Skin and Wound Care Student View PDF

SKIN INTEGRITY AND WOUND CARE Week4 !  Epidermis Top layer of skin When the skin is injured, the epidermis functions to resurface the wound and restore the barrier against invading organisms  Dermis Inner layer of skin Collage...

SKIN INTEGRITY AND WOUND CARE Week4 !  Epidermis Top layer of skin When the skin is injured, the epidermis functions to resurface the wound and restore the barrier against invading organisms  Dermis Inner layer of skin Collagen, blood vessels, and nerves are found in the dermis The dermis responds to injury by restoring the structural integrity (collagen) and the physical properties of the skin. Dermal–epidermal junction Separates dermis and epidermis Economic consequences of pressure injuries: More than 1.6 million patients each year in acute care settings develop pressure injuries The Centers for Medicare and Medicaid Services no longer reimburses hospitals for care related to Stage 3 and Stage 4 pressure injuries that occur during a hospitalization Psychosocial impact of wounds, factors include: Location of the wound the presence of scars, stitches, or drains (often needed for weeks or months) odor from drainage temporary or permanent prosthetic devices Pressure injuries-Current Terminology AKA pressure ulcer, decubitus ulcer, or bed sore Pathogenesis Pressure intensity is the amount of pressure required to collapse a capillary and the vessel is occluded, tissue ischemia occurs. Tissue ischemia If the patient has decreased sensation and cannot respond to the discomfort of ischemia, tissue death is the result. Blanching Place finger over affected area, if it blanches (turns lighter in color) and erythema returns when removed it is called “blanchable hyperemia” If the erythema doesn’t blanch when pressure is applied, it is called “non-blanchable erythema” and deep tissue damage is probable. Cultural aspects of care-patients with darkly pigmented skin cannot be assessed for PI risk by examining only skin color. For dark skin, assess factors such as: temperature moisture, pain discoloration at site of pressure previous pressure injury edema complaints of discomfort (bony prominences, under medical devices)  Extrinsic factors such as shear, friction, and moisture affect the ability of the skin to tolerate pressure  Pressure duration  Tissue tolerance Ability of tissue to endure pressure depends on the tissue integrity and supporting structures Systemic factors: affect the tolerance of tissue to externally applied pressure  RISK FACTORS FOR PRESSURE ULCER DEVELOPMENT Impaired sensory perception Impaired mobility Alteration in LOC Shear Friction Moisture Goal in Prevention: Early identification of an at-risk client and implementation of prevention strategies  Impaired Sensory perception-clients are unable to feel when a part of their body has increased, prolonged pressure or pain Impaired Mobility-individuals who are unable to independently change positions are at risk those with spinal cord injuries, seriously ill clients who are weak and less likely to turn independently Alteration in level of consciousness  Shear  Sliding movement of skin and subcutaneous tissue while the underlying bone and muscle are stationary  Shear force happens when the HOB is elevated and the sliding of the skeleton starts but the skin is fixed because of the friction of the bed.  Transferring a patient skin gets pulled across the bed  Tissue damage is deep in the tissues and causes undermining of the dermis leading to PI  Friction  The force of two surfaces moving across one another  Affect the epidermis; skin is red and painful  Mechanical force exerted when skin is dragged across a course surface such as bed linens. “sheet burn”  Moisture  Prolonged moisture softens skin making it more susceptible for damage.  Moisture-associated skin damage (MASDI) is inflammation or erosion due to prolonged exposure to moisture (wound drainage, urine/stool, perspiration, mucous, saliva.  CLASSIFICATION OF PRESSURE INJURIES Stage 1: Intact skin with localized area of non-blanchable erythema Changes in temperature, sensation or firmness may precede visual changes Purple or maroon discoloration may indicate deep tissue injury vs a Stage 1 pressure injury  Stage 2: Partial-thickness skin loss with exposed dermis Wound bed viable-pink or red and moist; fat and deeper tissue not visible Granulation tissue, slough and eschar are not present Not used to describe: Incontinence Associated Dermatitis (IAD) Moisture Associated Skin Damage (MASD) Medical Adhesive Related Injury Traumatic wounds such as burns abrasions  Stage 3: Full-thickness skin loss Adipose tissue is visible Granulation tissue and epibole (rolled wound edge) present Depth of tissue varies by anatomical location Undermining and tunneling may occur Fascia, muscle, tendons, ligaments, bone are NOT visible  Stage 4: Full-thickness skin and tissue loss With exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone Slough or eschar may be visible Epibole, undermining or tunneling occurs  Unstageable pressure injury: Full-thickness skin and tissue loss obscured by slough or eschar Unable to see visualize the wound bed to determine the total depth Once debrided, the wound can be staged (usually Stage 3 or 4) Deep-tissue pressure injury Intact or non-intact skin with localized area of non-blanchable dark discoloration, or epidermal separation with dark wound bed or blood-filled blister Injury results from intense and/or prolonged pressure STAGE I-IV PRESSURE INJURY Medical device-related pressure injures occurs when the skin or underlying tissues are subjected to sustained pressure or shear from medical devices or equipment. See table 48.1 pg. 1324 Critically ill and neonates particularly vulnerable Most occur on face, ears, head Caused by masks and oxygen tubing Medical adhesive-related skin injury skin injury after removal of adhesive that persists for 30 minutes or more.  WOUNDS Defined as: a disruption of the integrity and function of tissues in the body. From trauma, surgical procedures 2 Types Closed-surface intact but underlying tissue may be damaged Hematomas, contusions, Stage I pressure Injuries Open Skin is split, incised or cracked with underlying tissue exposed to the outside environment  WOUNDS  Wound classifications- see table 48.2, pg. 1325 Acute or chronic Acute: trauma, surgical incision Chronic: Wound that fails to proceed through an orderly and timely process to produce anatomical and functional integrity Vascular compromise, chronic inflammation, or repetitive insults to tissue Continued exposure to insult impedes wound healing. Process of wound healing  Healing by primary intention:  Surgical closure of a wound with sutures, staples, tapes, surgical glue.  Low risk for infection  Classified as clean or clean-contaminated  Healing by secondary intention:  a wound involving loss of tissue, such as a burn, Stage 2 PI, severe laceration  Not closed surgically due to unable to bring the tissues together safely from tissue loss.  Contaminated or dirty-infected  At risk for post surgical infection  Heal by granulation tissue, wound contraction, and epithelialization  Healing by tertiary intention: Delayed primary intention closure Planned period where superficial layers are left open (closed later by primary intention (surgically) May be closed later by skin graft, skin flap, or skin substitute Wound repair Partial-thickness wound repair Three components are involved in the healing process of a partial- thickness wound: inflammatory response epithelial proliferation (reproduction) and migration across the wound bed reestablishment of the epidermal layers. A wound that is kept moist can resurface in 4 days; open to air W/I 6-7 days Full-thickness wound repair The four phases involved in the healing process of a full-thickness wound: hemostasis (coagulation) inflammatory phase proliferation and new tissue formation remodeling and maturation  Hemostasis Bleeding stops clots form a fibrin matrix that later provides a framework for cellular repair Anticoagulants affects platelet production or blood clotting Inflammatory phase-this process is beneficial damaged tissue and mast cells secrete histamine vasodilation of surrounding capillaries migration of serum and white blood cells (WBCs) into the damaged tissues localized redness, edema, warmth, and throbbing. Neutrophils begin to ingest bacteria and small debris Monocytes transform into macrophages-these clean the wound of bacteria, dead cells and debris Macrophages release growth factors that attract fibroblasts which synthesize collagen Collagen is the main component of scar tissue  Proliferative with new tissue formation phase-begins 3-4 days after injury filling of a wound with granulation tissue (microscopic blood vessels that form on the surface of the wound) wound contraction wound resurfacing by means of 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 to form a matrix that supports the re-epithelialization.  Remodeling and maturation the final phase of wound healing begin several weeks after injury and continues 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. Collagen fibers undergo remodeling or reorganization before assuming their normal appearance scar tissue contains fewer pigmented cells (melanocytes) and has a lighter color than normal skin. Complications of wound healing Hemorrhage Bleeding from the wound site May occur internally or externally A surgical drain may be inserted to remove fluid accumulation Hemostasis occurs within minutes unless large vessels are involved Infection Wound infection is one of the most common health care–associated infections Surgical site infections (SSIs) Increase the cost of care, prolong hospitalization Incidence of SSIs is tracked by the Centers for Disease Control and Prevention (CDC)  LOCAL SIGNS OF INFECTION RECOGNIZE AND ANALYZE Erythema, increase in wound drainage Change in appearance of drainage Peri-wound warmth, pain, edema Increase in WBC count  Dehiscence a surgical incision fails to heal properly, the layers of skin and tissue separate. Approximately half of dehiscence occurrences are associated with wound infection Obesity is another risk because of the constant strain placed on the wounds and the poor healing qualities of adipose tissue Dehiscence can happen in abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed Patients often report feeling as though something has “given way.”  Evisceration Total separation of wound layers protrusion of visceral organs through a wound opening The condition is an emergency that requires surgical repair place sterile gauze soaked in sterile saline over the extruding tissues to reduce chances of bacterial invasion and drying of the tissues contact the surgical team do not allow the patient anything by mouth (NPO) observe for signs and symptoms of shock prepare the patient for emergency surgery  Factors influencing pressure injury formation and wound healing  Nutrition  Protein  Vitamin C for collagen synthesis  Trace minerals zinc and copper  Tissue perfusion  the ability to perfuse the tissues with adequate amounts of oxygenated blood is critical to wound healing  Infection  Wound infection prolongs the inflammatory phase  delays collagen synthesis  prevents epithelialization  increases the production of proinflammatory cytokines, which leads to additional tissue destruction  Indicated by purulent drainage, change in color, odor, fever, pain  Age  affects all phases of wound healing  CRITICAL THINKING Knowledge of normal integument and musculoskeletal physiology, the pathogenesis of pressure injuries, pressure injury stages, normal wound healing, and the pathophysiology of underlying diseases provides a scientific basis to approach an assessment for a specific patient. Examining a wound and observing how healing occurs will help you recognize abnormalities. Assessment Sensation Mobility Nutrition Continence Environment Often patients require frequent turning or position changes Complex dressing changes Provide privacy Assess Skin Assess on start of care At least once per shift (check agency policy) Inspect for breakdown or injury in prone areas such as sacral and heels High risk patients require frequent and thorough assessment Inspection is visual and tactile  Assessment Wounds and pressure injuries Slough-stringy substance attached to wound bed Must be removed before it can heal Eschar-black, brown, or necrotic tissue Must be removed before it can heal RECOGNIZING Surgical debridement, enzymatic debridement CUES Exudate should describe the amount, color, consistency, and odor of wound drainage Induration Formation of thickened or hardened edges around the wound Pain Use the 0-10 pain scale  Assess skin on admission and at transfer of care: to acute care, rehabilitation hospitals, nursing homes, home care, and other health care agencies, patients are assessed for risk of pressure injury development. Why? Assessment for pressure injury risk includes using an appropriate predictive measure What is this called? Assess: Mobility-note strength and muscle tone Nutritional status-look at mouth and teeth, any missing or loose Presence of body fluids specifically urine, bile, stool These are very caustic to the skin____  Assessment Surgical and traumatic wounds assess at time of injury, post-op, or with dressing changes Emergency setting-abrasion, laceration, puncture wounds Stable setting-dressing changes, assessment, analgesia Wound appearance-assess for signs and symptoms of infection; redness, purulent drainage, pain You would expect clean well approximated edges with a surgical incision Wound drainage-purulent, serous, serosanguinous Palpation of wound-observe for swelling and separation of edges Drains-type, amount of drainage (I&O’s) Wound closures-sutures, staples Wound cultures-check labs Normally skin around sutures or staples may be edematous in the first 2-3 days  ANALYZE CUES, INTERPRETING, PRIORITIZING DIAGNOSIS Pick a priority problem that is pertinent to your patient: Risk for Infection Acute or Chronic Pain Impaired Mobility Impaired Peripheral Tissue Perfusion Review your data to support your priority hypothesis  TAKE ACTION, IMPLEMENTATION Prevention of pressure injuries , RESPONDING Topical skin care incontinence management-cleanse gently and apply moisture barrier Positioning Support surfaces (therapeutic beds and mattresses) see pg. 1343 no need to memorize!  Done to reduce and relieve pressure POSITIONIN HOB elevated 30 degrees or less decreases chance of pressure injury development d/t G shearing Reposition q 1.5-2 hours or more Limit sitting in chair to 2 hours or less for those at risk and change positions when sitting eery 15 minutes  TAKE ACTION, IMPLEMENTATION , RESPONDING Healing nutrition First aid for wounds Hemostasis-apply pressure Do not remove foreign objects such as a knife-the presence provides pressure and may control bleeding Cleaning-normal saline neutral does not harm tissue Gentle removal of contaminants Management of pressure injuries Clean and irrigate w/ NS Apply appropriate dressing see table 48.10 pg. 1348 Debridement- removal of nonviable, necrotic tissue Methods: mechanical, autolytic, chemical, surgical  TAKE ACTION, IMPLEMENTATION, RESPONDING wound care  TAKE ACTION, IMPLEMENTATIO Comfort measures N, RESPONDING Administer analgesic medications 30 to 60 minutes before dressing changes, Carefully remove 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. Cleaning skin and drain sites Unless this is a sterile wound use water or normal saline). If it is a sterile wound, you need an order for sterile water or normal saline. You can use irrigation to remove debris from a wound Skin closures Staples, sutures, glue, tape Drainage evacuation Drains, dressings Bandages, binders, and slings Binders Slings Roll bandage application  TAKE ACTION, IMPLEMENTATION, RESPONDING Types of dressings: Gauze sponges Foam and alginate For wounds with large amounts of exudate and those that need packing highly absorbent Hydrocolloids support healing in clean granulating wounds and autolytically debride necrotic wounds Changing dressings Per provider order daily, BID, PRN Packing a wound Do not pack wounds too tightly, as overpacking causes pressure on the wound bed tissue Securing dressings bandages, tape, wraps  VACUUM ASSISTED CLOSURE (VAC) NEGATIVE PRESSURE WOUND THERAPY (NPWT) For the management of difficult wounds Delayed wound healing Difficult wounds in the elderly Complex wounds with large amounts of exudate Wound VAC therapy improves the possibility of primary closure of wounds and reduces the need for reconstructive procedures. WOUND DRAINS  HYPERBARIC OXYGEN Hyperbaric oxygen therapy THERAPY involves exposing the body to (HBOT) 100% oxygen at a pressure that is greater than normal. Hyperbaric oxygen therapy is used for certain types of wounds. Some of these are: Radiation injuries Infections Burns Certain skin grafts and flaps Crush injuries Diabetes related wounds  Application of heat and cold therapies Cold is used to decrease inflammation(superficial application) Heat is to increase blood flow to promote healing Warm, moist compresses Warm soaks Sitz baths Commercial heat and cold packs Cold, moist, and dry compresses Cold soaks Ice bags or collars You do need a provider’s order for application of heat or cold  TAKE ACTION, IMPLEMENTATION, RESPONDING Educating your patient Teach-back is an evidence-based health literacy intervention Promotes patient engagement, patient safety, adherence, and quality. The goal of teach-back is to ensure that you have explained medical information clearly so that patients and their families understand what you communicated to them “I want you to understand why we need to assess your skin on an ongoing basis. Tell me in your own words why we will be checking your skin on a regular basis.”  EVALUATE OUTCOMES, REFLECTING The following are examples of outcomes associated with preventing or reducing risk for pressure injuries and wound healing: Increase in the percentage of granulation tissue in the wound base No wound erythema or tenderness to palpation No further skin breakdown Increase in caloric intake by 10% Setting priorities patient preferences planning around daily activities family caregiver factors Teamwork and collaboration Wound care team Home health  SAFETY Follow proper aseptic technique. GUIDELINES Routinely assess for risks of pressure injuries. Inspect skin regularly. Use approaches to minimize friction and shear. History of previous skin damage and chronic diseases, especially vascular disease and diabetes, increase a patient’s risk for pressure injury development and impede wound healing.  https://npiap.com/store/ListProducts.aspx?catid=732 189&p=0 WHAT STAGE? WHAT STAGE? WHAT STAGE IS THIS?? WHAT STAGE?  REVIEW QUESTION After surgery the patient with a closed abdominal wound reports a sudden “pop” after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder.  REVIEW QUESTION Which of the following are measures to reduce tissue damage from shear? (Select all that apply.) 1. Use a transfer device (e.g., transfer board). 2. Have head of bed elevated when transferring patient. 3. Have head of bed flat when repositioning patient. 4. Raise head of bed 60 degrees when patient is positioned supine. 5. Raise head of bed 30 degrees when patient is positioned supine.  REVIEW QUESTION Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (Select all that apply.) 1. Frequent position changes 2. Keeping the buttocks exposed to air at all times 3. Using a large absorbent diaper, changing when saturated 4. Using an incontinence cleaner 5. Applying a moisture barrier ointment