Week 11 - Skin Integrity

Wound Vacuum assisted closure (V.A.C)

(uses negative pressure to support healing) Device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together removing fluid from area surrounding wound, reducing edema and improving circulation to area. Can be used for acute & chronic wounds

Cleaning Skin

1. Clean in a direction from the least contaminated area such as from the wound or incision to the surrounding skin or from an isolated drain site to the surrounding skin. 2. Use gentle friction when applying solutions locally to the skin. 3. When irrigating, allow the solution to flow from the least to the most contaminated area

Primary vs. Secondary Intention

A: Wound healing by primary intention such as a surgical incision. Wound healing edges are pulled together and approximated with sutures or staples, and healing occurs by connective tissue deposition. B: Wound healing by secondary intention. Wound edges are not approximated, and healing occurs by granulation tissue formation and contraction of the wound edges

The nursing assistant asks you the difference between a wound that heals by primary or secondary intention. You will reply that a wound heals by primary intention when the skin edges A. Are approximated. B. Migrate across the incision. C. Appear slightly pink. D. Slightly overlap each other

Are approximated

Heat and Cold Therapy

Assessment for temperature tolerance Assess the skin and skin integrity. Assess the patient's response to stimuli. Assess the equipment being used. Identify any contraindications. Local effects of heat and cold Factors influencing heat and cold tolerance Application of heat and cold therapies

Nutritional Assessment and Management of Pressure Ulcers

Assessment of Clinically Significant Malnutrition -Screen and assess the nutritional status of the patient with a pressure ulcer on admission and with each condition change. -Assess weight status to determine weight history and significant loss from usual weight (≥5% change in 30 days or ≥10% in 180 days). Interventions -Refer patients with pressure ulcers to the dietitian for early intervention for nutritional problems. -Provide 30-35 calories/kg body weight for individuals under stress with a pressure ulcer. -Consider nutritional support when oral intake is inadequate. -Encourage consumption of a balanced diet that includes good sources of vitamins and minerals

Partial-thickness wound repair

Inflammatory response (redness. swelling, exudate) Epithelial proliferation and migration Wound edges -> wound bed Need moist environment Re-establishment of epithelial layers Return to normal thickness Three components are involved in the healing process of a partial-thickness wound: inflammatory response, epithelial proliferation (reproduction) and migration, and reestablishment of the epidermal layers. Partial-thickness wounds are shallow wounds involving loss of the epidermis (top layer) and possibly partial loss of the dermis. These wounds heal by regeneration because epidermis regenerates. An example of this is the repair of a clean surgical wound or an abrasion

Stage I

Intact skin with nonblanchable redness Wound Care Options: None: allows visual assessment. Resolves slowly without epidermal loss over 7-14 days (turning schedule, support hydration, nutritional support) Transparent dressing. Protects from shear. Not to be used in presence of excessive moisture Hydrocolloid: Does not always allow visual assessment. Benefit: Pressure-redistribution surface or chair cushion

Debridement

Debridement (removal of nonviable, necrotic tissue) -Mechanical (W->D) -Autolytic ( Hydrocolloidal) -Chemical (Dakin's) -Sharp/surgical Prevents infection and promotes healing

Wounds

Disruption of the integrity and function of tissues in the body

Safety Suggestions for Applying Heat or Cold Therapy

Do explain to patient sensations to be felt during the procedure. Do instruct patient to report changes in sensation or discomfort immediately. Do provide a timer, clock, or watch so patient can help the nurse time the application. Do keep the call light within patient's reach. Do refer to the policy and procedure manual of the institution for safe temperatures. Do not allow patient to adjust temperature settings. Do not allow patient to move an application or place hands on the wound site. Do not place patient in a position that prevents movement away from the temperature source. Do not leave unattended a patient who is unable to sense temperature changes or move from the temperature source.

Prevention of Pressure Ulcers

Economic consequences ↑LOS No Medicare/Medicaid reimbursement Preventive measures Special beds/mattresses Good hygiene Good nutrition Good hydration Turning and positioning Assessment

Exposure to Body Fluids

Exposure to urine, bile, stool, ascitic fluid, and purulent wound exudates carries a moderate risk for skin breakdown, especially in patients who have other risk factors such as chronic illness or poor nutrition. Exposure to gastric and pancreatic drainage has the highest risk for skin breakdown. Again, it is important to prevent and reduce the patient's exposure to body fluids; and, when exposure occurs, you need to provide meticulous hygiene and skin care

Other Dressings

Foam and alginate dressings are for wounds with large amounts of exudate and those that need packing. Foam dressings are also used around drainage tubes to absorb drainage. Calcium alginate dressings are manufactured from seaweed and come in sheet and rope form. The alginate forms a soft gel when it comes in contact with wound fluid. These highly absorbent dressings are for wounds with an excessive amount of drainage and do not cause trauma when removed from the wound. Do not use these in dry wounds, and they require a secondary dressing. Several manufacturers produce composite dressings, which combine two different dressing types into one dressing. Research is ongoing regarding which type of dressing is best for which type of wound

Shear

Force on skin over bone when the skin remains at the point of contact while the bone moves; causes damage to the skin.

Stage IV

Full-thickness tissue loss with exposed bone, muscle, or tendon Hydrogel covered with foam dressing: Applied over wound to protect and absorb moisture. Heals through granulation and reepithelialization. Surgical consultation often necessary for closure (see stages I, II, and III) Calcium alginate: Used with significant exudate; must cover with secondary dressing Gauze: Used with normal saline or other prescribed solution; must unfold to make contact with wound; fill all dead space with gauze Growth factors: Used with gauze

Stage III

Full-thickness tissue loss with visible fat Wound Care Options: Hydrocolloid: Must change when seal of dressing breaks; maximal wear time 7 days. Heals through granulation and reepithelialization. See previous stages; evaluate pressure-redistribution needs Hydrogel covered with foam dressing: Applied over wound to protect and absorb moisture Calcium alginate: Used with significant exudate; must cover with secondary dressing Gauze: Used with normal saline or other prescribed solution; must unfold to make contact with wound Growth factors: Used with gauze per manufacturer instructions

Effects of Heat Application

Heat generally is quite therapeutic, improving blood flow to an injured part. However, if heat is applied for 1 hour or more, the body reduces blood flow by a reflex vasoconstriction to control heat loss from the area. Periodic removal and reapplication of local heat restores vasodilation. Continuous exposure to heat damages epithelial cells, causing redness, localized tenderness, and even blistering. Vasodilation: Improves blood flow to injured body part; promotes delivery of nutrients and removal of wastes; lessens venous congestion in injured tissues. Treats: Open wounds, rectal surgery, episiotomy, painful hemorrhoids, muscle tension, vaginal inflammation, wound debridement Reduced blood viscosity: Improves delivery of leukocytes and antibiotics to wound site Reduced muscle tension: Promotes muscle relaxation and reduces pain from spasm or stiffness Increased tissue metabolism: Increases blood flow; provides local warmth Increased capillary permeability: Promotes movement of waste products and nutrients

Complications of Wound Healing

Hemorrhage Hematoma Infection Dehiscence Evisceration

Stages of Full Thickness wound repair

Hemostasis A series of events designed to control blood loss, establish bacterial control, and seal the defect occurs when there is an injury. During hemostasis injured blood vessels constrict, and platelets gather to stop bleeding. Clots form a fibrin matrix that later provides a framework for cellular repair. Inflammatory Phase In the inflammatory stage damaged tissue and mast cells secrete histamine, resulting in vasodilation of surrounding capillaries and exudation of serum and white blood cells into damaged tissues. This results in localized redness, edema, warmth, and throbbing. The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment (e.g., ankle or neck). Leukocytes (white blood cells) reach the wound within a few hours. The primary-acting white blood cell is the neutrophil, which begins to ingest bacteria and small debris. The second important leukocyte is the monocyte, which transforms into macrophages. The macrophages are the "garbage cells" that clean a wound of bacteria, dead cells, and debris by phagocytosis. Macrophages continue the process of clearing the wound of debris and release growth factors that attract fibroblasts, the cells that synthesize collagen (connective tissue). Collagen appears as early as the second day and is the main component of scar tissue. In a clean wound the inflammatory phase establishes a clean wound bed. The inflammatory phase is prolonged if too little inflammation occurs, as in a debilitating disease such as cancer or after administration of steroids. Too much inflammation also prolongs healing because arriving cells compete for available nutrients. An example is a wound infection in which the increased metabolic energy requirements present in an infected wound compete for the available calorie intake. Proliferative Phase With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. Fibroblasts are present in this phase and are the cells that synthesize collagen, providing the matrix for granulation. Collagen mixes with the granulation tissue, and this matrix supports the reepithelialization. Collagen provides strength and structural integrity to a wound. During this period the wound contracts to reduce the area that requires healing. Finally the epithelial cells migrate from the wound edges to resurface. In a clean wound the proliferative phase accomplishes the following: the vascular bed is reestablished (granulation tissue), the area is filled with replacement tissue (collagen, contraction, and granulation tissue), and the surface is repaired (epithelialization). Impairment of healing during this stage usually results from systemic factors such as age, anemia, hypoproteinemia, and zinc deficiency. Remodeling Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound. The collagen scar continues to reorganize and gain strength for several months. However, a healed wound usually does not have the tensile strength of the tissue it replaces. Collagen fibers undergo remodeling or reorganization before assuming their normal appearance. Usually scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. In dark-skinned individuals the scar tissue may be more highly pigmented than surrounding skin.

First Aid for Wounds

Hemostasis Control bleeding Pressure bandage Allow puncture wounds to bleed. Removes dirt Contaminants Do not remove a penetrating object. Cleaning Gentle Normal saline Protection - covering

Full-thickness wound

Hemostasis Blood vessel constriction Platelet aggregation to form fibrin matrix Inflammatory phase Proliferative phase (epithelialization) Remodeling May be > 1 year Scar tissue becomes stronger The four phases involved in the healing process of a full-thickness wound are hemostasis, inflammatory, proliferative, and remodeling. Full-thickness wounds extending into the dermis (involving both layers of tissue) heal by scar formation because deeper structures do not regenerate. Pressure ulcers are an example of full-thickness wounds.

Warm Soaks

Immersion of a body part in a warmed solution promotes circulation, lessens edema, increases muscle relaxation, and provides a means to apply medicated solution. Sometimes a soak is also accompanied by wrapping the body part in dressings and saturating them with the warmed solution. Position the patient comfortably, place waterproof pads under the area to be treated, and heat the solution to about 40.5° to 43° C (105° to 110° F). After immersing the body part, cover the container and extremity with a towel to reduce heat loss. It is usually necessary to remove the cooled solution and add heated solution after about 10 minutes. The challenge is to keep the solution at a constant temperature. Never add a hotter solution while the body part remains immersed. After any soak dry the body part thoroughly to prevent maceration.

Risk Factors for Pressure Ulcer Development

Impaired sensory perception Alterations in level of consciousness Impaired mobility Shear Friction Moisture

Age

Increased age affects all phases of wound healing A decrease in the functioning of the macrophage leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization.

Classification

Onset and Duration Acute - trauma, surgical incision Restoration of integrity and function Chronic - vascular compromise, chronic inflammation Fails to restore integrity and function Healing Process Primary Intention - closed wound Secondary Intention - wound edges not approximated Tertiary Intention - left open

If you suspect abnormal reactive hyperemia

Outline the affected area with a marker to make reassessment easier Gently palpate the reddened tissue, observing for blanching with return to normal skin tones in patients with light-toned skin. In addition, palpate for induration, noting the size in millimeters or centimeters of the induration around the injured area and changes in temperature of the surrounding skin and tissues

Tissue Perfusion

Oxygen fuels the cellular functions essential to the healing process; therefore the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing Patients with peripheral vascular disease are at risk for poor tissue perfusion because of poor circulation. Oxygen requirements depend on the phase of wound healing (e.g., chronic tissue hypoxia is associated with impaired collagen synthesis and reduced tissue resistance to infection)

Serosanguineous

Pale, pink, watery; mixture of clear and red fluid

Dehiscence

Partial or total separation of wound layers, especially a surgical abdominal wound Risk Factors: (e.g., poor nutritional status, infection, or obesity) is at risk for dehiscence. Obese patients have a higher risk because of the constant strain placed on their wounds and the poor healing qualities of fat tissue Patients often report feeling as though something has given way Prevention: place a folded thin blanket or pillow over an abdominal wound when the patient is coughing. This provides a splint to the area, supporting the healing tissue when coughing increases the intraabdominal pressure.

Stage II

Partial-thickness skin loss involving epidermis, dermis, or both Wound Care Options: Composite film: Limits shear. Heals through re-epithelialization. Turning schedule. Support hydration. Nutritional support Hydrocolloid: Change when seal of dressing breaks; maximal wear time 7 days. Manage incontinence Hydrogel: Provides a moist environment

Stages of Partial Thickness Wound Repair

Tissue trauma causes the inflammatory response, which in turn causes redness and swelling to the area with a moderate amount of serous exudate. This response is generally limited to the first 24 hours after wounding. The epithelial cells begin to regenerate, providing new cells to replace the lost cells. The epithelial proliferation and migration start at both the wound edges and the epidermal cells lining the epidermal appendages, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air can resurface within 6 to 7 days, whereas one that is kept moist can resurface in 4 days. The difference in the healing rate is related to the fact that epidermal cells only migrate across a moist surface. In a dry wound the cells migrate down into a moist level before migration can occur New epithelium is only a few cells thick and must undergo reestablishment of the epidermal layers. The cells slowly reestablish normal thickness and appear as dry, pink tissue.

Purulent

Thick, yellow, green, tan, or brown

Wound Undermining

Tissue destruction underlying intact skin along the wound margins, caused by shearing

Hemorrhage

bleeding from a wound site, is normal during and immediately after initial trauma. Hemostasis occurs within several minutes unless large blood vessels are involved or the patient has poor clotting function. Hemorrhage occurring after hemostasis indicates a slipped surgical suture, a dislodged clot, infection, or erosion of a blood vessel by a foreign object (e.g., a drain). Hemorrhage occurs externally or internally.

Incontinence Dermatitis

inflammation of the skin that occurs when urine or stool comes. into contact with perineal or perigenital skin

Hematoma

localized collection of blood underneath the tissues. It appears as a swelling, change in color, sensation, or warmth or mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because pressure from the expanding hematoma obstructs blood flow.

Hemovac

portable wound suction device that is compressed to provide gentle suction; an internal spring slowly expands to create a negative suction pressure self suction, exacuator

Suspected Deep Tissue Injury

purple/maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure or shear

Infection

second most common health care-associated infection a wound is infected if purulent material drains from it, even if a culture is not taken or has negative results. A sample of drainage from an infected wound does not always reveal bacteria because of poor culture technique or administration of antibiotics. Positive culture findings do not always indicate an infection because many wounds contain colonies of noninfective resident bacteria. In fact, all chronic dermal wounds are considered contaminated with bacteria. What differentiates contaminated wounds from infected wounds is the amount of bacteria present. It is generally agreed that wounds with more than 100,000 (105) organisms per gram of tissue are infected (Stotts, 2012b). The chances of wound infection are greater when the wound contains dead or necrotic tissue, there are foreign bodies in or near t

Wound Tunneling

wound literally makes a path from the wound through healthy subcutaneous tissue or muscle; actual tunnels that can be probed with instruments to assess the damage to the tissues

Labs and Wound Cultures

(HH, CBC, Albumin, PreAlbumin, BUN) A low hemoglobin level decreases delivery of oxygen to the tissues and leads to further ischemia. When possible, maintain hemoglobin at 12 g/100 ml If you detect purulent or suspicious-looking drainage, obtaining a specimen of the drainage for culture may be necessary Never collect a wound culture sample from old drainage. Resident colonies of bacteria from the skin grow within exudate and are not always the true causative organisms of a wound infection. Clean a wound first with normal saline to remove skin flora. Aerobic organisms grow in superficial wounds exposed to the air, and anaerobic organisms tend to grow within body cavities. Use a different method of specimen collection for each type of organism per agency policy Gram stains of drainage are often performed as well. This test allows the health care provider to order appropriate treatment earlier than when only cultures are done. No additional specimens are usually required. The gold standard of wound culture is tissue biopsy. A health care provider or wound care specialist with special training obtains the biopsy

Hydrogel dressings

(maintains a moist surface to support healing) have a high moisture content (95%), causing them to swell and retain fluid. They are useful over clean, moist, or macerated tissues. These nonadherent dressings are very soothing and cooling, thus making them especially useful for painful burn wounds. -Is soothing and can reduce wound pain -Provides a moist environment -Debrides necrotic tissue (by softening the necrotic tissue) -Does not adhere to the wound base and is easy to remove A disadvantage is that some hydrogels require a secondary dressing and you must take care to prevent periwound maceration. Hydrogels come in a sheet dressing or a tube; thus you are able to squirt the gel directly into the wound base

Hydrocolloid

(protects the wound from surface contamination) They are adhesive and occlusive. The wound contact layer of this dressing forms a gel as fluid is absorbed and maintains a moist healing environment. Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds: -Absorbs drainage through the use of exudate absorbers in the dressing -Maintains wound moisture -Slowly liquefies necrotic debris -Is impermeable to bacteria and other contaminants -Is self-adhesive and molds well -Acts as a preventive dressing for high-risk friction areas -May be left in place for 3 to 5 days, minimizing skin trauma and disruption of healing This type of dressing is most useful on shallow to moderately deep dermal ulcers. Hydrocolloid dressings cannot absorb the amount of drainage from heavily draining wounds, and some are contraindicated for use in full-thickness and infected wounds. Some hydrocolloids leave a residue in the wound bed that is easy to confuse with purulent drainage.

Binder Application

Binders are especially designed for the body part to be supported. The most common type of binder is the abdominal binder. Well-fitting bras are now replacing breast binders. Both provide support after breast surgery or exert pressure to reduce lactation in a woman after childbirth. Abdominal Binders: An abdominal binder supports large abdominal incisions that are vulnerable to tension or stress as the patient moves or coughs. Secure an abdominal binder with safety pins, Velcro strips, or metal stays. Slings: Slings support arms with muscular sprains or fractures. A commercially manufactured sling consists of a long sleeve that extends above the elbow with a strap that fits around the neck. In the home patients can use a large triangular piece of cloth. The patient sits or lies supine during sling application. Instruct him or her to bend the affected arm, bringing the forearm straight across the chest. The open sling fits under the patient's arm and over the chest, with the base of the triangle under the wrist and the point of the triangle at his or her elbow. One end of the sling fits around the back of the patient's neck. Bring the other end up and over the affected arm while supporting the extremity. Tie the two ends at the side of the neck so the knot does not press against the cervical spine. Fold the loose material at the elbow evenly around the elbow and pin. Always support the lower arm and hand at a level above the elbow to prevent the formation of dependent edema.

Sanguineous

Bright red; indicates active bleeding

Nutrient Role in Healing

Calories: fuel for energy "protein protection" (35-40kcal/kg/day or enough to +Nitrogen balance) Protein: Fibroplasia, angiogenesis, collagen formation and wound remodeling, immune function (1-1.5g/kg/day or to maintain +Nitrogen balance) Found in: poultry, fish, eggs, beef Although the recommended intake of protein for adults is 0.8 g/kg/day, a higher intake of protein up to 1.8 g/kg/day is necessary for healing. Increased protein intake helps rebuild epidermal tissue. Vit C (ascorbic acid): Collagen synthesis, capillary wall integrity, fibroblast function, immunological function, antioxidant (100-1,000mg/day low toxicity) Found in: citrus fruits, tomatoes, potatoes, fortified fruit juices Vit A: Epithelialization, wound closure, inflammatory response, angiogenesis, collagen formation. Can reverse steroid effects on skin and delayed healing (1600-2000 retinol equiv/day. Supplement if deficient, steroid/delayed healing: 20,000 units × 10 days Found in: green leafy vegetables (spinach), broccoli, carrots, sweet potatoes, liver Vit E: No known role in wound healing, antioxidant No recommendations Found in: Fish, oysters, liver, dark meat, eggs, legumes Zinc: Collagen formation, protein synthesis, cell membrane and host defenses (15-30 mg, correct any deficiencies, no improvement in wound healing with supplementation unless zinc deficient, Use with caution—large doses can be toxic, May inhibit copper metabolism and impair immune function) Found in: Vegetables, meats, legumes Fluid: Essential environment for all cell function (30-35 mL/kg/day, Increase by another 10-15 mL/kg if patient is on an air-fluidized bed) Found in: use noncaffeine, nonalcoholic fluids without sugar, Water is best—6-8 glasses/day A loss of 5% of usual weight, weight less than 90% of ideal body weight, and a decrease of 10 pounds in a brief period are all signs of actual or potential nutritional problems

Comfort measures

Carefully removing tape Gently cleaning wound edges Carefully manipulating dressings and drains minimize stress on sensitive tissues. Careful turning and positioning also reduce strain on a wound. Administering analgesic medications 30 to 60 minutes before dressing changes (depending on the time of peak action of a drug) also reduces discomfort

Changing a Dressing

Changing Know type of dressing, placement of drains, and equipment needed. Prepare the patient for a dressing change Evaluate pain. Describe procedure steps. Gather supplies. Recognize normal signs of healing. Answer questions about the procedure or wound. During a dressing change Assess the skin beneath the tape. Perform thorough hand hygiene before and after wound care. Wear sterile gloves before directly touching an open or fresh wound. Remove or change dressings over closed wounds when they become wet, s/s of infection, and as ordered.

Cleaning Skin and Drain Sites

Cleaning: Apply noncytotoxic solution Irrigation: To remove exudates, use sterile technique with 35-mL syringe and 19-gauge needle. Suture Care: Consult health care facility policy. Drainage Evacuators: Portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage. The method of debridement depends on which is most appropriate to the patient's condition and care goals normal wound observations to make include an increase in wound exudate, odor, and size. You need to assess and prevent or effectively manage pain that occurs with debridement

Serous

Clear, watery plasma

Contraindications to Cold and Heat

Cold is contraindicated: If the site of injury is edematous In the presence of neuropathy If the patient is shivering If the patient has impaired circulation Heat is contraindicated: For areas of active bleeding For an acute localized inflammation Over a large area if a patient has cardiovascular problems

Irrigation

Irrigation of an open wound requires sterile technique. Use a 35-mL syringe with a 19-gauge needle to deliver the solution. This irrigation system has a safe pressure and does not damage healing wound tissue. It is important to never occlude a wound opening with a syringe because this results in the introduction of irrigating fluid into a closed space. The pressure of the fluid causes tissue damage and discomfort. Always irrigate a wound with the syringe tip over but not in the drainage site. Make sure that fluid flows directly into the wound and not over a contaminated area before entering the wound. Skill 48-5 on pp. 1224-1226 lists steps for wound irrigation

A postoperative patient arrives at an ambulatory care center and states, "I am not feeling good." Upon assessment, you note an elevated temperature. An indication that the wound is infected would be A. It has no odor. B. A culture is negative. C. The edges reveal the presence of fluid. D. It shows purulent drainage coming from the incision site.

It shows purulent drainage coming from the incision site.

Special Mattresses

Low-Air-Loss Available as a mattress placed directly on the existing bed frame or an overlay placed directly on top of an existing surface Pressure redistribution: Provides a flow of air to assist in managing the heat and humidity of the skin Prevention or treatment of skin breakdown Hill Rom/Flexicair Eclipse, Kinetic Concepts, Inc/First Step Select, The ROHO Group/Select Air Mattress (Potter Nonpowered Any support surface not requiring or using external sources of energy for operation Examples: Foam, interconnected air-filled cells Pressure redistribution: Air moves to and from cells as body position changes, Prevention or treatment of skin breakdown ROHO/ Dry Flotation Mattress, Gaymar Industries/Sof-Care Air-Fluidized Beds Surfaces that change load distribution properties when powered and when patient is in contact with the surface Provides pressure redistribution via a fluidlike medium created by forcing air through beads as characterized by immersion and envelopment Prevention or treatment of skin breakdown: May also be used to protect newly flapped or grafted surgical sites and for patients with excessive moisture Kinetic Concepts, Inc/FluidAir Elite, Hill Rom/Clinitron Lateral Rotation Provides passive motion to promote mobilization of respiratory secretions and provides low-air-loss therapy A feature of a support surface that provides rotation about a longitudinal axis as characterized by degree of patient turn, duration, and frequency Treatment and prevention of pulmonary complications associated with immobility Hill Rom/V-Cue Dynamic Air Therapy, Kinetic Concepts, Inc/TriaDyne

Braden Scale

Measures patients risk for developing pressure ulcers; measures sensory, moisture, activity, mobility, nutrition, friction, and shear (rated 1-4)

Advantages of Dry and Moist Applications

Moist Applications -Moist application reduces drying of skin and softens wound exudate. -Moist compresses conform well to most body areas. -Moist heat penetrates deeply into tissue layers. -Warm moist heat does not promote sweating and insensible fluid loss. Dry Applications -Dry heat has less risk of burns to skin than moist applications. -Dry application does not cause skin maceration. -Dry heat retains temperature longer because evaporation does not occur

Disadvantages of Dry and Moist Applications

Moist Applications -Prolonged exposure causes maceration of skin. -Moist heat cools rapidly because of moisture evaporation. -Moist heat creates greater risk for burns to skin because moisture conducts heat. Dry Applications -Dry heat increases body fluid loss through sweating. -Dry applications do not penetrate deep into tissues. -Dry heat causes increased drying of skin

Recommendations for Standardized Techniques for Wound Cultures

Needle Aspiration Procedure -Clean intact skin with a disinfectant solution. Allow to dry. -Use a 10-mL disposable syringe with a 22-gauge needle, pulling 0.5 mL of air into the syringe. -Insert the needle through intact skin next to the wound; withdraw plunger and apply suction to the 10-mL mark. -Move the needle back and forward at different angles for two to four explorations. -Remove the needle, expel the excess air, and cap and prepare the syringe for the laboratory Quantitative Swab Procedure -Clean the wound surface with a nonantiseptic solution. -Use a sterile swab from a culturette tube (Fig. 48-12). -Moisten the swab with normal saline. -Rotate the swab in 1 cm2 (0.4 in2) of clean tissue in the open wound. Apply pressure to the swab to elicit tissue fluid (Stotts, 2012b). Insert the tip of the swab into the appropriate sterile container, label, and transport to the laboratory

Factors Influencing Pressure Ulcer Formation and Wound Healing

Nutrition Tissue perfusion Infection Age Psychosocial impact of wounds

PUSH Tool

Pressure Ulcer Scale for Healing Length x Width: Measure the greatest length (head to toe) and the greatest width (side to side) using a centimeter ruler. Multiply these two measurements (length x width) to obtain an estimate of surface area in square centimeters (cm2). Caveat: Do not guess! Always use a centimeter ruler and always use the same method each time the ulcer is measured. Exudate Amount: Estimate the amount of exudate (drainage) present after removal of the dressing and before applying any topical agent to the ulcer. Estimate the exudate (drainage) as none, light, moderate, or heavy. Tissue Type: This refers to the types of tissue that are present in the wound (ulcer) bed. 4 - Necrotic Tissue (Eschar):black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than surrounding skin. 3 - Slough:yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. 2 - Granulation Tissue:pink or beefy red tissue with a shiny, moist, granular appearance. 1 - Epithelial Tissue:for superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface. 0 - Closed/Resurfaced:the wound is completely covered with epithelium (new skin).

Skin + Pressure = Pressure Ulcer

Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: (1) pressure intensity, (2) pressure duration, and (3) tissue tolerance. Pressure intensity -Tissue ischemia -Blanching Blanching occurs when the normal red tones of the light-skinned patient are absent. It does not occur in patients with darkly pigmented skin If the pressure applied over a capillary exceeds the normal capillary pressure and the vessel is occluded for a prolonged period of time, tissue ischemia can occur

Norton Scale

Pressure ulcer risk assessment - physical condition, mental condition, activity, mobility and incontinence. Greater than 18 = Low Risk Between 18 and 14 = Medium risk Between 14 and 10 = High Risk Lesser than 10 = Very High Risk

Unstageable

Pressure ulcer staging: Full-thickness tissue loss with the ulcer covered by slough and/or eschar. slough is yellow, tan, gray, green, or brown. Eschar is tan, brown, or black. Adherent film: Facilitates softening of eschar. Eschar lifts at edges as debridement progresses. See previous stages; surgical consultation sometimes considered for debridement Gauze plus ordered solution: Delivers solution and wicks wound drainage and softens eschar. Eschar softens Enzymes: Facilitate debridement. Eschar softens None: If eschar is dry and intact, no dressing used, allowing eschar to act as physiological cover; may be indicated for treatment of heel eschar

Purposes of Dressings

Protect from microorganism contamination Absorb drainage (above & inside; packing) Assist with debridement or provide a moist environment Support or splint the wound site Protect patients from seeing the wound Promote thermal insulation of the wound surface

Wound Colors

Red, Yellow, Black

Nursing Diagnosis and Planning

Risk for infection Impaired tissue integrity Acute or chronic pain Imbalanced nutrition: less than body requirements Impaired skin integrity Impaired physical mobility Ineffective peripheral tissue perfusion Risk for impaired skin integrity

Bandage Application

Rolls of bandage secure or support dressings over irregularly shaped body parts. Each roll has a free outer end and a terminal end at the center of the roll. The rolled portion of the bandage is its body, and its outer surface is placed against the patient's skin or dressing. Describes the steps for applying an elastic bandage. Use a variety of bandage turns, depending on the body part to be bandaged.

Skin Integrity - Nursing Assessment Questions

Sensation -Do you have decreased feeling in your extremities or any other region? -Are you sensitive to heat or cold? Mobility -Do you have any physical limitations, injury, or paralysis that limits your mobility? -Can you change your position easily? -Is movement painful? Continence -Do you have any problems with involuntary loss of urine or stool? -What assistance do you need using the toilet? -How often do you need to use the toilet? During the day? During the night? Presence of Wound -What caused the wound? -When did the wound occur? What is its location and dimensions? -When did you receive a tetanus shot? -What has happened to this wound since it occurred? What were the changes and what caused them? -Which treatments, activities, or care have slowed or helped the wound-healing process? Are there special needs for this wound to heal? -Are there associated symptoms such as pain or itching with the wound? How are they being managed, and are the interventions effective? -What is the goal for the patient, wound, and healing?

Biochemical indicators of malnutrition

Serum proteins are biochemical indicators of malnutrition Serum albumin is probably the most frequently measured of these laboratory parameters. Albumin alone is not sensitive to rapid changes in nutritional status. Transferrin also evaluates protein status, but alone it does not determine malnutrition. The best measure of nutritional status is prealbumin, because it reflects not only what the patient has ingested but also what the body has absorbed, digested, and metabolize

Patient Assessment

Skin Predictive Scales (Braden or Norton) Mobility status Sensation Nutritional status Exposure to body fluids/Continence Pain Any Wounds

Skin

Skin is largest organ in body Epidermis Top layer of skin (separated by the dermal epidermal junction) Dermis Inner layer of skin Collagen

Classification of Pressure Ulcers

Stage I Intact skin with nonblanchable redness Stage II Partial-thickness skin loss involving epidermis, dermis, or both Stage III Full-thickness tissue loss with visible fat Stage IV Full-thickness tissue loss with exposed bone, muscle, or tendon

Effects of Cold Application

The application of cold initially diminishes swelling and pain. Prolonged exposure of the skin to cold results in a reflex vasodilation. The inability of the cells to receive adequate blood flow and nutrients results in tissue ischemia. The skin initially takes on a reddened appearance, followed by a bluish-purple mottling, with numbness and a burning type of pain. Skin tissues freeze from exposure to extreme cold. Vasoconstriction: Reduces blood flow to injured body part, preventing edema formation; reduces inflammation. Treats: Direct trauma (sprains, strains, fractures, muscle spasms), superficial laceration or puncture wound, minor burn, suspected malignancy in area of injury or pain, injections, arthritis and joint trauma Local anesthesia: Reduces localized pain Reduced cell metabolism: Reduces oxygen needs of tissues Increased blood viscosity: Promotes blood coagulation at injury site Decreased muscle tension: Relieves pain

Packing a wound

The entire wound surface needs to be in contact with part of the moist gauze dressing It is important to remember not to pack the wound too tightly. Overpacking causes pressure on the tissue in the wound bed. Inner gauze needs to be moist, not dripping wet, to absorb drainage and adhere to debris. Excessively moist dressings result in moisture-associated skin damage (maceration) in periwound skin. Wound needs to be loosely packed to facilitate wicking of drainage into absorbent outer layer of dressing. Pack the wound only until the packing material reaches the surface of the wound; there should never be so much packing material that it extends higher than the wound surface. Packing that overlaps onto the wound edges causes maceration of the tissue surrounding the wound. Apply gauze as single layer directly onto wound surface If wound is deep, gently pack dressing into wound base by hand or forceps until all wound surfaces are in contact with gauze. If tunneling is present, use cotton-tipped applicator to place gauze into tunneled area. Be sure that gauze does not touch surrounding skin.

Braden Scale for Predicting Pressure Ulcer Risk

The higher the number, the lower risk you are Assesses sensory perception, moisture, activity, mobility, nutrition, friction, shear: each graded 1-4 (Score of 6-23) SEVERE RISK: Total score <9 HIGH RISK: Total score 10-12 MODERATE RISK: Total score 13-14 MILD RISK: Total score >15-18

Sitz Baths

The patient who has had rectal surgery, an episiotomy during childbirth, painful hemorrhoids, or vaginal inflammation benefits from a sitz bath, a bath in which only the pelvic area is immersed in warm or, in some situations, cool fluid. The patient sits in a special tub or chair or a basin that fits on the toilet seat so the legs and feet remain out of the water. Immersing the entire body causes widespread vasodilation and nullifies the effect of local heat application to the pelvic area. It is often necessary to add warm or cool water during the procedure, which normally lasts 20 minutes, to maintain a constant temperature. Agency procedure manuals recommend safe water temperatures. A disposable sitz basin contains an attachment resembling an enema bag that allows gradual introduction of additional water. Prevent overexposure of the patient by draping bath blankets around his or her shoulders and thighs and controlling drafts. The patient should be able to sit in the basin or tub with feet flat on the floor and without pressure on the sacrum or thighs. Because exposure of a large portion of the body to heat causes extensive vasodilation, assess the pulse and facial color and ask whether the patient feels light-headed or nauseated.

Psychosocial Impact of Wounds

The psychosocial impact of wounds on the physiological process of healing is unknown.The patient's psychological response to any wound is part of the nurse's assessment. Body image changes often impose a great stress on the patient's adaptive mechanisms. They also influence self-concept and sexuality. Make sure that the patient's personal and social resources for adaptation are a part of the assessment. Factors that affect the patient's perception of the wound include the presence of scars, drains (drains are often necessary for weeks or even months after certain procedures), odor from drainage, and temporary or permanent prosthetic devices.

Factors Influencing Heat and Cold Tolerance

The response of the body to heat and cold therapies depends on the following factors: -A person is better able to tolerate short exposure to temperature extremes than prolonged exposure. -Exposed skin layers and certain areas of the skin (e.g., the neck, inner aspect of the wrist and forearm, and perineal region) are more sensitive to temperature variations. The foot and palm of the hand are less sensitive. -The body responds best to minor temperature adjustments. If a body part is cool and a hot stimulus touches the skin, the response is greater than if the skin were already warm. -A person has less tolerance to temperature changes to which a large area of the body is exposed. -Tolerance to temperature variations changes with age. Patients who are very young or old are most sensitive to heat and cold. -If a patient's physical condition reduces the reception or perception of sensory stimuli, tolerance to temperature extremes is high, but the risk of injury is also high. -Uneven temperature distribution suggests that the equipment is functioning improperly

Montgomery Ties

To avoid repeated removal of tape from sensitive skin, secure dressings with pairs of reusable Montgomery ties Each section consists of a long strip; half contains an adhesive backing to apply to the skin, and the other half folds back and contains a cloth tie or a safety pin/rubber band combination that you fasten across a dressing and untie at dressing changes. A large, bulky dressing often requires two or more sets of Montgomery ties. Another method to protect the surrounding skin on wounds that need frequent dressing changes is to place strips of hydrocolloid dressings on either side of the wound edges, cover the wound with a dressing, and apply the tape to the dressing. To provide even support to a wound and immobilize a body part, apply elastic gauze or cloth bandages and binders over a dressing

Maintaining an Airtight Seal

To avoid wound desiccation, the wound needs to stay sealed once therapy is initiated. Problem seal areas include wounds around joints and near the sacrum. The following points assist in maintaining an airtight seal: -Clip hair around wound. -Cut transparent film to extend 3 to 5 cm (1.2 to 2 in) beyond wound parameter. -Avoid wrinkles in transparent film. -Patch leaks with transparent film. -Use multiple small strips of transparent film to hold dressing in place before covering it with large piece of transparent film. -Avoid adhesive remover because it leaves a residue that hinders film adherence

Suture Care

To remove sutures, first check the type of suturing used With intermittent suturing the surgeon ties each individual suture made in the skin. Continuous suturing, as the name implies, is a series of sutures with only two knots, one at the beginning and one at the end of the suture line. Retention sutures are placed more deeply than skin sutures, and nurses may or may not remove them, depending on agency policy. The manner in which the suture crosses and penetrates the skin determines the method for removal. Never pull the visible portion of a suture through underlying tissue. Sutures on the surface of the skin harbor microorganisms and debris. The portion of the suture beneath the skin is sterile. Pulling the contaminated portion of the suture through tissues can lead to infection. Clip suture materials as close to the skin edge on one side as possible and pull the suture through from the other side

Evisceration

Total separation of wound layers (protrusion of visceral organs through a wound opening) occurs. The condition is an emergency that requires surgical repair Places sterile towels soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues. If the organs protrude through the wound, blood supply to the tissues is compromised Immediately contact the surgical team, do not allow the patient anything by mouth (NPO), observe him or her for signs and symptoms of shock, and prepare him or her for emergency surgery

Assessment of Wounds

Trauma or not Superficial abrasion, lacerations, puncture, bleeding Appearance Location/Size Edges Base Tunneling Undermining Peri-wound area Edema Pulses PUSH Tool

Film

Use a film dressing as a secondary dressing and for autolytic debridement of small wounds. It has the following advantages: -Adheres to undamaged skin -Serves as a barrier to external fluids and bacteria but still allows the wound surface to "breathe" because oxygen passes through the transparent dressing -Promotes a moist environment that speeds epithelial cell growth -Can be removed without damaging underlying tissues -Permits viewing a wound -Does not require a secondary dressing

Securing a wound

Use tape, ties, or a secondary dressing and cloth binders to secure a dressing over a wound site. The choice of anchoring depends on the wound size and location, the presence of drainage, the frequency of dressing changes, and the patient's level of activity. Most often strips of tape are used to secure dressings if the patient is not allergic to it. Nonallergenic paper and plastic tapes minimize skin reactions. Common adhesive tape adheres well to the surface of the skin, whereas elastic adhesive tape compresses closely around pressure bandages and permits more movement of a body part. Skin sensitive to adhesive tape becomes severely inflamed and denuded and in some cases even sloughs when the tape is removed. It is important to assess skin under tape at each dressing change. Tape is available in various widths such as 1.3, 2.5, 5 and 7.5 cm ( , 1, 2, and 3 inches). Choose the size that sufficiently secures the dressing. For example, a large abdominal wound dressing needs to remain secure over a large area despite frequent stress from movement, respiratory effort, and possibly abdominal distention. Strips of 7.5-cm (3-inch) adhesive better stabilize such a large dressing so it does not continually slip off. When applying tape, ensure that it adheres to several inches of skin on both sides of the dressing and that it is placed across the middle of the dressing. When securing the dressing, press the tape gently, making sure to exert pressure away from the wound. This way, tension occurs in both directions away from the wound, minimizing skin distortion and irritation. Never apply tape over irritated or broken skin. Protect irritated skin by using a solid skin barrier and applying the tape over the barrier. To remove tape safely, loosen the ends and gently pull the outer end parallel with the skin surface toward the wound. Apply light traction to the skin away from the wound as the tape is loosened and removed. The traction minimizes pulling of the skin. Adhesive remover also loosens the tape from the skin. If tape covers an area of hair growth, the patient experiences less discomfort if you pull it in the direction of the hair growth

Before and after VAC therapy

Wear time for the dressing is anywhere from 24 hours to 5 days. As the wound heals, granulation tissue lines its surface. The wound has a stippled or granulated appearance. The surface area sometimes increases or decreases, depending on wound location and the amount of drainage removed by the NPWT system. NPWT is also used to enhance the take of split-thickness skin grafts.

Palpation of wound for swelling/tenderness, fluid accumulation

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

Further Wound Assessment

Wound closures: Sutures Staples SteriStrips Dermabond Adhesive The staple provides more strength than nylon or silk sutures and tends to cause less irritation to tissue. Look for irritation around staple or suture sites and note whether closures are intact. Normally for the first 2 to 3 days after surgery the skin around sutures or staples is edematous. Continued swelling may indicate that the closures are too tight. The skin can be cut by overly tight suture material, leading to wound separation. Early suture removal reduces formation of defects along the suture line and minimizes chances of unattractive scar formation.Palpation of wound for swelling/tenderness, fluid accumulation

Secondary Intention

Wound edges not approximated occurs when wound is extensive and involves considerable tissue loss. Causes: surgical incision, wound that is sutured or stapled Healing: occurs by epithelialization; heals quickly with minimal scar formation

Infection

Wound infection prolongs the inflammatory phase; delays collagen synthesis; prevents epithelialization; and increases the production of proinflammatory cytokines, which leads to additional tissue destruction (Stotts, Indications that a wound infection is present include the presence of purulent drainage; change in odor, volume, or character of wound drainage; redness in the surrounding tissue; fever; or pain.

Tertiary Intention

Wound left open for several days, then wound edges are approximated Causes: Wounds that are contaminated and require observation for signs of inflammation Healing: Closure of wound is delayed until risk of infection is resolved

Chronic Wound

Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity Causes: Vascular compromise, chronic inflammation, or repetitive insults to tissue Healing: Continued exposure to insult impedes wound healing.

Primary Intention

Wound that is closed little tissue loss. Skin edges are closed and the risk of infection is low. Causes: surgical incision, wound that is sutured or stapled Healing: occurs by epithelialization; heals quickly with minimal scar formation.

Acute Wound

Wound that proceeds through an orderly and timely reparative process that results in sustained restoration of anatomical and functional integrity Causes: Trauma, a surgical incision Wounds are usually easily cleaned and repaired. Wound edges are clean and intact.

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 lies under a dressing; at the time of placement a pin or clip is placed through the drain to prevent it from slipping farther into a wound It is usually the health care provider's responsibility to pull or advance the drain as drainage decreases to permit healing deep within the drain site

JP Drain

abbreviation for Jackson-Pratt drain; suction drain with tubing inside the body and a bulb reservoir which, when squeezed empty, applies suction and pulls fluid out of the body; used in thoracic or abdominal surgery self suction, exacuator

Penetrating Object

do not remove the object. The presence of the object provides pressure and controls some bleeding. Removal causes massive, uncontrolled bleeding. Except for skull injuries, apply pressure around the penetrating object but not on it and transport the patient to an emergency facility.