever risk< 10 -high resk 10-12 -moderate risk 13-14 -mild risk 15-18

contusion

clousd wouond

burn paties die form what?

deydration, losse to much fluid though their injures -> go into shock and die

Wound complications:Psychsocial impact

encourge verbilation of feellings encourge self care as toelrated by client

Stage 3 Pressure injury

fULL THINKSNESS SKIN LOSS -which adipsoe is visable under ulcer and granualtlion tissue adn epibole ( rooled woudn eges are often prestn) -slough and escahr may be viable -the epth of tissue damage veares by antaomical locataion, areas of signification adiposity can delvelop deep dousonds -undermining and tunneling may occure -faccia, muscle, tendon, ligament, cartilage adn or boen are not espoed ****-if sough or escar obser the exten of tisue loss this ins an unstaged presur injury

Helath goeals for integuemnty system

for meanoma: check for black spots and monitor them or if exposed to lots of sun - to prevent it: -avoid being outsied form 10-4 -use sun protective clothing -use sunscreen with > SPF 15 -avoid artifical sources fo UV light

penetaring wouonds

goes though dermis and deeper tissues or goragns

4 pahses of wouond healing

hemostasis: -stop bleeding -day1-3 inflammation -days 3-20 -new forma work for blood vessle growth proliferation of grnalultion -week 1-6 -pulls the wouodn closed Remodelog or maturation -week 6-2 years -final proper tissue

Types of Wouond healing

primary intention: -cean, strigh line, edges well approximated with sutures, rapid helaing, usually from surgery Secodnary Intention: -more common in tram, > chance of sepeis and edges dotn coem together -larger wounds with tissue loss, edes no approximted, helas from inside out, grnaulatlion tissue fills in the wouond, longer helin tiem larger sacares Tertiary Intetion: -greaater risk of infeciton, dleayed -delayed 3-5days before injuy is sutured, greater access for pathoges to invade , greater inflammation, mroe grnaulationl, laerer scares

Wound complications: Hemorrhage

s/s large amts sanguinous drainge + other symtoms fo hypovlemic shock -Check UNDER clients -bleeding soem is nromal, excessive bleeding can be caused by disloged clot, stich slipped , blood vessle erosion, may see a hematoma -> collection of blood under the skin looks reddish/blue bruise

Wound complications: Evisceration

s/s woudn opens revaling internal organs. -emergancy Rx = sterile NS gauze to cover, prepare for OR -protruison of internal vicera ( internal orans ) though the incision

abrasion

scraping away of skin layer

Pressure ulcers

stage 1: skin is unbroken but inflamed stage 2: skin is brok to epiderm or dermis, from here on there is a resk of infection stage 3: ulcer exteds to subcuatious fat layer stage 4: ulcer extends to mucle or boen, and undermining is likely prevetion is key**** -f pt gets dubicutis ulcer in hospital its our fault

Phagocytosis

macrophages engulf micrbes and secret groth factos that cause angiogeneisis ( new blood vessles form form pre-exisiting ones) -this stimulates peithelal buts at hte end of injured tissue reulitn in increse circulation which sustain the heling process

Stage 1 pressure injury

*NONON BLACHING ERYTHMA OF INTACT SKIN -intact skin w/ localized are of non blching erytham which may appear differnly in darly pig people, -presenc of blanchin erythm or chages in senstion, temp, firmness, may preced siual changes color chages dont includ purpl or maroon discolreaion, thees may indicat deep tissue pressu injury -get them on a new bed/space, can put barrier cream on them

a pressure injury

- is localized damage to teh skin and underlyign soft tissue usually over a boeny promince or related toa medical or otehr deviece -the injuy can present as intact skin or an open ulcer and may be painful -it occurs as a ruslt of intest/ prolonged prressur or pressu in combiation w/ sheer -the tolerance of soft tissue pressue and shear may also be affected by microlimte, nutrion, perfusion, comorbidities and condion of the soft tissue

Wouonds classification

-Indtenional: planned treatment, eg surgery - typically dosen under steril conditions, less risk of infection -Unitnetional : unexpected trauma, accidtns/burns/shooting, greater risk of infection -Open: skin , broken, portal of entery, > infection -closed: trauma from force, skin intact, soft tissue damage, internal injury, possible bleeding -Acute: goes though nomal/timely helaing process -Chronic: fials to go though normal stages of healing, no tiemly progerss in ehaling -> often leads to sepsis

Deep Tilssur Pressur Injuyr

-Intact or non-intact 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 the actual 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 (Unstageable, Stage 3 or Stage 4). -Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Case study - 72 yr old women admitted to CVA

-Nsg diagnosis: Alteration in skin integrity as evidenced by redness due to pressure on area of coccyx -What assessments would you perform: check temp, size, location, hix of how long its been there, past injures or toehr ones What is your Plan - move her arouond, put her in special bed, use pillows and special pads for cushoning

Phase II Inflamation

-also beings immeidatly fter injury and contiues in early stages -lenght of time depends on types of injury, permiability continues and plasma continues to leaks, eg. burns -phagosytosis -days 3-20 -meostais =plate aggrecation is sitmulated to stop bleeding, -> then relases histamine by mast cells and incree capillary peroomability -> also vasodiation -> plasma leaks in leading ot swelling

Binders

-amdominal binder, other minders eg. motgomery strps ( old term) -use them on obese, dieabetics or peoel who cant cough) applys pressure to support them to help wouodn helig or to be able to cough, and decrese pain -dressing goes under bidning bc dont change these every day

Wound complications: infection

-S/S purulent drianiage, pain, redness arouond wound, edema, incresed temp, elvated WBC -bacter enters becoems infected

Wouond healing

-a healthy body can restore itslef, depedning on amout of damage and stat of health of perosn -reffered to as regernation (renwal of tissue) -there are 4 phases of regeneration

factors/ stressors that impari wound helaing

-age biggest factore ( as they get older they get skinny, > chance of PVD, lots of time in bed) -malnutrition: -obesity ( lots of fatty tissue makes it hard to get lost of blood and hard to heal) -emaxiation (abnomally thin) -poor cirucaltion and oxygen - diabetics ( PAD) -mmunosupression -smoking -incontinence -medications( steriods long term, not worred about nasal oens for asthma)) -co-mormdidites ( diabetes) -wouond stress -rediation

Cold Therapy

-decresed pain by vasoconstircion -decrsed blood flow to teh area decrses inflamation adn edema -raises the threshold of pain receptrs therby decrsing pain -decrses uscle tension -on for 20-30 minutes -longer than that may cause reboudn pnumonia -often seen in kennes, ankels, muscle surgery, could constics tveslses, decrsing swelling arouodn area, need good ciruclation to sue cold therapy * alsways has to have feeling to sue temperature therapy adn needs good cerciluation speicifaclly for cold therapy

Phase II cont- inflam responsece - the systemeic responce

-elevated temperature ( due to relese of netrophils and leucocytes) -elveated WBC ( norm 5,000-10,000) Malasia ( tiered)

Phase III - Proliferation ( fibroplasisi) pahse

-fibroblast synthesixecollagens which add strnght to the wouond -begins 2-6 days after injury, last 2-20 weeks -thin layer of eptheelia cells forms, blood flow is reinsituted -tussue forms know as grnulation tissue ( trnslucen tred, color/frgile/bleeds esily) -capillares gro across, -> fibroblasts form fibrin, collagen continues to form, WBCS leav the site

Phase IV -Maturation (remodeling)

-final pahse beings about 3 weeks after the injury, 6 month deuration or longer if deep wouond -ocllagen orgiinally in haphazard order remodels and reorganizes into a more orderly structure -scar aka cicatrix forms -keloid

Wehn to have moist wound bed

-for frama bed sores, abcess, thoes want to keep it mosits, bc otherise indise willl dey and then wont gro together and infectioso wounds keep oist -surgical sounds are never mosit

Wouond Dressing Principles

-if exudate is prestn: select on ethat absoreds exudate -keep wouond bed mosit but surroungd iskin dry ( to enhance epithealzation/grwoth -pack wouonds loosely to avoid pressur on the new granulatuion tissue -fasten securly using tape, beindes... or self adhexive tape dressing materials -protext wouodn from tauma and microbial invasiions

Cellulites

-inflammation caused by breka in teh skin -often seen in arems, legs, joins, mosquito bites and spider bites -its dangerouos, pople can lose extermites from it, -mark/outline it to see if it will get better or worse -also try and firugre out fi they got the spider bites from hobo or blakc widows -> inflamtion can look like abcess -pt. w/ cellulies need to be put on antibioitcs -fle bits are typically on the legs ( form the carpt, while bed bugs are thoughout whol body form bed

Wound complications:

-invection -hemmorage -dehiscence -evisceration -pshychosical impact

Other types of wounds: Peripheral Vascular diseae

-irregularly shaped -lots of fluids -red, puffy/ edema -on sides of ankles and shins -elevate it

Nursing care preveinign pressure ulcers

-know pt at risk -sensory mositure -activity, mobility, friction/shear -nutrion

Unstablege pressure injury

-obsure full thinkness skin and tisue loss -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 (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed.

other factors to asssess for wouonds?

-odor -lab values: WBC -whata caused the wouond -need for tetanus ( get it every 10 years) -when did wouodn occur -what fi any terment have been tried so far?

Case Study Mr. T, a 67-yr-old Russian immigrant is admitted to the hospital for ulcer on the right foot. He worked 20 years as a construction worker in Southern Florida. He is also a chronic smoker. Admission H&P: What type of questions would you ask?

-pack history, -get a better idea of his history, -know what type of construction he does, -last tetnus shot, -has he had preious ingery there, - his skin integrity looks very poor, -has he been identified as pheripehral artierial disease, -how long has he had it, -did he get a bit there, or has he had it along time

Phase II cont - inflametory repsonse assessmen - 4 cardinal s/s

-pain: r/t nerve ending damabe, toxinins form bacteri, and pressur form edema -redness: due to > blood flow to area -heat: r/t metabolic activity occurin ont he cellular level -edema: r/t phagocytosis and incresed blood flow to the area -> need to know when these are normal v abnomal

Other types of wounds:Peripheral artierial disease

-puch hole shaped -less liuid -poor perfusion, palor -on side of feet and toes and -keep it lowereed * alos worred about gangre -> when blood is cut off to a large area

Case study A 6x8cm wound on R lateral ankle above the medial malleolus was noted. Irregular wound margins with some pallor on the edges. R leg skin hyperpigmented and ruddy. Some flaking is present, no hair growth. 3+ edema, capillary refill 4 seconds. L cool is cool, sensation decreased. Full ROM, strength 2+ and slightly decreased

DX: Venous ulcer Read what it is in Lewis or ATI Fundamentals What kind of ongoing assessment would you predict? Impaired tissue integrity Risk for fall Altered nutrition

promotion of wouond healing - nrusing intervetions

Dressings: -keep wouond covered and clean sterile chages -now doent alwasy cover all wounds in bc someies will not aloow bacter or fluid to get out wound bed moits/surrouond skin dry -for infected or deeper wouonds debrivement when necissary ( remvoing the dead tissue) -enzymtaic - protlytic enzymes ( brek down long chains of protiens) -mechanical -suggical -autolytic -maggots -remove exudate( fluid): drains wound vac, irrigation -pack wound loosely -nuritons intervetions -improve cerculation - ahve them move or lower limbs, message lightly

Dressings for Mosit Wouonds

hydrocolloid -hydrophilic particles mix with water to form a gel wouond stays mosti -***DONT use in infected wounds Absorption Materils: -beads, powders, rope or sheets that bsorbe large amouts of exuadate Foam: -made of hyrophilic material -highly absorbed Dry Gause: -Can absorbe wouond drinage -can be impregenated with agents to promote helaing

hematoma

is a localized collection of blood outside the vessles, due to diease, injury trauma, or surgery -ressure form this can casue pain, not necissarly infection, could be cause by sengious fluid ro seriousenguinous -ifst thing to do is check ther temperature to amke sure its not an infection

Safe precations for Heat and Cold therapy

need physcians order -very yon and very old -peripheral vasucla diease -decred LOC -spinal cord injury -> cant feel -presance of edma and or scar tissue -. cant feel -no longer then 20-30 min at a time, reboudn phonon ( vasdilat, vasodioal and constrict -> end up with burn)

other therpaties: wound VAC

negative rpessure vacuem assisted closure system -removes drainge and helps wound close

left shif/left differntiatl

nromal level of netrophils is <10 -this occures when ther is a greter number of immature netrophils which means the body is not able to keep up with the infection and puts an increse risk of goign into sepsiss

Drinas

open system: -penrose: simlest one, msot basic, looks like tubing it has not pressure, jsut literally a way fo rthe lfuid to flow out usually in area wher the is not a lot fo dringe, this needs to be steril, Closed sytems: -hmovac is the genric name for Jackson Pratt - its the ball and squishy tub, have sucion and presue, need to be thighly in plac eto suck fluid out not jsut air, usually pcp will pull it out, each day wnat less blood in it

perforating wouonds

pentrating wouond wich enters and exits an organ ( goes thougoh it)

Wound complications: Dehiscence

s/s wound edges pulling away, not well approximted -early sign= incresign serousanguinous drainage -partial or toatl rupturing of a sutured wound, more common with obse individuals , uslally comes aprart form the inside out!

lacteration

tering of tissues, uneven edges

What do nruses assess?

the 4 cardinal S/S -pain -redness -heata -edema -systemic changes

Wehn in dout of infection check

thier temperature