Ch. 48 Skin Integrity and Wound Care

What are the effects of applying heat?

1. Dilates peripheral blood vessels. 2. Increases tissue metabolism. 3. Reduces blood viscosity and increases capillary permeability. 4. Reduces muscle tension. 5. Helps relieve pain.

What are some ways to care for a wound?

1. Dry sterile dressing. 2. Saline soaked dressing. 3. Wound irrigation. 4. Applying steri strips. 5. Removing sutures and staples. 6. Culturing wounds. 7. Negative pressure wound therapy.

Who is at risk for problems with heat or cold?

1. Elderly. 2. Very young. 3. Open/broken skin. 4. Swollen/scarred areas. 5. Chronic conditions affecting circulation. 6. Confused/altered consciousness. 7. Nerve/spinal injury. 8. Abscess. 9. Appendicitis.

What factors affect the response to cold or hot treatments?

1. Method and duration of application. 2. Degree of heat and cold applied. 3. Patient's age and physical condition. 4. Amount of body surface covered by the application.

What are some topics you need to talk to your patient about when it comes to taking care of wounds at home?

1. Pain. 2. Appearance of the skin. 3. Infection prevention. 4. Nutrition. 5. Supplies. 6. Activity 7. Wound healing 8. Mobility. 9. Elimination (PAIN SAW ME)

What are the 3 pressure factors that contribute to pressure ulcer development?

1. Pressure intensity. 2. Pressure duration. 3. Tissue tolerance.

According to the "Braden Scale for Predicting Pressure Ulcers," what are the 6 risk factors that make a person prone for the formation of pressure ulcers?

1. Impaired sensory perception. 2. Moisture. 3. Activity level/ Impaired mobility. 4. Nutrition. 5. Friction and Shear. 15-18 at risk 13-14 moderate 10-12 high 9 or < 9 very high

Moisture

- Assess need for incontinence management. - Following each incontinent episode, cleanse area with no-rinse perineal cleanser and protect skin with a moisture barrier ointment.

Decreased sensory perception

- Assess pressure points for signs of nonblanching reactive hyperemia. - Provide pressure reduction or relief surface.

Obtaining a Wound Culture

- Cleanse wound with sterile non antiseptic solution. -Moisten swab with normal saline. - Rotate swab in clean tissue in open wound. - Sufficient pressure to allow some tissue fluid to be expressed - Collect on tip of the swab - Return to container - Transport to lab. (Or crush inner ampule containing medium for organism growth)

Decreased activity/mobility

- Establish and post individualized turning schedule. - Position client at a 30-degree lateral turn and limit head elevation to 30 degrees.

Contraindications to Heat

- For areas of active bleeding - For an acute localized inflammation - Over a large area if a patient has cardiovascular problems

Gauze Dressing

- Gauze sponges are absorbent and are especially useful in wounds to wick away the wound exudate. - Gauze can be saturated with solutions and used to clean and pack a wound. - When used to pack a wound, the gauze is saturated with the solution (usually normal saline), wrung out, unfolded, and lightly packed into the wound.

Hydrocolloid Dressing

- Hydrocolloid dressings are dressings with complex formulations of colloid, elastomeric, and adhesive components. 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. This type of dressing has the following functions: - 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

Hydrogel dressings

- Hydrogel dressings are gauze or sheet dressings impregnated with water- or glycerin-based amorphous gel. Hydrogel has the following advantages: - Is soothing and can reduce wound pain - Provides a moist environment - Debrides necrotic tissue (by softening necrotic tissue) - Does not adhere to the wound base and is easy to remove

Wound Drainage Systems

- If potential for drainage interferes with surgical wound healing, drain is surgically placed to empty excess drainage. - Provide constant low pressure suction - Collects drainage - Device must be emptied 1/2 to 2/3 full - Measure I & O

Contraindications to Cold

- If the site of injury is edematous - In the presence of neuropathy - If the patient is shivering - If the patient has impaired circulation

What are the effects of applying cold?

1. Constructs peripheral blood vessels. 2. Reduces muscle spasms. 3. Promotes comfort.

Negative-Pressure Wound Therapy (NPWT)

- NPWT is used in treating acute and chronic wounds. -- NPWT uses negative pressure to remove fluid from areas surrounding the wound, reducing edema and improving circulation to the area. - NPWT is also used to enhance the take of split-thickness skin grafts. It is placed over the graft intraoperatively, decreasing the ability of the graft to shift and evacuating fluids that build up under it. - An airtight seal must be maintained.

Purposes of Dressings

- Protect a wound from microorganism contamination - Aid in hemostasis - Promote healing by absorbing drainage and debriding a wound - Support or splint the wound site - Protect patients from seeing the wound (if perceived as unpleasant) - Promote thermal insulation of the wound surface

Poor Nutrition

- Provide adequate nutritional and fluid intake; assist with intake as necessary. - Consult a dietitian for nutritional evaluation.

Friction and shear

- Reposition client by using a draw sheet and lifting off of surface. Have a colleague assist in moving client. - Provide a trapeze to facilitate movement.

Film Dressing

- 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

Factors Influencing Pressure Ulcer Formation and Healing

-- NUTRITION: For maintenance of skin and wound healing, patients need 1500 kcal/day. At times, enteral or parenteral nutrition may need to be provided. Patients need vitamins A and C, calories, and proteins to heal. -- TISSUE PERFUSION: occurs when tissue oxygenation fuels cellular function. Patients who are in shock or who are diagnosed with diabetes mellitus are at risk for poor tissue perfusion. -- INFECTION: Wound infection prolongs the inflammatory phase, delays collagen synthesis, and prevents epithelialization and tissue destruction. Signs of wound infection include pus; change in odor, volume, or redness of tissue; fever; and pain. -- AGE: Increased age affects all phases of wound healing. A decrease in functioning of the macrophage leads to a delayed inflammatory response, delayed collagen synthesis, and slower epithelialization. -- PSYCHOSOCIAL impact of wounds: Body image changes caused by a wound may lead to problems with self-concept. 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.

Secondary Intention Wound Healing

-Burn, pressure ulcer; Loss of tissue -Left open -Higher risk of infection -Healing occurs slowly

Primary Intention Wound Healing

-Surgical incision; little tissue loss -Edges approximated -Low risk of infection -Healing occurs quickly

Chronic Wounds

-Wound that fails to proceed through an orderly and timely reparative process -Results in loss of anatomical and functional integrity

Acute Wounds

-Wound that proceeds through an orderly and timely reparative process -Results in restoration of anatomical and functional integrity

Hematoma

-a localized collection of blood underneath the tissues.

To irrigate and clean the ulcer, what do you use?

0.9% normal saline solution

How can you prevent complications when applying heat or cold?

1. Avoid use with high risk patients. 2. Educate your patient. 3. Set a timer no more than 15 to 20 minutes at a time. 4. Don't apply ice packs directly to skin. 5. Watch for early warning signs of a problem and intervene immediately.

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.

Pressure Ulcer Pathogenesis

1. Compression of soft tissue 2. Blood flow diminished 3. Ineffective Tissue Perfusion 4. Ischemia (skin redness/discoloration) 5. If pressure on skin > pressure in capillaries = blood doesn't reach tissue 6. Impaired tissue integrity 7. Tissue Death

What are the purposes of wound dressing? (7)

1. Provide physical, psychological, and aesthetic comfort. 2. Remove necrotic tissue. (surgical, chemical, or mechanical debridement). 3. Prevent, eliminate, or control infection. 4. Absorb drainage. 5. Maintain a moist wound environment. 6. Protect wound from further injury. 7. Protect skin surrounding wound.

When assessing a wound, what are the 4 types of drainage you could see?

1. Serous. 2. Sanguineous. 3. Serosanguineous. 4. Purulent.

What motions do you use to minimize trauma when cleaning a pressure ulcer?

1. careful. 2. gentle.

How many different stages of pressure ulcers are there? Name them.

5 different stages: Stage 1 (I), 2 (II), 3 (III), 4 (VI), and unstageable

Fistula

A Fistula is a permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body. - From poor wound healing or disease - Trauma, infection, radiation, cancer

Penrose Drain

A Penrose drain 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 the wound.

Types of Sutures

A, Intermittent. B, Continuous. C, Blanket continuous. D, Retention. 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.

Describe a Stage 1 (I) pressure ulcer.

Intact skin with nonblanchable redness of a localized area over a bony prominence.

Methods for Cleaning a Wound Site

Never use the same piece of gauze to clean across an incision or wound twice.

Autolytic debridement

Autolytic debridement uses synthetic dressings over a wound to allow the eschar to be self-digested by the action of enzymes that are present in wound fluids.

Describe a Unstageable pressure ulcer

Base of ulcer covered by slough and or eschar in wound bed (thick, leathery, dry, necrotic tissue)

Chemical debridement

Chemical debridement may use topical enzymes to induce changes in the substrate resulting in the breakdown of necrotic tissue. Depending on the type of enzyme used, the preparation digests or dissolves the tissue. These preparations require a health care provider's order. Dakin's solution breaks down and loosens dead tissue in a wound.

Cleaning a Drain Site

Clean in a direction from an isolated drain site to the surrounding skin

Wound Healing Complications

Complications include hemorrhage hematoma, infection, dehiscence, evisceration, and fistulas.

Dehiscence

Dehiscence is the partial or total separation of wound layers. - Due to improper wound healing CAUSED BY: Poor nutrition, Infection, & Obesity - 3-11 days after injury - Serosanguinous drainage increases - More common with abdominal wounds: Sudden strain cough, sneeze, vomit, sitting up - "Something has popped" - Prevention: Splinting abdomen for cough

Drainage Evacuators

Drainage evacuators are convenient portable units that connect to tubular drains lying within a wound bed and exert a safe, constant, low-pressure vacuum to remove and collect drainage. The evacuator collects drainage. Assess for volume and character every shift and as needed. When the evacuator fills, measure output by emptying the contents into a graduated cylinder, and immediately reset the evacuator to apply suction.

Jackson-Pratt Drainage Device

Evacuator units (such as Jackson-Pratt) exert constant low pressure as long as the suction device (bladder or container) is fully compressed.

Describe a Stage 4 (IV) pressure ulcer.

Full-thickness tissue loss with exposed bone, tendon, or muscle.

Describe a Stage 3 (III) pressure ulcer.

Full-thickness with tissue loss with visible fat. (open area with loss of dermis, epidermis and subcutaneous tissue)

Wound Repair Full-thickness

Full-thickness wounds heal via hemostasis, inflammatory response, proliferation, and remodeling.

Bandages & Binders

Functions: create pressure, immobilize and/or support a wound, reduce or prevent edema, secure a splint, secure dressings - Bandages: Rolled gauze, elasticized knit, elastic webbing, flannel, and muslin - Binder application: Breast, abdominal, sling

Packing a wound

Gently pack dressing into wound base by hand of forecast until all wound surfaces are in contact with gauze. Cover with sterile gauze and topper dressing.

Hemostasis

Hemostasis is a series of events designed to control blood loss, establish bacterial control, and seal the defect that results when an injury occurs. Clots form a fibrin matrix that later provides a framework for cellular repair.

Mechanical debridement

Mechanical debridement includes wound irrigation (high-pressure irrigation and pulsatile high-pressure lavage) and whirlpool treatments.

Wound Repair Partial-thickness

Partial thickness will heal via the inflammatory response, epithelial proliferation, and migration with reestablishment of epidermal layers.

Describe a Stage 2 (II) pressure ulcer.

Partial-thickness skin loss involving epidermis, dermis, or both.

What are the 4 color classifications of open wounds?

R= Red. Y= Yellow. B= Black. Mixed wound.

Blanchable Erythema

Reddened area that turns pale under applied light pressure. Not an ulcer.

Aerobic

Superficial wounds

Surgical debridement

Surgical debridement is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.

Non-Blanchable Erythema

The ulcer appears as a defined area of reddened that does not blanch (become pale) under light pressure. Stage I ulcer.

V.A.C. (Vacuum-Assisted Closure)

The vacuum-assisted closure (V.A.C.) is a device that assists in wound closure by applying localized negative pressure to draw the edges of a wound together.

To Remove Tape

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. 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.

Transparent Film Dressing

Transparent film dressing is ideal for small superficial wounds such as partial-thickness wounds and to protect high-risk skin.

When cleaning a pressure ulcer...

When cleaning a pressure ulcer, clean with each dressing change from cleanest to dirtiest and inside out.

Evisceration

With total separation of wound layers, protrusion of visceral organs through a wound opening occurs. The condition is an EMERGENCY that requires surgical repair. - Sterile towel soaked in saline - NPO (oral food and fluids) - S/S shock

Anaerobic

Within body cavities

Infection

Wound infection is the second most common health care-associated infection. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent and causes a yellow, green, or brown color, depending on the causative organism. - Wounds at greater risk are: Wound contains dead tissue (pressure ulcer), Foreign bodies in or near wound (GSW), Blood supply to tissue decreased (diabetic feet). - Wound healing delayed when infected. -Signs of infection: Occur 2-3 days for contaminated or traumatic wound Occur 4-5 days for surgical wound -S/S: Fever, Tenderness at wound site, Elevated WBC, & Drainage odor and purulent

Hemorrhage

bleeding from a wound site, is normal during and immediately after initial trauma. - Greatest risk 24-48 hours after surgery - If after bleeding stops (hemostasis) could be: Surgical suture came out, Clot dislodged, Blood vessel "wore down." - S/S External: Dressing saturated, and Pooling of blood under person. - S/S Internal: Distension or swelling, Change in type or amount of drainage, and Hypovolemic shock

Sanguineous wound drainage

bright red; this indicates active bleeding.

A wound classified Y (Yellow) should be ________.

cleanse

Serous wound drainage

clear, watery plasma

A wound classified B (Black) should be ________.

debride

The staging systems for pressure ulcers are based on the ________ of tissue destroyed.

depth

What do you report when cleaning a pressure ulcer?

drainage or necrotic tissue

Serosanguineous wound drainage

pale, pink, watery; this is a mixture of clear and red fluid.

A wound classified R (Red) should be ________.

protected

Debridement

the process of removing dead tissue from wounds.

Purulent wound drainage

thick, yellow, green, tan, or brown.