Skin Integrity and Wound Care PDF

Skin Integrity and Wound Care LEARNING OUTCOMES Describe factors affecting skin integrity. Identify clients at risk for pressure ulcers. Describe the four stages of pressure ulcer development. Differentiate primary and secondary wound healing. Describe the three phases of wound healing. Identify thr...

Skin Integrity and Wound Care LEARNING OUTCOMES Describe factors affecting skin integrity. Identify clients at risk for pressure ulcers. Describe the four stages of pressure ulcer development. Differentiate primary and secondary wound healing. Describe the three phases of wound healing. Identify three major types of wound exudate. Identify the main complications of and factors that affect wound healing. Identify assessment data pertinent to skin integrity, pressure sites, and wounds. INTRODUCTION The skin is the largest organ in the body and serves a variety of important functions in maintaining health and protecting the individual from injury. Important nursing functions are maintaining skin integrity and promoting wound healing. SKIN INTEGRITY Intact skin refers to the presence of normal skin and skin layers uninterrupted by wounds. The appearance of the skin and skin integrity are influenced by ▪ Internal factors - genetic, age and underlying health External activity factor - TYPES OF WOUNDS Body wounds are either intentional or unintentional If the tissues are traumatized without a break in the skin, the wound is closed. The wound is open when the skin or mucous membrane surface is broken. Describing a wound according to the degree of wound contamination Clean wounds are uninfected wounds in which there is minimal inflammation and the gastrointestinal, respiratory, genital, and urinary tracts are not entered. Clean wounds are primarily closed wounds Clean-contaminated wounds are surgical wounds in which the respiratory, gastrointestinal, genital, or urinary tract has been entered. Such wounds show evidence of infection. no Contaminated wounds include open, fresh, accidental wounds and surgical wounds. wounds show inflammation. Contaminated evidence of Dirty or infected wounds include wounds containing dead tissue and wounds with evidence of a clinical infection, such as purulent drainage. Specific Types Incision: of Wounds Sharp instrument (e.g., knife or scalpel). Contusion: Blow from a blunt instrument. Abrasion: Surface scrape, either unintentional (e.g., scraped knee from a fall)or intentional (e.g., dermal abrasion to remove pockmarks). Puncture: Penetration of the skin and often the underlying tissues by a sharp instrument, either intentional or unintentional Laceration: Tissues torn apart, often from accidents (e.g., with machinery. Penetrating wound Penetration of the skin and the underlying tissues, usually unintentional (e.g., from a bullet or metal fragments) PRESSURE ULCERS Pressure ulcers consist of injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of force alone or in combination with movement. Pressure ulcers were previously called decubitus ulcers , pressure sores , or bedsores. Etiology of Pressure Ulcers Ischemia After the skin has been compressed, it appears pale, as if the blood had been squeezed out of it. When pressure is relieved, the skin takes on a bright red flush, called reactive hyperemia The flush is due to vasodilation , Reactive hyperemia usually lasts one half to three quarters as long as the duration of impeded blood flow to the area. If the redness disappears in that time, no tissue damage is anticipated. If, however, the redness does not disappear, then tissue damage has occurred Risk Factors FRICTION AND SHEARING: Friction is a force acting parallel to the skin surface. For example, sheets rubbing against skin create friction. Shearing force is a combination of friction and pressure. It occurs commonly when a client assumes a sitting position in bed. In this position, the body tends to slide downward toward the foot of the bed. IMMOBILITY Immobility refers to a reduction in the amount and control of movement a person has. paralysis, extreme weakness, pain, or any cause of decreased activity can hinder a person’s ability to change independently positions INADEQUATE NUTRITION Prolonged inadequate nutrition causes atrophy, weight and loss, the muscle loss of subcutaneous tissue. These three conditions reduce the amount of padding between the skin and the bones. Inadequate intake of protein, carbohydrates, fluids, zinc, and vitamin C contributes to pressure ulcer formation. Hypoproteinemia (abnormally low protein content in the blood), FECAL AND URINARY INCONTINENCE Moisture from incontinence promotes skin maceration (tissue softened by prolonged wetting or soaking) makes the epidermis and more easily eroded and susceptible to injury. excoriation (area of loss of the superficial layers of the skin; also known as denuded area). Any accumulation of secretions or excretions is irritating to the skin, harbors microorganisms, and makes an individual prone to skin breakdown and infection DECREASED MENTAL STATUS Those who are unconscious, heavily sedated, or have dementia, are at risk for pressure ulcers. because they are less able to recognize and respond to pain associated pressure. with prolonged DIMINISHED SENSATION Paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area. Loss of sensation reduces a person’s ability to respond to trauma, to injurious heat and cold, and to the tingling that signals loss of circulation EXCESSIVE BODY HEAT An elevated body temperature increases the metabolic rate, thus increasing the cells’ need for oxygen. This increased need is particularly severe in the cells of an area under pressure, which are already oxygen deficient. ADVANCED AGE The aging process brings about several changes in the skin and its supporting structures, making the older person more prone to impaired skin integrity. These changes include the following Loss of lean body mass Generalized thinning of the epidermis Decreased strength and elasticity of the skin due to changes in the collagen fibers of the dermis Increased dryness due to a decrease in the amount of oil produced by the sebaceous glands Diminished pain perception due to a reduction in the number of cutaneous end organs responsible for the sensation of pressure and light touch Diminished venous and arterial flow due to aging vascular walls CHRONIC MEDICAL CONDITIONS Diabetes and cardiovascular disease are risk factors for skin breakdown and delayed healing Other factors Poor lifting and transferring techniques, positioning, surfaces, incorrect hard support Stages of Pressure Ulcers Stage I: Non-blanchable erythema signaling potential ulceration Stage II Partial-thickness skin loss (abrasion, blister, or shallow crater) involving the epidermis and possibly the dermis. Stage III Full-thickness involving skin loss damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia Stage IV Full-thickness skin loss with tissue necrosis or damage to muscle, bone, or supporting structures, such as a tendon or joint capsule Unstageable/unclassified Full-thickness skin or tissue loss— depth unknown: Actual depth of the ulcer is completely slough. obscured by Suspected deep tissue injury Depth unknown: purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear RISK ASSESSMENT TOOLS Several risk assessment tools are available that provide the nurse with systematic means of identifying clients at high risk for pressure ulcer development. The tool chosen for use should include data collection in the areas of immobility, incontinence, nutrition, and level of consciousness. The Braden Scale for Predicting Pressure Sore Risk consists of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A total of 23 points is possible and an adult who scores below 18 points is considered at risk. For best results, nurses should be trained in proper use of the scale. Another tool, is Norton’s Pressure Area Risk Assessment Scoring System It includes the categories of general physical condition, mental state, activity, mobility, and incontinence The Braden and Norton tools should be used when the client first enters the health care agency and whenever the client’s condition changes. This increases awareness of specific risk factors and serves as assessment data from which to plan goals and interventions to either maintain or improve skin integrity. Assessing Common Pressure Sites Ensure the lighting is good, preferably natural or fluorescent, because incandescent lights can create transilluminating effect. Regulate the environment before beginning the assessment so that the room is neither too hot nor too cold Heat can cause the skin to flush; cold can cause the skin to blanch or become cyanotic. Inspect pressure areas for discoloration. This can be caused by impaired blood circulation to the area. Inspect pressure areas for abrasions and excoriations. Palpate the surface temperature of the skin over the pressure areas (warm your hands first). Increased temperature is abnormal and may be due to inflammation. Palpate over bony prominences and dependent body areas for the presence of edema, which feels spongy or boggy. Types of Wound Healing Primary intention healing occurs where the tissue surfaces have been approximated (closed) and there is minimal or no tissue loss; It is characterized by the formation granulation of minimal tissue and scarring. It is also called primary union or first intention healing. a closed surgical incision. A wound that is extensive and involves considerable tissue loss, and in which the edges cannot or should approximated, not heals be by secondary intention healing. pressure ulcer. Secondary intention healing differs from primary intention healing in three ways (1) The repair time is longer, (2) the scarring is greater, (3) the susceptibility to infection is greater. Tertiary intention. This is also called delayed primary intention. Phases of Wound Healing INFLAMMATORY PHASE The inflammatory phase begins immediately after injury and lasts 3 to 6 days. Hemostasis (the cessation of bleeding) results from vasoconstriction of the larger blood vessels in the affected area, the deposition (connective tissue), of fibrin and the formation of blood clots in the area. blood clots provide a matrix of fibrin that becomes the framework for cell repair. A scab may also form on the surface of the wound Qatmagha or twegh Below the scab, epithelial cells migrate into the wound from the edges. The epithelial cells serve as a barrier between the body and the environment, preventing the entry of microorganisms.. The blood supply to the wound increases, bringing with it oxygen and nutrients needed in the healing process. The area appears reddened and edematous. Phagocytosis PROLIFERATIVE PHASE the second phase in healing, extends from day 3 or 4 to about day 21 postinjury. Fibroblasts (connective tissue cells), which migrate into the wound starting about 24 hours after injury, begin to synthesize collagen. If the wound is sutured, a raised “healing ridge” appears under the intact suture line. Capillaries wound, grow increasing across the the blood supply. Fibroblasts move from the bloodstream into the wound, depositing fibrin. As the capillary network develops, When the skin edges of a wound are not sutured, the area must be filled in with granulation tissue. proliferating over this connective tissue base to fill the wound. If the wound does not close by epithelialization, the area becomes covered with dried plasma proteins and dead cells. T.B\ Eschar: la deep wound da dabet w qula Scab: amayan tanha tewegheke tanka w superficial a MATURATION PHASE The maturation phase begins on about day 21 and can extend 1 or 2 years after the injury. Fibroblasts continue to synthesize collagen. During maturation, the wound is remodeled and contracted. The scar becomes stronger but the repaired area is never as strong as the original tissue. abnormal amount of collagen is laid down. This can result in a Hypertrophic scar, or keloid. Types of Wound Exudate Exudate is material, such as fluid and cells, that has escaped from blood vessels during the inflammatory process and is deposited in tissue or on tissue surfaces. The nature and amount of exudate vary according to the tissue involved. the intensity and duration of the inflammation, and the presence of microorganisms. Types of exudate A serous exudate consists chiefly of serum (the clear portion of the blood) derived from blood and the serous membranes of the body, such as the peritoneum. It looks watery and has few cells. An example is the fluid in a blister from a burn Ama be ranga A purulent exudate Is thicker than serous exudate because of the presence of pus , which consists of leukocytes, liquefied dead tissue debris, and dead and living bacteria. Example: wak zepka ka day taqenet Secretion ake spe zardbawe tyaya A sanguineous exudate Consists of large amounts of red blood cells, indicating damage to capillaries that is severe enough to allow the escape of red blood cells from plasma Amayan range swra chunka RBC n A serosanguineous exudate Consisting of both clear and bloodtinged drainage, is commonly seen in surgical incisions Ama 2 ranga rangeke awe ka ama Xanay mrdwe teda kama Balam ranga swraka ama wata RBC n A purosanguineous discharge Consisting of pus and blood, is often seen in a new wound that is infected Lamada chlk haya lagal xween Complications of Wound Healing HEMORRHAGE (bleeding) INFECTION DEHISCENCE (jyabwnaway taqalakan) WITH POSSIBLE EVISCERATION POSSIBLE EVISCERATION (bashek la woundaka dar dacheta darawa) Factors Affecting Wound Healing DEVELOPMENTAL CONSIDERATIONS NUTRITION LIFESTYLE MEDICATIONS NURSING MANAGEMENT Assessing: Assessment of Skin Integrity Removing barriers Nursing History and Physical Assessment to the nurse gathers assessment is very important. information regarding skin Anti-embolic stockings, diseases, previous bruising, braces, or devices must be general skin condition, skin removed to assess the skin lesions. condition underneath Inspection and palpation skin condition in areas most of the skin focus on likely determination of skin color skinfolds such as under the distribution, skin turgor, breasts, presence of edema, and characteristics of lesions that are present. any to break down: in in areas that are frequently moist such as the perineum, and in areas that receive extensive pressure such as the bony prominences. Assessment of Wounds Treated wounds, or the dressing is inspected sutured wounds, are and other data regarding usually assessed to the wound (e.g., the determine the progress of presence of pain) are healing. These wounds assessed. may be inspected during changing of a dressing. Estimating the amount of Moderate drainage wound drainage can be saturates difficult. without leakage prior to describe the degree to which the dressing is the dressing scheduled dressing changes. heavy drainage overflows saturated. Minimal drainage only stains the dressing. the dressing prior scheduled changes Drainage = Secretion to Sometimes, the wound reaches under the skin surface (called undermining). the nurse gently explores the undermined area with a sterile swab. One way to measure depth is to place a second swab parallel to the firs Pressure Ulcers Location of the ulcer, related to a bony prominence. Size of ulcer in centimeters. Measure greatest length, width, and depth. To measure depth, insert a sterile applicator swab at the deepest part of the wound, and then measure measuring guide. it against a Stage of the ulcer Integrity of surrounding skin. Condition of the wound margins. Color of the wound bed and location of necrosis (dead tissue) or eschar. Clinical signs of infection, such as redness, warmth, swelling, pain, odor, and exudate (note color of exudate). Laboratory Data Laboratory data can often A hemoglobin level support the nurse’s clinical below assessment of the wound’s range indicates poor progress in healing. oxygen delivery to A decreased leukocyte count can delay healing and increase the possibility of infection the the tissues. normal Prolonged coagulation times can result in excessive blood loss and prolonged clot absorption. Hypercoagulability can lead to intravascular clotting, and result in a deficient blood supply to the wound area. Serum protein Analysis. Albumin is an important indicator of nutritional status. A value below 3.5 g/dL indicates poor nutrition and may increase the risk of poor healing and infection Wound cultures can either confirm or rule out the presence of infection. Sensitivity studies are helpful in the selection of appropriate antibiotic therapy Implementing or intervening Supporting wound healing, Preventing pressure ulcers, Treating pressure ulcers, dressing and cleaning wounds, supporting and immobilizing wounds, applying heat and cold.