48 skin integrity
How would you prevent dehiscence?
Use folded thin blanket or pillow placed over ab wounds when client is coughing
Purulent
Yellow, green or brown color
Collagen
Tough, fibrous protein in the dermal layer. Made by fibroblasts.
treatment of stage II pressure ulcer
health with local therapy, heal by re-epitheliazation (saline or occlusive dressing to promote natural healing)
pressure ulcer prevention devices
pillows, rolls, heel protectants, lifting devices, beds
factors influencing for pressure ulcer development
poor nutrition (wound healing requires proper nutrition), tissue perfusion (oxygen critical for healing process), edema, age (do to decrease of macrophage functioning), anemia, poor circulation, infection (leads to additional tissue destruction), and obesity
3 pressure factors that contribute to pressure ulcer development
pressure intensity (occlusion of vessel, causing tissue ischemia), pressure duration, and tissue tolerance (shear, friction, and moisture affect the ability of the skin to tolerate pressure)
interventions for poor nutrition
provide adequate nutritional and fluid intake, assist as necessary, consult dietitian for eval
What are skin issues affecting older adults?
-Reduced skin elasticity, decreased collagen = easy for skin to tear -Concomitant medical conditions & polypharmacy interfere w/wound healing -Epidermis & dermis attachment becomes flattened = easy for skin to tear -Inflammatory response = slow epithelialization & wound healing -Hypodermis decreases in size = more skin breakdown -Reduced nutritional intake = increased risk for pressure ulcers and impaired wound healing
What are the two layers of the skin?
1) 1) Epidermis, 2) Dermis. Separated by dermal-epidermal junction.
edema grading scale
4 grades based on depth of indentation; 1+ is 2mm, 2+ is 4mm, etc.
What does ASSESSMENT of pressure ulcers include?
1. Depth of tissue involvement (staging), 2. Type & approximate percentage of tissue in wound bed, 3) Wound dimensions, 4) Exudate description, 5) condition of surrounding skin
3 Pressure Related Factors contributing to pressure ulcer development
1. pressure intensity, 2) pressure duration, 3) tissue tolerance
What % of an adult's total body weight does skin comprise?
15%
How many people develop pressure ulcers each year?
>1M. 1.6M is acute care settings. Costing $2.2 - $3.6B. Treatment is more costly than prevention.
What does wound healing depends on (nutrition wise)?
Avail of protein, vitamins (A and C), zinc and copper.
How do you assess tissue type?
Based on amount (%) and appearance (color) or viable and nonviable tissue.
Examples of partial thickness wounds
Shallow wounds w/loss of epidermis: surgical wound/abrasion
What does hemorrhage after hemostasis indicate?
Slipped surgical suture, dislodged clot, infection, or erosion of blood vessel by foreign object (e.g., drain)
Slough
Soft yellow/white, stringy substance attached to wound bed; must remove this before healing proceeds
What are some examples of shear force?
When head of bed is elevated & sliding of skeleton starts by skin is fixed b/c of friction w bed, when transferring client from bed to stretcher & skin is pulled across bed
When would you need to assess the type of tissue in a wound base?
When you encounter a wound w/nonviable tissue
How do you measure wounds?
Width & Length: disposable wound measuring device. Depth: cotton tipped applicator in wound bed
When do pressure ulcers usually develop?
Within first 2 wks of hospitalization
What does Wound Classification describe?
Status of skin integrity, cause of wound, severity/extent of tissue injury/damage, cleanliness of wound. Enables nurse to understand risks associated w wound & healing implications TABLE 48-1
What do you do when evisceration occurs?
Place sterile towel soaked in sterile saline over extruding tissues to reduce chances of bacterial invasion and drying of tissues. NPO! Observe for shock and prepare for emergency surgery.
What are terms use to describe impaired skin integrity?
Pressure ulcer, pressure sore (most common/recommended term), decubitus ulcer, and bedsore
What is the major cause of pressure ulcer formation?
Pressure: affects cellular metabolism by decreasing/obliterating blood flow = tissue ischemia/death
Evisceration
Protrusion of visceral organs through wound opening. Emergency requiring surgical repair.
Granulation Tissue
Red moist tissue composed of new blood vessels = progression toward healing
Hyperemia
Redness
Inflammatory response
Redness & swelling in area with serous exudates, usually first 24 hours
What S/S indicates risk for pressure ulcer development?
Decreased mobility, decreased sensory perception, fecal/urinary incontinence, and/or poor nutrition
What is the Staging System of pressure ulcers based on?
Describes the depth of tissue destroyed at point of ASSESSMENT. *You cannot stage an ulcer covered w necrotic tissue bc its covering the depth of ulcer. To assess, remove necrotic issue
Epithelial proliferation & migration
Epithelial cells begin to migrate across wound bed soon after wound occurs. Wound left open to air: resurface 6-7 days. Moist wound: resurface 4 days.
Remodeling
Final stage of healing, sometimes takes >1 yr.
What is the difference between friction & shear injuries?
Friction injuries affect epidermis/top layer (e.g., sheet burn). Typical in restless clients w uncontrollable movements & skin dragged rather than lifted from bed surface during position changes. Shear injuries lead to necrosis deep in tissue layers.
Stage IV
Full thickness tissue loss w/exposed bone, tendon or muscle.
Stage III
Full thickness tissue loss. Subcutaneous fat may be visible. Bone, tendon or muscle NOT exposed.
Nosocomial infection
Health care associated infection
Stage I
Intact skin w nonblanchable redness of localized area; usually over bony prominence. Darkly pigmented skin may not have visible blanching.
Examples of Wounds w/Tissue Loss?
Little tissue loss: clean surgical incision Tissue loss: burn, pressure ulcer, sever laceration
Hematoma
Localizaed collection of blood underneath tissues; dangerous if near major artery/vein bc obstruct blood flow
How do you detect internal bleeding?
Look for distention or swelling of affected body part; change in type and amount of drainage from surgical drain, signs of hypovolemic shock
What are the types of wounds?
Loss of tissue and those without loss of tissue
eschar
black or brown necrotic tissue that needs to be removed so the wound can heal
interventions for decreased sensory perception
access pressure points for signs of nonblanching reactive hyperemia and provide pressure-redistribution surface
factors affecting skin integrity
age, health status, mobility, hygiene, and nutritional status
interventions for moisture
assess need for incontinence management, cleanse after incontinence with no-rinse perineal cleanser and protect skin with a moisture barrier ointment
What are the 3 components involved in healing process of partial thickness wound?
1.inflammatory response, 2. Epithelial proliferation, 3. Reestablishment of epidermal layers
Proliferative Phase
3-24 days. Fills wound with granulation tissue, contraction of wound, and resurfacing
stage IV pressure ulcer
full-thickness tissue loss with exposed bone, muscle, or tendon
stage III pressure ulcer
full-thickness tissue loss with visible fat
treatment of stage III pressure ulcer
high calorie and protein intake, debridement of necrotic tissue and topical therapy (Wet-to-dry: wet saline gauze loose packing), mechanical, surgical, chemical
treatment of stage IV pressure ulcer
high calorie and protein intake, debridement of necrotic tissue, nonadhesive dressing change q 8-12 hours, skin grafts
nutrients in wound healing
calories (fuel), protein (collagen formation), vitamin C collagen synthesis and capillary wall integrity), A (epitheliazation), E (antioxidant), zinc (collagen formation and protein synthesis), and fluids (essential for all cell functions)
skin integrity
impaired integrity due to wounds or injuries
6 pressure ulcer risk factors
impaired sensory perception (unable to feel pain), impaired mobility, alteration in level of consciousness (unable to protect themselves), shear (skin adheres to the bed), friction (skin is dragged across course surface), and moisture (reduces the skin's resistance to physical forces and softens the skin)
possible pressure ulcer diagnoses
impaired skin integrity and risk of impaired skin integrity, as related to inability to move, inability to maintain proper position, or malnutrition
pressure ulcer
injury to the skin and underlying tissue, usually over a bony prominence
stage I pressure ulcer
intact skin with nonblanchable redness
turgor
normally tented skin quickly returns to original state, decreased turgor is tented skin that returns to normal very slowly
skin temperature
normally warm to touch, warmer than normal means inflammation, cooler than normal means poor circulation
skin edema
not normal, a decrease in skin mobility due to an accumulation of fluid in the intercellular spaces
stage II pressure ulcer
partial-thickness skin loss involving epidermis, dermis, or both
documentation of pressure ulcers
document length, width, depth on a regular basis (at least weekly)
pressure ulcer dressings
enzyme (protects and keeps bacteria from entering), transparent (protects from shear, allows skin to breathe, promotes moist environment), hydrocolloid (absorb drainage, maintain moisture, liquify necrotic debris, impermeable to bacteria), composite film (limits shear, heals through reepithelialization), hydrogel (reduces pain, maintains moisture, debrides the wound), calcium alginate (maintains wound moisture while absorbing excess drainage)
interventions for decreased activity
establish and post individualized turning schedule
skin care and prevention of pressure ulcers
prevention is key, assessment upon admission, daily skin assessment, skin cleansing and hygiene, protecting bony prominences, skin protectants, proper repositioning (head elevation no greater than 30 degrees), and avoid trauma
functions of the skin
protection, temp regulation, sensation, excretion, and vitamin D production and absorption
hydrocolloid
provides maintenance of a moist wound environment for healing
calcium alginate
provides maintenance of wound moisture while absorbing excess drainage
granulation tissue
red moist tissue composed of new blood vessels, indicates progression towards healing
how age affects skin
reduced elasticity, decreased collagen, thinning muscles, polypharmacy, attachment between epidermis and dermis becomes weak, diminished inflammatory response, loss of subq tissue causing proneness to skin breakdown, and reduced nutritional intake
interventions for friction and shear
reposition client using a drawsheet and lifting off surface, provide a trapeze, and position client at a 30-degree lateral turn and limit head elevation to 30 degrees
Norton scale
scores on 5 risk factors: physical and mental condition, activity, mobility, and incontinence
treatment of stage I pressure ulcer
should be considered a warning, will heal spontaneously if cause corrected
skin moisture
should be dry or moist to touch, and not hyperkeratosis (skin thickening, flaking, scales), eczema, dermatitis, and rashes
skin color
skin should be even toned, have normal variations in color (striae, freckles, birthmarks), abnormal colors: pallor, cyanosis, jaundice
assessment of skin
temperature, color, moisture, turgor, and integrity
debriding a wound
the removal of nonviable, necrotic tissue, necessary to rid the ulcer of a source of infection, enable visualization of the wound bed, and to provide a clean base necessary for healing; done with wet-to-dry dressing
blanching
when the skin becomes pale due to pressure, deep tissue damage is possible if color does not return when pressure is removed
slough
yellow or white substance attached to wound bed that needs to be removed prior to allow the wound to heal
Braden Scale
Most commonly used. Based on nursing home risk factors. 6 subscales. Total score ranges from 6 - 23. Lower score indicates higher risk for pressure ulcer development. Cutoff score is at 18. TABLE 48-4
When would a surgical wound infection typically develop?
4th or 5th post op day
Norton Scale
5 risk factors. Total score ranges from 5 to 20. Lower score indicates higher risk for pressure ulcer development. TABLE 48-3
Braden scale
6 subscales: sensory perception, moisture, activity, mobility, nutrition, friction, and shear
Fistula
Abnormal passage between 2 organs or between organ and outside of body. Result of poor wound healing or Crohn's disease, cancer. Increase risk of infection and electrolyte imbalances from fluid loss. Chronic draining through fistula leads to skin breakdown.
What differentiates contaminated wounds from infected wounds?
Amount of bacteria. >100,000 organisms/gram . Chances of infection increases w dead/necrotic tissue, foreign objects near, blood supply reduced
Inflammatory Phase
Begins within minutes...lasts approx 3 days
Eschar
Black or brown necrotic tissue; must remove this before healing proceeds
Hemorrhage
Bleeding from wound site; normal and immediately after initial trauma
How do wounds with tissue loss heal?
Burns, pressure ulcers...heal by secondary intention. Wound is left open and fills w scar tissue. Longer heal time. Higher infection risk. Heals by scar formation.
Wound exudate
Describes amount, color, consistency & odor of wound drainage [wound assessment].
Wound
Disruption of the integrity & function of tissues; not all wounds are created equal
Examples of full thickness wounds
Extend into dermis (both layers): pressure ulcers
What is an unstageable ulcer?
Full thickness tissue loss w base of ulcer is covered by slough (yellow, tan, gray, green, or brown) or eschar *Need to remove slough and eschar prior to determining stage(tan, brown, or black) in wound bed
What are FACTORS INFLUENCING pressure ulcer formation & wound healing?
Nutrition, tissue perfusion, infection, age, psychosocial impact of wounds
Blanching hyperemia
If an area blanches (turns lighter in color) & erythema returns when removing finger, hyperemia is transient and is attempting to overcome ischemic episode *if it doesn't blanch = nonblanching erythema **blanching does not occur in darkly pigmented skin
Hemostatsis
Injured blood vessels constrict, platelets gather to stop bleeding
Dehiscence
Partial or total separation of wound layers; when wound fails to heal properly. May involve sudden strain: coughing, vomiting, sitting up in bed
Stage II
Partial thickness skin loss involving epidermis, dermis or both. Superficial examples: abrasion, blister, shallow crater
What increases risk for poor wound healing?
Poor nutritional status, infection, obesity
What is the best measure of nutritional status?
Prealbumin bc it reflects not only what client ingested but also what body absorbed, digested and metabolized
What are the functions of the dermis (inner layer)?
Provides tensile strength, mechanical support, and protection to underlying muscles, bones, and organs. Differs from epidermis b/c it contains mostly connective tissue and few skin cells.
What is the most frequently measured lab parameter?
Serum albumin
Assessing Dark Skin @ Risk for Skin Breakdown
Need halogen/natural light to assess skin. AVOID fluorescent light b/c it casts blue. COLOR: appears darker than surrounding skin. TEMP: initial warmth TOUCH: indurated, edema, soft. APPEARANCE: taut, shiny, scaly
Can skin assessment for skin integrity or presence of skin breakdown be delegated?
No. Assistive personnel can report changes in clients skin and skin's exposure to body fluids (e.g., feces, urine, etc.)
Do positive culture findings always indicate infection?
No. Many wounds contain colonies of noninfective resident bacteria (e.g. chronic dermal wounds)
How do pressure ulcers move from stage to stage?
They don't! Once you have staged an ulcer, it ensues even if it shows healing. A stage III does not progress to a stage II; rather, a stage III showing healing is described as a healing stage III pressure ulcer.
Stratum Corneum
Thin, outermost layer of epidermis. Allows for evaporation of water & absorption of certain topical meds.
What tools are used to assess risk of pressure ulcers?
1. Norton scale, 2. Braden Scale
What are the 3 phases of full thickness wound repair?
1. Inflammatory, 2. proliferative, 3. remodeling
What are the RISK FACTORS for pressure ulcer development?
Impaired sensory perception, impaired mobility, ALOC, shear, friction, & moisture
How do surgical incisions heal?
Primary intention. Skin edges are approximated (closed). Low infection risk. Heals quickly & minimal scarring as long as infection and secondary breakdown is prevented. Heals by regeneration.
